RLE NCM 4165 - Nursing Care of Clients With Life Threatening Conditions

NCM 4164 | Nursing Care of Clients with Life Threatening
Conditions
RLE
by: Buenaflor, JC., Chatto, K., Decio, RM.
5. Determine if CO2 or HCO3 goes in the opposite
direction.
Arterial Blood Gas (ABG)
6. Assess if PO2 and O2 Sat are normal.
Purpose:
● ABG is performed to assess a client's acid-base
balance and oxygenation.
● Arterial blood is used for more accurate reflection of
pulmonary gas exchange
ABG Studies Aid in Assessing

● Lungs’ ability to provide oxygen and remove carbon
dioxide.
● Kidneys' ability to regulate bicarbonate ions for pH
balance.

● Radial
● Brachial
● Femoral

● ABG can be done by lab technicians, respiratory
therapists, or specialized nurses.
● Apply pressure to the puncture site after extraction.
● ABG syringe is used for collection.
ABG Measurements
● pH: Indicates blood acidity or alkalinity.
● PaO2: Measures dissolved oxygen in arterial blood.
● PaCO2: Measures carbon dioxide partial pressure in
arterial plasma.
● HCO3: Reflects the metabolic component of
acid-base balance.
● O2 Saturation: Measures oxygen saturation in blood.
ABG Normal Values

● pH: 7.35-7.45
● CO2: 35-45 mm Hg
● PaO2: 80-100 mm Hg
● HCO3: 22-26 mEq/L
● O2 Saturation: 95-100%
Analyzing ABG
1. Check if pH is normal.
2. Check if CO2 is normal.
3. Check if HCO3 is normal.
4. Match CO2 with HCO3 according to pH.
Conditions
RLE
Cardiopulmonary Resuscitation Main Components
● C- Chest Compression
Objectives ● A- Airway
1. Describe the importance of high- quality CPR and its ● B- Breathing
impact on survival;
Cardiac Arrest
2. Integrate the BLS concepts of the Chain of Survival;
3. Recognize the signs of someone needing CPR; ● Cessation of cardiac function;
4. Perform high-quality CPR for an adult; ● Unexpected and sudden;
5. Appraise the importance of team in multi-rescuer ● Within 20 to 40 seconds of a cardiac arrest: the victim
resuscitation; and is clinically dead;
6. Perform as an effective team member during ● After 4 to 6 minutes, the lack of oxygen supply to the
multi-rescuer CPR. brain causes permanent and extensive damage.
● Cardinal signs of cardiac arrest:
AHA Chains of Survival for adult IHCA and OHCA
1. Apnea;
2. Absence of a carotid or femoral pulse; and
3. Dilated pupils.
Respiratory (Pulmonary) Arrest
● Cessation of breathing;
● May occur abruptly or be preceded by short, shallow
breathing that becomes increasingly labored;
Important!
Nurses also can be instrumental in increasing community
awareness of the need for CPR training and ensuring its
availability.
CARDIAC ARREST ALGORITHM
(2020 AMERICAN HEART ASSOCIATION UPDATE)
Critical Characteristics of High-Quality CPR:
1. Start compressions within 10 seconds of recognition
of cardiac arrest.
2. Push hard, push fast: Compress at a rate of 100 to
120/min with a depth of:
AHA Chains of Survival for pediatric IHCA and OHCA
a. Push Hard, Push Fast
i. Adults: At least 2 inches (5cm)
ii. Children: At least one third the
depth of the chest, about 2 inches
(5cm), for children;
iii. Infants: At least one third the depth
of the chest, about 1 ½ inches
(4cm)
3. Allow complete chest recoil after each compressions
4. Minimize interruptions in compressions (try to limit
interruptions to less than 10 seconds)
5. Give effective breaths that make the chest rise;
6. Avoid excessive ventilation
Compression- Ventilation Ratio
● Adult: 1 or 2 rescuers: 30:2
● Combination of: oral resuscitation and external ● Infant- Children:
cardiac massage; ○ 1 rescuer: 30:2
● Also referred to as basic life support (BLS); ○ 2 or more rescuers: 15: 2
Conditions
RLE
● Continuous compressions at a rate of 100-120/min; ● Each health care facility has policies and procedures
Give 1 breath every 6 seconds (10 breaths/min) for announcing cardiac/respiratory arrest and initiating
● Compression rate: 100-120/min interventions;
● It is critical that each member of the client care team
Compression Depth
know the procedure for announcing this emergency.
● Adult: At least 2 inches (5cm)
The Code Team
● Children: At least 1/3 AP diameter of chest; About 2
inches (5cm) ● Made up of specially trained staff who can handle the
● Infant: At least 1/3 AP diameter of chest; About 1 1/2 emergency;
inches (4cm) ● Calling the code summons the code team to the
location of the emergency.
Members:
1. Perform rescue breathing,
2. Deliver chest compressions,
3. Administer medications,
4. Make a record of the code activities, and
5. Code leader
CARDIAC ARREST ALGORITHM

(2020 AMERICAN HEART ASSOCIATION UPDATE)
Hand Placement
● Adult: 2 hands on the lower half of the breastbone
(sternum)
● Children: 2 hands or 1 hand (optional for very small
child) on the lower half of the breastbone (sternum)
● Infant:
○ 1 rescuer: 2 fingers in the center of the
chest, just below the nipple line
○ 2 or more rescuers: 2 thumb – encircling
hands in the center of the chest, just below
the nipple line
Calling Code
Conditions
RLE
1. Victim scene safety.
2. Victim is unresponsive.
a. Shout for nearby help. Activate emergency
response system via mobile device (if
appropriate).
b. Get AED and emergency equipment (or
send someone to do so).
3. Look for no breathing or only gasping and check
pulse (simultaneously). Is the pulse definitely felt
within 10 seconds?
● Normal breathing, has pulse
● No normal breathing, has pulse
● No breathing or only gasping, no pulse
Normal breathing, has pulse
● Monitor until emergency responders arrive
No normal breathing, has pulse
● Provide rescue breathing: 1 breath every 5-6
seconds, or about 10-12 breaths/min USING
HEPA FILTER WITH BAG MASK
VENTILATION
○ Activate emergency response
system (if not already done) after 2
minutes
○ Continue rescue breathing; check
pulse about every 2 minutes. If no
pulse, begin CPR
○ If possible opioid overdose,
administer naloxone if available per
protocol
No breathing or only gasping, no pulse
● Begin CPR
4. Cardiopulmonary Resuscitation (CPR)
a. Begin cycles of 30 compressions and 2
breaths*.
b. Use AED as soon as it is available.
c.
5. AED arrives.
6. Check rhythm. Shockable rhythm?
7. Yes, shockable
a. Give 1 shock
b. Resume CPR immediately for about 2
minutes (until prompted by AED to allow
rhythm check)
c. Continue until ALS providers take over and
the victim starts to move.
8. No, non-shockable
a. Resume CPR immediately for about 2
minutes (until prompted by AED to allow
rhythm check).
b. Continue until ALS providers take over or the
victim starts to move.
Contraindications
1. Advanced directives
Conditions
RLE
6. Provide oxygen support via face mask or BVM
Cardioversion and Defibrillation
7. Have standby suction apparatus, intubation set, and
● Cardioversion is a procedure that restores the heart's monitor.
normal rhythm from an abnormal rhythm. It involves
Successful Cardioversion Indications:
the use of direct-current (DC) electricity at lower
levels than defibrillation. ● Restoration of sinus rhythm.
● Defibrillation, on the other hand, uses electricity to ● Presence of adequate peripheral pulses.
depolarize the heart muscle and promote coordinated ● Maintenance of adequate blood pressure.
contractions.
Defibrillation
● Used for ventricular fibrillation and pulseless
Cardioversion
ventricular tachycardia.
● Voltage used ranges from 50 to 360 J based on ● Not used in conscious patients with a pulse.
factors such as defibrillator technology, dysrhythmia ● Depolarizes a critical mass of myocardial cells to
type and duration, and patient size/status. allow the sinus node to regain pacemaker function.
● Synchronized with the ECG to discharge during ● When they repolarize, the sinus node usually
ventricular depolarization. recaptures its role as the pacemaker
● Involves delivering a timed electrical current to halt
Classification of Defibrillators
tachydysrhythmias.
● Monophasic: Deliver current in one direction, requiring
Steps in Performing Cardioversion
higher energy loads.
1. Prepare the patient (Explain the procedure and obtain ● Biphasic: Deliver electrical charge between paddles,
consent). allowing for potentially lower energy levels (eg, 150 J
2. Prepare necessary equipment. with each defibrillation) with potentially less
3. Assist with sedation myocardial damage.
4. Place paddles/pads
a. Place one paddle directly below the right
collarbone.
b. Place the other paddle to just below the left
nipple, near the apex of the heart.
c. If using pads, it can be placed anterolateral
position or anteroposterior position
5. Follow ACLS guidelines: Turn on defibrillator, select
energy level, activate synchronize mode, verify
correct R wave sensing.
Considerations
6. Charge machine to the prescribed energy level.
7. Announce "clear" three times before discharging. ● Epinephrine is administered after defibrillation
8. Deliver the shock. ● Antiarrhythmic medications such as amiodarone,
9. Document the procedure. lidocaine, or magnesium are administered if
10. Provide aftercare. ventricular dysrhythmia persists.
● This treatment with continuous CPR, medication
administration, and defibrillation continues until a
stable rhythm resumes or until it is determined that
Precautions and Nursing Responsibilities:
the patient cannot be revived.
1. Consider anticoagulation for a few weeks prior to
Cardioversion vs. Defibrillation
cardioversion.
2. Withhold digoxin 48 hours before cardioversion to
ensure the resumption of sinus rhythm with normal
conduction.
3. Instruct the patient not to eat or drink for at least 4
hours before the procedure.
4. Position gel-covered paddles or conductor pads front
and back (anteroposteriorly).
5. Administer moderate sedation and analgesics or
anesthesia
Conditions
RLE
● Cardioversion aims to restore normal rhythm from an

