MedSurg Laboratory Compilation

VELEZ COLLEGE – COLLEGE OF NURSING (Nursing Care Management 112 Skills Lab)
SKILLS LABORATORY MODULE NO. 1

OXYGEN THERAPY
LEARNING OBJECTIVES:
By the end of the module, the student will be able to:
1. Give the indications for oxygen therapy.
2. Identify different oxygen delivery systems (low-flow and high-flow).
3. Enumerate the parts of an oxygen setup (portable & in-line).
4. Describe procedure in administering oxygen through different oxygen delivery systems including how
to attach the device and regulate oxygen delivery.
5. Identify the parts of a bag-valve-mask resuscitator (Ambu®-bag).
6. Describe procedure in performing bag-valve-mask ventilation.
7. Explain accurately the rationale for each step of the procedure.
 Important Information related to this Module:

A. Indications for Oxygen Therapy:
▪ Hypoxemia (or insufficient oxygenation of arterial blood) resulting from a respiratory or

______________
cardiac emergency or an increase in metabolic function such as in patients with high fever.
Clinical manifestations of include:
- Restlessness & change in mental status (earliest sign)
- Tachycardia
- Tachypnea, dyspnea & nasal flaring
- Substernal or intercostal retractions
- Cool extremities
- Central cyanosis (late sign)
B. Oxygen Delivery Devices:

1. Low-flow systems = contribute partially to the inspired gas the patient breaths. This means the
patient breathes some room air along with the oxygen. These systems do not provide a constant
or known concentration of inspired oxygen. The amount of inspired oxygen changes as the
patient’s breathing changes.
Nasal Cannulae
a. ______________
• the most common method of oxygen administration
• oxygen is delivered through a flexible catheter that has
two short nasal prongs
• allows the patient to eat & talk, and it is generally more
comfortable than other oxygen delivery devices
• requires nose breathing for the device to be effective
• delivers a relatively low concentration of oxygen (24% to
45%) at flow rates of 2 to 6 L per minute.
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Medium Concentration O2 Masks
b. ________________
• delivers oxygen concentrations from 40% to 60% at
liter flows of 5 to 8 L per minute, respectively.
Partial Rebreather
c. _____________________ Mask
• delivers oxygen concentration of 60% to 90% at liter
flows of 6 to 10 L per minute, respectively.
• on inspiration, the patient inhales from the mask
and bag; on expiration, the bag refills with oxygen
and expired gases exit through perforations on both
sides of the mask and some enters bag
• the oxygen reservoir bag that is attached allows the
client to rebreathe about the first third of the
exhaled air in conjunction with oxygen
• the partial rebreather bag must not totally deflate
To avoid change in O2 intake %
during inspiration (Rationale:_________________)
and to maintain consistent O2 intake %
• if this problem occurs, the nurse increases the liter

flow of oxygen so the bag remains 1/3 to ½ full
Nonrebreather Mask
d. ______________________
• delivers the highest oxygen concentration possible -
95% to 100% - by means other than intubation or
mechanical ventilation, at liter flows of 10 to 15 L
per minute
• one-way valves on the mask and between the
reservoir bag and the mask prevent the room air
and the client’s exhaled air from entering the bag so
only the oxygen in the bag is inspired.
• The nonrebreather bag must not totally deflate
To avoid change in O2 intake %
during inspiration (Rationale:__________________)
and to maintain consistent O2 intake %
2
2. High-flow systems = provide the total amount of inspired air. A specific percentage of oxygen is
delivered independent of the patient’s breathing. High-flow systems are indicated
Venturi Mask
a. _________________
• the most reliable & accurate method for delivering
precise concentrations of oxygen through
noninvasive means
• the mask is constructed in a way that allows a
constant flow of room air blended with a fixed flow
of oxygen
• delivers oxygen concentrations varying from 24% to
40% or 50% at liter flows of 4 to 10 L per minute
b. Face Tent
• used when oxygen masks are poorly tolerated by
patients
• the tent is attached to the patient’s chin and
strapped around the neck; it is connected to an
oxygen source and humidifier through wide-bore
tubing
• provides varying concentrations of oxygen
• frequently inspect the client’s facial skin for
dampness or chafing and dry and treat as needed
c. Tracheostomy Collar
• a mask-like device that fits loosely over the
tracheostomy and is held in place with an
elastic band around the neck
• the collar is connected to a wide-bore
tubing that receives aerosolized oxygen
from a jet nebulizer
d. T-piece/Briggs adapter
• is used to administer oxygen to patient with
endotracheal tube or tracheostomy tube
who is breathing spontaneously
• is useful in weaning patients from
mechanical ventilation
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C. Parts of an Oxygen Setup:

▪ Portable Unit (oxygen is supplied from a tank/cylinder)
[1] Oxygen Tank/Cylinder
[2] Cylinder valve handwheel
[3] Humidifier Bottle
[4] Oxygen tubing to delivery device (e.g., cannula)
[5] Oxygen content or oxygen pressure gauge
[6] Flow meter or flow indicator gauge
 The flow meter type shown in the illustration is the
Bourdon gauge type or round type (the flow rate of
oxygen is normally read to where the gauge points))
[7] Flow control knob
[8] Cylinder wrench (made of brass that is non-sparking)
▪ In-Line/Wall Unit (oxygen is supplied from piped-in oxygen)

[1] Adapter (for attachment to wall source)
[2] Humidifier Bottle
[3] Port for oxygen tubing of delivery device
[4] Oxygen pressure gauge
[5] Flow meter or flow indicator gauge
 The flow meter type shown in the illustration is the vertical
type or tube type which usually has a silver ball or bullet
inside (the flow rate of oxygen is normally read at the
center of the ball/bullet)
[6] Flow control knob
D. Parts of a Bag-Valve-Mask Resuscitator (Ambu®-Bag):

[1] Clear oxygen face mask (cuffed or uncuffed; detachable)
[2] Adapter for endotracheal tube (ET) or tracheostomy tube
[3] Patient valve (contains exhalation valve or expiration diverter)
[4] Pressure regulator
[5] Ventilation bag (self-inflating)
[6] Intake valve
[7] Reservoir valve (may be detached from intake valve)
[8] Oxygen reservoir socket
[9] Reusable oxygen reservoir bag (may be detached from O2 reservoir socket)
[10] Oxygen inlet
[11] Oxygen connecting tubing
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 Nursing Skills to Develop in this Module & Materials/Equipment Needed: [materials/items with an
asterisk (*) are the materials the students should bring during skills laboratory period]
▪ Administering Oxygen Therapy:

- Disposable gloves*
- Stethoscope*
- Oxygen Setup (tank with content gauge, flowmeter & humidifier)
- Appropriate oxygen delivery device: e.g., simple face mask, nasal cannula, or T-piece with
adapter for artificial airway
▪ Performing Bag-Valve-Mask (Ambu®-Bag) Ventilation:

- Stethoscope*
- O2 connecting tubing
- Bag-valve-mask Resuscitator (Ambu®-bag) with appropriate size mask or artificial airway adapter
- Oropharyngeal or Nasopharyngeal Airway
- Appropriate personal protective equipment
 Procedure Guidelines:
A. Administering Oxygen Therapy
1. Determine client history and acute and chronic health problems.
2. Assess the client’s baseline respiratory signs, including airway, respiratory pattern, rate, depth, and
rhythm, noting indications of increased work of breathing.
3. Check the extremities and mucous membranes closely for color.
4. Review arterial blood gas and pulse oximetry results.
5. Note lung sounds for rales/crackles.
6. Assess the nares, behind the earlobes, cheek, tracheostomy site, or other places where oxygen tubing
or equipment is in constant contact with the skin to look for signs of skin irritation or breakdown.
7. Perform hand hygiene.
8. Verify the doctor’s order for prescribed liters per minute of oxygen.
9. Explain procedure and hazards to the client & SOs including NO smoking and keeping oxygen at least 6
feet away from any source of flame or electrical sparks.
10. If using humidity, fill humidifier to fill line with distilled water and close container (ready-to-use
humidifier systems are also available). Clients with artificial airway should use HUMIDIFIED oxygen.
11. Attach humidifier to oxygen flow meter.
12. Insert humidifier and flow meter into oxygen source in wall or portable unit.
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13. Attach the oxygen tubing and appropriate oxygen delivery device to the flow meter and turn it on to
the prescribed flow rate (1 to 5 liters per minute).
14. Use extension tubing for ambulatory clients so they can get up to go to the bathroom.
15. Check for bubbling in the humidifier which indicates that oxygen is flowing through it.
16. Apply appropriate delivery device to patient to commence oxygen therapy:
▪ For oxygen via nasal cannula: Place the nasal prongs in the client’s nostrils. Secure the cannula
in place by adjusting the tubing around the client’s ears and using the slip ring to stabilize it
under the client’s chin.
▪ For oxygen via simple face mask, partial rebreather & nonrebreather mask: Place the mask on
the client’s face, fasten the elastic band around the client’s ears and tighten until the mask fits
snugly. Allow the reservoir bag of the nonrebreathing or partial rebreathing mask to fill
completely.
▪ For oxygen via an artificial airway using a T-piece: Attach the T-piece to the client’s artificial
airway. Be sure it is firmly attached to the airway. Position wide-bore tubing of T-piece so that it
is not pulling client’s airway.
17. Monitor vital signs, oxygen saturation, and client condition every 4 to 8 hours (or as indicated or
ordered) for signs and symptoms of hypoxia.
18. Wean client from oxygen as soon as possible using standard protocols.
B. Performing Bag-Valve-Mask (Ambu®-Bag) Ventilation:

1. Put on gloves and other personal protective equipment
2. Before using the bag-valve-mask resuscitator, check the patient’s upper airway for foreign objects. If
present remove them.
3. Suction the patient for any secretions. If necessary, insert an oropharyngeal or nasopharyngeal airway.
If the patient has a tracheostomy or ET tube in place, suction the tube.
4. Secure oxygen connecting tubing to oxygen inlet of bag-valve-mask resuscitator. Adjust the flow
control knob of the portable/wall unit oxygen to deliver 10 L/min of oxygen. Make sure oxygen
reservoir bag is filled with air & collapses with each squeeze of the ventilation bag.
5. If appropriate, remove the patient’s headboard and stand at the head of the bed to help keep the
patient's neck extended and to free space at the side of the bed for other activities such as
cardiopulmonary resuscitation.
6. Tilt the patient's head backward, if not contraindicated, and pull his jaw forward to move the tongue
away from the base of the pharynx and prevent obstruction of the airway.
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7. Keeping your nondominant hand on the patient's mask, exert downward pressure to seal the mask
against his face.
8. If ventilating through an artificial airway, remove clear face mask from bag-valve-mask resuscitator
and insert adapter to client’s tracheostomy or endotracheal tube (ET). [see illustration A for ventilating
through a tracheostomy & illustration B through an endotracheal tube]
A B
9. For an adult patient, use your dominant hand to compress/squeeze the bag every 5 seconds.
(approximate amount of air delivered per ventilation in an adult is stated below)
▪ 1000 to 1500 mL = amount of air delivered after 1 full squeeze on ventilation bag with BOTH
hands
▪ 600 to 800 mL = amount of air delivered after 1 full squeeze on ventilation bag with ONE hand
ONLY.
10. For a child & infant, deliver 20 breaths/minute, or one compression of the bag every 3 seconds. Infants
and children should receive 250 to 500 mL of air with each bag compression. Use age-appropriate bag-
valve-mask resuscitator for pediatric clients [see accompanying illustration].
11. Deliver breaths with the patient's own inspiratory effort, if it's present. Don't attempt to deliver a
breath as the patient exhales.
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12. Observe the patient's chest to ensure that it rises and falls with each compression. Auscultate for
breath sounds with each ventilation. If ventilation fails to occur, check the fit of the mask and the
patency of the patient's airway; if necessary, reposition his head and ensure patency with an oral
airway.
 References & Suggested Readings:

▪ Berman, A., Snyder, S., & Frandsen, G.(2016). Kozier & Erb’s Fundamentals of Nursing: Concepts,
Process and Practice (10th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
▪ Nettina, S. & Mills, E.J. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia, PA:
Lippincott, Williams & Wilkins.
▪ Schilling-McCann, J. (2009). Lippincott’s nursing procedures (5th ed.). Philadelphia, PA: Lippincott,
Williams & Wilkins.
▪ Hinkle, J., & Cheever, K. (2014). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (13th ed.).
Philadelphia, PA: Wolter Kluwer Health/Lippincott, Williams & Wilkins.
▪ Williams, L. & Hopper, P. (2003). Understanding medical-surgical nursing (2nd ed.). Philadelphia, PA:
F.A. Davis Company.
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INCENTIVE SPIROMETRY
1. Cite the different benefits of incentive spirometry.
2. Give the two (2) types of incentive spirometers.
3. Describe the procedure in assisting & teaching a client with an incentive spirometer.
4. Explain rationale for each step of the procedure accurately.

Sustained Maximal Inspirational Devices (SMIs)
Incentive Spirometers, also known as ________________________________ measure the flow of air inhaled
through the mouthpiece
A. Benefits of Incentive Spirometry:

▪ Induces the patient to take a deep breath and hold it for several seconds. This deep breath
increases lung volume, boosts alveolar inflation, and promotes venous return. This exercise also
establishes alveolar hyperinflation for a longer time than is possible with a normal deep breath,
thus preventing and reversing the alveolar collapse that causes atelectasis and pneumonitis.
▪ Usual indications: patients on prolonged bed rest, especially postoperative patients who may
regain normal respiratory pattern slowly due to such predisposing factors as abdominal or
thoracic surgery, advanced age, inactivity, obesity, smoking, and decreased ability to cough
effectively and expel lung secretions.
B. Types of Incentive Spirometers:

▪ Flow Oriented Spirometer
____________________________
▪ Volume Oriented Spirometer

______________________________
 Nursing Skill to Develop in this Module & Materials/Equipment Needed:

Assisting & Teaching the Client with an Incentive Spirometer:
- Stethoscope
- Tissue
- Alcohol swab (for disinfection of device)
- Incentive spirometer with appropriate mouthpiece
- Kidney basin (for client’s secretions)
A. Assisting & Teaching the Client with an Incentive Spirometer
1. Explain the procedure to the patient, making sure that he understands the importance of performing
incentive spirometry regularly to maintain alveolar inflation.
3. Help the patient into a comfortable sitting or High Fowler's position to promote optimal lung
______________
expansion. If you're using a flow incentive spirometer and the patient is unable to assume or maintain
this position, he can perform the procedure in any position as long as the device remains upright.
Tilting a flow incentive spirometer decreases the required patient effort and reduces the exercise's
effectiveness.
4. Auscultate the patient's lungs to provide a baseline for comparison with posttreatment auscultation.
5. Instruct the patient to insert the mouthpiece and close his lips tightly around it because a weak seal
may alter flow or volume readings.
2
6. Instruct the patient to exhale normally and then inhale as slowly and as deeply as possible. If he has
difficulty with this step, tell him to suck as he would through a straw but more slowly. Ask the patient
to retain the entire volume of air he inhaled for 3 seconds or, if you're using a device with a light
indicator, until the light turns off. This deep breath creates sustained transpulmonary pressure near
the end of inspiration and is sometimes called a sustained maximal inspiration.
7. Tell the patient to remove the mouthpiece from the mouth and exhale normally. Allow him to relax
and take several normal breaths before attempting another breath with the spirometer. Repeat this
sequence 5 to 10 times during every waking hour. Note tidal volumes.
8. Evaluate the patient's ability to cough effectively and encourage him to cough after each effort
because deep lung inflation may loosen secretions and facilitate their removal. Observe any
expectorated secretions.
9. Auscultate the patient's lungs and compare findings with the first auscultation.
10. Place the mouthpiece in a plastic storage bag between exercises, and label it and the spirometer, if
applicable, with the patient's name to avoid inadvertent use by another patient.
11. Dispose of soiled tissues and perform hand hygiene.
 Special Considerations for Incentive Spirometry:

▪ Instruct patient that the mouthpiece of the incentive spirometer should be cleaned before & after use.
▪ If the patient is scheduled for surgery, make a preoperative assessment of his respiratory pattern and
capability to ensure the development of appropriate postoperative goals. Teach the patient how to
To ensure patient's respiratory system is able to function properly and may not cause
use the spirometer before surgery (Rationale_____________________________________________).
complications during surgery or may die during surgery due to ineffective resp system
A preoperative evaluation will also help in establishing a postoperative therapeutic goal.

▪ Demonstrating first may help with client teaching. After which, perform a return-demonstration to
evaluate client learning.
▪ May cause aspiration due to the presence of food in the mouth
AVOID exercising at mealtime (Rationale:________________________________________________).
If the patient has difficulty breathing only through his mouth, provide a nose clip to fully measure each
breath. Provide paper and pencil so the patient can note exercise times. Exercise frequency varies with
condition and ability.
▪ Immediately after surgery, monitor the exercise frequently to ensure compliance and assess
achievement.

3
Williams & Wilkins.
F.A. Davis Company.
4

CHEST PHYSIOTHERAPY
1. Give the indications for chest physiotherapy.
2. Give the contraindications of chest physiotherapy.
3. Describe procedure of performing chest physiotherapy which includes postural drainage, chest
percussion & vibration, and coughing and deep-breathing exercises.
4. Explain rationale for each step of procedure accurately.

A. Indications of Chest Physiotherapy:
▪ To mobilize and eliminate secretions, re-expand lung tissue, and promote efficient use of
respiratory muscles in patients who expectorate large amounts of sputum, such as those with
bronchiectasis and cystic fibrosis and in those with artificial airway (tracheostomy & ET)
▪ Helps prevent or treat atelectasis in bedridden clients and may also help prevent pneumonia.
B. Contraindications of Chest Physiotherapy:

▪ Active hemorrhage with hemodynamic instability
▪ Active pulmonary bleeding with hemoptysis
▪ Acute asthma or bronchospasm
▪ Bony metastasis
▪ Bronchopleural Fistula
▪ Conditions with increased intracranial pressure (ICP) such as hemorrhagic stroke
▪ Fractured ribs, flail chest or an unstable chest wall
▪ Empyema, lung abscess or tumor
▪ Lung contusions
▪ Pulmonary tuberculosis
▪ Recent myocardial infarction
▪ Recent head injury or spinal cord injury
▪ Recent spinal & intracranial surgery
▪ Uncontrolled hypertension
▪ Unstable head or neck injury
▪ Untreated pneumothorax
 Nursing Skills to Develop in this Module & Materials/Equipment Needed:

▪ Performing Chest Physiotherapy:
- Stethoscope
- Tissue
- Adjustable Hospital Bed
- Pillows
- Kidney basin (for client’s secretions)
A. Performing Chest Physiotherapy
1. Explain the procedure to the patient, provide privacy, and perform hand hygiene.
2. Auscultate the patient's lungs to determine baseline respiratory status and assess ability to clear
secretions. Take note of where adventitious breath sounds are heard to determine affected lung
segment.
3. Perform postural drainage by positioning client properly – lung segment to be drained is uppermost.
(see illustrations below)
* Affected Lung Segment: Lower Lobes – Posterior Basal Segments
* Affected Lung Segment: Lower Lobes – Lateral Basal Segments
* Affected Lung Segment: Lower Lobes – Superior Segments
2
* Affected Lung Segment: Right Middle Lobe – Medial & Lateral Segments
* Affected Lung Segment: Left Upper Lobe – Superior & Inferior Segments
* Affected Lung Segment: Upper Lobes – Anterior Segments
* Affected Lung Segment: Upper Lobes – Apical Segments
* Affected Lung Segment: Upper Lobes – Posterior Segments
3
4. Instruct the patient to remain in each position for 10 to 15 minutes. During this time, perform
percussion and vibration as ordered on area over affected lung segment.
Percussion instruct the patient to breathe slowly and deeply, using the diaphragm, to
5. To perform ____________,
promote relaxation. Hold your hands in a cupped shape, with fingers flexed and thumbs pressed tightly
against your index fingers. Percuss each segment for 1 to 2 minutes by alternating your hands against
the patient in a rhythmic manner. Listen for a hollow sound on percussion to verify correct performance
of the technique. (see illustration below)
Vibration
6. To perform ____________, ask the patient to inhale deeply and then exhale slowly through pursed lips.
During exhalation, firmly press your fingers and the palms of your hands against the chest wall. Tense
the muscles of your arms and shoulders in an isometric contraction to send fine vibrations through the
chest wall. Vibrate during five exhalations over each chest segment. (see illustration below)
7. After postural drainage, percussion, or vibration, instruct the patient to cough to remove loosened
secretions. First, tell him to inhale deeply through his nose and then exhale in three short huffs. Then
have him inhale deeply again and cough through a slightly open mouth. Three consecutive coughs are
highly effective. An effective cough sounds deep, low, and hollow; an ineffective one, high-pitched. Have
the patient perform exercises for about 1 minute and then rest for 2 minutes. Gradually progress to a
10-minute exercise period four times daily.
8. Provide oral hygiene because secretions may have a foul taste or a stale odor.
9. Auscultate the patient's lungs to evaluate the effectiveness of therapy.
4
 Special Considerations for Chest Physiotherapy:

▪ For optimal effectiveness and safety, modify chest physiotherapy according to the patient's condition.
For example, initiate or increase the flow of supplemental oxygen, if indicated. Also, suction the patient
who has an ineffective cough reflex. If the patient tires quickly during therapy, shorten the sessions
because fatigue leads to shallow respirations and increased hypoxia.
▪ Maintain adequate hydration in the patient receiving chest physiotherapy to prevent mucus dehydration
and promote easier mobilization. AVOID performing postural drainage immediately before or within 1½
To avoid the patient from vomitting during postural drainage
hours after meals (Rationale:____________________________________________________________).
▪ Because chest percussion can induce bronchospasm, any adjunct treatment (for example, intermittent
positive-pressure breathing, aerosol, or nebulizer therapy) should precede or be carried out BEFORE
chest physiotherapy.
▪ REFRAIN from percussing over the spine, liver, kidneys, or spleen to avoid injury to the spine or internal
organs. Also avoid performing percussion on bare skin or the female patient's breasts. Percuss over soft
clothing (but not over buttons, snaps, or zippers), or place a thin towel over the chest wall. Remember to
remove jewelry that might scratch or bruise the patient.
▪ Explain coughing and deep-breathing exercises preoperatively so that the patient can practice them
when he's pain-free and better able to concentrate. Postoperatively, splint the patient's incision using
your hands or, if possible, teach the patient to splint it himself to minimize pain during coughing.

Williams & Wilkins.
5

NEBULIZATION THROUGH AEROSOL MASK & METERED -DOSE
INHALER
 ________________ refers to the delivery medications to the respiratory tract through inhalation via an
aerosol mask or metered-dose inhaler, producing local and systemic effects. The mucosal lining of the
respiratory tract absorbs the propelled medication almost immediately.
1. Give the indications of nebulization.
2. Enumerate the parts of a nebulizer set.
3. Enumerate the parts of an air compressor.
4. Enumerate the parts of a metered-dose inhaler.
5. Describe the procedure for performing nebulization through aerosol mask & metered-dose inhaler.