abnormal rhythm.
● Defibrillation is used for emergency situations and
restores rhythm in ventricular fibrillation and pulseless
ventricular tachycardia.
Joules in Defibrillating a Child
● Initial dose of 2 J/kg recommended, escalating to 4
J/kg if needed.
● Avoid escalating beyond 4 J/kg as per current AHA
guidelines.
Conditions
RLE
Bag Valve Mask
"Code Blue"
● "Code Blue" is the term used to indicate a patient's
cardiopulmonary arrest, requiring immediate
resuscitation. It involves a designated "code team,"
but initial efforts are often started by the nearest
nurses on duty. Once the code team arrives, they
continue the resuscitation efforts.
● Start following the BLS guidelines until the code blue
team arrives.
● Code blue team must arrive within 5 minutes.
Nurse’s Roles During Code Blue:
1st Responder:
● Assesses the patient and calls for help.
● Ensures the patient is flat on the bed,
removes pillows, and lowers the head of the
bed. In summary
● Initiates chest compressions. ● Activate code blue team
● Checks for the carotid pulse (best site) ● bring e-cart resuscitation
2nd Responder: ● Place blackboard under patient
● Brings e-cart and other emergency ● Initiate 2 man Cardiopulmonary resuscitation
equipment to the scene. ● Administer ventilators with 100% O2 with Bag/
● Places a backboard under the patient. valve/mask
● Manages the airway using an ambu bag or ● Attach ECG leads
pocket mask with one-way valve ● Attach “hands off” defibrillator pads
● Switches roles with the 1st responder for ● Ensure patient intravenous access
chest compressions. ● Prepare suction
3rd Responder: ● Obtain supplies from CPR Cart/ Ward Stock
● Operates the AED/defibrillator for pulseless
patients.
4th Responder: Code Team Composition:
● Ensures IV fluids and emergency
medications are ready for use.
5th Responder: ● Typically includes a physician, unit staff nurse, critical
● Handles documentation. care/ICU nurse, pharmacist, respiratory therapist,
clinical supervisor, compressor, security, and pastoral
services.
● Physician serves as the code team leader and
directs medical management to be followed by the
rest of the Code Team
● Unit Nurse assists the team and initiates basic life
support.
● ICU Nurse leads until the physician arrives, manages
and monitors the defibrillator and cardiac rhythm
strips.
○ Relayes ECG findings to the physician and
the nurse documenting the code
○ Administers emergency drugs as indicated
● Pharmacists prepare emergency medications and
calculate infusion rates.
○ Ensured drug incompatibilities are avoided
Conditions
RLE
○ Ensures the e-cart is properly restocked ● Leave the code immediately.
● Respiratory therapist manages airway and ○ Once the Code Team has arrived, don’t
respiratory assessment, assists with intubation. leave the scene right away.
○ Secure settings of mechanical ventilator ○ You know your patient well and the team
○ Obtains and reports ABG as ordered. might need some information from you as
the patient’s charge nurse.
● Switching roles without proper communication
Code Blue Team ○ If you feel the need to switch roles,
communicate with the team to ensure
someone will take place of your role.
● Trained patient care providers who perform
● Shouting
resuscitation on any person who sustains
○ Be calm and communicate clearly.
○ Cardiopulmonary arrest
○ Do not shout or yell as it adds up to the
○ Respiratory arrest
tension of the team during a code.
○ Airway problem
○ Speaking calmly also maintains your
● Train providers:
presence of mind throughout the event.
○ Doctor, Nurse, respiratory therapist and
support personnel
Medications Used During a Code:
● Ventricular Fibrillation/Tachycardia: Epinephrine,

Amiodarone, Lidocaine, Magnesium.
● Asystole/PEA: Epinephrine.
● Bradycardia: Atropine, Dopamine.
● Tachycardia: Diltiazem, Beta-blockers, Digoxin,
Verapamil, Magnesium.
Dos and Don'ts During a Code:

Do’s
● Get involved
○ Be active with the code team even if it’s your
first time to be involved.
○ It’s a rare opportunity to be involved in an
ongoing Code Blue and you can gain
valuable experience as a nurse.
● Participate in mock codes
○ Healthcare institutions usually conduct mock
codes especially for new nurses so they will
be oriented with the hospital’s policies during
Code Blue.
○ You will learn all the essential do’s and
don’ts by participating with these mock
codes.
● Debrief with the team afterward for learning and
improvement.
○ Talk with the team about the things that went
well and what areas need improvement.
Debriefing after the code will help you
improve your skills and knowledge in
responding to codes
Don'ts:
Conditions
RLE
Different techniques and approaches are used based
CardioPulmonary Resuscitation
on the age and needs of the patient.
Cardiopulmonary Resuscitation (CPR) is an emergency ● CPR is a critical skill that can significantly improve the
lifesaving procedure performed when the heart stops beating. chances of survival in cases of cardiac arrest. Proper
It can double or triple chances of survival after cardiac arrest. technique, adherence to guidelines, and quick action
CPR involves a combination of chest compressions and rescue can make a life-saving difference.
breaths. Key points about CPR include
● High-Quality CPR: Starting compressions within 10

seconds of recognizing cardiac arrest, compressing
the chest at a rate of 100 to 120 times per minute,
ensuring sufficient depth (at least 2 inches for adults,
proportionate for children and infants), allowing full
chest recoil after each compression, minimizing
interruptions, and providing effective breaths.
● Personal Protective Equipment (PPE): PPE is
essential to protect the rescuer from health risks. It
can include medical gloves, eye protection, full body
coverage, high-visibility clothing, safety footwear, and
helmets, varying based on protocols and situations.
● Chain of Survival: The Chain of Survival is a series
of critical steps to maximize the chances of survival
during cardiac arrest. The latest 2020 Chain of
Survival emphasizes early recognition, calling for
help, starting CPR, and using defibrillation.
● Differences Between In-Hospital Cardiac Arrest
(IHCA) and Out-of-Hospital Cardiac Arrest
(OHCA): IHCA occurs within a healthcare facility,
whereas OHCA happens outside. IHCA usually has a
witnessed arrest, while OHCA often occurs without
witnesses. IHCA often has a reversible cause,
whereas OHCA is often caused by a heart rhythm
problem.
● Sudden Cardiac Arrest vs. Heart Attack: Sudden
cardiac arrest is when the heart suddenly stops
beating, causing a loss of blood flow, while a heart
attack is caused by a blocked artery disrupting blood
supply to the heart muscle.
● Building Blocks of CPR: Different CPR efforts
include:
● Hands-Only CPR: Chest compressions
performed by a single rescuer with minimal
training.
● 30:2 CPR: Compressions and breaths given
in a ratio of 30 compressions to 2 breaths,
suitable for drowning victims or adults in
cardiac arrest.
● Teamwork CPR: Multirescuer coordinated
CPR involving chest compressions,
bag-mask breaths, and defibrillation
performed by emergency responders.
● Adult and Pediatric CPR Algorithms: Specific
algorithms guide CPR for adults and children.
Conditions
RLE
4. Tracheal incision and tube insertion, often through the
second or third tracheal ring.
Tracheostomy: A Comprehensive Overview
5. Closure of the skin incision and secure attachment of
the tracheostomy tube.
Tracheostomy is a medical procedure involving the creation of
an artificial opening in the throat to facilitate breathing or
establish an alternate airway. Commonly performed in patients Post-Procedure Care:
with extended ICU stays or requiring ventilator support,
tracheostomy serves several vital purposes
Proper care is essential for tracheostomy patients:
Indications for Tracheostomy: 1. Suctioning: Frequent suctioning of secretions through

the tube to prevent blockage.
2. Humidification: Ensuring adequate air humidification
Tracheostomy becomes necessary under various
to minimize irritation and secretion production.
circumstances:
3. Monitoring: Regular checks to confirm proper tube
function and prevent dislodgment.
1. Upper Airway Obstruction: Conditions like laryngeal 4. Communication: Providing alternatives for speech, as
cancer or edema can impede airflow. tracheostomy bypasses vocal cords.
2. Secretion Management: When patients are unable 5. Cuff Deflation: Periodic deflation of the cuff to relieve
to clear respiratory secretions due to factors like coma tracheal pressure.
or paralysis, tracheostomy aids in secretion removal.
3. Respiratory Insufficiency: In cases of chronic lung
diseases, tracheostomy improves oxygen ventilation Complications
by minimizing respiratory dead space.
4. Prophylactic Measures: Prolonged endotracheal
tube use increases the risk of tracheal stenosis, Potential complications include bleeding, blockage,
making tracheostomy a preventive measure. dislodgment, tracheitis, crusting, initial breathing difficulties,
5. Adjunct to Other Procedures: Tracheostomy can apnea, infections, and damage to surrounding structures.
facilitate access to the airway for anesthesia or serve
as a precaution during extensive neck surgeries. Decannulation
Types of Tracheostomy: Once a patient's condition improves, attempts at decannulation

(tube removal) may be made. The patient undergoes a trial
Tracheostomy procedures and tubes vary based on patient with the tube occluded for 24 hours. Successful tolerance
circumstances and treatment goals. Common procedure types leads to tube removal and wound closure. In cases of
include emergency, elective, permanent, percutaneous, and intolerance, progressively smaller tubes may be used for a
mini tracheostomy. Tubes come in different designs like cuffed, successful transition to normal breathing.
non-cuffed, double lumen, speaking valves, and metallic tubes,
among others. Understanding tracheostomy, its indications, procedures, care
requirements, and potential complications is crucial for medical
practitioners to ensure patient safety and effective treatment.
Procedure
Performing Oropharyngeal Suctioning:

Tracheostomy is usually performed under general anesthesia, Safety and Procedure Guidelines
but emergencies may require local anesthesia. Key steps in
the procedure include:
Safety Measures:
1. Patient positioning with an extended neck.

2. Incision, fat and muscle dissection, and retraction of ● Be prepared to restore oxygen if SpO2 falls or
neck muscles. respiratory distress occurs during suctioning.
3. Potential thyroid gland displacement or sectioning. ● Store the suction catheter in a non-airtight container
to prevent bacterial growth.
Conditions
RLE
● Adhere to clean technique principles. 12. Dispose of equipment, perform hand hygiene, and
● Be cautious when using a Yankauer tip in older adults document the procedure.
or post-oral/head/neck surgery patients.
Follow-up:
Equipment Needed:
● Compare vital signs and SpO2 before and after
● Yankauer suction catheter suctioning.
● Suction tubing ● Assess the patient's breathing and congestion.
● Clean gloves ● Observe airway secretion character.
● Pulse oximeter
● Stethoscope Documentation:
● Disposable drape or towel
● Mask, goggles, or face shield (optional)
● Record secretions' amount, consistency, color, and
● Sterile water (1 L)
odor.
● Washcloth
● Document catheter size, suction route, patient's
● Toothbrush and toothpaste
response, and vital signs.
● Emesis basin
● Note any complications or concerns related to the
● Oral airway (optional)
procedure.
Delegation:
This guideline outlines the safety measures and steps involved
in performing oropharyngeal suctioning, ensuring patient
● Oropharyngeal suctioning can be delegated to comfort and proper airway management.
nursing assistive personnel (NAP) in some cases.
● Nurse assesses the patient's respiratory status and
communicates essential instructions to NAP.
Preparation:
● Assess risk factors for airway obstruction.

● Evaluate hypoxia, hypoxemia, hypercapnia, and signs
of respiratory distress.
● Explain the procedure to the patient and assess their
ability to participate.
● Position the patient comfortably.
Procedure Steps:
1. Gather equipment and supplies.

2. Perform hand hygiene and ensure privacy.
3. Identify the patient using two identifiers.
4. Apply pulse oximeter and assess the patient's
position.
5. Connect suction tubing, check equipment, and ensure
proper function.
6. Apply sterile gloves, if necessary.
7. Insert catheter into nares or mouth following
guidelines.
8. Apply suction while withdrawing the catheter.
9. Rinse catheter and tubing.
10. Disconnect catheter, remove gloves, and turn off
suction.
11. Reposition the patient and provide oral hygiene.
Conditions
RLE
Administering feeding or medications via NGT for patients who
Enteral Nutrition and Nasogastric Tube (NGT) Insertion:
cannot take them orally. It restores/maintains nutrition and
administers medications. Equipment includes correct feeding
Enteral nutrition involves alternative feeding methods that solution, catheter-tip syringe, emesis basin, clean gloves, pH
ensure adequate nutrition by administering nutrients through test strips, water, clean towel, and infusion pump for feeding
the gastrointestinal (GI) system. One method is the tube.
Nasogastric Tube (NGT) insertion, where a tube is passed
Managing a Nasogastric Tube:
through the nostrils down to the stomach to provide nutrition.
Classification: Safety and Monitoring:
1. Open System: Uses an open-top container or syringe ● Regularly check the feeding tube position based on
for administration. Formula should be discarded after the patient's condition and agency policy, often every
8-12 hours. Bag and tubing need replacement every 4 to 6 hours, and before administering formula or
24 hours. medications.
2. Closed System: Involves a refilled container spiked ● Monitor external tube length, appearance, volume,
with enteral tubing, safe for hanging up to 48 hours and pH of fluid aspirated through the tube.
with proper sterile technique. ● Be cautious of medication-related discoloration in
aspirate. Notify the healthcare provider if unusual
Types of Feeding: colors are observed.
● If severe respiratory distress occurs due to aspiration
● Intermittent: Administered several times a day, or tube displacement into the lung, stop feedings,
preferred site is the stomach. notify the healthcare provider, and obtain a chest
● Continuous: Over 24 hours using an infusion pump, x-ray as needed.
administered in the small bowel.
● Cyclic Feedings: Administered in less than 24 hours, Equipment:
often at night, allowing the patient to eat regular
meals during the day. ● 60-mL catheter-tip syringe
Purposes of NGT Insertion: ● Stethoscope
● Clean gloves
● pH indicator strip
● Administer tube feedings and medications to those
● Small medication cup
unable to eat or swallow normally.
● Liter bottle of sterile water
● Prevent gastric distention, nausea, and vomiting.
● NG tube
● Remove stomach contents for analysis.
● NG tube plug
● Lavage (wash) the stomach in case of poisoning or
● Paper measuring tape
overdose.
Equipment for NGT Insertion Delegation:
● Nasogastric Tube ● The skill of irrigating a feeding tube and verifying tube
● Non-allergic adhesive tape placement should not be delegated to NAP (nursing
● Clean Gloves assistive personnel). NAP should report when
● Water-soluble Lubricant continuous tube feeding stops or if any concerning
● Syringe Bulb changes occur.
● Kidney Basin
● Flashlight Preparation:
● Stethoscope
● pH Test Strip or Meter
● Familiarize yourself with agency policy for checking
● Clean Towel
NG tube placement.
● Infusion Pump for Feeding Tube
● Identify the risk of spontaneous tube dislocation
Feeding Through NGT: based on the patient's condition.
Conditions
RLE
● Observe external tube movement and assess bowel ● 30-mL or larger catheter-tip syringe (Asepto Syringe)
sounds. ● Stethoscope
● Position the patient comfortably. ● Enteral infusion pump (for continuous feedings)
● Prescribed enteral formula
Procedure Guidelines for Managing a Nasogastric Tube: ● Clean gloves
● Alcohol swabs
● Permanent marker
1. Verify healthcare provider's orders.
● 500-mL container of water
2. Check tube length and gather equipment.
3. Perform hand hygiene and ensure patient privacy.
4. Identify the patient. Delegation:
5. Prepare equipment at the bedside, wear clean gloves.
6. Assess the patient for nausea or abdominal pain. ● Administering nasoenteric tube feeding can be
7. Verify NG tube placement before feedings or delegated to NAP, but tube placement and patency
medications. verification must be done by an RN or LPN/LVN.
8. Draw air into a syringe, flush tube with air, then
aspirate fluid. Preparation:
9. Mix aspirate, measure pH, compare to reference
values.
● Assess patients for allergies, perform abdominal
10. Irrigate NG tube: draw water into a syringe, instill into
assessment including bowel sounds, and review lab
the tube, reposition if needed, reconnect tubing.
results.
11. Assist patient's comfort and tidy up the environment.
● Confirm healthcare provider's orders for formula type,
12. Ensure patient safety, raise side rails, and lower the
rate, route, and frequency.
bed.
● Explain procedure to patient.
13. Dispose of supplies, perform hand hygiene.
14. Observe patient for respiratory distress and confirm
tube parameters. Procedure Guidelines for Providing Enteral Feeding:
15. Document pH, aspirate appearance, irrigation details,
and any concerns. 1. Verify orders, gather equipment, and check patient's
baseline weight and lab results.
Follow-up: 2. Perform hand hygiene and ensure patient privacy.
3. Identify patient using two identifiers.
4. Ask about food allergies and explain the procedure.
● Record pH and aspirate appearance.
5. Apply clean gloves.
● Document irrigation details.
6. Assess abdomen and auscultate bowel sounds,
● Report clogs or abnormalities.
positioning the patient.
Providing Enteral Feedings: 7. Prepare formula using aseptic technique.
8. Verify tube placement as demonstrated in "Managing
a Nasogastric Tube."
Safety and Monitoring:
9. Draw air into the syringe, aspirate gastric contents,
and note appearance and pH.
● Maintain proper head-of-bed elevation during feeding 10. Prepare formula, label bag, and prime tubing.
to reduce aspiration incidents. 11. Administer formula, adjusting infusion rate if needed.
● Avoid adjusting feeding rate; follow ordered infusion 12. Flush tubing before and after feedings, as specified
rate. by agency policy.
● Monitor patient weight gain; sudden gain over 2 13. Maintain proper patient positioning and safety
pounds in 24 hours may indicate fluid retention. precautions.
● Respond to patient aspiration or vomiting promptly 14. Dispose of supplies, perform hand hygiene.
and notify healthcare provider. 15. Monitor patient's response, intake and output,
respiratory status, and tube site integrity.
Equipment Needed: 16. Record and report feeding details, GRV, patient
response, and any adverse outcomes.
● Disposable feeding bag, tubing, or ready-to-hang
system Follow-up:
Conditions
RLE
● Continue monitoring the patient's intake, output, and
weight.
● Observe respiratory status, auscultate bowel sounds,
and assess tube site.
● Document feeding details and patient's condition.
Removing a Feeding Tube:
Safety and Preparation:
● A healthcare provider's order is necessary to remove

a feeding tube.
● Assess the patient's mental status, ability to
cooperate, presence of gag reflex, and other relevant
factors.
● Position the patient in high Fowler's position, use a
disposable pad for chest, and explain the procedure.
Equipment Needed:
● Disposable waterproof pad
● Tissues
● Clean gloves
● Stethoscope
● Basin or disposable bag
● Oral hygiene supplies
Delegation:
Feeding tube removal cannot be delegated to NAP, but they
may assist with patient positioning and comfort.
Procedure:
1. Verify healthcare provider's orders.
2. Gather necessary equipment.
3. Perform hand hygiene and ensure patient privacy.
4. Identify patient using two identifiers.
5. Position patient, cover chest, disconnect tube, and
explain the procedure.
6. Put on clean gloves.
7. Remove tape or fixation device securing the tube.
8. Instruct patient to take a deep breath, kink the tube,
and withdraw it quickly.
9. Offer tissues and mouth care to the patient.
10. Ensure patient's comfort and accessibility to personal
items.
11. Place call light within reach and ensure bed safety.
12. Dispose of supplies, perform hand hygiene, and
document patient's response.
Follow-Up:
● Monitor bowel sounds, abdomen, and patient's comfort.
● Inspect nares and assess pain if present.
● Document removal and patient's tolerance, report any
unexpected outcomes and interventions performed.
Conditions
RLE
to the end of the S-wave and multiply by
PERFORMING an
0.04 seconds.
ELECTROCARDIOGRAPHY
● The QRS complex duration is typically
0.06-0.12 seconds.
4. Identify the Rhythm: Determine if the rhythm is
An ECG (Electrocardiogram) machine is a medical device used regular or irregular.
to record the electrical activity of the heart. It consists of 10 5. Identify the Heart Rate:
ECG cables that produce a 12-lead trace. The ECG lead ● Two methods:
placement involves two main components: limb leads and ● 6-Second Method: Count the
precordial leads. number of QRS complexes in a
6-second strip and multiply by 10.
● Big Box Method: Divide 300 by the
The process of performing an ECG involves several steps:
number of big boxes between two
consecutive R-waves.
1. Check the order: Follow verbal or written instructions 6. Interpret the Strip: Draw conclusions based on the
for the ECG procedure. observed P-wave, PR interval, QRS complex, rhythm
2. Identify patient and obtain consent: Obtain patient regularity, and heart rate.
consent, implied consent in emergency cases.
3. Explain the procedure: Communicate the ECG
Overall, this method provides a structured approach to
procedure to the patient.
analyzing an ECG strip by focusing on key components like
4. Prepare equipment: Ensure the ECG machine and
P-wave, PR interval, QRS complex, rhythm, heart rate, and
cables are ready for use.
interpretation.
5. Hand hygiene: Maintain proper hand cleanliness
BASIC ELECTROCARDIOGRAM
before starting the procedure.
● Some hospitals has different equipment but we have
6. Privacy: Provide privacy for the patient during the
the same procedures that’s why we still need to be
procedure.
oriented when we go to the hospital (different buttons)
7. Clean skin surface: Clean the patient's skin with an
alcohol swab and trim hair if necessary.
Pre lectio:
8. Electrode placement: Attach electrodes to their
● In a 12 lead ECG, how many electrodes are you
designated positions on the patient's body.
going to prepare?
9. Start/Run the ECG machine: Begin the ECG
○ 10
recording process on the machine.
● Trace the cardiac conduction system
10. Refer ECG strip: Provide the recorded ECG strip to a
○ SA, VA,
physician for analysis.
● Trace the blood circulation
11. Aftercare: Once the procedure is done, remove
○ Deoxygenated blood → superior & infecrior
electrodes, clean the machine, wash hands, and
vena cava → right atrium → tricuspid valve
attach the ECG strip to the ECG sheet as required.
→ right ventricle → pulmonary valve →
pulmonary artery → lungs → oxygenated
The "6-Step Method of ECG Interpretation" blood → pulmonary veins → left atrium →
mitral/bicuspid valve → left ventricle → aortic
valve → aorta → body system
1. Identify and Examine the P-wave: The P-wave
should be present and upright.
2. Measure the PR Interval:
● Calculate the distance between the start of
the P-wave and the start of the QRS
complex (0.12-0.20 seconds or 3-5 small
boxes).
● Count the number of small boxes from the
beginning of the P-wave and multiply by 0.04
seconds.
3. Measure the QRS Complex:
● Similar to the PR interval, count the number
of small boxes from the start of the Q-wave
Conditions
RLE
● Bundle of HIS: Left & Right Bundle Branch
ECG
● Purkinje Fibers
● Process of recording the electrical activity of the heart
over a period of time using electrodes placed on the
skin.
● 10 electrodes
History:
● Willem Einthoven (1903)
○ A dutch and physiologist. He invented the
first practical electrocardiogram and received
the nobel prize in medicine in 1924 for it
○ Dati malaki until paliit ng paliit
Saan makita ang conduction system sa heart?