A. Indications of Nebulization (depends on type of medication nebulized)
▪ To improve airway patency and facilitate mucous drainage (_______________)
▪ To liquefy tenacious bronchial secretions (______________)
▪ To decrease airway inflammation (______________).
B. Parts of a _______________:
(1) Mouthpiece
(2) Nebulizer T-piece
(3) Nebulizer Cap
(4) Nebulizer chamber or cup
(5) Nebulizer Air-inlet Connector
(6) Nebulizer Baffle
(7) Tubing
(8) Aerosol mask (different sizes for adult
& pedia)
C. Parts of an ____________________:
(1) Storage compartment
(2) Storage compartment door with operating instructions
(3) Power switch
(4) Filter cap
(5) Air-outlet connector
(6) Carrying handle
(7) Power cord storage
(8) Nebulizer holder
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D. Parts of a _________________________
(1) Prepackaged dispenser [containing medication] or medication canister with;
(2) Applicator/actuator
(3) Aerochamber or spacer device
(4) ________________
▪ Administering Nebulized Medications through an Aerosol Mask:

- Tissue*
- 5-mL Syringe*
- 0.9% Sodium Chloride Solution (vial)*
- Alcohol swab*
- Air compressor
- Nebulizer set (with mouthpiece or mask)
- Nebule containing medication
▪ Administering Nebulized Medications through a Metered-Dose Inhaler:

- Medication on Metered-Dose Inhaler (e.g., Ventolin® inhaler or Seretide® discus) with spacer
device or aerochamber*
- Tissue*
A. Administering Nebulized Medications through an Aerosol Mask
1. Verify doctor’s orders.
2. Check for drug allergies & hypersensitivity.
3. Assess the client’s _______________ status. Auscultate client’s chest for wheezes & crackles.
4. Perform hand hygiene before setting up the nebulizer.
5. Pour prescribed amount of drug into the nebulizer chamber. Avoid touching the drug while pouring into
the nebulizer chamber. If medication is not in a nebule, use a syringe or medication dropper to withdraw
prescribed amount of medication (usually indicated for pediatric & elderly clients). Saline may also be
instilled as prescribed with the medication in the nebulizer chamber using a syringe.
6. Cover the chamber with the cap and fasten.
7. Fasten the face mask or T-shaped tube with mouthpiece to the end of the cap. Avoid touching the
nebulizer mouthpiece or the interior part of the mask.
8. Identify the client prior to administration of medication.
9. Identify the medication to the client and clearly explain the therapeutic purpose of the medication.
10. Advise the client to sit in an upright position.
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11. Attach tubing to the nebulizer air-inlet connector and attach the other end to the air compressor.
12. Instruct the client to breathe in and out slowly and deeply through the mouthpiece/mask. The client’s
lips should be sealed tightly around the mouthpiece.
13. Remain with the client long enough to observe the proper inhalation-exhalation technique.
15. Do appropriate documentation.
16. When the nebulizer chamber is empty, turn off the compressor.
17. Do aftercare of equipment and carefully clean the nebulizer set, ready for next use.
18. Assess the client (particularly respiratory status) immediately following the treatment for results or
adverse effects from the treatment.
19. Reassess the client __________ minutes following the treatment.
B. Administering Nebulized Medications through a Metered-Dose Inhaler

1. Assess the client for ability to use the metered-dose inhaler
3. Check for drug allergies and hypersensitivity.
5. Shake the prepackaged dispenser of the metered-dose inhaler containing the medication.
6. Place the prepackaged dispenser into its applicator (if not yet attached).
7. Place the aerochamber onto the mouthpiece of the applicator if needed. The aerochamber provides
dead space for the medicated mist while the client inhales.
8. Have the client seal his lips around the mouthpiece of the metered-dose inhaler or around the
aerochamber.
9. Instruct client to take two deep breaths through the nose and after last exhalation, have client press
down on the prepackaged dispenser as he simultaneously inhales through the mouthpiece of the
metered-dose inhaler or through the aerochamber. Have client hold his breath for _________________
and then breathe out slowly. If second dose is needed, patient should wait ________________ before
taking another dose. [see illustration below]
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10. If there is an aerochamber or spacer attached to the inhaler, have the client inhale slowly and deeply
from the aerochamber or spacer. [see illustrations below]
11. Wipe clean the mouthpiece of the metered-dose inhaler & aerochamber, ready for next use.
12. Observe client for several minutes to assess for possible adverse effects from the medication.
 Special Considerations:
▪ If two different inhaled medications are prescribed and one of the medications contains a glucocorticoid
(corticosteroid), administer the _________________ first and the _______________ second. Wait 5
minutes following the bronchodilator before inhaling the corticosteroid.
▪ Client should be instructed to _____________ with water after inhaling a corticosteroid.
▪ Dust may accumulate on the nebulizer equipment. Always clean equipment in between use.
▪ Teach client how to perform a
“______________” to approximate how much
medication is in the metered-dose inhaler, by
observing its displacement in water [see
illustration]. However, client must be warned
that some medication canisters are not to be
submerged in water; thus, instruct client to
read package insert of inhaler for directions
on use.

▪ Altman, G.B. (2010). Fundamental & advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage
Learning.
▪ Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s fundamentals of nursing: Concepts,
process and practice (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Williams & Wilkins.
49
▪ Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth’s textbook of medical-
surgical nursing (12th ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott, Williams & Wilkins.

ASSISTING WITH THORACENTESIS
 Thoracentesis is the process of inserting a large-bore needle through the chest wall into the pleural cavity
utilizing sterile technique. This procedure is usually performed at the bedside & one of the nurse’s roles is to
assist the physician in carrying out the procedure.
1. Give the indications for thoracentesis.
2. Identify the parts of a thoracentesis set.
3. Describe the procedure in assisting with thoracentesis.
 Indications for Thoracentesis:

 To remove fluid in clients with pleural effusion (such fluid may also be used as specimen for diagnostic
purposes) = needle usually inserted on the______________________ of affected thorax
 To remove blood in patients with hemothorax = site of needle insertion same with pleural effusion
 To remove air in clients with pneumothorax = needle usually inserted on the______________________
of affected thorax
 To administer medications intrapleurally = site of needle insertion varies
 Materials to Bring for this Module:

 [all materials will be prepared by your facilitator]
 Nursing Skill to Develop in this Module:

A. Assisting with Thoracentesis
1. Perform hand hygiene before baseline assessment and as necessary throughout the preparation,
procedure & follow-up.
2. Identify client and obtain baseline assessment and medical history of client paying close attention to
respiratory status and vital signs.
3. Be sure a signed consent has been completed.
4. Review necessary pretests (e.g., X-ray) and have information available at the bedside.
 A fluid marker is usually placed after chest x-ray of a client with pleural effusion & is usually
written on client’s skin using permanent ink marker by the physician/radiologist before the
procedure.
 The nurse should instruct patient NOT to remove marking on skin as this would serve as a guide for
the physician on where to insert the needle during thoracentesis.
5. Prepare necessary equipment at bedside as follows: (always check expiry dates of meds & sterile packs)
 Thoracentesis set (may be individually procured if not in set)
- Antiseptic solution (usually povidone-iodine)
- Sterile gauze sponges (4x4 in. & 2x2 in.)
33
- Sterile towels & drapes

- Local anesthetic (e.g. lidocaine 2%)
- Sterile syringes & needles: two 3- to 5-mL with 23- to 25- gauge needles for administration
of local anesthetic medication; two 20- to 50-mL syringes with 14- to 17-gauge needles 5 to
7 cm in length for fluid drainage
- ___________ stopcock
- ____________ set
- Bandage scissors or mayo scissors
- Hemostat or Kelly forceps
- Fluid receptacle (usually an empty 1-L sterile bottle)
- Sterile specimen containers
 Adhesive tape (e.g. Leukoplast®)
 Personal protective equipment
 Sterile gloves in appropriate size for physician or qualified practitioner & anyone assisting in the
sterile field.
 Premedications (e.g., sedation, pain medication, cough suppressant)
6. Explain the procedure to the patient. Inform him that he may feel some discomfort and a sensation of
pressure during the needle insertion. Provide privacy and emotional support.
7. Instruct client to void.
8. Pre-medicate the client as ordered.
9. Position the patient. Make sure he's firmly supported and comfortable. Although the choice of position
varies, you'll usually [A] seat the patient on the edge of the bed with his legs supported and his head and
folded arms resting on a pillow on the overbed table. Or [B] have him straddle a chair backward and rest
his head and folded arms on the back of the chair. If the patient is unable to sit, [C] turn him on the
unaffected side with the arm of the affected side raised above his head. Elevate the head of the bed 30
to 45 degrees if such elevation isn't contraindicated [see illustration below for different client positions
for thoracentesis]. Proper positioning ______________________________________________________.
34
10. Remind the patient ______________________________________________ during the procedure to

avoid puncture of the visceral pleura or lung. If the patient coughs, the physician will briefly
____________________________________.
11. Expose the patient's entire chest or back as appropriate.
12. Shave the aspiration site as ordered or per institution policy.
13. Perform hand hygiene again before touching the sterile equipment. Then using sterile technique, open
the thoracentesis tray and assist the physician as necessary in disinfecting the site with povidone-iodine
solution.
14. Assist the physician in draping the puncture site.
15. If an ampule of local anesthetic isn't included in the sterile tray and a multidose vial of local anesthetic is
to be used, assist the physician by wiping the plastic/rubber stopper with an alcohol pad and holding the
inverted vial while the physician withdraws the anesthetic solution.
16. After draping the patient and injecting the anesthetic, the physician attaches a_________________ with
the aspirating needle in one end & the 20-mL syringe on the opposite end. The physician cuts the tubing
of the macrodrip set (to remove the drip chamber up to the spike) & inserts the hub of the macrodrip set
on the remaining end of the stopcock. [see illustration below]
17. While maintaining sterile technique, the physician then places end of macrodrip set tubing to the floor.
The nurse then grasps & tapes end of tubing to the drainage bottle.
18. To commence the procedure, the physician turns the stopcock so that the conduit leading to macrodrip
set is closed. The aspirating needle is then inserted into the pleural space. A _______________ may be
used to hold the needle in place and prevent pleural tear or lung puncture.
35
19. The physician then pulls on the 20-mL syringe to aspirate fluid from the client’s pleural space. [see
illustration; also note position of stopcock & see direction of arrows for direction of flow of fluid]
20. After enough fluid is aspirated on the 20-mL syringe, the physician
closes all conduits of the stopcock (to prevent air from entering the
pleural space) and then replaces the 20-mL syringe with a 50-mL
syringe. [see illustration for position of stopcock with all conduits
closed before syringe is replaced]
21. Once the 50-mL syringe is attached, the stopcock is then turned so
that the conduit leading to the macrodrip set tubing is closed again.
The physician then pulls on the 50-mL syringe to aspirate additional
fluid from the pleural space. [see illustration for position of stopcock &
direction of flow of fluid]
22. Once there is adequate fluid on the 50-mL syringe, the physician turns
the stopcock so that the conduit leading to the aspirating needle is
closed. The physician then pushes on the plunger of the syringe to
move some fluid from the syringe to the macrodrip set tubing. [see
illustration for position of stopcock & direction of flow of fluid]
23. Once the entire macrodrip set tubing is filled with fluid & the drainage
bottle partially filled with fluid as well, the physician turns the
stopcock so that the conduit leading to the macrodrip set tubing is
closed again. The physician then pulls one more time on the 50-mL
syringe to aspirate fluid from the client’s pleural space. [see
illustration for position of stopcock & direction of flow of fluid]
36
24. Afterwhich, the physician turns the stopcock so that the conduit from
the 50-mL syringe is closed. In this step, the fluid from client’s pleural
space passively flows from the aspirating needle to the macrodrip set
tubing leading to the drainage bottle. The physician then continues to
monitor the flow of drainage. [see illustration for position of stopcock
& direction of flow of fluid]
25. Support the patient verbally throughout the procedure, and keep him informed of each step. Assess him
for signs of anxiety, and provide reassurance as necessary.
26. Check vital signs regularly during the procedure. Continually observe the patient for such signs of distress
such as pallor, vertigo, faintness, weak and rapid pulse, decreased blood pressure, dyspnea, tachypnea,
diaphoresis, chest pain, blood-tinged mucus, and excessive coughing. Alert the physician if such signs
develop because they may indicate complications, such as hypovolemic shock or tension pneumothorax.
27. Put on gloves and assist the physician as necessary in specimen collection, fluid drainage, and dressing
the site.
28. After the physician withdraws the needle or catheter, apply pressure to the puncture site, using a sterile
4x4 gauze pad. Then apply a new sterile gauze pad, and secure it with tape.
29. Position the patient on the ________________(which is the side opposite the thoracentesis site). This
position allows lung re-expansion on operative side.
30. Take client’s vital signs, and assess respiratory status.
31. Label the specimens properly, and send them to the laboratory.
32. Discard disposable equipment. Clean nondisposable items, and return them for sterilization.
33. Check the patient's vital signs and the dressing for drainage every 15 minutes for 1 hour. Then continue
to assess the patient's vital signs and respiratory status as indicated by his condition.
34. Obtain order for chest x-ray to evaluate effectiveness of procedure & to detect possible complications
such as pneumothorax.
 Special Considerations in Thoracentesis:

 To prevent pulmonary edema and hypovolemic shock after thoracentesis, fluid is removed slowly, and
_______________________________________________. Removing the fluid increases the negative
intrapleural pressure, which can lead to edema if the lung doesn't reexpand to fill the space.
 ________________________ may indicate pleural irritation by the needle point.
37

 Altman, G.B. (2010). Fundamental & advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage
Learning.
 Nettina, S. & Mills, E.J. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia, PA:
 Schilling-McCann, J. (2009). Lippincott’s nursing procedures (5th ed.). Philadelphia, PA: Lippincott,
Williams & Wilkins.
 Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth’s textbook of medical-
38

CHEST TUBE THORACOTOMY
 Chest Tube Thoracotomy (CTT) is the insertion of a tube into the pleural space to evacuate air or fluid, or to
help regain negative pressure [see illustration below]. Whenever the chest is opened, from any cause, there is
loss of negative pressure, which can result in collapse of the lung. The collection of air, fluid, or other
substances in the chest can compromise cardiopulmonary function and even cause collapse of the lung,
because these substances take up space. Insertion of a chest tube is usually done in the operating room.
1. Give the indications for chest tube thoracotomy.
2. Enumerate the sites for chest tube placement.
3. Explain principles of chest drainage in a one-, two-, or three-bottle system.
4. Describe procedure of maintaining a chest tube and chest drainage system.
5. Perform proper reading of chest drainage for output measurements & describe monitoring.
6. Describe procedure of chest tube removal.

A. Indications of Chest Tube Thoracotomy:
 To evacuate air or fluid, or to help regain negative pressure in clients during or immediately after
thoracic surgery, in clients with spontaneous pneumothorax, ,hemothorax, pneumothorax
caused by trauma or those with massive pleural effusion untreated by repeated thoracentesis.
B. Sites for Chest Tube Placement:

 For pneumothorax: second or third intercostal space along_______________________
 For hemothorax: sixth or seventh lateral intercostal space in the __________________
39
C. Chest Tube Drainage Systems:
D. Reading the Calibrations on the Water Seal & Drainage Collection Chamber [of a 1-bottle System]:
40
reflects the
total reflects the
amount of total volume
drainage inside the
only in the entire bottle
chamber
 Materials to Bring for this Module:

 [all materials will be prepared by your facilitator]
 Nursing Skills to Develop in this Module:

A. Maintaining a Chest Tube and Chest Drainage System
1. Repeatedly note the character, consistency, and amount of drainage in the drainage collection chamber.
2. Mark the drainage level in the drainage collection chamber by noting the time and date at the drainage
level on the chamber____________ (or more often if there's a large amount of drainage).
3. Check the water level in the water-seal chamber every 8 hours. If necessary, the doctor adds sterile
distilled water until _____ centimeters of the tube is submerged on the water-seal chamber.
4. Check for fluctuation in the water-seal chamber as the patient breathes. Normal fluctuations of
_______________ reflect pressure changes in the pleural space during respiration. To check for
fluctuation when a suction system is being used, momentarily disconnect the suction system so the air
vent is opened, and observe for fluctuation.
5. Check for_______________ in the water-seal chamber. This occurs normally when the system is
removing air from the pleural cavity. If bubbling isn't readily apparent during quiet breathing, have the
patient take a deep breath or cough. Absence of bubbling indicates that the pleural space has sealed or
there is an__________________________.
41
6. NURSING ALERT: Some facilities permit milking of tubing when clots are visible. This is a controversial
procedure because it creates increased intrapleural pressure, so be sure to check your facility's policy. If
permitted, gently milk the tubing in the direction of the drainage chamber when clots are visible.
7. Check the water level in the suction control chamber. Detach the chamber or bottle from the suction
source; when bubbling ceases, observe the water level. If necessary, the doctor adds sterile distilled
water until 20 cm of the tube is submerged.
8. Check for _________________ in the suction control chamber because it indicates that the proper
suction level has been reached. Vigorous bubbling in this chamber increases the rate of water
evaporation.
9. Periodically check that the air vent in the system is working properly. Occlusion of the air vent results in
a buildup of pressure in the system that could cause the patient to develop a tension pneumothorax.
10. Coil the system's tubing, and secure it to the edge of the bed. Be sure the tubing remains at the level of
the patient. AVOID creating dependent loops, kinks, or pressure on the tubing. AVOID lifting the
drainage system above the patient's chest because fluid may flow back into the pleural space.
11. Be sure to keep two rubber-tipped clamps at the bedside to clamp the chest tube if a bottle breaks or if
the system cracks or when locating an air leak in the system.
12. Encourage the patient to cough frequently and breathe deeply to help drain the pleural space and
expand the lungs.
13. Tell him to sit upright for optimal lung expansion and to splint the insertion site while coughing to
minimize pain.
14. Check the rate and quality of the patient's respirations, and auscultate his lungs periodically to assess air
exchange in the affected lung. Diminished or absent breath sounds may indicate that the lung hasn't
re-expanded.
15. Tell the patient to report breathing difficulty immediately. Notify the physician immediately if the patient
develops cyanosis, rapid or shallow breathing, subcutaneous emphysema, chest pain, or excessive
bleeding.
16. Check the chest tube dressing at least every 8 hours. Palpate the area surrounding the dressing for
_____________________________, which indicates that air is leaking into the subcutaneous tissue
surrounding the insertion site. Change the dressing if necessary or according to your facility's policy.
17. Encourage active or passive range-of-motion (ROM) exercises for the patient's arm or the affected side if
he has been splinting the arm. Usually, the thoracotomy patient will splint his arm to decrease his
discomfort.
18. Give ordered pain medication as needed for comfort and to help with deep-breathing, coughing, and
ROM exercises.
19. Remind the ambulatory patient to keep the drainage system below chest level and to be careful not42
to
disconnect the tubing to maintain the water seal. With a suction system, the patient must stay within
range of the length of tubing attached to a wall outlet or portable pump.
 Special Considerations in Maintaining a Chest Tube Drainage System:

 Instruct staff and visitors to avoid touching the equipment to prevent complications from separated
connections.
 If excessive continuous bubbling is present in the water-seal chamber, especially if suction is being used,
rule out a leak in the drainage system. Try to locate the leak by clamping the tube momentarily at
various points along its length. Begin clamping at the tube's proximal end, and work down toward the
drainage system, paying special attention to the seal around the connections. If a connection is loose,
push it back together and tape it securely. The bubbling will stop when a clamp is placed between the air
leak and the water seal. If you clamp along the tube's entire length and the bubbling doesn't stop, the
drainage unit may be cracked and need replacement.
 In the event that the drainage collection chamber is almost full but client’s chest tube is not yet due to
be removed, inform the physician. If indicated, the nurse will need to assist the physician in emptying
the drainage bottle. While the physician clamps the proximal part of the tube, the nurse then opens &
empties the drainage bottle. Afterwhich, the physician disinfects the bottle with Lysol solution & water.
After the bottle is disinfected, the nurse fills the bottle with saline solution up to water-seal level (or until
2 cm of tube in chamber is submerged) and closes the drainage collection bottle. The integrity of the
drainage system is re-assessed.
 NURSING ALERT: The chest tube is never left clamped for more than a minute to prevent a tension
pneumothorax, which may occur when clamping stops air and fluid from escaping.
 If bottle in the chest drainage system breaks or cracks, clamp the chest tube momentarily with the two
rubber-tipped clamps at the bedside (placed there at the time of tube insertion). Place the clamps close
to each other near the insertion site; they should face in opposite directions to provide a more complete
seal. Observe the patient for altered respirations while the tube is clamped. Then replace the damaged
equipment (prepare the new unit before clamping the tube). Instead of clamping the tube, the nurse can
submerge the distal end of the tube in a container of normal saline solution to create a temporary water
seal while the bottle is replaced. This procedure may vary depending on institutional policy
 If the chest tube gets accidentally pulled out of the chest, the nurse immediately places vaselinized
gauze over the insertion site. The physician is then notified immediately for replacement of the tube.
B. Assisting with Chest Tube Removal 43

1. Assess whether the client has a new or larger air leak present prior to chest tube removal and notify the
physician.
2. Ensure that the client has had a chest x-ray prior to the removal of the chest tube. This assesses whether
the lung is expanded prior to chest tube removal.
3. Gather all equipment in the client’s room as follows:
 Sterile gloves (gowns & goggles if needed)
 Vaselinized gauze (1 package for each chest tube to be removed)
 Sterile 4x4 pads (2 packages for each chest tube to be removed)
 Foam tape, preferably a 2-inch roll
 Disposable waterproof absorbing pads
 Sutures, if requested by physician
 Suture removal kit or sterile scissors, if requested by physician
 Chest tube clamps
 Pain medication as premedication

5. Premedicate the client 15 to 30 minutes prior to chest tube removal.
6. Assist the client into bed and place in accessible and comfortable position for chest tube removal.
7. Reassure client and explain what you are doing as you proceed.
8. Assess for effects of premedication on respiratory status.
9. Apply gloves.
10. Assist physician as directed.
11. Instruct client to exhale fully and bear down or to perform the Valsalva’s maneuver as the tube is
removed to prevent air from being pulled back into the pleural space at the moment of chest tube
removal.
12. Once the tube is out and the dressing is applied, check that the dressing is secure and airtight. The
dressing should not be removed for 24 hours; if drainage is soaking through, reinforce with 4x4 pads and
foam tape.
13. Check that the post-chest tube removal x-ray has been ordered.
14. Dispose of gloves and wash hands.
15. Assess client in 30 minutes, watching for signs and symptoms of pneumothorax including rapid heart
rate, decreased breath sounds, increased shortness of breath, decreased oxygen saturation, chest pain
or pain with inspiration. Assess the dressing. Be sure it is dry and intact.

44
Learning.
Williams & Wilkins.

SUCTIONING
 Suctioning is defined as the removal of bodily fluids from an opening or orifice through the use of
negative pressure.
 Oropharyngeal suctioning involves the removal of secretions from the client’s oropharynx with a suction
catheter inserted through the mouth. Nasopharyngeal suctioning, on the other hand, removes secretions
from the nasal cavity apart from the oropharynx, with catheter inserted into the client’s nares.
 Tracheal suctioning involves the removal of secretions from the trachea or bronchi by means of a
catheter inserted through a tracheal stoma or an artificial airway such as a tracheostomy tube, or an
endotracheal (ET) tube.
1. Give the indications of suctioning.
2. Identify suction catheter sizes with their respective international color codes.
3. Determine appropriate size of sterile suction catheter for each age group.
4. Identify the parts of a suction set-up.
5. Determine adequate pressure of suction equipment for each age group.
6. Identify the parts of an artificial airway particularly of an endotracheal (ET) tube [parts of a
tracheostomy discussed in next module].
7. Discuss the complications of suctioning.
8. Assemble a portable suction set-up.
9. Perform oropharyngeal & nasopharyngeal suctioning.
10. Perform tracheal suctioning through artificial airways.
11. Apply principles of asepsis & infection control throughout the procedure.