● NOW: Modern ECG machine has evolved into ● SA node: upper portion of the atrium, specifically right
compact electronic systems that often include atrium
computerized interpretation of the electrocardiogram ○ It would send impulse to AV
● AV node: delays conduction and send to bundle of
HIS going to purkinje fibers
Standard 12 lead ECG
● 3 Standard Limb Leads (Lead I, II, III)

● 3 Augmented Limb Leads (AVR, AVL, AVF)
● 6 Precordial Leads (V1, V2, V3, V4, V5, V6)
Why 12 lead but we only have 10 electrodes?
● ECG is a diagnostic examination so ang ginatest ni
ECG is ang angles so we are trying to identify the
cardiac activity in 12 angles (the most common one
kasi meron din 15-18 leads)
AN ECG IS USED TO MEASURE:

● Rate and Regularity (rhythm)
● Size and Position of Chambers
● Effect of Drugs and Devices (ex. Heart rate)
○ Ex of drugs: digoxin, beta blockers
○ Devices: pacemaker
● Any Damage of the Heart
CARDIAC CONDUCTION SYSTEM

● SA (sinoatrial) Node: Primary pacemaker 60-100 bpm
● AV (atrioventricular) Node: Delays impulse 40-60 bpm
○ Delays conduction that’s why lower ang ● If you slice the apple vertically, you are trying to check
heart rate compare to SA the vertical activity
Conditions
RLE
○ AVR, AVL, LEAD 1,2,3 AVF
● These are your:
○ Augmented Vector Right
○ Augmented Vector Left
○ Augmented Vector Foot
● If you slice the apple horizontally, we are checking the
precordial leads that include V1,V2,V3,V4,V5,V6
12- Lead ECG Placement
● Row: checks time

○ 1 big box = 5 small boxes
○ 1small box: 0.04 sec
○ 1 big box = 0.2sec
● height/column: voltage
○ 1small box = 1mm
○ 1big box = 5mm
● In order for you to identify an ECG tracing, you have

Limb Leads
to know the PQRST
Precordial lead
● Technique: before you go to V3, ilocate muna si V4 SOME TERMINOLOGIES:
because it is placed at 5th intercostal space at
midclavicular line (just below the nipple) ● Waveform: Movement away from the baseline
● Now balik na kay V3 because this will be placed in ○ Also known as isoelectric line (yang magstart
between you V2 and V4 pa og curve)
● Segment: Line between waveforms
● Interval: Waveform and segment
ECG Paper ● Complex: Consist of several waveforms. Maraming
waveforms
○ PQR complex
Conditions
RLE
○ PQRST complex
● SA node: fires, sending an impulse going to your AV

● Atrial depolarisation
○ This is atrial depolarization that is seen in
○ Depo: contraction
your P wave
● Atrial repolarization
● AV node: normally SA will go to AV node
○ Repo: relaxation
○ Delays that is seen in PR segment
○ Normally, meron but cannot be seen
● Ventricular depolarization: ventricles will contract and
because natatakpan ng ventricular
that is seen in QRS complex
repolarization kasi low magnitude lang.
○ QRS: ventricles
Nacoconceal ni ventricular repolarization
○ P wave: atrium
● Ventricular Repolarization:
○ Seen in T wave
● No electrical activity: isoelectric line
○ Minsan merong PQRSTU (in cases of your
hypovolemia
Standard 12 lead ECG
● P wave: atrial depolarization (contraction)

○ SA node fires
● QRS complex: activation of the ventricles through the
help of AV node (ventricular depolarization)
● T wave: recovery wave/relaxation (ventricular
repolarization)\
1. P wave
● Normal height: ≤ 0.2 mv (2mm)
○ 2 boxes
● Duration: <0.12 sec
○ Count small boxes then multiply to .04
Conditions
RLE
4. ST Segment and T wave

● Depression
2. PR interval ● Elevation
● Normal: 0.12 - 0.20 sec (3-5 small squares) ❖ Isoelectric line: basis if ST is depressed or elevated
SYSTEMATIC APPROACH IN ECG INTERPRETATION
● Initial Survey
○ Assessment of the pt
○ Bakit sya nandito
● Rhythm: Regular or Irregular
● Rate: Ventricular and Atrial Rate
● PR interval
● QRS complex
● ST elevation/ ST depression
● Conduction Abnormality
● Arrhythmia
● Interpretation
RHYTHM
● Check R-R
○ Watch for the distance/number of boxes
● Regular
3. QRS
● Normal: 0.12 sec.
● Wide QRS: greater than 0.12 sec ● Irregular
○ Ventricular tachycardia?
● Narrow QRS: less than 0.12 sec RATE
○ Supraventricular tachycardia ● To check HR
● Ventricular Rate: R-R interval

○ Ventricular depo: QRS
○ Look for R-R
● Atrial Rate: P-P interval
Conditions
RLE
○ Kailan nag cocontract si atrium? P wave ● P wave: upright & uniform; precedes each QRS
○ So if you want to check for your atrial rate, complex
check your p-p interval. First p wave up to ○ Seen before QRS
the next p wave ● PRI (PR interval): 0.12 - 0.20 sec; constant
● 1, 500 / small squares ● QRS: Narrow (≤0.10 sec); sometimes wide
○ For uniformity and based on actual practice, ● Interpretation: SINUS RHYTHM
this formula is more accurate compared to
300
○ Constant
○ If big boxes, you cannot clearly tell if
included pa ba ang other big box if half lang
ang nasulod ● Rhythm: regular (R-R)
● 300 / big boxes ● Rate: <60 bpm
● P wave: upright & uniform; precedes each QRS
complex
○ Seen before QRS
● PRI (PR interval): 0.12 - 0.20 sec; constant
● QRS: Narrow (≤0.10 sec); sometimes wide
Ex. ● Interpretation: SINUS BRADYCARDIA
● 300/6 = 50 bpm ● Is this harmful or not? NO
● 1500/30 = 50 bpm ● Ex of pts. athlete
○ Usually yung mga HR nila nasa 40
○ Their hearts have pumped enough blood.
Every time they work out, lumalakas ang
heart kaya meron silang cardiomegaly sa
x-ray
● Atrial Rate: indiscernible

○ If you are asked for atrial rate and the p
wave cannot be appreciated, write
indiscernible
○ Walang p wave ● Rhythm: regular (R-R)
○ Atrial flutter: looks like a saw tooth ● Rate: > 100 bpm ; <160 bpm
● Ventricular Rate:79 bpm ○ If beyond 150 is it still sinus tachycardia?
YES. as long as may p wave
○ If there is absence of p wave and the HR is
beyond 150 then that is SVT
(supraventricular tachycardia)
○ In the picture, that is still a p wave,
● Atrial Rate: indiscernible nakacompress lang
● Ventricular Rate: 188 bpm ● P wave: upright & uniform; precedes each QRS
○ Widened complex
○ Seen before QRS
● PRI (PR interval): 0.12 - 0.20 sec; constant
ANALYZING AN ECG STRIP
● QRS: Narrow (≤0.10 sec); sometimes wide
● Interpretation: SINUS TACHYCARDIA
Sinus: normal
● Rhythm: regular (R-R)
● Rate: 60-100 bpm SINUS ARRHYTHMIA
Conditions
RLE
● R-R sometimes lumalayo ■ HR: 60-100
● Kumpleto ang complex PQRST ○ AF in RVR (Rapid ventricular response)
● Irregular heart beat, either too fast or too slow ■ >100
● Danger of AF: pt is at risk to develop stroke
(thrombotic stroke)
ATRIAL ARRHYTHMIAS
○ It’s because of the chaotic impulses of the
❖ Problem is in the atrium which is also responsible for atrium that may lead to thrombus formation
firing (SA node) later on that may go to your circulation
● Atrial Flutter ○ Nursing goal: control the HR because hindi
● Atrial Fibrillation pwedeng mag RVR always si pt (prone to
● SVT stroke) that’s why meron silang mga meds
(metoprolol - beta blockers, cardiac
Atrial Flutter glycosides)
○ Be cautious on beta blockers. We have
cardio selective and non cardio selective
beta blockers. If pt has pulmo problem, the
meds that will be given to the pt is
cardiogenic beta blockers (bisoprolol).
Cardio selective beta blockers, affects B1
receptors (specifically acting on heart) while
noncardio selective beta blockers (walang
ginapili)– has action sa pulmo and heart (ex.
● Impulses travel in circular course in atria propanolol) it acts on B1 (heart) and B2
● Before the impulse go to AV node, ikot muna sya sa (lungs) if that happens, gipainom si pt ng non
atrium cardio selective with COPD, there will be
● Regular R-R thrombo constriction. Always cardioselective
if may problem sa pulmo
Atrial Fibrillation ● Upon auscultation, what would you hear sa pt na may
AF?
○ SR: 1-2-3-4-5-6-7-8-9-10
○ AF: 1-2-3-4,5,6-9-10-11-12,13,14
● Why check the Ventricular rate in AF?
● Baseline irregular, ventricular response irregular ○ How to check the rate if the pt is Afib? R-R is
not regular
○ Identify R-R na may shortest and longest
interval. Then HR will be in range (ex.
65-105 bpm) because it is an afib
● Impulses have chaotic, random pathways in atria
Supraventricular Tachycardia (SVT)
○ Nag fire ng impulse si atrial node, but meron
ding mga area sa site na naga fire din kaya
maraming impulses sa atrium
○ This is evident in your waves that is termed
as your fibrillatory waves (nanginginig si
heart)
○ No p wave
○ Atria ang problema so SA/P wave
● Irregular R-R
● Sinus arrhythmia vs AFib: SA is irregular, however
merong P wave
● AF has 3 types
○ AF in SVR (slow ventricular response)
■ HR: <60
○ AF in CVR (controlled ventricular response)
also known before as MVR (moderate)
Conditions
RLE
Ventricular Tachycardia
● Rhythm: regular
○ Regular R-R
○ Don't be confused with sinus tachy. ST -
merong p wave ; SVT - walang p wave
● Rate: >100
● P: not visible
● P-R: not defined ● Abnormal electrical signals in the ventricles (ang
● QRS: narrow complex problem is sa AV)
● We also have vtach impulse and pulseless vtach
● Atrial flutter: ikot muna sa atrium bago punta sa AV
○ If pulseless na ang pt, perform CPR
● SVT: ideally from SA node, magpalahi. Hahanap sya ○ The electrolyte expected to be given to pt is
ng ibang wave. Dadaan muna sa accessory pathway magnesium because it helps on relaxation.
bago magpunta sa AV that’s why we have rapid or On the other hand, potassium and calcium
increased rate for contraction
● Drug of choice: ace inhibitors (adenosine - 6mg per ● Rate: 100-250 bpm
ampule. Mejo mahal) ○ Imagine gaano kapagod ang heart
● No P wave
● Nursing responsibility: assist doctors to whatever ● Wide QRS
order he will give. Make sure when the pt is having an
SVT, make sure that we have a patent IV line with a
Types of VTach
large needle (brachial), either gauge 18 or 20. Site for
adenosine. Administer adenosine through IV push ● Sustained vtach
and flush it with 10-20mL of pnss and raise arm for ● Non-sustained vtach
faster absorption ● Monomorphic
○ Check the conversion, if di parin nachange ● polymorphic
into sinus rhythm then expect for another
dose of adenosine and the second dose will
be 12mg (2ampules) same manner of
administration. Ideally you would prepare 5-6
ampules. 6 mg (1st admin) 12mg (2nd dose)
another 12 for 3rd dose) ● Sustained: V tach more than 30 secs. requiring
○ If walang line ang pt then nahirapan na termination
huminga, so cardioversion - place paddle sa ○ Tuloy-tuloy ang vtach ni pt
chest ni pt then it’s the machine that will ○ Continuous electrical activity of the ventricle
identify when mag fire → ask how many and that should be stopped within 30
seconds or the patient will arrest
joules) → mag fire ang machine sa QRS.
ginaiwasan ng machine ang T wave
(ventricular repolarization - relaxation) if mag
fire dito, continuous fib na resulting to arrest
○ Meds to prepare for pt having SVT -
magnesium: recommended/indicated for
● Non-sustained: V tach less than 30 secs. not
relaxation (potassium and calcium is for requiring termination
contraction) ○ Not continuous
○ Normal, nag vtach kadali then normal naman
VENTRICULAR ARRHYTHMIAS
· Ventricular Tachycardia
· Ventricular Fibrillation
Conditions
RLE
Fine V Fib= <3mm
● Monomorphic
○ Uniform appearance ECTOPIC BEATS
● Extra heartbeats that occur just before a regular beat

○ Normal, normal, normal, extra heartbeat,
normal normal, …
● Polymorphic “Torsades de Pointes” (twisting of

points) Premature Atrial Contraction (PAC)
○ May mataas, may maiksi ● Tingnan ang R-R interval with P wave
● PAC has p wave pero mejo different ang appearance
ng p wave compared to other p wave. Parang
nacompress (nisingit lang sandali
Premature Ventricular Contraction (PVC)

● Nasingit lang talaga ang p wave
● Compared to PAC: Widened QRS
● Ex of “my heart skipped a beat” lol
● Without cardiac monitor, you wouldn’t know if it’s a
PAC or PVC unless the pt will have a lot of
manifestations then probably you will think that he has
PVC because often times, PVC won’t show a lot of
manifestations
Ventricular Fibrillation ○ Mostly asymptomatic kaya di madetect
● disorganized electrical impulse causing the ventricles ● PVC: comes from the ventricles meaning the
to quiver instead of pumping blood contractions of the muscle is not that effective. The
○ hindi na nag pupump ng blood cardiac output will be affected also
● Rate: rapid ● PVC has different appearances
● rapid unorganized rhythm ● Premature Ventricular Contraction (PVC) subtypes
● No identified P wave, QRS, T ○ Bigeminy, Trigeminy, Quadrigeminy,
● Types: Coarse V Fib & Fine V Fib Couplets, ventricular “Runs”
○ Tingnan ang height
● We also have shockable and non shockable p wave
● Shockable: pwedeng mag retrieve
○ Vfib: shockable/ defibrillate
● Nonshockable: hindi pwedeng mag retrieve
○ Pulses electrical activity (PEA), asystole is
nonshockable. Meaning the emergency tool
is to start CPR already kasi minsan sa PEA
gising pa ang pasyente Bigeminy
○ Even in ventricular and cardiac, gising pa ● Every other beat is aPVC
ang pt à dapat mag sedate kasi masakit ● Normal, PVC, normal, PVC, normal, PVC, …
masyado ● Sinus rhythm with PVC in bigeminy
Coarse V Fib= >3mm

Trigeminy
Conditions
RLE
● PVC every third beat
● Normal, normal, PVC, normal, normal, PVC, …
Fixed prolonged PR interval
Quadrigeminy
● PVC every fourth beat
● Normal, normal, normal, PVC, normal, normal,
normal, PVC, …
Second Degree AV Block (Type 1)

● 2nd Degree AV Block (Type 1) à WENKEBACH
Couplets ● The P-R interval successively widens until QRS fails
● Two consecutive PVCs (drops)
● Couple, magkatabi ● The ventricular rhythm is irregular
● Normal, normal, normal, PVC, PVC, normal, normal, ● The atrial rhythm is usually regular
normal, PVC, PVC, … ■ o Kasi ang affected is ang AV
(ventricles), atrium is not affectd
·
Ventricular “Runs”
● The same with non-sustained
● It could be 3 PVCs, 4 PVCs
● Pwedeng sinus rhythm with ventricular runs
● if 4 PVCs runs na Second Degree AV Block (Type 2)
● If PVC na lahat, then that is sustained ● Rhythm: regular (atrial) and irregular (ventricular)
● Rate: characterized by atrial rate usually faster than
ventricular rate (usually slow)
PULSELESS ELECTRICAL ACTIVITY (PEA) ● P wave: normal form, but more p waves that QRS
complexes
● Tracing can be seen pero pag check ng pulse, wala ● PR interval: Normal or prolonged
na ● QRS: Normal or wide
● The absence of a palpable pulse with a presence of
an organized electrical activity on the cardiac monitor.
● Treatment: CPR
CONDUCTION ABNORMALITIES Constant PR interval, with dropped QRS
● First Degree AV Block

● 2nd Degree (type 1&2)
● 3rd Degree
Third Degree AV Block

● A-V block, third degree
● Impulses originate at AV-node and proceed to
First degree AV block ventricles
· Ang problem is si conduction mismo ● Atrial and ventricular activities are not synchronous.
· May blockage kay AV node ● P-P interval normal and constant
· A-V block, first degree ○ However marami syang p wave
o Atrioventricular conduction lengthened. ● QRS complexes normal, rate constant, 20-55/min
o P wave precedes each QRS-complex but ● If the pt has 2nd or 3rd degree AV block, the HR is slow
the interval is > 0.2sec (normal PR and the pt is advised for pace maker
interval is .12- .20)
o If you look at it, pra lang normal sinus
rhythm but when you count the PR
interval, it’s beyond .2
Conditions
RLE
● Nakatago ang p wave sa QRS
PACEMAKER BEATS
● Pacemaker only do 2 things:

JUNCTIONAL RHYTHMS ○ Pacing: The pacemaker paces the heart in
case the heart’s own rhythm is interrupted,
● Abnormal heart rhythm resulting from impulses irregular, or too slow
coming from the area of the AV node, the “junction” ■ 2nd-3rd degree advised to have
between atria and ventricles. pacemaker
● Junction: gitna ng dalawang area ■ if masyadong mabagal ang HR:
mag spike si pacemaker
○ Sensing: The pacemaker monitors the
heart’s natural electrical activity. If a
pacemaker senses a natural heartbeat, it will
not stimulate the heart
■ If nasense ni pacemaker na
merong na merong natural HR si
pt, then di sya mag stimulate kay
heart
● Impulses originate at AV node with retrograde and
antegrade direction PACEMAKER BEATS
○ Pwede syang papunta sa atria or sa ventricle
● Rhythm: Regular Red arrows are referring to pacing spikes

● Rate: 40-66 bpm (impulse originates from AV junction)
● P waves: consistently either inverted before QRS,
hidden in QRS complex (meaning absent), or inverted
and after the QRS complex
● PRI: usually < 0.12 sec but may be 0.12 – 0.20 sec; if
p wave is late or not visible there will be no PRI
● QRS: Narrow (<0.12 sec); sometimes wide
Straight line: ito ang spike, meaning pacemaker ang
gumagana dito
TYPES OF JUNCTIONAL RHYTHMS
● Same: rhythm, tachy, brady
● Junctional Escape Rhythm

● HR: 40-60 bpm
● Absent p wave
● Dual-Chamber Pacing
● Dual: merong pacemaker sa atrium, meron din sa
ventricle
● · Accelerated Junctional Rhythm ● You can identify kung saan nakalagay. Either sa
● · HR: 60-100 bpm atrium or ventricle
● · Inverted p wave
● Junctional Tachycardia
● HR: above 100 bpm ● Single chamber
Conditions
RLE
○ Kug ang spike ni pacemaker is before your p
wave then it is located in your atrium
○ If the spire is in the QRS then nasa ventricle
sya
PACEMAKER BEATS
May times na nagloloko rin (machine lang)
● FAILURE TO PACE ● ST-Segment elevation and Depression
● FAILURE TO CAPTURE ● To be considered a significant elevation or depression
● UNDERSENSING the ST must deviate at least 1 mm above or below the
● OVERSENSING baseline (in at least 2 or more correlating leads
○ 2 boxes
FAILURE TO PACE
● Failure to Pace: Pacemaker does not generate an
electrical impulse. On an ECG tracing, pacemaker
spikes will be missing WALLS OF THE HEART
● Sa ECG strip, walang makita na spike
·
FAILURE TO CAPTURE
● Failure to Capture: The ventricles fail to respond to
the pacemaker impulse. On an ECG tracing, the
pacemaker spike will appear, but it will not be followed
by a QRS complex
● · Si heart naman ang hindi nag function. May
spike but hindi nasundan ng QRS. Normally after
spike, may QRS ● Lateral: lead I and aVL
● Lateral: V5, V6
● Anterior V3, V4
● Septal V1, V2
● Inferior II, III, aVF
● Para malaman kung anong area ang affected, ex. The
pt is diagnosed with CAD. Dapat merong karugtong
UNDERSENSING kung anong artery ang blocked
● Failure to Sense/Undersensing: When the pacemaker
fails to detect inherent cardiac beats. This can often
be seen on an ECG tracing as a spike following a
QRS complex too early
○ Hindi nasense na may normal heart rhythm
si pt so nag spike sya.
○ Nauuna ang spike following your QRS
OVERSENSING
● Oversensing: Pacing does not occur when intrinsic
rhythm is inadequate.
● Nagkahiyaan sila. Hindi nag spike si pacemaker, hindi
rin nag beat si heart
● Makita sa ECG anong artery ang blocked
● RCA: Right Carotid artery
ST ELEVATION/ ST DEPRESSION ● PDA: posterior descending artery
● OM: obtuse marginal
● LCX
● LAD
Conditions
RLE
● Left Main Coronary
● Diagonal branch
● Familiarize the arteries. Sa diagnosis, naka specify
anong artery ang may blockage
● Tingnan ngayon, saan merong depression or

elevation
● I: normal
● Sa MI kasi, nagpapalakas a si heart. Anong part ang ● II: elevated
merong blockage ● III: elevated
● Anterior: occlusion of proximal anterior left ● aVR: normal
descending artery so merong occlusion dito ● aVL: normal
● Left circumflex: paikot ● aVF: slightly elevated
● Paano ito ngayon nakikita sa 12 leads ECG? ● Anterior descending artery: normal
● The rest normal
If infero lateral wall: inferior and lateral wall
- Just look at the leads
CPR: SIR IAN (1:03:33)
● This is the 12 leads ECG