A. Indications of Suctioning:
▪ To maintain oral hygiene and comfort for the patient
▪ To remove blood and vomit in an emergency situation
▪ To remove pulmonary secretions in patients who are unable to cough and clear their own
secretions effectively
▪ To maintain airway patency
▪ To prevent atelectasis secondary to blockage of smaller airways
▪ To ensure that adequate gas exchange (particularly oxygenation) occurs
B. Sizes of Suction Catheters with International Color Code: [the larger the number, the larger the lumen]
▪ French 5 (Fr 5) = Gray ▪ French 14 (Fr 14) = Green
▪ French 8 (Fr 8) = Blue ▪ French 16 (Fr 16) = Orange
▪ French 10 (Fr 10) = Black ▪ French 18 (Fr 18) = Red
▪ French 12 (Fr 12) = White
C. Appropriate Suction Catheter Sizes [per age group] NURSING ALERT: In suctioning a
▪ Adult = Fr 12 – 18 ▪ Infant = Fr 5 – 8 tracheostomy & ET, suction catheter
▪ Child = Fr 8 – 10 diameter should NOT be more than half
the diameter of the artificial airway.
1
D. Parts of a Suction Set-up:

[ 1 ] Power button (portable unit) or On/Off Knob (wall unit)
[ 2 ] Plastic/Glass Collection Jar/Bottle/Container
[ 3 ] Vacuum Gauge
[ 4 ] Vacuum Adjustment knob
[ 5 ] Plastic/Rubber connecting tubing
[ 6 ] Vacuum pump (for portable unit)
Portable Unit
E. Appropriate Suction Pressure [per age group]

▪ Wall Unit:
- Adult = 100-120 mmHg
- Child = 95 – 100 mmHg
- Infant = 50 – 95 mmHg
▪ Portable Unit:
- Adult = 10 – 15 mmHg
- Child = 5 – 10 mmHg
- Infant = 2 – 5 mmHg
Wall Unit
F. Parts of an Endotracheal (ET) Tube
2
G. Complications of Suctioning
▪ Hypoxia (restlessness & irritability are earliest signs)
▪ Dysrhythmia (secondary to vagal stimulation/overload)
▪ Traumatic injury & bleeding
▪ Pulmonary Infection (if there is breach in aseptic technique)
 Materials/Equipment Needed: [materials/items with an asterisk (*) are the materials the students should
bring during skills laboratory period]
- Sterile gloves*
- Appropriate size suction catheter*
- Sterile Water or Normal Saline Solution for Irrigation*
- Water-soluble lubricant (single packet)*
- Suction machine (portable or wall unit) with collection jar/bottle & plastic/rubber connecting tubing
- Sterile forceps (if not using glove technique)
- Sterile bottle/container (2 pieces)
- Oxygen or bag-valve-mask resuscitator/Ambu®-Bag
- Personal protective equipment
- Nasopharyngeal or oropharyngeal airway (optional)

A. Performing Nasopharyngeal & Oropharyngeal Suctioning and Tracheal Suctioning through Artificial
Airway
1. Review the patient’s blood gas and oxygen saturation values, and check vital signs. Evaluate the patient's
ability to cough and deep-breathe to determine his ability to move secretions up the tracheobronchial
tree. _Auscultate lung fields to evaluate airway and determine need for suctioning.
 Instances in which suctioning may be needed: (a) Raised respiratory rate, (b) Inability of client to
clear secretions effectively, (c) Diminished breath sounds, (d) Audible secretions, (e) Spontaneous
but ineffective cough, (f) Reduced oxygen saturation levels
 The need for suction should be assessed on an individual basis rather than as a ‘ritualized’ activity,
meaning that patients should only receive suctioning when they need it, not because a certain
length of time has elapsed since it was last performed
2. Check for history of clotting disorders which increases risk for bleeding during suctioning. For
nasopharyngeal suctioning, check patient history for a deviated septum, nasal polyps, nasal obstruction,
traumatic injury, epistaxis, or mucosal swelling.
3. If no contraindications exist, gather and place the suction equipment on the patient's overbed table or
bedside stand. Position the table or stand on your preferred side of the bed to facilitate suctioning.
4. Attach the collection bottle to the suctioning unit, and attach the connecting tubing to it. Date and then
open the bottle of normal saline solution or sterile water.
5. Explain the procedure to the patient even if he's unresponsive. Inform him that suctioning may stimulate
transient coughing or gagging, but tell him that coughing helps to mobilize secretions. If he has been
3
suctioned before, just summarize the reasons for the procedure. Reassure him throughout the
procedure to minimize anxiety and fear, which can increase oxygen consumption. Also, ask which nostril
is more patent.
6. Perform hand hygiene. Put on personal protective equipment as appropriate.
7. Place the patient in semi fowler's or high fowler's position, if tolerated, to promote lung expansion
and effective coughing. Unconscious clients may be positioned side-lying or lateral recumbent.
8. Hyperoxygenate patient prior to suctioning by increasing supplemental oxygen or ventilating
patient with a bag-valve-mask resuscitator, as per facility protocol. Hyperoxygenation is also done in
between suction passes and after suctioning.
9. Turn on the suction from the wall or portable unit, and set adequate pressure. Higher pressures cause
excessive trauma without enhancing secretion removal. Occlude the end of the connecting tubing to
check suction pressure.
10. Using strict sterile technique, open the suction catheter enough to expose but not touch its proximal end.
11. Don sterile gloves; consider your dominant hand sterile and your nondominant hand nonsterile.
12. Using your nondominant hand, pour the sterile water or saline into a sterile bottle/container.
13. With your nondominant hand, place a small amount of water-soluble lubricant on the sterile area (if
you’re doing nasopharyngeal suctioning. The lubricant is used to facilitate passage of the catheter during
nasopharyngeal suctioning.
14. Pick up the catheter with your dominant (sterile) hand, and secure it to the connecting tubing attached
to the suction machine. To activate suction, use the thumb of your nondominant hand to cover the
suction valve while your dominant hand manipulates the catheter. [see illustration below]
15. Instruct the patient to cough and breathe slowly and deeply several times before beginning suction.
Coughing helps loosen secretions and may decrease the amount of suctioning necessary, while deep
breathing helps minimize or prevent hypoxia.
4
16. For nasal insertion:

- Raise the tip of the patient's nose with your nondominant hand to straighten the passageway and
facilitate insertion of the catheter.
- Coat distal 2 to 3 inches (6 to 8 cm) of catheter with water-soluble lubricant.
- Without applying suction, gently insert the suction catheter into the patient's nares.
- Roll the catheter between your fingers to help it advance through the turbinates.
- Continue to advance the catheter approximately 5 to 6 inches (12.5 to 15 cm) until you reach the
pool of secretions or the patient begins to cough. [RULE OF THUMB: distance of insertion is about
the distance from tip of patient’s nose to base of earlobe]
17. For oral insertion:

- Without applying suction, gently insert the catheter into the patient's mouth. Advance it 3 to 4
inches (7.5 to 10 cm) along the side of the patient's mouth until you reach the pool of secretions
or the patient begins to cough. Suction both sides of the patient's mouth and pharyngeal area.
18. For tracheal insertion via artificial airway (endotracheal tube or tracheostomy):
- Insert catheter into the trachea without suction (thumb not covering suction valve). [see
illustration below on a tracheostomy tube]
- When resistance is felt upon insertion, this indicates that catheter has reached the carina.
Slightly withdraw catheter about 1 inch (2.5 cm) and then, activate suction (thumb covering
suction valve). [see illustration below on an ET]
5
- NOTE: If client is on mechanical ventilation, secure adapter of artificial airway to ventilator tubing
in between suction attempts. If on continuous Ambu®-bagging, ventilate patient in between
suction attempts [as shown in illustration below on a patient with an ET]
19. Using intermittent suction, withdraw the catheter from the mouth, nose or trachea with a continuous
rotating motion to minimize invagination of the mucosa into the catheter's tip and side ports. Apply
suction for only 10 to 15 seconds at a time to minimize tissue trauma (for tracheal suctioning, suction
should NEVER be applied for more than 10 seconds).
20. Allow 20 to 30 seconds interval between each suction pass to bring up mucous secretions and
prevent hypoxia. Between passes, wrap the catheter around your dominant hand to prevent
contamination. This will also be the opportune time to hyperoxygenate the client (using your
nondominant hand).
21. If secretions are thick, clear the lumen of the catheter by dipping it in sterile water or saline and applying
suction. [see illustration below]
22. For an artificial airway, 5 to 10 mL of sterile normal saline may be instilled before tracheal suctioning if
secretions are thick, per agency protocol.
23. Repeat the suctioning procedure until gurgling or bubbling sounds stop and respirations are quiet.
24. After completing suctioning, pull off your sterile glove over the coiled catheter, and discard it.
25. Flush the connecting tubing with normal saline solution or water and turn off suction afterwards.
6
26. Replace the used items so they're ready for the next suctioning, and perform hand hygiene.
27. Assess patient after the procedure and compare findings with baseline.
28. Monitor secretions for amount, color, consistency & odor to assess for evidence of bleeding or signs of
infection
▪ Sterile forceps may be used instead of sterile gloves when performing suctioning still using aseptic
technique.
▪ Separate catheters should be used for nasopharyngeal, oropharyngeal & tracheal suctioning when
performing these together.
▪ If the patient has no history of nasal problems, alternate suctioning between nostrils to minimize
traumatic injury.
▪ If repeated oronasopharyngeal suctioning is required, the use of a nasopharyngeal or oropharyngeal
airway will help with catheter insertion, reduce traumatic injury, and promote a patent airway; this will
also help prevent the patient from biting the catheter. [see illustration of nasopharyngeal &
oropharyngeal airway & procedure of insertion below]
- Insert the oropharyngeal airway upside down to
avoid pushing the tongue toward the pharynx,
and slide it over the tongue toward the back of
the mouth. Rotate the airway as it approaches the
posterior wall of the pharynx so that it points
downward
- To insert the nasopharyngeal airway, hyperextend
the patient's neck (unless contraindicated). Then
push up the tip of his nose and pass the airway
into his nostril. Avoid pushing against any
resistance to prevent tissue trauma and airway
kinking.
▪ A Yankauer suction tip may also be used for oropharyngeal suctioning. This is a rigid hollow tube made of
metal or disposable plastic with a curve at the distal end to facilitate the removal of thick pharyngeal
secretions during oropharyngeal suctioning. [see illustration below]
7
▪ Suctioning may also be utilized to retrieve tracheal aspirate specimen. For such procedure, a mucus or
sputum collection trap is used [see illustration below]
▪ The use of closed or in-line suction systems is now a trend. If used, closed system catheters may be left
in place and changed every 24 hours.
▪ Using standard precautions, the collection jar/bottle/container of
the portable or wall unit suction should be constantly drained
making sure the level does NOT exceed the fill line or more than
half of the container. DON’T wait for the container to be full before
draining it. If this happens, contents of container may “backfire” or
be sucked into the portable or wall unit suction.

Learning.
Williams & Wilkins.
F.A. Davis Company.
8

TRACHEOSTOMY CARE
 Tracheostomy is the formation of an opening into the trachea into which a tube is inserted through which
the patient breathes.
1. Give the indications for a tracheostomy.
2. Give the complications of a tracheostomy.
3. Identify the parts of a tracheostomy tube.
4. Discuss the emergency nursing management in the event accidental extubation occurs.
5. Perform tracheostomy care.
6. Apply the principles of asepsis and infection control throughout the procedure.
7. Explain rationale for each step of the procedure.

A. Indications for a Tracheostomy:
 Acute respiratory failure

 Anticipated upper airway obstruction from edema or soft tissue swelling due to head & neck
trauma
 CNS depression
 Facial or airway burns
 Neuromuscular disease
 Patients who require long-term ventilatory assistance (e.g., cervical spine injury)
 Severe obstructive sleep apnea syndrome
 Upper airway obstruction (tumor, inflammation, foreign body, laryngeal spasm)
B. Complications of a Tracheostomy: [consult textbook for clinical manifestations, prevention & management]
 Early Complications
- Air embolism - Posterior tracheal wall penetration
- Aspiration - Recurrent laryngeal nerve damage
- Bleeding - Subcutaneous emphysema
- Pneumothorax
 Long-Term Complications
- Airway obstruction (from accumulation of copious secretions)
- Laryngeal/tracheal injury (ulceration or necrosis of tracheal mucosa, postextubation tracheal
stenosis, tracheal dilation, tracheo-esophageal & tracheal-arterial fistula, innominate artery erosion,
tracheomalacia)
- Pulmonary infection & sepsis
- Dependence on artificial airway
1
C. Parts of a Tracheostomy Tube:
2
D. Emergency Nursing Management for Accidental Extubation

 Things to keep at the client’s bedside always: (1) obturator, (2) forceps/hemostat, (3) extra
tracheostomy tube, (4) bag-valve-mask resuscitator/Ambu®-bag attached to oxygen source
 In case tracheostomy tube is accidentally dislodged, HYPEREXTEND the client’s neck and grasp
retention sutures of stoma with sterile forceps to keep airway open.
 Call for help.
- Sterile gloves*
- Cotton-tip applicators*
- Sterile 4x4 gauze (without cotton lining)*
- Hydrogen peroxide*
- Sterile water or sterile saline*
- Disposable inner cannula (if available)
- 2 basins (preferably sterile; e.g., carbolized carrier pans are commonly used)
- Tracheostomy brush
- Tracheostomy ties
- Sterile towel

A. Performing Tracheostomy Care
1. Assess respirations for rate, rhythm & depth.
2. Auscultate lung fields.
3. Check ABG and pulse oximetry values.
4. Assess passage of air through tracheostomy tube.
5. Assess anxiety and restlessness.
6. Assess condition of stoma before tracheostomy care (note redness, swelling, character of secretions, and
presence of purulence or bleeding).
7. Examine neck for subcutaneous emphysema.
8. Explain procedure to the client.
10. Suction trachea & pharynx thoroughly before tracheostomy care (refer to Module 9 for this procedure).
11. Assemble tracheostomy care equipment. Place hydrogen peroxide solution on one sterile basin and
sterile water or saline on the other. Put on personal protective equipment and don gloves. Open and
moisten cotton-tip applicators (some will be moistened with sterile water/saline, some with hydrogen
peroxide and some are kept dry)
3
12. Remove soiled dressing and discard.

13. Change a disposable inner cannula, touching only the external portion, and lock it securely into place.
14. If inner cannula is reusable, remove it with your contaminated hand.
15. While holding external portion with your contaminated hand, immerse inner portion of reusable cannula
in the basin with H2O2 solution briefly.
16. Using a tracheostomy brush or cotton applicator, clean cannula with your sterile hand.
17. When clean, still holding external portion with contaminated hand, immerse inner portion of cannula
into basin of sterile water or saline solution. Agitate it to rinse thoroughly.
18. Tap inner cannula gently unto inner rim of sterile container to remove excess water but not dry enough
to facilitate reinsertion.
19. Reinsert reusable cannula and lock it securely into place.
20. Cleanse external end & neck plate of tracheostomy tube with cotton applicator moistened with H2O2.
21. Rinse external end & neck plate of tracheostomy tube with cotton applicator moistened with sterile
water or saline.
22. Wipe with dry cotton applicator.
23. Cleanse skin under neck plate of tube/stoma with cotton applicator moistened with H2O2. Make only a
single sweep with each applicator before discarding.
24. Rinse with cotton applicator moistened with sterile water or saline. Make only a single sweep with each
applicator before discarding.
25. Wipe with dry cotton applicator. Make only a single sweep with each applicator before discarding.
26. Change tracheostomy ties. Secure ties at the side of the neck in a square knot (ties should be tight
enough to keep tube securely in the stoma, but loose enough to permit two fingers to fit between the
tapes and the neck).
• NURSING ALERT: It is important to obtain assistance from another nurse or a respiratory
therapist because of the risk of accidental tube expulsion during this procedure. Patient
movement or coughing can dislodge the tube.
• If changing tracheostomy ties alone or without assistance, remove soiled ties one side at a time
as you attach the new tie on each eye of the flange. You may also ask the client to place his/her
fingers over the flange to secure tube as you change the tie.
• In removing the soiled ties, DON’T cut it. Simply untie the square knot during removal.
4
27. Change tracheostomy dressing. Place a gauze pad between the stoma site and the tracheostomy tube to
absorb secretions and prevent irritation of the stoma. [see illustration below]
28. Discard all used materials & perform hand hygiene.
 Sterile technique is used for tracheostomy care of a fresh or newly-created stoma. Once healed, clean
technique may be used.
 Tracheostomy care is routinely done every shift; inner cannula may be cleaned more frequently (as
often as every 2 hours)
 Tracheostomy ties should be changed every 24 hours or more frequently if soiled or wet.
 Assess tightness of tracheostomy ties at least once per shift.
 In preparing a tracheostomy dressing, make sure to fold the gauze in such a way that loose fibers are
tucked in and away from contact into tracheostomy tube opening. Loose gauze fibers may result in
aspiration.
 If the patient's neck or stoma is excoriated or infected, apply a water-soluble lubricant or topical
antibiotic cream as ordered. Remember not to use a powder or an oil-based substance on or around a
stoma because aspiration can cause infection and abscess.

Learning.
 Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s fundamentals of nursing: Concepts,
Williams & Wilkins.
 Williams, L. & Hopper, P. (2003). Understanding medical-surgical nursing (2nd ed.). Philadelphia, PA:
F.A. Davis Company.
5

INTRAVENOUS (I.V.) THERAPY
 Intravenous Therapy is the administration of fluids or medication via a needle or catheter (cannula) directly
into the bloodstream.
1. Identify the commonly used intravenous fluids in the clinical area and state their classification &
common uses.
2. Identify different equipment used for peripheral I.V. line insertion & infusion.
3. Name the basic parts of an intravenous therapy setup.
4. Prepare appropriate equipment essential for accurate delivery of an I.V. solution.
5. Perform preparation of the IV bag and priming of the I.V. Tubing.
6. Perform incorporation of prescribed potassium chloride solution accurately in the client’s IVF.
7. Perform taping of a venous access site using various methods and applying of splint & padded
restraints as applicable.
8. Enumerate techniques to assess for patency of the peripheral I.V. line.
9. Apply principles of asepsis & infection control throughout each procedure.
10. Explain accurately rationale for each step of the procedure.
11. Discuss computation of IVF flow rate & other relevant computations.
12. Describe routine peripheral I.V. line maintenance.
13. Describe measures used for preventing complications of intravenous therapy.

A. Intravenous Fluids Commonly Used in the Clinical Area:
Common
Name of Solution Classification Common Use/s
Abbreviation
Universal IVF; Diabetic Clients; Used in
0.9% Sodium Chloride Solution PNSS Isotonic adjunct with Blood Transfusion; Flushing
I.V. Line
Lactated Ringer’s Solution PLR Isotonic Clients with burns & metabolic acidosis
Vehicle for mixing medications for I.V.
5% Dextrose in Water D5W Isotonic
delivery
5% Dextrose in Lactated Ringer’s Anticipated blood loss (e.g., obstetric &
D5LR Hypertonic
Solution surgical patients)
Fluid & electrolyte loss (e.g., clients with
5% Dextrose in Normosol-M D5NM Hypertonic
LBM & vomiting)
5% Dextrose in Multiple Balance Fluid & electrolyte loss (e.g., clients with
D5IMB Hypertonic
Solution LBM & vomiting)
5% Dextrose in 0.9% Sodium
Chloride Solution D5NSS Hypertonic Diabetic clients on NPO
A. Intravenous Fluids Commonly Used in the Clinical Area: (continued)

1
Common
Name of Solution Classification Common Use/s
Abbreviation
5% Dextrose in 0.3% Sodium Clients with fluid overload such as in those
D50.3NaCl Hypertonic
Chloride Solution with congestive heart failure
Anticipated blood loss (e.g., surgical
Plasmalyte-148 PL148 Hypertonic patients); may be used in adjunct with
blood transfusion
50% Dextrose in Water D50W Hypertonic Severe hypoglycemia (as IV bolus)
Replaces cellular fluid; provides free water
0.3% Sodium Chloride Solution 0.3NaCl Hypotonic
for excretion of body wastes
Replaces cellular fluid; provides free water
0.45% Sodium Chloride Solution 0.45NaCl Hypotonic
for excretion of body wastes
B. Different Equipment Used for Peripheral I.V. Line Insertion & Infusion:
 Intravenous (I.V.) Cannulas
 Standard Color Coding of Bore-Sizes: [the bigger the number, the smaller the lumen]
• 18-gauge (18G) = Green • 24-gauge (24G) = Yellow
• 20-gauge (20G) = Pink • 26-gauge (26G) = Purple
• 22-gauge (22G) = Blue
 Types:
1. Steel Needles/Winged Infusion Set/Butterfly Needle
 Used when infusion time will be short
 Commonly used in children & elderly, whose veins are likely to be small or
fragile
 Infiltration is MORE common with this type of cannula
2. Plastic Cannulas [common brands: Kitkath®, BD Venflon®, BD Neoflon®]

 Two kinds of plastic cannulas:
a. Over-the-needle cannula  preferred for rapid infusion; ideal for an
agitated patient
Some over-the-needle cannulas

may also have plastic wings.
2
b. In-needle or Through-the-needle cannula  increased risk for catheter

embolism if tip of cannula
breaks
 Intravenous (I.V.) Containers
 Types:
1. Plastic container
• Squeeze the plastic bag to ensure intactness.
• DO NOT WRITE on the plastic IV bag with a marking
pen because the ink may be absorbed through the
plastic in the solution.
• Use a label and a ballpoint pen for marking the bag,
placing the label onto the bag.
2. Glass container
• Assess the glass bottle for any cracks before

hanging.
• Use vented tubing for glass containers to
allow air to enter and displace the fluid as it
leaves (fluid will not flow from a glass IV
container unless it is vented)
• Some have a tube inside the bottle that
serves as a vent
3
 IV Administration or Infusion Sets & Drip Chambers

 Types:
1. Microdrip Set
• Chamber has a short vertical metal piece where the
drop forms
• Drop factor: 60 gtts/mL
• Used if fluid will be infused at a slow rate (less than
50 mL/hr)
• Used if the solution contains potent medication that
needs to be titrated, such as in a critical care setting
or in pediatrics
2. Macrodrip Set
• Used if the solution is thick or is to be infused rapidly
• Drop factor: 10 – 20 gtts/mL (usually 15 gtts/mL)
3. Solu-Set or Volume-Control Set

• An I.V. line with a graduated chamber
• Delivers precise amounts of fluid and
shuts off when the fluid is exhausted,
preventing air from entering the I.V.
line
• May be used as a secondary line in
adults for intermittent infusion of
medication
• Used as a primary line in children for
continuous infusion of fluids or
medication.
• Drop factor: 60 gtts/mL
 NURSING ALERT: Special I.V. tubing is used for medication that absorbs
into plastic (e.g., chemotherapy drugs)

 Intravenous (I.V.) Extension Sets [common brand : BD Twin-Site®]
 Used mainly to extend or lengthen intravenous (I.V.) tubing to allow extra movement. 4
 May also be attached to an existing I.V. line preoperatively especially in surgeries requiring
a lot of sophisticated equipment (e.g., eye surgery) to prevent IV line from obscuring
operative site.
 Intermittent Infusion Devices: Male adapter

(this is the part that fits
 Commonly Used Device: to patient’s IV cannula)
1. Saline/Heparin Lock or Injection Site Adapter (ISA)
• Used when intravascular accessibility is desired
for intermittent administration of medications by
IV push or IV piggyback. Rubber access port
• Patency is maintained by periodic flushing with (needle of syringe is injected
here to administer medication)
normal saline solution (0.9% sodium chloride)
• Always disinfect the rubber access port with alcohol swab before & after
introducing solutions.
• When administering medication, flush with 1 to 2 mL of normal saline to confirm
placement of the IV cannula; administer the prescribed medication, and then flush
the cannula again with 1 to 2 mL of normal saline to maintain patency.
• If resistance is met while heplock is being flushed, a clot may be occluding it.
DON’T exert pressure on the syringe plunger in an attempt to restore patency
because doing so may dislodge the clot into the vascular system or rupture the
catheter.
 3-Way Stopcock = a valve or turning plug that controls the flow of fluid from a container through
a tube; can be used on IV tubing to turn off one solution and turn on another. Has 2 varieties:
Stopcock with 3 knobs Stopcock with 1 knob

(arrows where the 3 knobs (the knob points to the conduit that
point indicate open conduits to is closed or to which the solution
which the solution will flow) will not flow)
 Transparent Permeable Dressing

[common brand: Tegaderm®]
5
 Electronic Controller or Infusion Pump = an apparatus

designed to deliver precise amounts of a drug or IV
solution (e.g., in gtts/min or mL/min) through IV
injection over time.
 IV Prep Kit = a kit which already comprises all

materials for insertion of an IVF including the
IV cannula.
 Closed-Needleless Hub Device [common brand: CLAVE®] = a device that works similarly to a
heplock/ISA but allows needle-free connection of syringes to an existing intravenous (IV) line.
Needleless port is still disinfected with alcohol swab before & after introducing solutions.
Male adapter
Needleless Access Port (this is the part that fits to the
(this is the port where patient's IV cannula or Y-site
medication/solution is given via of IV tubing)
a luer-lock syringe w/o needle)
C. Basic Parts of an Intravenous Therapy Setup:
[1 ] IV container (plastic or glass)

[2 ] Air Vent (closed systems don’t have this)
[3 ] Administration/Infusion Set Spike
[4 ] Drip Chamber
[5 ] Clamp (has three different variations)
Roller Screw Slide Clamp

Clamp Clamp
[6 ] Tubing
[7 ] Y-site
[8 ] Injection port of Y-site
[9 ] Distal End/Hub/Adapter
(for attachment to IV Cannula)
6
D. Techniques to Assess for Patency of the I.V. Line:

 Check if the IVF is flowing at prescribed rate
 Briefly compress the IV cannulated vein above the site & note for slowing or momentary
cessation of IV rate with a positive blood return
 Pinch the tubing proximal to IV insertion site and assess for tenderness
 Assess for coolness, tenderness & any other unusualities on IV insertion site
 Place IV solution in a dependent position & check for backflow of blood (make sure clamp is
opened while doing this technique)
E. Formulas for Intravenous Calculations:

1. Flow Rates
Total volume (in mL) x Drop Factor = Drops per minute
No. of Hours to Infuse x 60
2. Infusion Time
_Total volume (in mL) to infuse_ = Infusion time
Milliliters per hour being infused
3. Number of Milliliters per Hour

Total volume in milliliters = Number of milliliters per hour
Number of hours
F. Complications of Intravenous Therapy: (consult textbook for clinical manifestations, prevention &
management)
 Infection (local & systemic)  Catheter embolism
 Tissue damage  Circulatory overload
 Phlebitis  Electrolyte overload
 Thrombophlebitis  Hematoma
 Infiltration  Air embolism
A. Preparing an IV Bag, Incorporating KCl Solution & Priming the I.V. Tubing:
- Alcohol swab*
- Appropriate IV Solution (bottle or bag)
- Appropriate IV Administration or Infusion Set (macrodrip, microdrip or volume-control set)*
- IV Cannula (use appropriate bore size)
- Potassium Chloride Solution (vial)
- 10 mL disposable syringe with needle*
- Permanent marker (for labeling)*
- IV pole
7
- Container for Sharps
B. Taping a Venous Access Site and Applying a Splint & Padded Restraint:
- Adhesive tape (e.g., Leukoplast®, Micropore® or Transpore® White)
- Bandage Scissors*
- Cardboard or Wooden Splint (covered with paper) – appropriate size (e.g. 2x5 inch)
- Small diaper, cheese cloth or hand towel (as padded restraint for pediatric patients)*
A. Preparing an IV Bag, Incorporating KCl Solution and Priming the I.V. tubing
1. Check doctor’s order for the IV solution
2. Review information regarding the solution and nursing implications in order to ensure accurate
administration.
3. Check all additives in the solution and other medications so that there will be no incompatibilities with
the solution.
5. Open package of administration/infusion set.
6. Slide the flow clamp of the administration set tubing down to the drip chamber or injection port and
close the clamp.
7. Place the IV bag on a flat, stable surface. Check the expiration date on the bag and assess for
cloudiness or leakage.
8. Remove the protective cap or tear the tab from the tubing insertion port/rubber membrane of the IV
bottle/bag [see illustration]. It is important to keep the tubing insertion port/rubber membrane of the
IV bottle/bag sterile.
9. Using a syringe with needle, withdraw prescribed dosage of KCl solution (in mEqs) from its vial .
8
10. Maintaining aseptic technique, incorporate KCl by injecting solution through the tubing insertion
port/rubber membrane of the IV bottle/bag. [Prior to incorporating KCl, you may wipe tubing insertion
port with an alcohol swab if you have touched it during the removal of the protective cap]
11. Agitate or shake IV bottle/bag vigorously.
12. Label IV bottle/bag indicating amount of KCl incorporated in mEqs.
13. Remove the protective cap from the administration set spike [see illustration].
14. Holding the port firmly with one hand, insert the spike with your other hand [see illustration].
15. Hang the bag on the I.V. pole, and squeeze the drip chamber until it is half full [see illustration].
9
16. Aim the distal end of the tubing over a wastebasket or sink and slowly open the flow clamp. Most
distal tube coverings allow the solution to flow without having to remove the protective cover. Leave
the clamp open until the I.V. solution flows through the entire length of tubing to release trapped air
bubbles and force out all the air [see illustration].
17. After priming the tubing, close the clamp. Then loop the tubing over the I.V. pole.
B. Taping a Venous Access Site and Applying a Splint & Padded Restraint
1. Assess patient for latex allergy to determine appropriate adhesive tape to be used. People allergic to
kiwi, banana, pineapple, passion fruit, avocado and chestnuts may be allergic to latex. The client may
also have a latex allergy if he/she ever had swelling, itching, hives or other symptoms after contact
with a balloon, condom, or after a procedure in which the examiner wore rubber/latex gloves.
2. Cut strips of adhesive tape while maintaining aseptic technique.
3. Insert distal end of administration set/adapter to the IV cannula once backflow of blood to the cannula
is noted.
4. Open the clamp at a slow rate because doing so at a faster rate may rupture fragile veins.
5. Once peripheral I.V. line is established, regulate client’s IV at the prescribed rate.
6. Tape plaster strips on venous access site.
 Below are the BASIC techniques for taping:
 Cut a long 5- to 6-inch strip of ½ inch tape. Place

one strip of tape, sticky side under hub, parallel
with the dressing.
 Cross the end of the tape over the opposite side of
the needle so that the tape sticks to the patient’s
skin.
Chevron Method
(used for an IV cannula
10
WITHOUT plastic wings)
 With sticky side up, place one strip of ½ inch tape

under tubing.
 Bring each side of the tape up, folding it over the
wings of the needle. Press it down, parallel with
the tubing.
U Method
WITH plastic wings)
 Cut three strips of 1-inch tape.

 Place one strip of tape over each wing; keep the
tape parallel with the needle.
 Place another strip of tape perpendicular to the
first two. Place over the wings to stabilize wings
and hub.
H Method
WITH plastic wings)
NOTE: Making use of the above-mentioned basic steps, refer to the procedure demonstrated by
your instructor on how the venous access site is taped in CVGH.
7. Make sure tape sticks to the patient’s skin to ensure stabilization of cannula.
8. Loop the tubing and secure it with another piece of adhesive tape.
9. A splint and padded restraints may be applied (especially on pediatric & agitated clients) using the
method demonstrated by your facilitator [see illustration below].
APPLYING SPLINTS:
 The nurse should see to it that tapes are NOT
applied too tightly on the splint.
 Apply splint on areas where flexion of extremity
increases the chances of dislodging I.V. Site
 I.V. site should be visible to allow periodic
assessment.
11
APPLYING PADDED RESTRAINTS:
 The nurse may use a CLEAN diaper, cheese cloth
or hand towel as padded restraint over the
splinted I.V. site.
 The nurse should see to it that padded restraints
are NOT applied too tightly over the splint & site.
 I.V. site should also be visible to allow periodic
assessment.
 Padded restraints are changed every I.V. dressing
change or when it becomes wet or soiled, as the
restraint too can become moist & foul-smelling
(especially the inside) & harbor pathogens.
 Precautions & Special Considerations:

 Clients with respiratory, cardiac, renal, or liver diseases, older clients and very young persons cannot
tolerate an excessive fluid volume, and the risk of fluid overload exists with these clients.
 A client with congestive heart failure usually is not given a solution containing a high concentration
saline because this type of fluid encourages the retention of water and would therefore exacerbate
heart failure by increasing the fluid overload; thus, an IV fluid with a lower saline concentration (e.g.,
D50.3NaCl) or with no saline at all is used.
 A client with diabetes mellitus usually does not receive dextrose (glucose) solutions except when on
NPO (e.g., D5NSS).
 Lactated Ringer’s solution contains potassium and should NOT be administered to clients with renal
failure.
 Change the venipuncture site every 48 to 72 hours, depending on agency policy.
 Change the IV dressing every 72 hours, when the dressing is wet or contaminated, or as specified by
agency policy.
 Label the tubing, dressing and solution bags clearly, indicating the date and time when changed.
 DO NOT let an IV bag or bottle of solution hang for more than 24 hours because of the potential for
sepsis.
 DO NOT allow the IV tubing to touch the floor because of the potential for bacterial contamination.
 Before adding medications or solutions, swab access ports with 70% alcohol.
 AVOID checking the blood pressure on the arm receiving the IV infusion if possible.
 DO NOT place restraints over the venipuncture site.
12
 Some IV medications, such as antibiotics,

need to be infused over a short period of
time. This may be done as an intermittent
infusion. If the patient already has a
primary continuous IV infusing, the
secondary infusion can be “piggybacked”
into the primary IV line/main line. In order
for the piggyback medication to infuse, it
must hang HIGHER than the primary
infusion/main line. [see illustration]

Learning.
 Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s fundamentals of nursing: Concepts,
Williams & Wilkins.
 Silvestre, L.A. (2005). Saunders comprehensive review for the NCLEX-RN examination (3rd ed.).
Philadelphia: Elsevier Saunders.
F.A. Davis Company.

WOUND DRAIN MANAGEMENT
 Not all surgical wounds need drains, however, if indicated, it promotes healing and prevents swelling by
drawing out or suctioning the serosanguineous fluid that accumulates at the wound site postoperatively. By
removing this fluid, the wound drain helps reduce the risk of infection and skin breakdown as well as the
number of dressing changes.
1. Give the general uses of surgical wound drains.
2. Identify the most commonly used wound drains & name its parts.
3. Describe nursing care of clients with wound drains.
4. Perform emptying of a Jackson-Pratt drain.
5. Perform emptying of a HemoVac drain.
6. Apply principles of asepsis & infection control throughout each procedure.
7. Explain accurately rationale for each step of the procedure.

A. General Uses of Wound Drains:
▪ To prevent accumulation of fluid (blood, pus and infected fluids)
▪ To prevent accumulation of air
B. Commonly Used Wound Drains:

1. Penrose Drain
• the most commonly used wound drain
• a flexible, soft rubber/latex tube, 1 to 2 cm in width and of
varying length, placed through a stab wound adjacent to the
patient’s main surgical incision
• has a large safety pin outside to maintain its position
• to facilitate drainage & healing of tissues from the inside to
the outside, the tube is often pulled out (usually with dressing
forceps or hemostat) and shortened 1 to 2 inches each day
until it falls out
2. Jackson-Pratt Drain
• also called ‘bulb drain’; consists of a flexible rubber
bulb – shaped something like a hand grenade – that
connects to an internal drainage tube
• removing the bulb’s spout cap, squeezing air out of
the bulb & replacing the cap, creates a constant
suction in the drainage tubing, thereby drawing
excess fluid from the surgical wound
• generally used after abdominal, breast, & thoracic
surgery with small amounts of drainage
1
3. HemoVac Drain
• consists of a large round drainage
reservoir that connects to an internal
drainage tube
• removing the drainage reservoir’s plug,
squeezing air out by compressing the
reservoir & replacing the plug, creates a
constant suction in the drainage tubing,
thereby drawing excess fluid from the
surgical wound
• generally used after abdominal, breast, &
thoracic surgery with large amounts of
drainage
▪ Emptying a Jackson-Pratt Drain

- Alcohol Swab*
- Safety Pin *
- Calibrated Glass (for collecting drainage)
- Permanent Marker (for labeling if more than one drain is used)
▪ Emptying a HemoVac Drain
- Alcohol Swab*
- Calibrated Glass (for collecting drainage)
A. Emptying a Jackson-Pratt Drain
1. Review order of physician or standing order for drain care.
2. Provide privacy & explain procedure to client.
3. Perform hand hygiene and set up supplies. Apply clean exam gloves.
4. Unpin drain tube from gown or clothing.
5. Assess site for signs of infection. Ascertain that the sutures that secure tube to skin are intact; check
the placement of the drain and that tubing is not kinked.
6. Assess the bulb for contents. The fluid in the JP drain system is red immediately post-op to about 24
hours, then changes to light red 1 to 3 days post-op, then changes to straw-colored.
7. Wipe the spout of the drainage collection bulb with alcohol swab.
8. Remove the cap to the spout, being careful not to touch the tip of the spout cap or the spout to
anything.
2
9. Pour the drainage collected in the drain bulb into the measuring container. Use a small calibrated cup.
If diagnostic tests will be performed on the fluid specimen, pour the drainage directly into a sterile
laboratory container, note the amount and appearance, and send it to the laboratory.
10. Once emptied, while the cap is still off and the system is open, squeeze the bulb [see illustration
below] and while compressed, reapply the cap to the spout.
(Rationale: to establish vacuum system negative pressure)
11. Wipe the spout with alcohol swab.

12. Secure JP drain to patient gown/clothing. Fasten below wound level.
(Rationale: to allow gravity to facilitate wound drainage). Don't apply tension on drainage tubing
when fastening the unit to prevent possible dislodgement.
13. Remove and properly dispose of gloves and perform hand hygiene.
14. Record drainage in the intake & output record and dispose of the drainage.
15. Empty the drain and measure its contents once during each shift if drainage has accumulated, more
often if drainage is excessive. Removing excess drainage maintains maximum suction and avoids
straining the drain's suture line.
16. If the patient has more than one closed drain, number the drains so you can record drainage from
each site. Record also each JP drain separately on intake & output record.
(Rationale: to allow for an accurate recording of drainage.)
B. Emptying a HemoVac Drain

1. Review order of physician or standing order for drain care.
2. Provide privacy & explain procedure to client.
3. Perform hand hygiene and set up supplies. Apply clean exam gloves.
4. Assess site for signs of infection. Ascertain that the sutures that secure tube to skin are intact; check
the placement of the drain and that tubing is not kinked.
5. Assess the reservoir for contents. The fluid in the HemoVac system is red immediately post-op to
about 24 hours, then changes to light red 1 to 3 days post-op, then changes to straw-colored.
6. Clamp the drainage tubing to prevent backflow of drainage during compression of reservoir.
7. Wipe the plug of the drainage collection reservoir with alcohol swab.
8. Open the plug, being careful not to touch the tip or its inside [see illustration below].
9. Pour the drainage collected in the reservoir into the measuring container. Use a small calibrated cup. If
diagnostic tests will be performed on the fluid specimen, pour the drainage directly into a sterile
laboratory container, note the amount and appearance, and send it to the laboratory.
10. To reestablish suction, compress the drainage unit against a firm surface
to expel air and, while holding it down, replace the plug with your other
hand. Don't apply tension on drainage tubing when compressing the
unit to prevent possible dislodgment. [see illustration]
11. Wipe the plug with alcohol swab.
12. Unclamp drainage tubing and make sure that the reservoir is placed below wound level to promote
drainage.
13. Remove and properly dispose of gloves and perform hand hygiene.
14. Record drainage in the intake & output record and dispose of the drainage.
15. Empty the drain and measure its contents once during each shift if drainage has accumulated, more
often if drainage is excessive. Removing excess drainage maintains maximum suction and avoids
straining the drain's suture line.

Learning.
Williams & Wilkins.
4

CAPILLARY BLOOD GLUCOSE (CBG) MONITORING
 Capillary Blood Glucose (CBG) Monitoring, usually indicated in clients diagnosed with diabetes mellitus,
involves pricking a finger (or other alternate site) with a lancet device to obtain a small capillary blood sample,
applying the drop of blood onto a reagent strip, and determining the glucose concentration by inserting the
strip into a reflectance photometer or more commonly called blood glucose meter or glucometer, for an
automated reading. Unlike a Fasting Blood Sugar (FBS) test, the procedure doesn’t require laboratory analysis
of specimen and results are obtained instantly (usually in less than 2 minutes).
 Self-Monitoring of Blood Glucose (SMBG) is a new trend in diabetes management which involves capillary
blood glucose monitoring performed solely by the client or a caregiver, at home & at work, with the objective
of collecting detailed information about blood glucose levels at many time points so as to enable maintenance
of a more constant glucose level by more precise therapeutic regimens. Apart from obtaining blood glucose
levels, SMBG requires the patient to keep a logbook of results (although most modern blood glucose meters
have a built-in memory). These SMBG results can be used by the patient to correct any deviations out of a
desired target range by changing his/her carbohydrate intake, exercising, or using more or less insulin. Client
teaching in SMBG is thus an important role to be played by the nurse.
1. Give the indications of CBG monitoring.
2. Perform capillary blood glucose (CBG) monitoring.
 Indications of CBG Monitoring:

▪ To evaluate effectiveness of the medication regimen of clients with diabetes mellitus (i.e., insulin,
oral hypoglycemic agents)
▪ To assess glucose excursion after meals (referred to as postprandial blood glucose)
▪ To assess glucose response to exercise regimen
▪ To evaluate episodes of hypoglycemia and hyperglycemia to determine appropriate treatment
▪ To distinguish between diabetic coma & non-diabetic coma
▪ Also used to screen for neonatal hypoglycemia
- Blood glucose meter* with appropriate test/reagent strip (& calibrator, if needed)*
- Lancet/lancing device*
- Alcohol swab*
- Cotton ball* (& adhesive bandage; however, optional)
1
1. Explain the procedure to the patient and instruct him NOT to eat or drink two (2) hours prior to CBG
monitoring. Blood glucose levels are usually monitored three times a day before meals (TID ac) and at
bedtime (q HS).
2. Prepare the finger to be lanced by having the patient wash hands in warm water and soap. Washing in
warm water will increase the blood flow to the finger. Allow to air dry. For convenience, an alcohol swab
may be used to cleanse the finger. Alcohol must dry thoroughly (by air drying) before finger is lanced.
3. CLINICAL TIP: In diabetic clients with ineffective peripheral tissue perfusion (usually manifested as pallor &
cold clammy fingers), it is necessary to dilate the capillaries prior to obtaining blood sample by applying
warm, moist compresses to the hand for about 10 minutes (or until there is adequate blood flow to
fingers). If this doesn’t work, an alternate site such as the earlobe may be used; however, site should NOT
be used when accuracy is critical (i.e., suspected hypoglycemia, before or after exercise, or before driving).
4. PEDIATRIC ALERT: Select the heel or great toe for an infant to obtain blood sample for CBG.
5. Don disposable gloves. Turn on the glucose meter. Prepare the meter by validating the proper calibration
with the strips to be used. (This usually involves matching a code number on the strip bottle to the code
registered on the meter.) Errors in glucose readings can result from miscalibrated or improperly coded
meters.
6. The meter will indicate its readiness for testing blood glucose by message or symbol. Some meters require
that the glucose test strip be inserted at this time.
7. To collect a sample from the fingertip with a disposable lancet (smaller than 2
mm), position the lancet on the side of the patient's fingertip, perpendicular to
the lines of the fingerprints (this area has lesser nerve endings). Pierce the skin
sharply and quickly to minimize the patient's anxiety and pain and to increase
blood flow. A lancet device or spring-loaded lancing pen may also be used for
convenience [see accompanying illustration].
8. After puncturing the fingertip, DON’T squeeze the puncture site to avoid diluting the sample with tissue
fluid. Wipe & DISCARD the first drop of blood to prevent serous fluid from causing a false positive result.
9. Obtain a large, hanging drop of blood. Most inaccurate readings of blood glucose result from insufficient
blood samples.
10. Drop (& DON’T smear) the blood carefully to the strip test area (varies by glucose
meter model). Some glucose meters require that the test area be covered
completely for accurate results. Others use only a small drop of blood inserted at
the side of the test strip [see accompanying illustration].
2
11. For a “no-wipe” system, blood remains on the strip as the meter times and
processes the result. Meters with a “wipe” system require that the blood be
wiped off from the test strip with a firm stroke using a cotton ball at the
appropriate end time (usually 60 seconds). The strip is inserted into the meter for
the final result/reading [see accompanying illustration].
12. After collecting the blood sample, briefly apply pressure to the puncture site to prevent painful
extravasation of blood into subcutaneous tissues. Ask the adult patient to hold a dry cotton firmly over
the puncture site until bleeding stops.
13. After bleeding has stopped, you may apply a small adhesive bandage to the puncture site.
14. Do aftercare of equipment and discard used disposable items appropriately. DO NOT recap the used
lancet; discard it in the sharps container.
15. Do appropriate documentation and referral of results. A value of less than 60 mg/dL suggests
hypoglycemia and a value greater than 120 mg/dL suggests hyperglycemia.
16. For SMBG, instruct client to record CBG results on a logbook for future reference [see illustration below].
17. Most blood glucose meters also have an enclosed logbook or blood sugar diary for recording results [see
a sample logbook recording below]. Diabetes management software & online logbook software are also available
for keeping track of client’s blood glucose recordings which could be downloaded from the physician’s office.
*on the insulin column in the example above, the number refers to the amount of insulin taken by the client in units; the h means
Humulin-R &; the L means Lente insulin
3

▪ An alternate term for CBG which is used in some institutions is HGT (or hemoglobin glucose test).
▪ BEFORE using reagent strips, check the expiration date on the package and replace outdated strips.
Check for special instructions related to the specific reagent. The reagent area of a fresh strip should
match the color of the block on the color chart (may vary from one device to another).
▪ Protect the reagent strips from light, heat, and moisture. A desiccant may come with the strip
packaging to absorb moisture.
▪ BEFORE using a blood glucose meter, calibrate it and run it with a control sample to ensure accurate
test results. Follow the manufacturer's instructions for calibration.
▪ AVOID selecting cold, cyanotic, or swollen puncture sites to ensure an adequate blood sample. If you
can't obtain a capillary sample (even in alternate sites), perform venipuncture and place a large drop of
venous blood on the reagent strip. If you want to test blood from a refrigerated sample, allow the
blood to return to room temperature before testing it.
▪ Newer blood glucose meters, such as the One Touch® Ultra®, require smaller amounts of blood; the
puncture may be done on the patient's arm instead of his finger.
▪ Bear in mind that hematocrit may affect results of glucose testing because erythrocytes in the whole-
blood sample can alter the ratio of blood glucose to plasma glucose, as well as the flow of plasma and
delivery of oxygen into the test strip. Higher-than-normal hematocrit concentrations will
underestimate blood glucose levels, while lower-than-normal concentrations will overestimate levels.
Checking the hematocrit range specified by the device manufacturer is a key safety measure, especially
in the hospital setting so as to avoid discrepancies in the meter readings.
▪ For clients on SMBG:
- Remind patients to clean their meters as directed and to wash their hands before testing.
- Patients engaging in high-altitude activities, particularly at low temperatures, should be alerted
of the potential for false high or low readings (there is clinical evidence that humidity, altitude &
temperature may affect accuracy of meter readings)
- The patient may opt to purchase an auto-coded blood glucose meter (a new variation of blood
glucose meters in which calibrating is no longer needed)
- Perform a return demonstration with the patient on technique for SMBG. Assess every 1 to 6
months to ensure procedure is done properly & that accurate readings are obtained.
- Inform client that diabetes cannot be cured but it can be managed. Through SMBG, therapeutic
management can be individualized, complications are promptly addressed & patient well-being
is maximized.
4

▪ Hirsch, I., Bode, B., Childs, B., Close, K., Fisher, W., Gavin, J., ..., Verderese, C. (2008). Self-monitoring of
blood glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: Consensus
recommendations for improving SMBG accuracy, utilization, and research. Medscape. Retrieved
June 5, 2010 from http://cme.medscape.com/viewarticle/581962
▪ Schilling-McCann, J. (2002). Patient teaching reference manual. Philadelphia, PA: Springhouse
Corporation.
5

INSULIN THERAPY
 Insulin therapy involves the subcutaneous injection of insulin at various times to achieve the desired effect.
Short-acting regular insulin, a type of insulin, can also be given intravenously. Insulin is a hormone which
generally decreases blood glucose and is exogenously given to clients with Type 1 & Uncontrolled Type 2
Diabetes Mellitus.
1. Discuss the different categories of insulin preparations and give examples of each.
2. Cite the various complications of insulin therapy and explain their prevention & management.
3. Identify the parts of an insulin syringe.
4. Explain how an insulin syringe differs from a tuberculin syringe.
5. Identify the parts of an insulin pen injection device.
6. Perform proper withdrawal of insulin from a vial to an insulin syringe & perform mixing of two
different types of insulin into one syringe.
7. Enumerate the subcutaneous injection sites.
8. Perform subcutaneous injection of insulin using an insulin syringe.
9. Perform subcutaneous injection using a flexpen or insulin pen injection device.
10. Discuss nursing implications of insulin therapy.