● In inferior wall, it infarcts II,III and aVF
● For Anteroseptal wall: that’s V1,V2,V3,V4
● Lateral wall: I,aVL,V5,V6
● All of these are seen in tracing. Ito ang mag appear
sa chart ni pt
Conditions
RLE
IV THERAPY
Equipment:
● Non-sterile gloves
● Tourniquet
● Antiseptic wipes
● 5-ml syringe
● Sterile gauze
● Cannula
● Saline
● Adhesive plaster
Start with distal veins and work proximally. Start choosing

from the lowest veins first then work upward. Starting at the
most proximal point can potentially lose several sites you could
have below it.
Conditions
RLE
Use a vein locator. Locating veins in infants or small children
can be challenging. Tools like transilluminator lights and pocket
ultrasound machines help visualize vein pathways, guiding
catheter insertion. Be cautious of skin burns; minimize contact
time.
Flow where you want to go. When disinfecting the site, rub
the alcohol pad in the direction of venous flow to enhance vein Don’t go all in. Recognize when to stop catheter
filling by moving blood past valves. advancement: upon vein entry and blood flash, cease and
reduce angle. Excessive advancement risks vein puncture.
Conditions
RLE
Calculating Drip Rates

● Drop Factor: Number of drops in one milliliter of
solution.
● Microdrip: For small or precise infusions; 60 gtts/mL
● Macrodrip: For quick or large infusions; 10-20
gtts/mL
Stress tape to prevent accidental yanking.Apply minimal

stress tapings (1-2) to prevent direct IV pull when tubing snags.
Avoid taping excessive loops that reduce tubing length. Skip
taping near flexing joints as it's easily removed. Don't wrap
tubing around digits; clenching can disrupt flow. Use a short
loop double-back for secure taping.
Quick tip: When IV tubing is microdrip (60 gtts/mL), the drops

per minute will be the same as the mL per hour!
IV Tubing & Changing IV Fluids and Tubing
For older patients and pediatric patients. Pediatric veins are

tiny and fragile. Choose smaller gauges for flow. Opt for
suitable hand insertion, mindful of patient movement
tendencies. Stabilization is vital.
Conditions
RLE
Conditions
RLE
● Observe IV tubing and venous access device for
PREPARING AN INFUSION SITE SAFETY
patency.
● Evaluate patient's fluid and electrolyte imbalance risk,
Regulating an Intravenous Infusion considering fluid type and medical history, especially
for neonates.
● Follow the Ten Rights of Medication Administration for

IV fluids. PROCEDURE:
● Note that patient position, IV site movement, and
device occlusion impact infusion rates.
● Be mindful of factors like vasospasm, venous trauma,
and manipulation affecting infusion rates. ● Verify the health care provider's orders.
● Regularly assess the IV system and flow rate as per ● Gather the necessary equipment and supplies.
agency policy for optimal outcomes. ● Perform hand hygiene.
● Consider using volume-control devices to prevent ● Provide for the patient's privacy
inadvertent fluid boluses in vulnerable patients. ● Introduce yourself to the patient and family if present.
● Check MAR for IV fluid and prescribed rate at the
Equipment: bedside.
● Confirm the patient's identity with two identifiers and
● Watch with second hand compare with records and bracelet.
● Calculator ● Prepare for gravity-based IV regulation with paper,
● Paper and pencil pen, or calculator.
● Label for IV Solution ● Identify drop factor (microdrip or macrodrip) to
● IV administration set (tubing with drip chamber) determine infusion calibration.
● IV fluids ● Calculate hourly volume (mL/hr = Total infusion /
Hours) to derive flow rate.
Delegation: ● Determine drops per minute (gtt/min = Hourly volume
x drop factor / 60).
● The skill of regulating IV flow rate may not be ● Adjust roller clamp to modify flow rate; verify accuracy
delegated to nursing assistive personnel (NAP). by counting drops.
Delegation to licensed practical nurses (LPNs) ● Advise patients not to touch clamps or raise hands to
varies according to each state’s nurse practice maintain flow rate.
act. Be sure to inform NAP of the following: ● Arrange patients comfortably with accessible items
and call light.
○ Instruct NAP to inform you when less than ● Raise side rails, lower bed, ensure patient's safety.
100 mL remains in the fluid container. ● Dispose of supplies, tidy room, perform hand hygiene.
○ Instruct NAP to report any patient complaints ● Document IV details, flow rate, and IV site
regarding the intravenous infusion, including appearance.
pain, burning, bleeding, or swelling at the
insertion site.
Follow-Up:
Preparation:
● Monitor IV infusion hourly, noting volume and rate.
● Review and verify orders: Check patient's details, ● Watch for signs of electrolyte imbalance and fluid
solution specifics, infusion rate, and therapy duration. issues.
● Follow the Ten Rights of Medication Administration. ● Assess for IV-related complications like infiltration and
● Note common use of abbreviated IV orders such as phlebitis.
“D5W with 20 mEq KCl/L 125 mL/hr continuous.” ● Report flow rate and remaining fluid to the next nurse
● Check infusion set label for drop factor. during shift change or breaks.
● Assess patient's understanding of IV site's flow rate
impact. Documentation:
● Perform hand hygiene. Monitor IV site for infiltration or
phlebitis signs. ● Document infusion rate as per agency policy.
● Note IV insertion site appearance according to policy.
Conditions
RLE
● Note date and time of last IV tubing and solution
Changing Intravenous Tubing and Fluids
change.
● Assess tubing for punctures, contamination, or
Safety occlusion needing immediate change.
● Check IV solution for integrity, including discoloration,
● Follow the Six Rights of Medication Administration. cloudiness, leakage, and expiration date.
● Replace fluid container within 24 hours after adding ● Verify compatibility of IV fluids and additives using
medication or set, as per INS recommendation. online databases, references, or pharmacist.
● Maintain sterility during tubing and solution changes ● Assess VAD site for patency, noting complications like
to prevent bacteria entry. redness and swelling.
● Replace tubing if it leaks, gets damaged, or ● Review relevant lab data, such as potassium levels.
contaminated, irrespective of change schedule.
● Use Luer Lok connections to prevent accidental
Procedure
disconnection.
Equipment a. Confirm patient's identity using two identifiers, like

name and birth date or name and account number.
b. Inform and prepare the patient about the procedure's
● Clean gloves
purpose and expectations.
● Alcohol wipes
c. Coordinate tubing and solution changes whenever
● Macro drip administration set infusion tubing &
possible.
Adapter tubing with injection cap
d. Unpack new infusion set, connect add-ons, and
● Tubing label
secure connections.
● 3-mL to 5-mL syringe normal saline
e. Put on clean gloves. If needed, remove dressing but
● IV solution to be administered
not cannula tape.
● Tape
f. Hang solution bag on IV pole.
g. Prepare infusion tubing with ongoing IV bag.
Delegation ❖ Move new IV tubing's roller clamp to "off"
position.
❖ Decrease old tubing's infusion rate to KVO
● The skills of changing infusion tubing and IV
rate using EID or roller clamp.
solution may not be delegated to nursing
❖ Fill 1/3 or 1/2 of old tubing's drip chamber,
assistive personnel (NAP). Delegation to licensed
per manufacturer.
practical nurses (LPs) varies according to each
❖ Invert container, remove old tubing, keeping
state's Nurse Practice Act. Be sure to inform NAP
spike sterile.
to report any of the following.
❖ Insert new tubing's spike into solution
container, hang on IV pole.
○ If the tubing becomes disconnected or is
❖ Fill new tubing's drip chamber one-third to
lying on the floorWhen less than 100 mL
one-half full.
remains in the the IV container
❖ Gradually open roller clamp, prime new
○ Leakage from or around the IV tubing
tubing, place near IV site.
○ Cloudiness or precipitate in the IV solution
❖ If using EID, pause pump, turn roller clamp
○ If the alarm sounds on the electronic infusion
off, remove old tubing from EID channel.
device (EID)
❖ Place primed new tubing in pump regulator
○ Patient complaints of pain or discomfort at
chamber, insert into channel.
the IV site
h. To prepare tubing with an extension set or a saline
lock:
Preparation ❖ If using short extension tubing, connect new
cap with sterile technique.
❖ Swab cap with antiseptic, inject 3-5 mL
● Confirm accuracy of health care orders in medical saline through cap into extension.
record, checking patient details, solution, volume, i. Reestablish the infusion
additives, flow rate, and duration. ❖ Disconnect old tubing, insert new tubing's
adapter quickly.
Conditions
RLE
❖ For continuous infusion, open new tubing's ● Observe the patient for signs of fluid volume
roller clamp, regulate drip rate. If EID used, deficit (FVD) or fluid volume excess (FVE). Ontior
restart pump. Check the entire IV system for patency, starting
❖ Attach tape or label with change date and with the hanging solution bag and working all the
time below drip chamber. way down the system to the patient's IV access
j. Form a loop of tubing and secure it to the patient's site.
arm with a strip of tape.
k. Remove and discard the old IV tubing. If necessary, ● Assess the patient for signs of IV-related
apply a new dressing at the IV site. Remove and complications.
dispose of your used gloves. Perform hand hygiene.
● Palpate the skin above the insertion site, noting
7. To change the intravenous solution: its temperature and assessing for edema,
tenderness, and redness.
a. Gather required equipment.
b. Verify patient's identity with two identifiers. Documentation
c. Prepare the next solution in advance,
ensuring proper labeling and expiration date.
d. Inform patient and caregiver about the need ● Record the tubing change, type of solution,
for new IV fluids. volume, and rate of infusion on the patient's MAR
e. Perform hand hygiene. according to your agency's policy. Use a special
f. Change solution when remaining fluid is IV therapy flowsheet for parenteral fluids if
about 50 mL or when new solution is required.
ordered.
g. Hang new solution bag, remove protective
cover from tubing port.
h. Stop flow using roller clamp (gravity) or
"Pause" button (EID).
i. Remove old fluid container, insert spike into
new container.
j. Hang new container, remove air bubbles
from tubing.
k. Fill drip chamber one-third to one-half full.
l. Regulate flow using roller clamp (gravity) or
"Start" button (EID). Reprogram if needed.
m. Place time label on bag, note hanging and
completion times..
8. Assist patient into comfortable position, place items