A. Categories of Insulin Preparations:
TIME COURSE EXAMPLE ONSET PEAK DURATION INDICATIONS / REMARKS
- Rapid reduction of glucose
insulin aspart 10 – 15 40 - 50 level, to treat postprandial
Rapid-Acting 4 – 6 hours
(NovoRapid) minutes minutes hyperglycemia, and/or to prevent
nocturnal hypoglycemia
- Usually administered 20–30
regular insulin ½-1 minutes before a meal; may be
Short-Acting 2 – 3 hours 4 - 6 hours
(Humulin-R) hour taken alone or in combination with
longer-acting insulin
neutral
protamine - Usually taken after meals
Intermediate- 2-4 6 – 12 16 – 20
Hagedorn/NPH - Covers insulin needs for about half
Acting hours hours hours
insulin the day or overnight
(Humulin-N)
Long-Acting
insulin detemir 1–2
6 – 8 hours Up to 24 - Covers insulin needs for about 1
(Levemir) hours hours full day.
insulin glargine continuous
Very Long-Acting 1 hour 24 hours - NEVER mix with ANY type of insulin
(Lantus) (no peak)
* note that onset, peak & duration varies per category & brand of insulin; always see package insert of medication for
complete drug information.
1
B. Complications of Insulin Therapy: (see textbook for detailed discussion & nursing management)
▪ Hypoglycemia
▪ Local & systemic allergic reactions
▪ Insulin lipodystrophy
▪ Insulin resistance
▪ Dawn phenomenon
▪ Somogyi effect
▪ Insulin waning
C. Parts of an Insulin Syringe:
D. Insulin Syringe vs. Tuberculin Syringe:
Insulin Syringe Tuberculin Syringe
* NOTE: a 100-unit insulin syringe has a capacity of 1 mL

& a 50-unit insulin syringe, 0.5 mL.
E. Parts of an Insulin Pen Injection Device or Flexpen:

Short Cap Needle
2
F. Subcutaneous Injection Sites [areas in the illustration indicated with dots]:
- Disposable insulin syringe with needle* (or insulin pen injection device with insulin cartridge)
- Short cap needle (for flexpen or insulin pen injection device)*
- Alcohol swabs*
- Dry absorbent cotton*
- Prescribed vial/s of insulin
- Container for sharps

A. Mixing Insulin from Two Vials into One Syringe :
1. Check client’s most recent blood glucose level, dietary intake, oral intake status (i.e., is
NPO), and signs and symptoms of hypoglycemia & hyperglycemia.
3. Check for drug allergies especially to beef or pork if preparing to withdraw beef/pork insulin.
5. Gather the equipment needed. Prepare medication for one client at a time.
6. After checking expiry date & syringe compatibility, remove caps from insulin vials (if
necessary). Gently rotate (never shake) the suspension (cloudy) insulin, such as
intermediate- or long-acting insulin, until no sediment is at the bottom of the vial. (Rationale:
Vigorous shaking may result in air bubbles, so rotating or rolling is preferred.)
7. Wipe off tops on insulin vials with an alcohol swab.
3
8. Draw back the amount of air into the syringe that equals the total dose of both insulin solutions.
Insert the needle and syringe into the vial with the cloudy, suspension (intermediate- or long-acting)
and inject air equal to the amount to be given of that insulin. Do not touch solution with needle.
9. Insert needle and syringe into vial of short-acting or regular insulin and inject air equal to the
amount to be given.
10. Keep needle and syringe in regular insulin solution. Invert vial of short-acting or regular insulin and
withdraw medication slowly and accurately.
11. Withdraw needle and expel any air bubbles and check dose with another nurse. An inaccurate dose
of insulin can be life-threatening. (Rationale: to avoid “splash reactions,” which reduce precision)
12. Invert the vial with longer-acting insulin, holding plunger carefully, and withdraw long-acting insulin,
being careful not to inject any regular insulin into vial. Check dose with another nurse.
13. Store insulin properly according to manufacturer’s specifications.
14. Perform hand hygiene and prepare to administer injection.
B. Subcutaneous Insulin Injection using an Insulin Syringe:

1. Confirm the patient's identity by asking his name and checking the name, room number, and bed
number on his wristband.
2. Explain the procedure to the patient and provide privacy.
3. Select an appropriate injection site. Rotate sites according to a schedule for repeated injections,
using different areas of the body to prevent insulin lipodystr.
4. Put on gloves.
5. Position and drape the patient if necessary.
6. Clean the injection site with an alcohol swab, beginning at the center of the site and moving outward
in a circular motion. Allow the skin to dry before injecting the drug to avoid a stinging sensation from
introducing alcohol into subcutaneous tissues.
7. Remove the needle cap. With your nondominant hand, grasp the skin around the injection site firmly
to elevate the subcutaneous tissue, forming a 1 inch (2.5-cm) fat fold. Holding the syringe in your
dominant hand, position the needle with its bevel up [see illustration below].
4
8. Tell the patient he'll feel a needle prick.

9. Insert the needle quickly in one motion at a 45- or 90-degree angle. Release the patient's skin to
avoid injecting the drug into compressed tissue and irritating nerve fibers [see illustration below].
10. DON’T aspirate for blood return when giving insulin.

11. After injection, remove the needle gently but quickly at the same angle used for insertion.
12. Cover the site with dry absorbent cotton or alcohol swab. DON’T
massage the site. (Rationale: doing so can interfere with the absorption of the insulin, creating an
unpredictable glucose response)
13. Remove cotton or alcohol swab, and check the injection site for bleeding and bruising.
14. Dispose of injection equipment. To avoid needle-stick injuries, DON’T recap the needle.
C. Subcutaneous Insulin Injection using a Flexpen or Insulin Pen Device:
1. Before every injection, check client identity & verify doctor’s orders. Check the label to ensure that
flexpen or insulin pen device contains the correct type of insulin. Pull off the pen cap. Disinfect the
rubber stopper or rubber membrane with an alcohol swab prior to use.
2. Remove the protective tab from short cap needle and screw the needle onto flexpen securely [see
illustration].
3. Pull off the big outer needle cap and the inner needle cap. Do not discard the outer needle cap [see
illustration].
5
4. Prime the flexpen. To do this, dial 2 units [as shown below]. (Rationale: this removes the air bubbles and
ensures the pen and needle are working properly.)
5. Hold flexpen with the needle upwards and tap the reservoir gently with your finger a few times to
make any air bubbles collect at the top of the reservoir. With the needle still pointing upwards, press
the push button fully in. The dose selector should return to zero, and a drop of the medication
should appear at the needle tip [see illustration below]. If one does not appear, change the needle
and repeat the priming procedure up to 6 times until a drop of insulin does appear. If a drop of
insulin still does not appear, the flexpen has failed to prime and must not be used.
6. Set the prescribed dose. To do this, check that the dose

selector is set at zero. Dial the number of units you need to
inject [see accompanying illustration]. Do not use the
residual scale to measure dose of insulin. If you have set an
incorrect dose, simply turn the dose selector forwards or
backwards until the correct number of units has been set.
When dialing backwards, be careful NOT to push the push
button, as insulin will be expelled. You cannot set a dose
larger than the number of units left in the cartridge (60
units is usually the maximum dose).
6
7. Disinfect skin with an alcohol swab. Insert the needle into client’s
skin using the same injection technique as you would use when
injecting with an insulin syringe [see illustration].
8. Inject insulin by pressing the push button all the way in.
Be careful to only press the push button when injecting;
don’t exert direct pressure on client’s skin [see
accompanying illustration]. After the injection, leave the
needle under the skin for at least 6 seconds. Keep the
push button fully pushed in until you remove the needle
from the skin. This will ensure that the full dose has been
delivered and will also mean that there is less risk of
blood or other body fluids flowing back into the needle or
cartridge. If blood appears after the needle has been
withdrawn, press the injection site lightly with an alcohol
swab or absorbent cotton.
9. Remove the needle by replacing the big outer needle cap and unscrewing the needle [as shown
below]. Dispose of it carefully in the sharps container.
10. Put the pen cap and store the flex pen or insulin pen device without the needle attached.
11. Use a new needle for each injection, otherwise temperature changes may cause liquid to leak out of
the needle.
7
13. NOTE: Different manufacturers have different guidelines in using their flexpen or insulin pen device.
Always check literature containing manufacturer recommendations which is usually enclosed with
the device upon purchase.
▪ Perform client teaching as you perform the procedure. Schedule a return demonstration with the client
to evaluate teaching.
▪ Teach patient the signs and symptoms of hypoglycemia and how to manage it.
▪ Make sure that the patient stores insulin in a clean, secure place away from sunlight and heat. Never
store insulin in the freezer.
▪ Check manufacturer recommendations for when to discard insulin vials and pens (even if there is still
medication in vial or pen); recommendations may vary from 10 to 30 days after opening.
▪ Always administer insulin at room temperature. Cold insulin may induce lipodystrophy.
▪ To further prevent lipodystrophy, teach client to rotate injection sites and to keep a chart as a guide as
shown below:
▪ The physician may prescribe insulin using a sliding scale which means that the dose of insulin given shall
be on the basis of the client’s blood sugar results. A sample insulin sliding scale would be:
- CBG < 160 = no insulin
- CBG 160-200 = 4 units Humulin-R SQ
• NOTE: Insulin coverage & dosage varies per
- CBG 200-300 = 6-10 units Humulin-R SQ patient; always consult physician for an
- CBG 300-400 = 10-14 units Humulin-R SQ individualized insulin sliding scale for your
patient.
- CBG > 400 = call attending physician
▪ Only regular, short-acting insulin may be given intravenously (I.V.). If it is incorporated in client’s IV bag
or in a bag of TPN solution, always label the bag and indicate amount of insulin incorporated.
▪ When administering regular insulin through IV bolus, always follow administration with a saline solution
flushing to facilitate IV delivery of insulin.
▪ For an insulin drip, a syringe pump is ideally used [see

accompanying illustration]. The drip usually contains 250
mL of PNSS + 50 units Humulin-R and usually administered
at 5 to 50 μgtts/min or mL/hour. Blood glucose levels are
monitored as often as every 1 to 4 hours for dose titration.

Learning.
▪ Ong, W. & Ong, A.L. (2004). Medicine blue book (6th ed.). Philippine Copyright.
Corporation.
Williams & Wilkins.
9
SKILLS LABORATORY M ODULE NO. 13

CYSTOCLYSIS / CONTINUOUS BLADDER IRRIGATION (CBI)
 Cystoclysis or Continuous Bladder Irrigation (CBI) is a procedure which involves a continuous infusion of
sterile solution into the bladder, usually by using a closed three-way irrigation system.
1. Give the indications of cystoclysis/continuous bladder irrigation (CBI).
2. Identify and assemble the parts of a continuous bladder irrigation (CBI) setup.
3. Describe nursing management of clients on CBI.
4. Discuss how urine output is computed in a client on CBI.

A. Indications of Cystoclysis/Continuous Bladder Irrigation:
▪ Primarily done to encourage hemostasis and flushing of blood clots & debris out of the
bladder usually after bladder & prostate surgery (e.g., transurethral prostatectomy)
▪ Also done to instill medicated solution into the bladder
B. Parts of a Continuous Bladder Irrigation (CBI) Setup:
162
- Sterile gloves*
- Alcohol or povidone-iodine swabs*
- Closed irrigation tubing (a macrodrip set is commonly used)
- Ordered irrigation solution (ideal solution for CBI is normal saline solution)
- three-way indwelling catheter (a triple-lumen catheter allows irrigating solution to flow into the
bladder through one lumen and flow out through another; the third lumen is used to inflate the balloon that
holds the catheter in place)
- IV pole
- Large urine collection bag
- Toomey syringe

A. Assembling & Maintaining a Continuous Bladder Irrigation Setup:
1. Verify physician’s order of prescribed irrigating solution to be used and flow rate.
2. Perform hand hygiene. Assemble all equipment at the patient's bedside. Explain the procedure and
provide privacy.
3. Insert the spike of the irrigation tubing (macrodrip set) into the container of irrigating solution (make
sure tubing is clamped before spiking).
4. Squeeze & fill half of the drip chamber on the spike of the tubing.
5. Open the flow clamp and flush the tubing to remove air, which could cause bladder distention. Then
close the clamp.
6. To begin, hang the bag of irrigating solution on the I.V. pole.
7. Clean the opening to the inflow lumen of the catheter with the alcohol or povidone-iodine swab.
8. Insert the distal end of the irrigation tubing (macrodrip set) securely into the inflow lumen (third port)
of the catheter.
9. Make sure the catheter's outflow lumen is securely attached to the drainage bag tubing.
10. Open the flow clamp under the container of irrigating solution, and set the drip rate as ordered.
11. To prevent air from entering the system, DON’T let the primary container empty completely before
replacing it.
12. Empty the drainage bag about every 4 hours, or as often as needed. Use sterile technique to avoid the
risk of contamination.
163
▪ The insertion of the three-way indwelling catheter is usually done by the surgeon in the operating room
immediately after surgery. Thus, insertion is not a nursing responsibility. However, the nurse should be
aware that 30 mL of sterile water is used to inflate the balloon of a 3-way catheter which is important to
note especially during catheter removal.
▪ Check the inflow and outflow lines periodically for kinks to make sure the solution is running freely. If the
solution flows rapidly, check the lines frequently.
▪ As an alternative to flow clamp administration, an infusion pump may be used, requiring the pump tubing
to be primed. Set the flow rate as ordered by the physician.
▪ Be sure the irrigating solution is at least at room temperature to avoid bladder spasms. Body temperature
is preferable. The solution can be soaked in a water bath prior to use with sterility maintained at all times.
▪ Be sure to track the amount of irrigating solution instilled (inflow volume) and the amount of drainage
(outflow volume). The outflow volume must ALWAYS equal or exceed inflow volume.
▪ To calculate a client’s URINE OUTPUT, get the difference of the outflow volume (‘cysto-out’) and the
inflow volume (‘cysto-in’). [e.g., outflow volume = 300 mL, inflow volume = 200 mL; thus, urine output is
100 mL]. Note that the normal urine output per hour is 30 to 60 mL. A negative urine output must be
reported to the physician immediately for this may indicate bladder rupture at suture lines or renal
damage.
▪ Also assess outflow for changes in appearance and for blood clots, especially if irrigation is being
performed postoperatively to control bleeding (in this case, outflow is normally light pink or straw-
colored). If drainage is bright red, irrigating solution should usually be infused rapidly with the clamp wide
open until drainage clears. Notify the physician at once if you suspect hemorrhage. If drainage is clear, the
solution is usually given at a rate of 40 to 60 drops/minute or as prescribed.
▪ A Toomey syringe [see illustration below] should always be placed at client’s bedside. This syringe will be
used by the physician to irrigate the catheter in the event that the CBI system gets clogged or obstructed
with large clots.
▪ Monitor for transurethral resection syndrome or severe hyponatremia (water intoxication) caused by the
excessive absorption of bladder irrigation during surgery (altered mental status, bradycardia, increased
blood pressure, and confusion).
▪ Discontinue CBI and Foley catheter as prescribed, usually 24 to 48 hours after surgery.
164
▪ Monitor for continence and urinary retention when the catheter is removed.
▪ Inform the client that some burning, frequency, and dribbling may occur following catheter removal.
▪ Inform the client that he should be voiding 150 to 200 mL of clear yellow urine every 3 to 4 hours a day
by 3 days after surgery.
▪ Inform the client that he may pass small clots and tissue debris for several days.
▪ Teach the client to AVOID heavy lifting, stressful exercise, driving, Valsalva maneuver, and sexual
intercourse for 2 to 6 weeks to prevent strain and to call the physician if bleeding occurs or there is a
decrease in urinary stream.
▪ Instruct the client to drink 2400 to 3000 mL of fluid each day, preferably before 8 PM.
▪ Instruct the client to AVOID alcohol, caffeinated beverages, and spicy foods and to avoid overstimulation
of the bladder.
▪ Instruct the client that if urine becomes bloody, to rest and increase fluid intake and that if the bleeding
does not subside, to notify the physician.

Learning.
Williams & Wilkins.
▪ Silvestre, L.A. (2005). Saunders comprehensive review for the NCLEX-RN examination (3rd ed.).
▪ Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth’s textbook of medical-surgical
nursing (12th ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott, Williams & Wilkins.
165
SKILLS LABORATORY M ODULE NO. 14

URINARY CATHETERIZATION
 Urinary Catheterization involves the gentle insertion of a short, plastic tube (a catheter) into a patient’s
bladder via his or her urethra to allow urine to drain freely among other purposes.
1. Give the indications of urinary catheterization.
2. Discuss the types of urinary catheterization.
3. Describe urinary catheter & closed drainage system maintenance and care.
4. Describe how a catheterized urine specimen is obtained.
5. Perform indwelling catheter insertion on a male & female patient.
6. Perform indwelling catheter removal.
7. Perform condom catheter application.

A. Indications of Urinary Catheterization:
▪ To relieve acute or chronic urinary retention

▪ To allow continuous urine drainage when the urinary meatus is swollen from childbirth or local
trauma.
▪ To drain urine preoperatively and postoperatively
▪ To determine the amount of residual urine after voiding
▪ To determine accurate measurement of urinary drainage in critically ill patients
▪ Clients with urinary tract obstruction (by a tumor or enlarged prostate) and those with
neurogenic bladder paralysis caused by spinal cord injury or disease
B. Types of Urinary Catheterization:
▪ Indwelling catheterization → uses a Foley bag catheter that remains in the bladder to provide
continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of
the bladder after insertion. [see illustration below]
166
▪ Intermittent or straight catheterization → involves the use of a straight plastic or rubber catheter
that is inserted into the urethra every 3 hours or more to empty the bladder. Once the bladder is empty,
the catheter is removed.
▪ Condom catheterization → makes use of a latex or rubber catheter (condom catheter or also known
as Texas catheter) that fits over the penis and connects to a drainage bag.
▪ Suprapubic catheterization → involves an indwelling catheter that is inserted through an incision in

the lower abdomen directly into the bladder.
C. Urinary Catheter & Closed Drainage System Maintenance & Care:

▪ Perform hand hygiene before and after handling any part of the system. Wear clean, disposable
gloves when handling the system.
▪ Maintain unobstructed urine flow
- Keep the drainage bag in a dependent position, below the level of the bladder.
- Urine should not be allowed to collect in the tubing because a free flow of urine must be
maintained to prevent infection
▪ Keep the drainage bag or closed drainage unit off the floor.
▪ To empty the drainage bag:
- Perform hand hygiene and don gloves.
- Disinfect drainage port with antiseptic solution. Empty the bag in a separate collecting
receptacle for each patient being careful not to contaminate the drainage valve or spout.
Disinfect drainage port again.
▪ Clean around the area where catheter enters urethral meatus (meatal-catheter junction) with
soap and water during the daily bath to remove debris.
▪ AVOID using powders and sprays on the perineal area. Powder can encrust and cause soreness
and infection.
▪ AVOID pulling on the catheter during cleaning. Backward and forward displacement of the
catheter introduces contaminants into the urinary tract.
D. Steps to Obtain a Catheterized Urine Specimen

▪ Clamp the drainage tubing below the aspiration (sampling) port
for 30 minutes to allow urine to collect.
▪ Clean the aspiration port with povidone-iodine or 70% alcohol.
▪ Insert a sterile 21G needle (attached to a sterile syringe) into the
aspiration port of the catheter tubing [see illustration].
167
▪ Aspirate a small volume of urine (about 5 to 10 mL).

▪ Remove needle from syringe and release urine carefully into sterile specimen container.
▪ Unclamp the drainage tube.
▪ Send specimen to laboratory immediately.
 Nursing Skills to Develop in this Module & Materials/Equipment Needed: [materials/items with an asterisk
(*) are the materials the students should bring during skills laboratory period]
▪ Indwelling Catheter Insertion (male & female):

- Sterile gloves & clean disposable gloves*
- Sterile indwelling or 2-way Foley bag catheter (average adult sizes are Fr 16 to 18 for males & Fr 14 to
16 for females)*
- Sterile drainage collection bag or closed drainage unit*
- Sterile 10 mL disposable syringe with a luer-lock (not a slip tip)*
- Sterile water for injection (vial)*
- Two linen-saver or absorbent pads*
- Receptacle with cotton balls saturated with povidone-iodine solution (or other antiseptic solution
if patient is allergic to povidone-iodine)*
- Sterile water-soluble lubricant (single-use packet)*
- Adhesive tape*
- Soap* and water
- Washcloth
- Towel
- Optional: sterile urine specimen container, gooseneck lamp or flashlight, pillows or rolled blankets
or towels.
▪ Indwelling Catheter Removal

- Absorbent cotton*
- Alcohol swabs*
- 10 mL syringe with a luer-lock (not a slip tip)*
▪ Condom Catheter Application:

- Correct-sized condom or Texas catheter with enclosed double-sided tape or adhesive strip*
- Sterile drainage collection bag or closed drainage unit*
- Scissors (for trimming pubic hair)*
- Soap* and water
- Washcloth
- Towel
A. Indwelling Catheter Insertion (male & female):
1. Assess if patient has allergy to povidone-iodine solution. If positive, use another antiseptic solution.
2. Check the order on the patient's chart to determine if a catheter size or type has been specified.
168
4. Select appropriate equipment, and assemble it at the patient's bedside.

5. Explain the procedure to the patient and provide privacy. Check patient’s chart and ask when he/she
voided last. Percuss and palpate the bladder to establish baseline data. Ask if he/she feels the urge to
void.
6. Elicit assistance from a coworker or colleague to handle non-sterile items or open packages of sterile
items and to hold a flashlight or place a gooseneck lamp next to the patient's bed so that you can see
the urinary meatus clearly in poor lighting.
7. Place the female patient in dorsal recumbent position (with her knees flexed and separated and her
feet flat on the bed, about 2 feet apart). If client is unable to assume this position, she may be placed
on a side-lying position with upper leg flexed.
8. ELDER ALERT: The elderly patient may need pillows or rolled towels or blankets to provide support
with positioning.
9. Place the male patient in the supine position with his legs extended and flat on the bed. Ask the
patient to hold the position to give you a clear view of the urinary meatus.
10. Place the linen-saver or absorbent pads on the bed between the patient's legs and under the hips.
Drape the patient.
11. Don clean gloves. Use the washcloth to clean the patient's genital area and perineum thoroughly with
soap and water. Dry the area with the towel.
12. After drying, perform perineal care using the cotton balls saturated in povidone-iodine solution.
Urethral meatus should be thoroughly cleansed with povidone-iodine. Be more meticulous when
doing this procedure on an uncircumcised client, retracting the foreskin to clean the glans penis &
urethral meatus.
13. Remove clean gloves, and then perform hand hygiene.
14. Don sterile gloves. Save the paper enclosure of your sterile gloves by keeping it sterile and placing it
in an accessible area (this will be used as your sterile field later).
15. Have coworker partially open the package of a 10-mL disposable syringe. Making sure not to
contaminate your gloves, grasp syringe and remove it from its package. Tighten needle and aspirate
10 mL of air.
16. Have coworker open a vial of sterile water for injection using aseptic technique. While coworker holds
the vial, inject 10 mL of air into the vial and aspirate 10 mL of sterile water. Make sure fluid does not
drip on the paper enclosure of your sterile gloves.
169
17. Have coworker partially open package of sterile indwelling or Foley bag catheter. Grasp catheter and
remove it from its package using aseptic technique.
18. Inflate the indwelling catheter balloon with sterile water to inspect it for leaks. To do this, attach the
sterile water-filled syringe to the luer-lock (you will need the needle on the syringe if catheter inflation
port is not luer-lock), then push the plunger and check for seepage as the balloon expands. Aspirate
the sterile water to deflate the balloon. Also inspect the catheter for resiliency. Rough, cracked
catheters can injure the urethral mucosa during insertion, which can predispose the patient to
infection. Always make sure not to contaminate the catheter.
19. After checking, place sterile water-filled syringe on paper enclosure of sterile gloves (which will now
be called your sterile field). The catheter should still be on your gloved hand.
20. Have coworker partially open the drainage collection bag or closed drainage unit. Grasp entire unit
and remove it from its package. Secure tubing of the bag to the drainage port of the indwelling
catheter. Make sure all tubing ends remain sterile. Also make sure the clamp at the emptying port of
the drainage bag is closed to prevent urine leakage from the bag.
21. Have coworker hold the bag of the closed drainage unit (which is considered not sterile), as you hold
the catheter (now with tubing of closed drainage unit attached).
22. With your dominant gloved hand, coil the catheter (not including the tubing of the closed drainage
unit) around your fingers. Have coworker open the packet of water-soluble lubricant and drop it on
nondominant gloved hand making sure not to contaminate glove. Still holding the coiled catheter with
your dominant hand, coat its tip with the lubricant.
23. For the female patient, separate the labia majora and labia minora as widely as possible with the
thumb, middle, and index fingers of your nondominant hand (part of the gloved hand touching the
labia is now considered not sterile) so you have a full view of the urinary meatus. [see illustration
below]
170
24. For the male patient, hold the penis with your nondominant hand. If he's uncircumcised, retract the
foreskin. Then gently lift and stretch the penis to a 60- to 90-degree angle. Hold the penis this way
throughout the procedure to straighten the urethra [see illustration below].
25. Prepare to insert the lubricated catheter tip into the urinary meatus. To facilitate insertion by relaxing
the sphincter, ask the patient to cough as you insert the catheter. Tell him to breathe deeply and slowly
to further relax the sphincter and spasms. Hold the catheter close to its tip to ease insertion and control
its direction.
26. NURSING ALERT: NEVER force a catheter during insertion. Maneuver it gently as the patient bears down
or coughs. If you still meet resistance, stop and notify the physician. Sphincter spasms, strictures,
misplacement in the vagina (in females), or an enlarged prostate (in males) may cause resistance.
27. For the female patient, advance the catheter 2 to 3 inches (5 to 7.5 cm) while continuing to hold the
labia apart until urine begins to flow [see illustration below]. If the catheter is inadvertently inserted into
the vagina, leave it there as a landmark. Then begin the procedure over again using new supplies.
171
28. For the male patient, advance the catheter to the bifurcation and check for urine flow [see illustration
below]. If the foreskin was retracted, replace it to prevent compromised circulation and painful swelling.
29. When urine stops flowing, attach the saline-filled syringe to the luer-lock.
30. Push the plunger and inflate the balloon to keep the catheter in place in the bladder [see illustration
below].
31. NURSING ALERT: NEVER inflate a balloon without first establishing urine flow, which assures you that
the catheter is in the bladder.
32. Hang the collection bag below bladder level to prevent urine reflux into the bladder, which can cause
infection, and to facilitate gravity drainage of the bladder. Make sure the tubing doesn't get tangled in
the bed's side rails.
33. Tape the catheter to the female patient's inner thigh to prevent possible tension on the urogenital
trigone [see illustration below].
172
34. Secure the indwelling catheter to the male patient's abdomen or upper outer thigh [see illustration
below]. Properly securing the catheter prevents catheter movement and traction on the urethra.
Securement to the abdomen in males may prevent pressure on the scrotal-penile junction.
35. Assist client in wearing comfortable clothing.

36. Dispose of all used supplies properly.
37. Empty the collection bag at least every 8 hours. Excessive fluid volume may require more frequent
emptying to prevent traction on the catheter, which would cause the patient discomfort, and to prevent
injury to the urethra and bladder wall.
B. Indwelling Catheter Removal

1. Verify doctor’s orders. Perform hand hygiene. Assemble the equipment at the patient's bedside.
Explain the procedure and tell him that he may feel slight discomfort. Tell him that you'll check him
periodically during the first 4 to 6 hours after catheter removal to make sure he resumes voiding.
2. With alcohol swabs, remove adhesive tape securing the catheter.
3. Put on clean gloves. Attach the syringe to the luer-lock mechanism on the catheter.
4. Pull back on the plunger of the syringe. This deflates the balloon by aspirating the injected fluid. The
amount of fluid injected is usually indicated on the tip of the catheter's balloon lumen usually 10 mL.
5. Grasp the catheter with the absorbent cotton and gently pull it from the urethra. Instruct client to take
a deep breath as catheter is removed.
6. Coil catheter around gloved finger. Pull gloves over the coiled catheter and discard it.
7. Measure and record the amount of urine in the collection bag before discarding it.
9. Patient should be able to void freely in 4 to 6 hours after catheter removal. Assess the patient for
incontinence (or dribbling), urgency, persistent dysuria or bladder spasms, fever, chills, or palpable
bladder distention. Report these to the physician.
C. Condom (Texas) Catheter Application

2. Protect the client’s privacy by closing the door and pulling curtains around the bed.
3. Position the client in a comfortable position, preferably a supine position, if tolerated by the client.
Raise the bed to a comfortable height for the nurse.
4. Don clean gloves.
5. Fold the client’s gown across the abdomen and pull the sheet up over the client’s legs.
6. Assess the client’s penis for any signs of redness, irritation, or skin breakdown. The client may require
an indwelling catheter if there is a significant amount of skin breakdown.
7. Clean the client’s penis with warm soapy water. Retract the foreskin on the uncircumcised male and
clean thoroughly in folds.
8. Return the client’s foreskin to its normal position.
9. Cut any excess hair around the base of the penis.
10. Rinse and dry the area.
11. Apply the double-sided adhesive strip around the base of the client’s penis in a spiral fashion. The strip
is applied 1 inch from the proximal end of the penis [see illustration below]. Don't let the edges of the
tape overlap. DON’T stretch the tape or you'll wind it too tightly. NEVER wrap the tape in a circle
around client’s penis — you may cut off circulation.
12. Position the rolled condom at the distal portion of the penis and unroll it, covering the penis and
double-sided strip of adhesive. Leave a 1- to 2-inch space between the tip of the penis and the end of
the condom.
174
13. Gently press the condom to the adhesive strip.

14. Attach the drainage bag tubing to the catheter tubing. Make sure the tubing lies over the client’s legs,
not under. Secure the drainage bag to the side of the bed below the level of the client’s bladder or to
the drainage bag attached to the leg [see illustration below].
15. Determine that the condom and tubing are NOT twisted.
16. Cover the client.
17. Dispose of the used equipment in appropriate receptacle and wash hands.
18. Return the client’s bed to the lowest position and reposition client to comfortable or appropriate
position.
19. Empty the bag, measure the client’s urinary output and record every 4 hours. Remove gloves and
wash hands after procedure.
20. Remove the condom once a day to clean the area and assess the skin for signs of impaired skin
integrity.
▪ Erection may occur as a normal physical response during the catheterization. This can be an embarrassing
moment for the male client. Deal with the situation professionally. Withhold the procedure and leave the
room; come back in 10 to 15 minutes to finish the procedure.
▪ If the area for taping to secure the indwelling catheter is hairy, prepare and shave the area to prevent any
discomfort. Allow enough space between penis and the taped area to allow the client’s mobilization, and
possible erection during sleep.
▪ DO NOT reattach a condom catheter if it falls off. It will not stick any better the second try. Start over with
a new strip and catheter.
175
▪ Sometimes a cotton ball is placed at the opening of a female client’s vagina as a landmark to prevent
inserting in the wrong pathway. Be sure to remove the cotton ball upon completion of the skill to prevent
unnecessary infection.
▪ If female client is in the menstrual cycle when being placed with a urinary catheter, perineal care should
be administered daily to prevent urinary tract infection.
▪ Depending on the length of catheterization, a bladder training or retraining may be ordered before
removal of an indwelling catheter. The physician usually orders that the drainage tube be clamped for 2
hours or until client feels the urge to void then tube is unclamped to facilitate urine flow and clamped
again after 30 minutes. The cycle is repeated until client feels the urge to void more frequently when
catheter is clamped. The physician then orders the indwelling catheter be removed.
▪ In male clients with benign prostatic hypertrophy (BPH), a Coude catheter, a semi-rigid catheter that has
a curve or bend at the tip, may be used for urinary catheterization. The curved tip allows it to navigate
over the curvature of the prostate or any other urethral obstruction it may encounter.

Learning.
▪ Perry, A.G. & Potter, P. (2010). Clinical nursing skills & techniques (7th ed.). St. Louis, MO: Mosby.
Corporation.
Williams & Wilkins.
▪ Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth’s textbook of medical-surgical
nursing (12th ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott, Williams & Wilkins.
176

BLOOD TRANSFUSION
 Blood Transfusion refers to the administration of blood or blood products from one person (the donor) into
another person’s (the recipient’s) bloodstream.
1. Describe the several blood products used in transfusion therapy, give its uses, and highlight the most
important nursing considerations for each.
2. Identify plasma volume expanders commonly used in the area when blood transfusion is delayed.
3. Discuss the different acute & delayed transfusion reactions and their corresponding management.
4. Compare & contrast a blood transfusion set, platelet administration set & a standard IV set.
5. Familiarize himself/herself with the forms related to blood transfusion: (a) Blood Bag Label, (b) Cross-
matching Compatibility Report, (c) Blood Transfusion Form
6. Identify the parts of a blood transfusion setup.
7. Perform blood transfusion safely, ensuring proper client identification & clerical check.
8. Apply the principles of asepsis & infection control throughout the procedure.
9. Explain the rationale for each step of the procedure accurately.

A. Commonly Used Blood Products in Transfusion Therapy:
Blood Component Indications/Uses Nursing Considerations
Whole Blood • To restore blood volume • Avoid giving whole blood when the patient can’t
[pure blood; volume: 500 lost from tolerate the circulatory volume.
mL] hemorrhaging,trauma • Warm blood if giving a large quantity.
____________________.
or burns • Before administering, bag is inverted several
times to mix the cells.
Packed Red Blood Cells • To correct severe • Provides less risk of fluid overload than whole
(PRBCs) anemia & replenish blood
[same RBC mass as whole blood loss aliquots
• May be given in __________(packed RBCs divided
blood but with 80% of • May also be given into 2 or more blood bags for multiple small-
plasma removed; volume: preoperatively on a volume administration) to clients with heart
250 mL or less] client with a hemoglobin failure, other hypervolemic states & those who
7 g/dL or
of less than ___ can’t tolerate large-volume transfusion
when excessive blood
loss is anticipated
Sedimented Red Blood • To correct severe • Only RBC component is usually transfused with
Cells anemia & replenish remaining plasma in bag discarded
[plasma separated from blood loss • Not a conventional blood product & administered
RBC by centrifugation with only when packing of RBCs will take long & RBC
the latter settled at the transfusion needs to be commenced immediately
bottom of the blood bag; or when client can’t pay for packing (sedimenting
volume: 500 mL but usually RBCs is faster & cheaper than packing)
only RBC component of 250 • DON’T shake the blood bag; this will cause RBC &
mL or less is transfused] plasma to mix or recombine.
96
A. Commonly Use Blood Products in Transfusion Therapy (continued):
Blood Component Indications/Uses Nursing Considerations
Washed Packed Red Blood • Same use as PRBCs with • Usually takes an additional 1 hour to be
Cells the added benefit of processed before use
[PRBCs washed with saline to decreasing occurrence or • Has a shortened shelf life; must be used
remove WBCs & cytokines; severity of a febrile 24 hours of washing
w/in _____
volume: 250 mL or less] reaction in susceptible • Leukocyte-removing filters may be used
patients during transfusion
• Also ideal for patients with
hepatic failure as washing
also removes the ammonia
from the blood unit
Platelet Concentrate ▪ To treat • Use a platelet administration set for
[platelet sediment from RBCs or thrombocytopenia
______________caused by transfusion
plasma obtained by centrifuging decreased platelet • Transfused rapidly at moderate fast drip
units of whole blood from production, increased or at a rate of 15 minutes per 100 mL
multiple donors or from a single platelet destruction, or • Avoid administering platelets when the
platelet donor by apheresis ; massive transfusion of patient has a fever.
volume: varies] transfused blood • ABO compatibility is not necessary but
▪ To treat acute leukemia preferred with repeated transfusions
and marrow aplasia
▪ To improve platelet count
preoperatively in a patient
whose count is 100,000 or
less
Fresh Frozen Plasma (FFP) ▪ To expand plasma volume • Administer infusion rapidly; one unit is
[uncoagulated plasma ▪ To treat postoperative usually completed within 15 to 30
separated from RBCs & rich in hemorrhage or shock minutes
clotting factors V & VIII, frozen ▪ To correct an • Observe patient closely for volume
within 6 hours of collection ; undetermined coagulation overload
volume: 200 to 250 mL] factor deficiency • Large volume transfusions of FFP may
▪ To replace a specific require correction of hypocalcemia
clotting factor when that because citric acid in FFP binds with
factor alone isn’t available ionized calcium
▪ To correct factor • ABO compatibility is not necessary but
deficiencies resulting from preferred with repeated transfusions
hepatic disease • Ideally administered within 6 to 24 hours
after thawing
Cryoprecipitate ▪ To correct deficiencies of • Use administration set supplied by
[contains clotting factors VIII
_________, factor VIII
_________(i.e., hemophilia manufacturer
XIII & fibrinogen suspended in
____ A & Von Willebrand’s • Prepared from FFP & can be stored for 1
plasma ; volume: 10 to 20 mL] factor XIII &
disease), _______ year; but must be used once thawed.
fibrinogen (i.e., DIC) • Administer infusion rapidly; one unit is
usually completed within 3 to 15 minutes
• Half life of Factor VIII is 8 to 10 hours;
thus, repeated transfusions at specified
intervals is necessary for patients with
hemophilia A to maintain normal levels
*consult textbook for other blood products.
97
B. Commonly Used Plasma Volume Expanders:

▪ Crystalloid-based: lactated ringer’s solution (PLR), normal saline solution (PNSS)
▪ Colloid-based:
- human albumin (available brands: Albuminar®, Albumax®, Albutein®, Zenalb®)
- hydroxyethyl starch (available brands: Haes-Steril®, Voluven®, Xpand®)
- dextran
- pentastarch
- succinylated/modified fluid gelatin (Gelofusine®) – not yet locally available
C. Blood Transfusion Reactions: [consult textbook for causes, clinical manifestations, prevention &
nursing management]
▪ Acute Reactions (occurs within minutes to hours of transfusion)
- Allergic reaction
- Febrile, non-hemolytic reaction
- Septic reaction
- Circulatory overload
- Hemolytic Reaction MOST LIFE-THREATENING
_________________________→
- Air embolism
- Electrolyte imbalances: Hyperkalemia & Hypocalcemia (especially with repeated transfusions)
▪ Delayed Reactions (occurs within days to months of transfusion)

- Delayed hemolytic reaction
- hemosiderosis
Iron overload (__________)
- Graft vs. Host Disease (GVHD)
- Infectious diseases: hepatitis B & C, cytomegalovirus (CMV), Epstein-Barr virus (EBV), malaria,
human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV), syphilis
- Prescribed blood product from blood bank

- Blood transfusion set* (filter and tubing with drip chamber for blood), if transfusing whole blood or other
blood products except platelets)
- Platelet administration set (no filter), if transfusing platelet concentrate
- Adhesive tape*
- Alcohol swabs*
- Disposable syringe*
- 20 mL vial of normal saline solution (used for flushing if main IV line is not normal saline or if administering
through an intermittent infusion device)*
- I.V. pole
- Blood warmer (if available)
- Blood infuser or pressure infuser
- Blood transfusion form or any form required by hospital protocol (see CVGH blood transfusion form on
succeeding page)
98
 Cebu (Velez) General Hospital Blood Transfusion Form (actual format – FRONT of form):
CEBU (VELEZ) GENERAL HOSPITAL

Blood Bank Section
BLOOD TRANSFUSION FORM
To be filled up by LABORATORY PERSONNEL
Name of Recipient _________________________________ Ward/Room No. ______________ Date ________________

Recipient’s Hospital No. ____________________________
Age _________ Sex _____________ Blood Type __________________
Clerical Check:
Unit Source Bag Number Segment Number ABO Rh Date Collected Expiry Date
( ) Whole Blood ( ) Platelet Concentrate

( ) Red Blood Cells ( ) Cryoprecipitate
( ) Plasma ( ) Others ___________________
Result of Compatibility Testing: ________________________________________________________________________

Crossmatching Done By: __________________________________________ Date: _____________________________
(Signature and Title)
( ) Emergency Testing
( ) Uncrossmatched
( ) Crossmatched
( ) Saline Phase Only
( ) Saline and Albumin Phase Only
( ) Saline, Albumin and Antiglobulin Phase
( ) ABO / Rh Compatible
________________________________________ __________________________________
Signature of Releasing Medical Technologist Date and Time
To be filled up by HOSPITAL MEDICAL/NURSING PERSONNEL
Blood Unit Taken By: __________________________________ Date and Time: ____________________________

Blood Unit Received By: _______________________________ Date and Time: ____________________________
Clerical Check: (must be done by at least two (2) personnel)

Unit Source Bag Number Segment Number ABO Rh Date Collected Expiry Date
Clerical Check Done By: _______________________________ Date and Time: ____________________________

_______________________________ Date and Time: ____________________________
Appearance of Unit Checked By: _________________________ Date and Time: ____________________________
_________________________ Date and Time: ____________________________
Transfusion Started By: ________________________________ Date and Time: ____________________________

Transfusion Completed: ________________________________ Date and Time: ____________________________
Transfusion Set Removed By: ___________________________
(Printed Name, Signature and Title)
99
 Cebu (Velez) General Hospital Blood Transfusion Form (actual format – BACK of form):
Vital Signs Prior to Blood Transfusion During Height of Blood 30 min After Blood
Transfusion Transfusion has been
stopped
TEMPERATURE
BLOOD PRESSURE
R.R.
P.R.
Remarks:
( ) Transfusion completed without immediate transfusion reaction noted.
( ) Transfusion stopped with transfusion reaction noted.
FOR NURSING STAFF on Duty – Check if done:

1. Stop transfusion immediately; but leave needle in situ with a slow saline drip.
2. Summon the Resident-on-Duty to immediately attend to the patient.
3. Check if all identifying numbers/names/letters to the blood bag label, the patient’s blood bank result form, the release tag,
the patient’s name and/or wrist tag tally. REPORT immediately any discrepancies.
4. Obtain and record accordingly all vital signs.
5. Collect an immediate post-transfusion urine specimen and label properly. Exactly five (5) later collect another urine
sample, label.
6. After the ROD has attended to the patient, request him to write the relevant clinical data required below and on the
transfusion reaction investigation form.
7. Submit to the blood blank the entire blood transfusion unit in question, keeping the needle in place, properly and tightly
covered, observing strict asepsis.
Note: The ward will be provided with the results of the investigation of the suspected transfusion reaction.
___________________________________________________________________________________________________
TRANSFUSION REACTION CLINICAL SIGNS AND SYMPTOMS
During After
Yes No Yes No
Chilly sensation ( ) ( ) ( ) ( )
Severe shaking chills ( ) ( ) ( ) ( )
Severe low back pain ( ) ( ) ( ) ( )
Nausea / Vomiting ( ) ( ) ( ) ( )
Urticaria ( ) ( ) ( ) ( )
Headache ( ) ( ) ( ) ( )
Dyspnea ( ) ( ) ( ) ( )
Profuse Sweating ( ) ( ) ( ) ( )
Fever ( ) ( ) ( ) ( )
Dark Urine ( ) ( ) ( ) ( )
Comments/Findings by Clinical Resident(s):

Submitted by:
________________________________________
Clinical Resident-on-Duty
(Signature over printed name)
Prepared by:
__________________________ _____________
Signature over printed name date and time
Received in the laboratory by: _______________________________ Date and Time _____________

Remaining blood _________________cc.
PLEASE RETURN THIS TO THE LABORATORY
100
 Sample Blood Bag with Label:
The Segment Number is a series of letters & numbers unique to

each blood bag imprinted along the blood bag tubing. This is
where you’ll look for the segment number [see close-up of a
portion of sample tubing below]:
[Close-Up of Blood Bag Lab el]
You’ll find the Unit Source and

Bag Number on this portion
You’ll find the ABO on this

portion
You’ll find the Rh on this
portion
You’ll find the Expiry Date on

this portion
You’ll find the Date Collected

on this portion
The Unit Source refers to the

blood bank where the blood was
issued or extracted from the
donor (e.g., CVGH-Blood Bank,
RBCC)
NOTE: Blood bag labels may vary from one manufacturer to another. Always read the blood bag label carefully
especially during clerical check before blood transfusion.
101
 CVGH Cross-Matching Compatibility Report (actual format w/ sample data):
CEBU VELEZ GENERAL HOSPITAL

79 F. Ramos Street, Cebu City LABORATORY REPORT FORM
Tel. No. 253-1871
Name: Santos, John Age: 3 Sex: M Room: VI-II Hosp.
No.: 36689
Physician: Dr. Gomez

Patient’s Blood ABO titration
Group: Group “A” Rh (+) Rh titration
C OM P ATI BI LI TY TEST
Date Donor No. Donor’s Blood Group Saline Hi-protein Coombs Performed by
COMPATIBLE De la
5/29/10 D10-332 Group “A” Rh (+) with patient’s Cruz,
serum RMT
 Parts of a Blood Transfusion Setup:
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 Procedure Guidelines for Blood Transfusion:

1. Assess the client for the indication of the blood product to be given, that is, low hematocrit or platelet
count. This will enable more specific evaluation of response to the transfusion.
2. Review the client’s transfusion history, especially any reactions or pre-transfusion medications to be
given. If prior reaction has occurred, pre-medications may be given to prevent a subsequent reaction.
3. Verify the physician’s order for the type of blood product to be given.
4. Inform the patient of the procedure, blood product to be given, approximate length of time, and
desired outcome.
5. Instruct the patient to report unusual symptoms immediately. Review side effects (dyspnea, chills,
headache, chest pain, itching) with client and ask him or her to report these to the nurse. Prompt
reporting of a side effect will lead to earlier discontinuation of transfusion and minimized the reaction.
6. Have the client sign consent forms per agency protocol.
7. Obtain client’s vital signs just before procuring blood product from blood bank. If the patient's clinical
status permits, delay transfusion if baseline temperature is greater than 38 C or per institutional
____,
policy. The physician should be informed if vital signs are not normal.
8. Prepare infusion site. Select a large vein that allows patient some degree of mobility. Start the
normal
saline
prescribed I.V. infusion (preferably ________). Solutions other than normal saline may be incompatible
agglutination or hemolysis.
with blood product and may cause ___________
9. Patency of the I.V. line should ALWAYS be ensured before transfusion. An 18- or 20-gauge IV cannula
should be used when transfusing whole blood or PRBCs. For platelets & FFP, a 22-gauge or larger bore
IV cannula is used. (TIP: You may refer to color-code on the IV cannula to determine if gauge of
cannula is appropriate for IV line that has already been started a few days prior to transfusion; DON’T
use an existing line if the cannula is smaller than gauge-20 when transfusing whole blood or PRBCs)
10. Obtain blood product from the blood bank within30 minutes of the transfusion start time to prevent
__________
bacterial growth and destruction of red blood cells. If transfusion cannot begin immediately, return
product to blood bank. Blood out of proper storage (above 10°C) for more than 30 minutes cannot be
reissued. NEVER store blood in unauthorized refrigerators, such as those on the nurse’s station.
11. Verify and record the blood product with another nurse. Full name and signatures of RNs (including
date & time) are recorded on a hospital-approved blood transfusion form. During clerical check, one
nurse should be reading ONLY the label on the blood bag & the other nurse reading ONLY the blood
transfusion form, reading out loud the following information simultaneously:
 Client or Recipient Information:
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▪ Name, Age, Sex & Blood Type (ABO group & Rh type)
▪ Ward/Room number & Case/Hospital ID number
 Type of blood product compared with physician’s order (if whole blood, PRBCs, FFP, etc.)
 Screening & Cross-matching compatibility Results (there is a separate form for this usually
issued with the blood unit; cross-matching may not be needed on some blood products/units;
some patients may also defer screening of blood unit by signing a waiver; but cross-matching is
always IMPERATIVE)
 Information on Donor blood:
▪ Unit Source (refers to the name of the blood bank who issued the unit)
▪ Bag number (found on label of blood bag)
▪ Segment number (series of letters or numbers imprinted along the tubing of the blood
bag)
▪ ABO blood group (if type A, B, AB or O)
▪ Rh type (if positive/”+” or negative/”-“)
▪ Date & time of collection
▪ Date & time of expiry
 Appearance of the unit/blood product (observe for abnormal color, RBC clumping, gas bubbles,
extraneous material & other impurities; take note that platelets are normally cloudy)
 Volume of blood product or unit (to validate this, the nurse will use a spring scale or weighing
scale; weight in grams is equal to volume of blood bag in milliliters/mL or cc)
12. Any inconsistency, discrepancy or irregularity noted by the two nurses during the clerical check should
be reported to blood bank immediately. Always return outdated/abnormal blood or wrong blood
product/unit to the blood bank.
13. Perform hand hygiene and assemble needed equipment.
14. Using aseptic technique, prime the blood unit using appropriate blood or platelet administration set.
- Spike blood unit (making sure roller clamp on administration set is closed)
- Squeeze drip chamber and allow the filter (if present) to fill with blood
- Open roller clamp and allow tubing to fill with blood to the hub. Attach hub to a filtered-
needle (usually gauge 18 to 20) if not transfusing on a needleless device.
15. If client’s main line is NOT normal saline (PNSS), prepare a disposable syringe filled with 10 mL or more
of normal saline. This will be used to flush the tubing before & after administration of blood product.
16. Put on appropriate personal protective equipment & assemble needed materials before approaching
client’s room.
17. Verify patient identification.
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- Ask the patient to state his or her full name and compare with name on wrist band. If the patient
is unable to state his or her name, verify identity with an individual familiar with the patient.
- Verify client blood type (ABO group & Rh type) & other essential information
18. Obtain & record client’s vital signs immediately before transfusion to establish baseline.
19. Review the procedure and signs/symptoms of transfusion reaction before commencing transfusion.
20. Reassure client & entertain questions to allay anxiety.
21. Close the clamp of the client’s main IV line.
22. Wipe the Y-port of the main IV line with alcohol swab.
23. Flush the tubing of main IV line with 10 mL or more of normal saline by injecting it onto the Y-port.
24. Piggyback blood administration set with a needle to the Y-port of the main IV line and secure all
connections with adhesive tape.
25. Initially, start the infusion slowly (less than the ordered infusion rate). Acute transfusion reactions are
usually manifested during infusion of the initial 50 to 100 mL of blood. Remain at bedside for 15 to 30
minutes.
26. If signs of blood transfusion develop, STOP the transfusion immediately & record vital signs. Infuse
saline solution at a moderately slow infusion rate, and notify the physician at once.
27. In some institutions, for a circulatory overload reaction the transfusion is not stopped but the rate is
_____________________,
decreased. The physician is notified at once and the transfusion is stopped if it is ordered.
28. If no signs of a reaction appear within 15 minutes, you'll need to adjust the flow clamp to the ordered
infusion rate (usually 10 to 20 gtts/min). Continue to monitor if blood is infusing adequately at
4 hours to avoid bacterial
prescribed flow rate. Transfusion of a unit of blood should NOT exceed _________
growth.
29. Monitor client’s vital signs throughout the blood transfusion every 15
___ minutes for the first hour of
30 minutes for the 2nd hour, then hourly until 1 hour after the infusion is
transfusion, then every ____
completed, or per institution policy. Also continue monitoring for blood transfusion reactions.
30. An accepted blood infuser or

pressure infuser [see
illustration] may be used to
facilitate infusion especially
when the flow rate on blood
administration set slows down
(as what usually occurs when
transfusing packed RBCs) &
there is still blood product

remaining in the bag.
31. Inflating the blood infuser will apply pressure on the blood bag which facilitates infusion of remaining
contents. NEVER squeeze the blood bag with your hands & DO NOT OVERINFLATE the bag of pressure
infuser (usually not exceeding 300 torr or not exceeding marked line on the air pressure indicator). Be
aware that excessive pressure may develop, leading to broken blood vessels and extravasation, with
hematoma and hemolysis of the infusing RBCs.
32. After blood has infused, close the clamp of the blood administration set and remove tubing with
needle from the Y-port of the IV main line.
33. If main line is NOT normal saline, DON’T open the clamp of the main IV line yet. Flush it again first with
10 mL or more of normal saline to clear blood from the line.
34. If main IV line is saline, simply open the clamp of the main IV line and allow tubing to clear of blood.
35. Regulate main IV line at prescribed flow rate.
36. Do aftercare.
37. Return the empty blood bag to the blood bank, and discard the tubing and filter or per agency policy.
38. Record the patient's vital signs & do appropriate documentation.

normal saline
▪ (PNSS)
NO solution other than _____________ should be added to blood components.
▪ Medications are NEVER added to blood components or piggybacked into a blood transfusion. If the
client is receiving multiple IV medications on a strict schedule (e.g., antibiotics), consider starting a
second IV line for a lengthy blood transfusion
▪ Blood products should NOT be transfused simultaneously or immediately preceding or following
medications also capable of causing allergic-type reactions. Distinguishing the etiology of the reaction
could be difficult.
▪ Routine blood transfusions should not be warmed as hemolysis of blood occurs at temperatures above
40°C. Multiple rapid transfusions & hypothermia, however, requires blood warming.
▪ NEVER administer blood that is too _______. warm the blood on a hot water bath either or
cold DON’T _______
place it in a microwave or by other unacceptable means. In the absence of an authorized blood
warmer, the nurse may simply wrap the blood bag with a thick towel until it is not cold for transfusion.
▪ Always handle the blood bag CAREFULLY so as not to cause RBC hemolysis.
▪ Platelets are administered immediately on receipt from the blood bank and are given rapidly, usually
over 15 to 30 minutes.
▪ For multiple blood transfusions, always use a different blood administration or platelet administration
set for each unit.
▪ Always obtain physician’s order for follow-up laboratory tests needed post-blood transfusion to
monitor effectiveness of the therapy.
▪ A Jehovah Witness CANNOT receive blood or blood products; this group believes that blood
transfusions have eternal consequences. Always assess for any cultural or religious beliefs regarding
blood transfusions.

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ASSISTING WITH BONE MARROW ASPIRATION & BIOPSY
 Bone Marrow Aspiration is the removal of a small amount of organic material from the _______
Medulla of certain
bones by a large-bore needle.
 Bone Marrow Biopsy is the removal of a core of bone marrow cells by a biopsy needle. The cells are then
examined in the laboratory to describe the number, size, shape, and development of the erythrocytes and
megakaryocytes. Both bone marrow aspiration & biopsy could be performed at the bedside. [see illustration]
1. Give the indications for bone marrow aspiration & biopsy.
2. Identify the common sites for bone marrow aspiration & biopsy.
3. Give the major complications of the procedure.
4. Describe the procedure and explain rationale for each step accurately.
108

A. Indications for Bone Marrow Aspiration & Biopsy:
▪ Diagnosis of hematologic disorders, monitoring of course of illness & response to treatment
▪ Diagnosis of other disorders, such as primary and metastatic tumors, infectious diseases and
certain granulomas
▪ Isolation of bacteria & other pathogens by culture
B. Common Sites for Bone Marrow Aspiration & Biopsy:

vital organs
▪ or vessels
Posterior Superior Iliac Crest (most preferred site because no _____________ are nearby)
▪ Anterior Iliac Crest (preferred site for patients who can’t lie prone because of severe abdominal
distention)
▪ Sternum (seldom used because of greatest risk for complications)
C. Complications of Bone Marrow Aspiration & Biopsy:

▪ Bleeding
▪ Infection
▪ Puncture of the heart, major blood vessels, mediastinum, & lungs (due to needle puncturing the
sternum)
109
 Materials/Equipment Needed:
▪ Bone marrow aspiration set (may be individually procured if not in set)
- Antiseptic solution (povidone-iodine)
- Gauze sponges (4x4)
- Sterile towels
- Local anesthetic solution (lidocaine)
- Sterile syringes: two 3-mL with 23- to 25-gauge needles for anesthetic
- Two 10-mL syringes for marrow aspiration (physician may prefer slip tip rather than luer-lock)
Jamshidi needle most commonly used]
- Two bone marrow needles with inner stylus [ ________
- One biopsy needle
- Test tubes and glass slides
- Povidone-iodine ointment
- Sterile gauze and tape or Band-Aid
▪ Sterile gloves
▪ Personal protective equipment
▪ Pain medication or sedative as ordered (to be given before procedure)
 Procedure Guidelines for Bone Marrow Aspiration & Biopsy:

1. Review client’s signature on the informed consent form.
2. Have the client void.
3. Administer medication for sedation for pain. Be alert to medications that may alter clot formation (e.g.,
anticoagulants, aspirin).
5. Set up sterile tray.
6. Assist client in maintaining correct position for site to be aspirated:
- Side-lying w/ one leg fixed/prone
Posterior iliac crest: ______________________
side-lying or supine
- Anterior iliac crest: ____________
- Sternum: supine or semi-Fowler’s
7. Reassure client while explaining each step of the procedure. A sharp sting usually occurs with the local
anesthetic & a brief dull pain when the needle enters the bone.
8. Assess client’s condition during the procedure.
9. Physician or qualified practitioner performs the aspiration or biopsy:
- Select the site to be used.

- Perform hand hygiene.
- Put on personal protective equipment and sterile gloves.
- Disinfect client’s skin with antiseptic solution and dry with cotton swab.
- Drape client with sterile towels or drape.
- Inject local anesthetic to the site and ask client when it has taken effect.
110
- Bone marrow aspiration: Insert the needle with inner stylus into the bone, then advance the
needle until it reaches the area of softer, spongy bone and remove the stylus. Attach the 10-ml
syringe to the needle and aspirate bone marrow.
- Bone marrow biopsy: Screw the core biopsy instrument into the bone and remove a plug of
tissue.
- Place specimens into appropriate container for transfer to the laboratory.
- Label specimens with client name and date.
- After removing the needle or biopsy corer, apply pressure to the puncture site.
10. The nurse puts on gloves and applies pressure to the aspiration site with a gauze pad for 5 minutes to
control bleeding while an assistant prepares the marrow slides. The area is then cleaned with alcohol
to remove the povidone-iodine, the skin is dried thoroughly with a 4x4 gauze pad, and a sterile
pressure dressing is applied.
11. Specimen is usually placed in normal saline or 10% formaldehyde solution on glass slides or in a test
tube, are labeled appropriately, placed in laboratory biohazard transport bags, and sent to the
laboratory for cytologic and histologic evaluation.
operative side
12. Position client on _________________ to enhance pressure on the said area.
13. Discard supplies appropriately.
14. Remove gloves and perform hand hygiene.

▪ Bone marrow specimens SHOULD NOT be collected from irradiated areas because radiation may have
altered or destroyed the marrow.
▪ If a hematoma occurs around the puncture site, apply warm soaks. Give analgesics for site pain or
tenderness as prescribed.
▪ Use pillows, rolled towels, or blankets to assist the client in a comfortable position.

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111

NASOGASTRIC TUBE (NGT) INSERTION & REMOVAL
 A Nasogastric Tube (NGT) is a pliable plastic or rubber tube inserted through the patient’s nose and
advanced to the stomach.
1. Give the indications for NGT insertion.
2. Identify different types of nasogastric tubes.
3. Properly perform NGT Insertion.
4. Describe procedure for NGT removal

A. Indications for NGT Insertion:
 To remove gas and fluids from the stomach (decompression)
 To diagnose GI motility and to obtain gastric secretions for analysis
 To relieve and treat obstructions or bleeding within the GI tract
 gavage feeding), hydration and medication when the oral
To provide a means for nutrition (______
route is not possible or contraindicated
 To promote healing after esophageal or gastric surgery by preventing distention of the GI tract
and strain on the suture lines
 lavage that have been ingested either accidentally or
To remove toxic substances (_______)
intentionally and to provide for irrigation
B. Types of Nasogastric Tubes: [may contain a radiopaque line to verify tube placement by x-ray]
 Levin tube – most commonly used for feeding; a rubber or

plastic tube that has a single lumen, a length of 42 to 50
inches (106.5 to 127 cm), and holes at the tip and along the
side.
 Salem Sump or Anderson tube – a double-lumen tube;

“pigtail” acts as an air vent and prevents excess suction,
which could damage stomach lining; commonly used for
decompression, irrigations, and lavages. It is usually
connected to a Gomco suction machine.
112
 NGT Insertion:
- Nasogastric Tube (normal adult sizes: Fr 12 to 18; international color-coding same with suction
catheters)*
- Facial tissues*
- Adhesive hypoallergenic tape*
- Tongue depressor*
- Water-soluble lubricant [single packet]*
- Sterile gloves*
- Stethoscope*
- Penlight*
- Towel or absorbent pad
- Emesis/kidney basin
- Cup or glass of water with straw or ice chips (if appropriate)
- Asepto syringe
- Rubber band
- Safety pin
- Ordered suction equipment
- Clamp for tubing
 NGT Removal:
- Stethoscope*
- Asepto syringe
- Normal saline solution
- Materials for oral care & lubricant
A. NGT Insertion:
1. Ask the patient if he has ever had nasal surgery, trauma, a deviated septum, or bleeding disorder.
2. Explain procedure to the patient, and tell how mouth breathing, panting, and swallowing will help in
passing the tube.
sitting or High-Fowler's pos place a towel across chest.
3. Place the patient in a ______________________;
4. Determine with the patient what sign he might use, such as raising the index finger, to indicate wait a
few moments because of gagging or discomfort.
5. Remove dentures; place emesis basin and tissues within the patient's reach.
6. With sterile package not yet opened, inspect for defects on the tube; look for partially closed holes or
rough edges.
7. Place rubber tubing in ice-chilled water for a few minutes to make the tube firmer. Plastic tubing may
already be firm enough; if too stiff, dip in warm water.
8. Have the patient blow nose to clear nostrils.
113
9. Inspect the nostrils with a penlight, observing for any obstruction. Occlude each nostril, and have the
patient breathe. This will help determine which nostril is more patent.
10. Prepare two tapes – one long strip that is split lengthwise halfway [see illustration] and a short one.
11. Perform hand hygiene. Put on gloves.

12. After donning gloves, have coworker partially open the package of NGT. Making sure not to
contaminate your gloves, grasp tube and remove it from its package.
nose, earlobe, xiphoid and mark the tube
13. Maintaining sterility of tube, measure the patient's NEX (___________________),
appropriately [see illustration below]. Some tubes may be pre-marked to indicate length, but this may
not correlate exactly with the measurement obtained.
- The distance from the nose to the earlobe is the

first mark on the tube. This measurement
represents the distance to the nasal pharynx.
- When the tube reaches the xiphoid process (tip of
the breast bone) a second mark is made on the
tube. This measurement represents the length
required to reach the stomach.
14. With your dominant gloved hand, coil the first 3-4 inches (7-10 cm) of the tube around your fingers.
Have coworker open the packet of water-soluble lubricant and drop it on nondominant gloved hand
making sure not to contaminate glove.
15. Still holding the coiled tube with your dominant hand, coat its distal end with the lubricant. AVOID
occluding the tube's holes with lubricant.
16. Tilt back the patient's head before inserting tube into nostril, and gently pass tube into the posterior
nasopharynx, directing downward and backward toward the ear.
17. When tube reaches the pharynx, the patient may gag; allow patient to rest for a few moments.
18. Have the patient tilt head slightly forward. Offer several sips of water through a straw, or permit
patient to suck on ice chips, unless contraindicated. Advance tube as patient swallows.
19. Gently rotate the tube 180
___ degrees to redirect the curve.
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20. Continue to advance tube gently each time the patient swallows.
21. If obstruction appears to prevent tube from passing, do not use force. Rotating tube gently may help. If
unsuccessful, remove tube and try other nostril.
22. If there are signs of distress such as gasping, coughing, or cyanosis, IMMEDIATELY remove tube.
23. Continue to advance the tube when the patient swallows, until the mark reaches the patient's nostril.
24. To check whether the tube is in the stomach:
- X-rays may be done to confirm tube placement.

______
- Obtain aspirate with 30 to 60 mL syringe & check for the pH. If stomach contents cannot be
aspirated, reposition the patient and attempt to aspirate again.
- Attach an Asepto syringe to the end of the NG tube. Place a stethoscope over the left upper
quadrant of the abdomen, and inject 5 to 10 mL of air while auscultating the abdomen.
- Ask the patient to talk or hum.
- Use the tongue blade and penlight to examine the patient's mouth especially an unconscious
patient.
25. After tube is passed and the correct placement is confirmed, attach the tube to suction (if indicated) or
clamp the tube. Remove gloves.
26. Anchor tube with hypoallergenic tape; attach unsplit end of long strip of tape to nose, and cross split
ends around tubing. Apply the short strip of tape across bridge of client’s nose. [see illustration below]
27. Anchor the tubing to the patient's gown. Use a rubber band to make a slip-knot to anchor the tubing
to the patient's gown. Secure the rubber band to the patient's gown using a safety pin [see illustration
below]. However, omit this step of the procedure for clients with psychiatric illness & suicidal
ideations.
115
28. After anchoring the tubing, perform hand hygiene.

29. Assure the patient that most discomfort he feels will lessen as he gets used to the tube.
30. Irrigate the tube at regular intervals (every 2 hours unless otherwise indicated) with small volumes of
prescribed fluid.
31. Cleanse nares and provide mouth care every shift.
32. Apply petroleum jelly to nostrils as needed, and assess for skin irritation or breakdown.
gastroesophageal reflux
33. Keep head of bed elevated at least 30 degrees to minimize ___________________.
34. Record the time, type, and size of tube inserted. Document placement checks after each assessment,
along with amount, color, consistency of drainage.
B. NGT Removal:
1. Verify the health care provider's order for removal.
2. Make sure that gastric drainage is not excessive in volume.
3. Make sure, by auscultation, that audible peristalsis is present.
4. Determine whether the patient is passing flatus; this indicates peristalsis.
Semi-Fowler's pos Then drape a towel or absorbent pad across her chest to
5. Help the patient into _______________.
protect her gown and bed linens from spills.
6. Using an Asepto syringe, flush the tube with 20
__ ml of air or normal saline solution to ensure that the
tube doesn't contain stomach contents that could irritate tissues during tube removal.
7. Apply disposable gloves.
8. Unpin tube from patient’s gown and remove tape from nose.
9. Clamp the tube by folding it in your hand.
10. Instruct the patient to _____________________.
take a deep breath and hold it in This maneuver closes the epiglottis.
11. Slowly, but evenly, withdraw tubing and cover it with a towel as it emerges. Covering the tubing helps
dispel patient's nausea. (As the tube reaches the nasopharynx, you can pull quickly)
12. Coil tube around gloved finger. Pull gloves over the coiled tube and discard it.
13. Provide the patient with materials for oral care and lubricant for nasal dryness.
14. Dispose of equipment in appropriate receptacle. Perform hand hygiene.
15. Document time of tube removal and the patient's reaction.
16. Continue to monitor the patient for signs of GI difficulties.
116
 Similar to suction catheters, the international color code for the sizes of nasogastric & orogastric tubes
are: [NOTE: the larger the number, the larger the lumen]
 French 5 (Fr 5) = Gray  French 14 (Fr 14) = Green
 French 8 (Fr 8) = Blue  French 16 (Fr 16) = Orange
 French 10 (Fr 10) = Black  French 18 (Fr 18) = Red
 French 12 (Fr 12) = White
 If your patient lies unconscious, tilt her chin toward her chest to close the trachea. Then advance the
tube between respirations to ensure that it doesn't enter the trachea.
 While advancing the tube in an unconscious patient (or in a patient who can't swallow), stroke the
patient's neck to encourage the swallowing reflex and facilitate passage down the esophagus.
 While advancing the tube, observe for signs that it has entered the trachea, such as choking or
breathing difficulties in a conscious patient and cyanosis in an unconscious patient or a patient without
a cough reflex. If these signs occur, remove the tube immediately. Allow the patient time to rest; then
try to reinsert the tube.
 Tincture of benzoin (if iodine allergy is not present) may be used to prep the skin on the bridge of the
_______________
nose. This acts as an adhesive as well as a skin prep.
 After tube placement, vomiting suggests tube obstruction or incorrect position. Assess immediately to
determine the cause.
 Assess client’s lungs and breathing carefully after an NG tube has been removed. There is a risk for
aspiration. Also, the presence of the tube may suppress the client’s coughing and attempts to clear
secretions from the throat, which could cause respiratory complications. These complications may not
appear until after the tube is removed.
 Sore throat or difficulty in swallowing may present as a symptom of inflammation of the insertion area.
This symptom should subside in 1 to 2 days. Lozenges or ice chips can be used to minimize discomfort.
 In infants & young children, an orogastric tube (OGT) may be inserted instead of an NGT. Since tube
lumen is too narrow, a 5- or 10-mL luer-lock syringe is used instead of an Asepto.