within reach.
9. Put call button nearby, ensure patient knows how to
use it.
10. Raise appropriate side rails, lower bed for safety.
11. Dispose of supplies, leave room tidy.
12. Perform hand hygiene.
13. Document new IV solution details in MAR.
Follow-Up
● Evaluate the flow rate hourly and observe the

connection site for leakage.
Conditions
RLE
Troubleshooting Intravenous Infusions PREPARATION:
SAFETY: ● Evaluate the patient’s current health status.
● Observe the Ten Rights of Medication ● Determine the expected response to IV therapy.
Administration.
● Review the signs and symptoms of potential
● Monitor the infusion for patency every 1 to 2 complications of IV therapy.
hours or according to agency policy.
● Ask the patient if he or she has any discomfort at
● Check the infusion rate carefully to avoid an the IV site.
infusion that is too rapid or too slow.
● Instruct the patient to position his or her arm to PROCEDURE:

maintain the flow of solution. If arm positioning
alters the flow rate consistently, plan to restart the ● Review health care orders.
IV. ● Gather needed equipment.
● Introduce yourself and verify patient's identity.
● Wear gloves because of the risk of contact with ● Assess patient's comfort and expected IV therapy
infectious microorganisms. response.
● Monitor vital signs, fluid status, intake, and output
every 8 hours or as per policy.
EQUIPMENT:
● Observe patient's IV infusion every 1-2 hours.
● Review infusion pump record for correct solution
● Blood pressure cuff amount.
● If volume infused is less, check flow rate or drip count.
● Stethoscope ● If pump alarms for occlusion, check tubing for kinks.
● Ensure tubing is patent and assess IV device for
● Towel and pillow leakage.
● Bleeding may be caused by:
● Clean gloves
○ Disconnection of the tubing from the IV device
● Washcloth (optional)
○ A bleeding disorder
DELEGATION:
○ Anticoagulant therapy
● The skill of troubleshooting intravenous infusions
may not be delegated to nursing assistive ● Check dressing for dryness and integrity. Examine
personnel (NAP). Before delegating related skills, site for color, swelling, and drainage.
be sure to inform NAP of the following: ● Palpate around the site, note skin temperature.
● Watch for phlebitis or infiltration. If signs, assess
○ Instruct NAP to inform you if the patient severity with scale
reports burning, bleeding, swelling, or ○ Zero means no symptoms.
coolness at the IV insertion site. ○ Severity goes up to four: pain, redness,
swelling, streaking, palpable cord over 1
○ Instruct NAP to notify you if the patient’s inch, purulent drainage.
dressing becomes wet. ● Act accordingly. For phlebitis or infiltration, stop
infusion and discontinue IV, as in “Discontinuing
○ Discuss the need to inform you if the Intravenous Therapy” video. If ordered, insert new IV.
volume of solution in the IV bag Follow agency policy: elevate extremity, use warm
becomes low or if the infusion pump compress if needed.
alarm sounds. ● Assist patient, arrange items.
● Position call light, ensure patient knows how to use it.
Conditions
RLE
● Raise side rails, lower bed for safety.
● Dispose of supplies, leave tidy room.
● Remove, dispose of gloves; perform hand hygiene.
● Document, report complications, note actions, patient
response.
DOCUMENTATION:
● Record your assessment findings. Use scoring criteria

for phlebitis.
● Document your interventions related to IV infusion
problems.
● Record the patient’s response to your interventions.
● Document any complications and your corrective
actions.
Conditions
RLE
Discontinuing Intravenous Therapy Procedure
Safety: ● Verify the health care provider’s orders.

● Gather the necessary equipment and supplies.
● Follow infection prevention guidelines. ● Perform hand hygiene.
● Be careful not to break catheter during removal, ● Provide for the patient’s privacy.
preventing embolus. ● Introduce yourself to the patient and family, if present.
● Avoid scissors for tape removal to prevent catheter ● Identify patient with two identifiers, match to MAR or
damage. bracelet, or ask patient.
● Don't lift catheter before complete removal to prevent ● Explain procedure, instruct stillness.
trauma and hematoma. ● Turn off IV tubing clamp or EID and clamp.
● Perform hand hygiene, wear clean gloves.
● Carefully remove site dressing, stabilize device,
untape extension set.
Equipment ● Put sterile gauze above site, remove catheter slowly
parallel to skin.
● Apply pressure for 30 seconds or more if on
● Clean gloves
anticoagulants.
● Sterile 2 × 2–inch or 4 × 4–inch gauze sponge
● Inspect catheter post-removal for integrity.
● Antiseptic swab
● Watch for bleeding, pain, exudate, swelling.
● Tape
● Apply sterile gauze dressing, secure with tape.
● Dispose of catheter in sharps container.
Delegation ● Dispose of supplies, remove gloves, hand hygiene.
● Assist patient, place items in reach.
● Position call light, ensure patient knows its use.
● The skill of discontinuing a short peripheral
● Ensure safety: raise rails, lower bed, tidy room.
intravenous line may not be delegated to nursing
● Document and report patient response and outcomes.
assistive personnel (NAP). Delegation to licensed
practical nurses (LPNs) varies by state Nurse
Practice Act. Be sure to inform NAP of the Follow-Up:
following:
● Observe the site for evidence of any

○ Instruct NAP to report bleeding
complications, such as bleeding, pain, exudate,
post-catheter removal and patient
and swelling.
pain/redness.
Table
Preparation:
● Observe the existing IV site for signs and Category Category Category Category
symptoms of IV- related complications, such as 1 2 3 3
pain, infiltration, phlebitis, and exudate.
● Assess if the patient is receiving an anticoagulant

or has a history of a coagulopathy. Item 1 4.5 2.3 1.7 5
● Review the accuracy and completeness of the

health care provider’s orders to discontinue IV
therapy. Item 2 3.2 5.1 4.4 3
● Assess the patient’s understanding of the need to

discontinue the IV.
Conditions
RLE
Item 3 2.1 1.7 2.5 2.8
Item 4 4.5 2.2 1.7 7
DOCUMENTATION:
● Document the procedure in the patient’s medical

record.
Conditions
RLE
ENDOTRACHEAL INTUBATION
Often an emergency procedure that’s performed on people

who are unconscious or who can’t breathe on their own. It
maintains an open airway and helps prevent suffocation.
Indication for Intubation
● Respiratory Failure: conditions that makes it difficult
for the patient to breathe on his own causing
hypoxemia and hypercapnia.
● Heart Failure: a long-term condition in which your

heart can’t pump blood well enough to meet your
body’s needs all the time.
● Apnea
● Decreased LOC (based on GCS less than or equal
to 8)
● Rapid change of sensorium or mental status
● Injuries to neck, abdomen or chest

● Airway injury or trauma
● High risk of aspiration
● MULTIPLE ORGAN FAILURE(MOF) is a severe,
life-threatening condition that usually occurs as a
result of major trauma, burns, or fulminant
infections.
Nurse’s Responsibilities
● Ensure that the required oxygen support indicated for
the patient is provided.
● Monitor respiratory status every 2 hours or as
frequently as needed. Note the lung sounds and
presence of secretions
● Monitor presence and level of humidifier
● Suction secretions as needed. Monitor the type of
secretions suctioned
● Secure ET using tape or ET holder to prevent
deviation of tube in trachea.
Conditions
RLE
● Ensure ET placement by noting the lip line marking
and compare to the desired placement
● Reposition the patient every 2 hours for lung
expansion and prevent secretion stagnation
● Closely monitor cuff pressure, maintaining a pressure
of 20 to 25 mmHg to minimize the risk of tracheal
necrosis
● Provide oral care every 4 hours. A mouth guard can
be used.
● Avoid oral feeding
Nurse’s Responsibilities
● Facial Swelling
● Sore Throat
● Chest Pain
● Difficulty Swallowing and Speaking
● Neck pain
● Shortness of breath
Conditions
RLE
● Ventilator settings are ordered by the physician and
MECHANICAL VENTILATION MANAGEMENT
are individualized for each patient. Ventilators are
● To ensure a patent airway through which effective designed to monitor many components of the patient’s
ventilation can take place. respiratory status. Various alarms and parameters can
● An obstructed airway causes the body to be deprived be set to warn healthcare providers that the patient is
of oxygen and, if ventilation isn’t reestablished, having difficulty with the settings.
causes brain death within minutes.
Indications
● Respiratory failure or arrest
● Respiratory distress with impaired gas exchange
● Hypercapnia and hypoxemia
Role of the Nurses
● Monitoring the patient’s respiratory status.
○ Breathing effort
○ Oxygen saturation
○ Breath sounds
● Keep an eye on any equipment required by the
patient, including ventilators and monitoring
equipment, and to respond to monitor alarms.
● Notifying the respiratory therapist when mechanical
problems occur with the ventilator, and when there
are new physician orders that call for changes in the
settings or the alarm parameters
● The nurse is responsible for documenting frequent
respiratory assessments
Ventilators
There are two general kinds of ventilators:
● VOLUME CYCLED VENTILATOR: Tidal volume is
set and airway pressure is measured
● PRESSURE CONTROLLED VENTILATOR: Pressure
is set and volume is measured
Operation and Maintenance
● Many ventilators are now computerized and have a
user-friendly control panel.
● To activate various modes, settings, and alarms, the
appropriate key need only be pressed.
● Ventilators are electrical equipment and must be
plugged in.
● BMV should be present at bed side at all times for
patients on mechanical ventilator
● When mechanical ventilation is initiated, the ventilator
goes through a self-test to ensure that it’s working Respiratory Rate (RR)
properly. ● The respiratory rate is the number of breaths that the
● The ventilator tubing should be changed every 24 ventilator delivers to the patient each minute
hours and another self-test run afterwards. ● The rate chosen depends on the tidal volume, the
● The bacteria filters should be checked for occlusions type of pulmonary pathology, and the patient’s target
or tears and the water traps PaCO2.
Ventilator Settings Tidal Volume (TV)
● The tidal volume is the volume of gas the ventilator
delivers to the patient with each breath.
Conditions
RLE
● The usual setting is 5-15 cc/kg, based on compliance, ● CV delivers the preset volume or pressure regardless
● resistance, and type of pathology. of the patient’s own inspiratory efforts. This mode is
used for patients who are unable to initiate a breath.
Fractional Inspired Oxygen (FIO2)
● It is indicated in patients with severe neurological
● The fractional inspired oxygen is the amount of alterations, deep sedation, shock or severe
oxygen delivered to the patient respiratory failure
● It can range from 21% (room air) to 100%.
● It’s recommended that the FIO2 be set at 1.0 (100%) Assist-Control Ventilation (A/C)
upon the initiation of mechanical ventilation. ● A/C delivers the preset volume or pressure in
● Most ventilators have a temporary 100% oxygen response to the patient’s own inspiratory effort, but
setting that delivers 100% oxygen for only a few will initiate the breath if the patient does not do so
breaths. This should always be used prior to and after within the set amount of time.
suctioning; during bronchoscopy, chest ● This mode is used for patients who can initiate a
physio-therapy, or other stressful procedures; and breath but who have weakened respiratory muscles.
during patient transport. ● Any inspiratory attempt by the patient triggers a
ventilator breath.
Inspiratory: Expiratory (I:E) Ratio
● The patient may need to be sedated to limit the
● The I:E ratio is usually set at 1:2 or 1:1.5 to number of spontaneous breaths since
approximate the normal physiology of inspiration and hyperventilation can occur.
expiration
Synchronous Intermittent Mandatory Ventilation (SIMV)
Pressure Limit
● Developed as a result of the problem of high
● The pressure limit regulates the amount of pressure respiratory rates associated with A/C and is used as a
the volume-cycled ventilator can generate to deliver primary mode of ventilation, as well as a weaning
the preset tidal volume mode.
● Because high pressures can cause lung injury, it’s ● SIMV delivers the preset volume or pressure and rate
recommended that the plateau pressure not exceed while allowing the patient to breathe spontaneously in
35 cm H20. between ventilator breaths.
● Causes: obstructed airway due to mucus, coughing, ● The disadvantage of this mode is that it may increase
biting on the ETT, breathing against the ventilator or the work of breathing and respiratory muscle fatigue.
kinked ventilator tubings
● The high pressure is usually resolved with suctioning Pressure Support Ventilation (PSV)
● PSV is preset pressure that augments the patient’s
spontaneous inspiratory effort and decreases the
work of breathing
● The patient completely controls the respiratory rate
and tidal volume.
● PSV is used for patients with a stable respiratory
status and is often used with SIMV to overcome the
resistance of breathing through ventilator circuits and
tubing.
Positive End Expiratory Pressure (PEEP)
● PEEP is positive pressure that is applied by the
ventilator at the end of expiration.
● This mode does not deliver breaths, but is used as an
adjunct to CV, A/C, and SIMV to improve oxygenation
by opening collapsed alveoli at the end of expiration
Ventilator Modes
● This mode does not deliver breaths, but is used as an
● Mode refers to how the machine will ventilate the adjunct to CV, A/C, and SIMV to improve oxygenation
patient in relation to the patient’s own respiratory by opening collapsed alveoli at the end of expiration
efforts.
Constant Positive Airway Pressure (CPAP)
Control Ventilation (CV)
● CPAP is similar to PEEP except that it works only for
patients who are breathing spontaneously.
Conditions
RLE
● The effect of both is comparable to inflating a balloon
and not letting it completely deflate before inflating it
again.
● CPAP can also be administered using a mask and
CPAP machine for patients who do not require
mechanical ventilation, but who need respiratory
support
Methods of Weaning
● T-piece/CPAP trials
● SIMV
● Pressure Support
Extubation
● The nurse should obtain the ABG prior to the weaning
● Once the physician’s order to extubate is received,
the nurse and RT coordinate a time when they can
Alarms and Common Causes both be in the patient’s room.
● The RT is usually responsible for assembling the
oxygen delivery system to be used after extubation.
● The nurse should explain the procedure to the patient
and prepare suction. The patient should be sitting up
at least 45 degrees. Prior to extubating, the patient
should be suctioned both via the ETT and orally.
● All fasteners holding the ETT should be loosened.
● The patient should be asked to cough and speak.
Quite often, the patient’s first request is for water
because of a dry, sore throat. Generally, you can
immediately swab the patient’s mouth with an oral
swab dipped in water
Post- Extubation Care
● Humidified oxygen
● Respiratory exercises
● Assessment and monitoring
● Prepare for re-intubation if extubation is not tolerated
Weaning & Extubation

● It is usually a gradual process.
● Accomplished by decreasing the number of breaths
supplied by the ventilator
● Should not be attempted until the patient’s respiratory
status is stable
● Allow the patient to initiate more breaths while the
ventilator provides less.
Conditions
RLE
Foot Assessment Procedure
Foot Assessment Form 1. Introduction

2. Observation and assessment of gait
● Patient Information: 3. Observation and assessment of gait - tiptoes and
● Ask for a medical history of: heels
○ DM: If yes specify the diagnosis if Type 1 or 4. Inspection of the ankles and feet
Type 2. 5. Assessment of ankle joint temperature
● Hypertension: Year Diagnosed 6. Palpation of dorsalis pedis pulse
● Osteoarthritis 7. Palpation of posterior tibial pulse
8. Palpation of Achilles tendon
● If with history of smoking, specify since when the 9. Palpation of joints and bones in the foot
patient started smoking and when he/she quit 10. Assessment of active movement of ankle and foot
smoking. 11. Assessment of passive movement of ankle and foot
● Ask for the any present medications: Include dosage, 12. Simmonds' test - Achilles tendon rupture
frequency and timing of medications. 13. Summary of findings and further investigations
● Ask the patient for the status of mobility:
● If the patient can walk more than 200m (>2 blocks) Ankle Brachial Index Test
● If the patient can walk 100-200m (>1block) ● The ankle brachial index, or ABI, is a simple test that
● • <10m compares the blood pressure in the upper and lower
● If the patient cannot walk >200m, specify or ask for a limbs.
cause. ● Health care providers calculate ABI by dividing the
● Ask if the patient has shortness of breath, and assess blood pressure in an artery of the ankle by the blood
respiratory rate pressure in an artery of the arm. The result is the ABI.
● Assess for pain in the lower extremity If this ratio is less than 0.9, it may mean that a person
has peripheral artery disease (PAD) in the blood
vessels in his or her legs.
Procedure
1. Lie flat for the procedure.

2. Place cuff above ankle.
3. Ultrasound probe listens to blood flow.
4. The technician inflates the cuff until blood flow stops.
5. Note systolic pressure upon cuff release.
6. Repeat process on other ankle and arms.
7. Calculate ABI using ankle and arm pressures.
MONOFILAMENT TEST
● Monofilament testing is a cost-effective, portable

method to assess loss of protective sensation.
Recommended for detecting peripheral neuropathy, it
employs calibrated nylon threads (Semmes-Weinstein
monofilaments) with values from 1.65 to 6.65 to
generate reproducible buckling stress.
How to do it?
• Demo by touching monofilament to the patient's arm/hand.

• Patient says "yes" feeling monofilament pressure on foot.
Conditions
RLE
• Keep feet neutral, toes pointing straight up.
Interpretation of Values
● Abnormally low ABI = 0.9mm Hg Below

● Borderline = 0.9mm Hg -1.00 mmHg
● Normal ABI = 1-1.40 mmHg
● Abnormally high = 1.40mm Hg and above
• Note: If ABI cannot be taken in either leg, specify the cause
Areas to test:
● Use the filament and test the 10 areas of the foot
1. Plantar Surface Distal Halux

2. Plantar Surface 3rd toe
3. Plantar Surface Terminal Phalynx
4. 1st, 3rd and 5th Plantar Proximal metatarsal
head
5. Medial and lateral plantar area (midfoot)
6. Calcaneous area
7. Interphalyngeal Joint (1" metatarsal)

RLE NCM 4165 - Nursing Care of Clients With Life Threatening Conditions

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RLE NCM 4165 - Nursing Care of Clients With Life Threatening Conditions

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NCM 4164 | Nursing Care of Clients with Life Threatening

ABG Studies Aid in Assessing

ABG Studies Aid in Assessing

ABG Studies Aid in Assessing

ABG Normal Values

CARDIAC ARREST ALGORITHM

● Cardioversion aims to restore normal rhythm from an

Nurse’s Roles During Code Blue:

Medications Used During a Code:

● Ventricular Fibrillation/Tachycardia: Epinephrine,

Dos and Don'ts During a Code:

● High-Quality CPR: Starting compressions within 10

Indications for Tracheostomy: 1. Suctioning: Frequent suctioning of secretions through

Types of Tracheostomy: Once a patient's condition improves, attempts at decannulation

Performing Oropharyngeal Suctioning:

1. Patient positioning with an extended neck.

● Assess risk factors for airway obstruction.

1. Gather equipment and supplies.

Classification: Safety and Monitoring:

Removing a Feeding Tube:

Safety and Preparation:

● A healthcare provider's order is necessary to remove

Saan makita ang conduction system sa heart?

Standard 12 lead ECG

● 3 Standard Limb Leads (Lead I, II, III)

AN ECG IS USED TO MEASURE:

CARDIAC CONDUCTION SYSTEM

12- Lead ECG Placement

● Row: checks time

● In order for you to identify an ECG tracing, you have

● SA node: fires, sending an impulse going to your AV

Standard 12 lead ECG

● P wave: atrial depolarization (contraction)

4. ST Segment and T wave

SYSTEMATIC APPROACH IN ECG INTERPRETATION

● Ventricular Rate: R-R interval

● Atrial Rate: indiscernible

Fine V Fib= <3mm

● Extra heartbeats that occur just before a regular beat

● Polymorphic “Torsades de Pointes” (twisting of

Premature Ventricular Contraction (PVC)

Coarse V Fib= >3mm

Fixed prolonged PR interval

Second Degree AV Block (Type 1)

CONDUCTION ABNORMALITIES Constant PR interval, with dropped QRS

● First Degree AV Block

Third Degree AV Block

● Pacemaker only do 2 things:

● Rhythm: Regular Red arrows are referring to pacing spikes

● Same: rhythm, tachy, brady

● Junctional Escape Rhythm

● Tingnan ngayon, saan merong depression or

CPR: SIR IAN (1:03:33)

● This is the 12 leads ECG

Start with distal veins and work proximally. Start choosing

Calculating Drip Rates

Stress tape to prevent accidental yanking.Apply minimal

Quick tip: When IV tubing is microdrip (60 gtts/mL), the drops

For older patients and pediatric patients. Pediatric veins are

● Follow the Ten Rights of Medication Administration for

Equipment a. Confirm patient's identity using two identifiers, like

8. Assist patient into comfortable position, place items

● Evaluate the flow rate hourly and observe the