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117
SKILLS LABORA TORY MODULE NO. 18

ENTERAL FEEDING THROUGH A NASOGASTRIC TUBE (NGT) &
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)
C Enteral feeding involves delivery of a liquid feeding formula directly to the stomach (known as gastric
gavage), duodenum, or jejunum. Gastric gavage typically is indicated for a patient who can't eat normally
because of dysphagia or oral or esophageal obstruction or injury. Gastric feedings also may be given to an
unconscious or intubated patient or to a patient recovering from GI tract surgery who can't ingest food orally.
C Liquid nutrient solutions for enteral feeding come in various formulas for administration through a
nasogastric tube, or through a gastrostomy.
C Enteral feeding through a nasogastric tube may be done through bolus feeding (still the most common
kangaroo [as shown below].
method) or through a continuous controlled pump or more commonly, a ____________
pump
C The most common gastrostomy procedure done which allows transabdominal enteral feeding access is a
percutaneous endoscopic gastrostomy [as shown below].
_______________________________
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1. Give the ways to assess for patency & placement of the nasogastric tube (NGT).
2. Give the common complications of enteral feeding and preventive measures.
3. Perform NGT feeding.
4. Perform PEG feeding.
I Important Information related to this Module:

A. Ways to Assess for NGT Placement & Patency:
§ Most reliable method: By X-Ray, which should be performed after initial placement
§ 2nd most reliable method: Measure pH of aspirated gastric contents with color-coded pH paper
with range of number 1 to 11
- gastric aspirates have decidedly acidic pH values, preferably 4 or less, compared with;
_______
- intestinal
_______aspirates, which are usually greater than 4, or;
- respiratory
_______ secretions, which are usually greater than 5.5.
§ 3rd most reliable method: Aspirate gently back on syringe to obtain gastric contents, observing
color [if color is not consistent with that of how gastric contents should appear, NG tube tip is
either at the duodenum or esophagus and thus, not in proper placement]
- gastric contents usually appear cloudy & green but may be off-white, tan, bloody or brown in color
- duodenal contents are yellow or bile-stained
- esophageal contents may or may not have saliva-appearing aspirate
- NOTE: if stomach contents cannot be aspirated, place the patient on left side and advance the tube
1 to 2 inches and try again.
§ Most convenient method: Perform air insufflation method by inserting 5 to 10 mL of air into the
NGT and listening for the rush of air over the stomach with a stethoscope placed over the left
upper quadrant of the abdomen [if belching occurs, the tube is probably in the esophagus]. Take
note that a muffled or faint sound of injected air may signal that the tube is in the lungs. It may
be necessary to inject air two or three times in obese clients as the sound of injected air may be
faint. Remove air to prevent distention & discomfort.
§ Other acceptable methods:
- Ask client to talk or hum (client is unable to talk or hum if NG tube has passed through vocal cords)
- Use tongue blade/depressor and penlight to examine the patient’s mouth – especially an
unconscious patient; inspect posterior pharynx for presence of coiled tube (tube is pliable and can
coil up in back of pharynx instead of advancing into esophagus)
- NURSING ALERT: NEVER place the end of the tube in water while checking placement. If the tube is
in the trachea, the patient could aspirate.
119
B. Prevention of Complications of Enteral Feeding:

§ Diarrhea
- Use fiber-containing feedings
- Administer feeding slowly at room temperature
§ Aspiration
- Verify tube placement
- Do not administer feeding if residual is 150
___ mL or greater
- Keep the head of the bed elevated
- If aspiration occurs, suction as needed, assess respiratory rate, auscultate lung sounds,
monitor temperature for aspiration pneumonia, and prepare to obtain chest radiograph
§ Clogged tube
- Use liquid forms of medication, if possible.
- Flush the tube with 30 to 50 mL of water before and after medication administration and
before and after bolus feeding.
- Flush tube with water every 4 hours for continuous feeding
- If feeding tube becomes clogged or seems to be running slowly, water, a carbonated
beverage, or cranberry juice instilled into the tube will sometimes help clean out the inside
of the tube. Be sure this is compatible with the client’s diet and orders.
§ Vomiting
- Administer feedings slowly, and for bolus feedings, make the feeding last for 30 minutes
- Measure abdominal girth
- Do not allow feeding to run dry
- Do not allow air to enter the tubing
- Administer feeding at room temperature
- Elevate the head of the bed
- Administer antiemetics as prescribed
- If client vomits, place in side-lying position and suction if needed.
I Materials/Equipment Needed: [materials/items with an asterisk (*) are the materials the students should
- Stethoscope*
- Feeding formula (see specifications on label of container for amount of feeding)
- Asepto syringe
- Calibrated glass
- 120 ml of water (preferably distilled or cooled boiled water)
- Medication (if prescribed)
120
I Procedure Guidelines:
A. Bolus Feeding via NGT:
1. Verify doctor’s order for NGT feeding.
2. Explain the procedure to the client.
high Fowler’s
3. Position the client in _________________ in bed or sitting
____________
position in a chair or slightly elevated right
position
side-lying position if comatose.
4. Warm feeding to room temperature to prevent diarrhea & cramps. For refrigerated feeding, warm it
by adding hot water until desired temperature of feeding is obtained.
5. Aspirate all stomach contents (residual), to measure the amount, and return the contents to the
stomach to prevent electrolyte & acid-base imbalances.
6. Check physician’s order and agency policy regarding residual amounts; usually if the residual is less 150
mL, feeding is administered; if the residual is 150 mL or greater, hold the feeding (however, in some
books, if residual is 50 mL or more, verify with physician if the feeding will be given)
7. Assess tube placement & patency.
8. Assess bowel sounds; hold feeding and notify the physician if bowel sounds are absent.
9. Instill 30 mL of water into the NGT before introducing the feeding.
10. Introduce feeding slowly (over 10 to 15 minutes) to prevent ________,
flatulence crampy pain or reflex vomiting.
11. Height of feeding should NOT be more than 12 inches above the tube’s point of insertion into the
client (this allows slow introduction of feeding).
12. Administer medication if prescribed.
13. Instill another 30 mL of water into the NGT after feeding to cleanse the lumen of the tube.
14. Clamp the NGT before all of the water is instilled to prevent entry of air into the stomach.
15. Leave the client in high-Fowler’s position or in slightly elevated right lateral position for at least 30
minutes (to prevent potential aspiration of feeding); some institutions leave the patient in the said
position for 45 minutes to 1 hour.
B. PEG Feeding:
1. Verify doctor’s order for PEG feeding.
2. Explain procedure to the client.
3. Auscultate for bowel sounds before feeding. Consult physician if bowel sounds are absent (absence of
bowel sounds may indicate decreased or absent peristalsis and increased risk of aspiration or
abdominal distention)
4. Have tube feeding at room temperature (cold formula may cause gastric cramping and discomfort
because the liquid is not warmed by mouth and esophagus)
121
5. Elevate head of bed 30 to 45 degrees (helps prevent chance of aspiration although uncommon)
6. Verify tube placement & patency and assess residual by aspirating gastric contents. Observe its
appearance and check pH; return aspirated contents to stomach unless the volume exceeds 150 mL
(gastric fluid is usually cloudy and grassy green or tan to off-white in color). In some books, if residual
formula is 50 mL or more, verify if the feeding will be administered.
7. Flush PEG tube with 30 mL of water
8. Administer feeding slowly. Hold syringe 7 to 15 cm (3 to 6 inches) above the ostomy opening to
prevent flatulence, crampy pain & reflex vomiting.
9. Administer medication if prescribed.
10. Flush the PEG tube again with 30 mL of water.
11. After feeding, have client remain position (head of bed elevated 30 to 45 degrees) for at least 30
minutes to prevent gastric reflux and aspiration.
12. Assess skin around PEG tube exit site. The skin around the tube should be cleansed daily with warm
water & mild soap. Dressings around exit site are not recommended (report any drainage, redness,
swelling, or displacement of PEG tube to the physician)
I Precautions & Special Considerations:
§ When administering medications through an NGT or PEG tube, be guided with the following:
MEDICATION FORM PREPARATION

Liquid None
Simple compressed tablets Crush and dissolve in water
Buccal or sublingual tablets Administer as prescribed
Soft gelatin capsules filled with liquid Make an opening in capsule & squeeze out contents
Enteric-coated tablets Do not crush; change in form is required
Do not crush tablets because doing so may release too
Time-release tablets much drug too quickly (overdose); check with
pharmacist or physician for alternative formulation
Some can be opened and contents added to tube-
Time release or sustained-release capsules feeding formula; always check with pharmacist or
physician before doing this
122
§ The social aspect of eating should be emphasized. All gastric feedings should have a friendly
atmosphere and should be treated as a meal rather than a procedure.
§ If using food coloring to identify formula in pulmonary aspirate, be sure to use a small amount. It only
needs a tinge of color to be identifiable. Some food colorings, such as methylene blue, can deposit in
client’s tissues and mucous membranes and cause a blue tinge in the skin. In some facilities, it is now
prohibited to use methylene blue or other food coloring as it could be fatal to a client with poor
circulation or sepsis.
§ Remember, formulas can spoil. This is especially true in non-air-conditioned areas in hot, humid
weather. Discard them if they have been opened and unused. Always check expiry date of formulas.
Discard formula that is outdated, not labeled properly or not stored correctly.
room
§ Be sure to warm the formula to at least ______________
temperature before using it for feeding. The temperature
of formula can be judged the same way a baby’s formula is, on the inside of the wrist.
§ Administer feeding at prescribed rate if using continuous controlled pump or via gravity flow.
§ Oral hygiene and denture care should not be overlooked simply because an NGT or PEG tube is in
place.
I References & Suggested Readings:

§ Altman, G.B. (2010). Fundamental & advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage
Learning.
§ Nettina, S. & Mills, E.J. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia, PA:
§ Schilling-McCann, J. (2009). Lippincott’s nursing procedures (5th ed.). Philadelphia, PA: Lippincott,
Williams & Wilkins.
§ Silvestre, L.A. (2005). Saunders comprehensive review for the NCLEX-RN examination (3rd ed.).
§ Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth’s textbook of medical-
§ Williams, L. & Hopper, P. (2003). Understanding medical-surgical nursing (2nd ed.). Philadelphia, PA:
F.A. Davis Company.
123

HYPERALIMENTATION / PARENTERAL NUTRITION
 When a patient can't meet his nutritional needs by oral or enteral feedings, he may require I.V. nutritional
support, or parenteral nutrition. The patient's diagnosis, history, and prognosis determine the need for
parenteral nutrition. Generally, this treatment is prescribed for any patient who can't absorb nutrients through
total parenteral nutrition
the GI tract for more than 10 days. There are two types of parenteral nutrition: (1) ______________________
peripheral parenteral nutrition [see illustration]
and (2) ______________________.
 total parenteral nutrition

______________________ (TPN) refers to any nutrient solution, including lipids, given through a central
venous line (e.g., Broviac®, Groshong® or Hickman® catheter) inserted into the vena cava usually threaded
through the subclavian vein.
 Peripheral Parenteral Nutrition(PPN), which is given through a peripheral line (i.e., on an arm vein),
__________________________
supplies full caloric needs while avoiding the risks that accompany a central venous line.
1. Give the indications of parenteral nutrition.
2. Familiarize himself/herself with the different solutions used for hyperalimentation/parenteral nutrition
and give important nursing implications.
3. Discuss the complications of parenteral nutrition and corresponding nursing management.
4. Describe nursing responsibilities for a patient receiving parenteral nutrition.
124

A. Indications of Parenteral Nutrition:
 Conditions in which patient cannot tolerate enteral nutrition including but not limited to:
- Paralytic ileus
- Intestinal obstruction
- Acute pancreatitis
- Severe malabsorption
- Persistent vomiting and jejunal route not possible
- Severe diarrhea
- Fistula and enteric feeding not possible
- Inflammatory bowel disease
- Short bowel syndrome
 Hypermetabolic states for which enteral therapy is either not possible or inadequate, such as
burns, trauma, sepsis, chemotherapy, severe malnutrition, etc.
B. Commonly Used Parenteral Nutrition Solutions (by brand name) in the Clinical Area:
 Amino Acids: Aminoleban®, Aminosteril ®, Moriamin S-2® [skin test usually done before
administration], Aminopro®, Moriavit®, Nephrosteril® [ideal for clients with acute & chronic renal
insufficiency], Vamin®
 Carbohydrates: [dextrose-containing solutions; e.g., D5NSS, D5W, D50W]
 Lipids (see nursing considerations below): Intralipid®, Soyacal®, Celepid®
- Assess client for allergies to eggs or soybean which may induce hypersensitivity reaction with fat
emulsion.
- Examine bottle for separation of emulsion into layers or fat globules or for the accumulation of
froth; if observed, do not use and return the solution to the pharmacy.
- DO NOT put additives into the fat emulsion solution.
- DO NOT use an intravenous (IV) filter because particles in the fat emulsion are too large to pass
through filters
- Use vented IV tubing because the solution is usually supplied in a glass container for administration
- Monitor liver function tests for evidence of impaired liver function indicating the inability of the
liver to metabolize the lipids.
- Change IV tubing & solution every 24 hours (even if there is still solution remaining).
- May cause thrombocytopenia especially when administered to children.
- Signs of adverse reaction to lipids:
chills, fever, flushing, diaphoresis, dyspnea, cyanosis, chest and back pain, nausea and vomiting, headache, pressure over eyes, vertigo, sleepiness
_______________________________________________________________________________
 Total Nutrient Admixture [contains amino acids, dextrose & lipids]: Kabiven® – available in a 3-
chamber bag; use a 1.2 micron filter during administration; requires mixing before
administration by breaking seal of the 3 bag chambers; mixture shelf-life is about 24 hours
125
C. Complications of Parenteral Nutrition: (consult textbook for prevention & nursing management)
 Pneumothorax
 Air embolism
 Clotted catheter line
 Catheter displacement & contamination
 Sepsis
 Hyperglycemia
 Fluid overload
 Rebound hypoglycemia
 Patient Monitoring during Parenteral Nutrition:
diminish anxiety, and encourage cooperation

1. Explain the procedure to the patient to __________________________________________. Instruct
him to inform you if he experiences any unusual sensations during the infusion.
2. Record vital signs every 4 hours or more often if necessary because increased temperature is one of
the earliest signs of catheter-related sepsis.
3. Perform I.V. site care and dressing changes at least three times a week (once a week for transparent
semipermeable dressings) or whenever the dressing becomes wet, soiled, or nonocclusive. Use strict
sterile technique.
4. Physically assess the patient daily. If ordered, measure arm circumference and skin-fold thickness over
the triceps.
5. Weigh the patient at the same time each morning (after voiding), in similar clothing, and on the same
scale. Compare this data with his fluid intake and output record. Weight gain, especially early in
fluid overload rather than increasing ___________________.
treatment, may indicate ________________ fat and protein stores A patient
shouldn't gain more than 3 lb (1.4 kg) a week; a gain of 1 lb (0.5 kg) a week is a reasonable goal for
most patients. Suspect fluid imbalance if the patient gains more than 1 lb daily. Assess for peripheral
and pulmonary edema.
6. Monitor the patient for signs and symptoms of glucose metabolism disturbance, fluid and electrolyte
imbalances, and nutritional aberrations. Remember that some patients may require supplemental
insulin for the duration of parenteral nutrition; the pharmacy usually adds insulin directly to the
parenteral nutrition solution, but additional subcutaneous insulin by sliding scale may be required.
7. Monitor levels of electrolytes and protein frequently daily at first for electrolytes and twice weekly for
serum albumin. Later, as the patient's condition stabilizes, you won't need to monitor these values
albumin levels may drop
quite as closely. (Be aware that in a severely dehydrated patient, ____________
initially as treatment restores hydration.)
126
8. Pay close attention to magnesium and calcium levels. If these electrolytes have been added to the
parenteral nutrition solution, the dose may need adjusting to maintain normal serum levels. Assess the
patient for signs and symptoms of magnesium and calcium imbalances.
9. Monitor serum glucose levels every 6 hours initially and then once a day, and stay alert for signs and
symptoms of hyperglycemia, such as thirst and polyuria. Periodically confirm blood glucose meter
readings with laboratory tests.
10. Check kidney function by monitoring blood urea nitrogen and creatinine levels; increases can indicate
excess amino acid intake Also assess nitrogen balance with 24-hour urine collection.
_____________________.
11. Assess liver function by periodically monitoring liver enzyme, bilirubin, triglyceride, and cholesterol
levels. Abnormal values may indicate an
intolerance/excess of lipid emulsions or prob w/ metabolizing protein/GLU in parenteral nutrition formula
____________________________________________________________________________________.
12. Change the I.V. administration set every 24 hours. Because the risk of contamination is so high with
parenteral nutrition, each facility should continuously evaluate protocols based on quality-control
findings. Use aseptic technique and coordinate the change with a solution change. Keep in mind that
the tubing, injection caps, stopcocks, catheter, and even the patient's skin are potential sources of
microbial contamination. The catheter hub, where most manipulations take place, is especially
vulnerable. (The parenteral nutrition formula itself, which is prepared aseptically in the pharmacy, is
seldom the source of infection.)
13. Monitor for signs of inflammation, infection, and sepsis, the most common complications of parenteral
nutrition. Microbial contamination of the venous access device is the usual cause. Watch for
redness and drainage at the venous access site, and monitor the patient for fever and
_______________________________
other signs and symptoms of sepsis.
14. While weaning the patient from parenteral nutrition, document his dietary intake and work with the
nutritionist to determine the total calorie and protein intake. Also teach other health care staff caring
for the patient the importance of recording food intake. Use percentages of food consumed (ate 50%
of a baked potato) instead of subjective descriptions (had a good appetite) to provide a more accurate
account of patient intake.
15. Provide emotional support. Keep in mind that patients often associate eating with positive feelings and
become disturbed when eating is prohibited.
16. Provide frequent mouth care.
17. Keep the patient active to enable him to use nutrients more fully.
18. When discontinuing parenteral nutrition, decrease the infusion rate slowly, depending on the patient's
current glucose intake, to minimize the risk of hyperinsulinemia and resulting hypoglycemia. Weaning
127
usually takes place over 24 to 48 hours but can be completed in 4 to 6 hours if the patient receives
sufficient oral or I.V. carbohydrates.
 Always maintain strict sterile technique when handling the equipment used to administer therapy.
Because the parenteral nutrition solution serves as a medium for bacterial and fungal growth and the
central venous (CV) line provides systemic access, the patient risks infection and sepsis.
 Parenteral nutrition solutions should be stored under refrigeration and administered within 24 hours
from the time they were prepared; administer parenteral nutrition solutions at room temperature
(remove from refrigerator 30 minutes to 1 hour before use).
 Parenteral nutrition solutions that are cloudy or darkened should NOT be used and should be returned
to the pharmacy.
 DON’T let parenteral nutrition solutions hang for more than 24 hours.
 Be careful when using the parenteral nutrition line for other functions. If using a single-lumen CV
catheter, don't use the line to infuse
blood or blood products, to give a bolus injection, to administer simultaneous IV solutions, to measure CV pressure, or to draw blood for
___________________________________________________________________________________.
laboratory tests
Also, don't use a three-way stopcock, if possible, because add-on devices increase the risk of infection.
 NEVER add medication to a parenteral nutrition solution container. However, heparin may be added
fibrinous clot
to the parental nutrition solution to reduce the build-up of ________________ at the catheter tip. If so,
partial thromboplastin time and clotting time is monitored. Insulin may also be added to control the
blood glucose level because of the high concentration of glucose solution in the TPN.
 When a patient is severely malnourished, starting parenteral nutrition may spark a refeeding
Potassium ___________,
syndrome, which includes a rapid drop in ____________, Magnesium and ___________
Phosphoruslevels. To
avoid compromising cardiac function, initiate feeding slowly and monitor the patient's blood values
especially closely until they stabilize.

Learning.
Williams & Wilkins.
 Silvestre, L.A. (2005). Saunders comprehensive review for the NCLEX-RN examination (3rd ed.).
128

HOT SITZ BATH
 A Sitz Bath involves immersion of the pelvic area in warm or hot water. It is used to relieve discomfort,
especially after perineal or rectal surgery (e.g., hemorrhoidectomy) or childbirth. The bath promotes wound
healing by cleaning the perineum and anus, increasing circulation, and reducing inflammation. It also helps
relax local muscles.
1. Describe procedure in performing hot sitz bath.
 Materials/Equipment Needed:
- Disposable gloves
- Portable sitz bath (toilet insert or stand-alone model)
- Towels
- Hot water
1. Perform hand hygiene and assemble equipment.
2. Run tap water to preferred temperature (between 38°C to 43°C). Have client test the temperature on
dorsal surface of the wrist to prevent burn injury.
the _____________
3. For toilet insert model, raise the seat of the toilet. Set the basin on the rim of the toilet bowl. Fill water
bag and prime tubing. Close the clamp. Hang the water bag above the toilet. Thread the tubing
through the front of the basin. Secure the tubing in the notch in the bottom of the basin [see
illustration below].
129
4. For stand-alone model, fill basin with water. Pad the seat with a towel.
5. Don disposable gloves.
6. Have client remove and dispose of peri-pad.
7. Ensure that the floor is dry. Assist client to the bathroom if necessary.
8. Have client sit on the basin. For toilet insert model, demonstrate how to unclamp the tubing to start
the water flow.
9. Cover the client’s lap for warmth and modesty.
10. For stand-alone model, after 5 to 10 minutes, instruct client to stand and assist him to a chair (privacy
still provided). Recheck the temperature of the water; if it is not adequate, drain the water and refill it
with warm water. Afterwhich, assist client to sit back on the bath.
11. After 20 minutes (or sooner if client is finished), help the client dry the area by gently patting with
clean towels.
12. For toilet insert model, empty remaining water into toilet. Rinse basin and bag and allow to air dry. For
stand-alone model, empty water from drain tap into basin.
congestion
13. Assist client to bed. Encourage to lie flat or elevate hips for 20 minutes. This prevents ___________
swelling
and decreases ___________ of perineal area.
14. Clean equipment and do aftercare. Remove gloves & perform hand hygiene.
15. Sitz baths may be taken two to four times per day.

Learning.
 Schilling-McCann, J. (2002). Patient teaching reference manual. Philadelphia, PA: Springhouse
Corporation.
Williams & Wilkins.
130

COLOSTOMY & ILEOSTOMY CARE
 An ostomy is a surgically created opening that diverts stool to the outside of the body through an opening
colostomy
on the abdomen called a ________________. [see illustration below]
 An ________________
ileostomy is a surgically created opening between the ileum (usually the terminal ileum) of the
small intestine and the abdominal wall. On the other hand, a colostomy is a surgically created opening
between any segment of the colon and the abdominal wall to allow fecal elimination. Colostomies can be
further classified as to which segment of the colon they are created [see illustration]. Ileostomies &
colostomies are also called bowel diversions.
B C
A
A. ascending colostomy
_________________
B. transverse colostomy
_________________
C. descending colostomy
_________________
D. cecostomy
_________________
E. sigmoid colostomy
_________________
F. ileostomy
_________________
F E
1. Give the indications & complications of colostomy & ileostomy creation or of a bowel diversion.
2. Describe the characteristics of a healthy stoma.
3. Perform ostomy care which includes removal of a soiled ostomy appliance, cleansing of stoma &
peristomal skin and fitting & application of a new ostomy appliance.
5. Discuss the standards of care guidelines in caring for a patient with an ostomy.
131

A. Indications for Bowel Diversion:
▪ Usual Indications for a Colostomy
- May be performed as part of an abdominoperineal resection for rectal cancer
- A fecal diversion for unresectable cancer
- A temporary measure to protect an anastomosis
- Surgical treatment for inflammatory bowel diseases, trauma, ischemic bowel, cancer, and
congenital conditions
▪ Usual Indications for an Ileostomy
ulcerative colitis
- ___________________________
Crohn's disease
- ___________________________
Familial polyposis
- ___________________________
Cancer
- ___________________________
Congenital Defects
- ___________________________
Trauma
- ___________________________
B. Complications of Bowel Diversion:

▪ Mucocutaneous separation (between skin and stoma)
▪ Stomal ischemia
▪ Stomal stricture or stenosis (usually a long-term complication)
▪ Stomal prolapse
▪ Peristomal hernia
▪ Peristomal skin breakdown from exposure to fecal output, allergic reaction to products, or infection,
such as candidiasis
C. Stoma Classifications:
1. End stoma = is formed when the proximal end

of the bowel is brought to the outside of the
abdominal wall.
Loop stoma
2. __________________ = is formed when a loop of
bowel, usually the transverse colon, is pulled to the
outside abdominal wall & a bridge is slipped under
the loop to hold it in place. An incisional slit is made in
the top of the exposed colon to allow stool to exit.
The entire loop of bowel is not cut through.
132
3. Double-Barrel Stoma = is formed

___________________
when the bowel is completely
dissected and both ends of the colon
are brought to the outside abdominal
wall to form two separate stomas.
proximal
The _______________ stoma is the
functioning stoma that expels stool
distal
while ______________ stoma expels
mucous.
D. Location of Stoma and Character of Effluent:

 Effluent = the collective term for the fecal discharge/drainage that comes out of a colostomy or
ileostomy. The consistency & character of the effluent is dependent on the location of the bowel where
the stoma is created. The table below summarizes this information:
LOCATION OF STOMA CHARACTER OF EFFLUENT

Liquid to mushy; contains protoeolytic enzymes w/c can be
Ileostomy harmful to the skin; drains freq (ave 4-5x per day); odor is
not offensive
Cecostomy, ascending colostomy Liquid to mushy; foul odor
Right transverse colostomy Mushy to semiformed; foul odor

Left transverse colostomy Semiformed, soft; foul odor
Soft to Hard formed; foul odor; discharge is reg and
Descending or sigmoid colostomy least freq (1/2x a day)
E. Types of Ostomy Appliance & Basic Parts:

 An ostomy appliance is placed over the stoma to protect the skin, collect stool/effluent, and control
odor. [see illustration below]
133
E. Types of Ostomy Appliance & Basic Parts: [continued]

Skin barrier
One-Piece
1. __________________ appliance = consists of (already
a skin barrier that is already attached to the attached to
pouch pouch)
Pouch
Two-Piece
2. __________________ appliance = consists of a separate pouch with a flange and a separate skin
barrier with a flange (also called a wafer) where the pouch fastens to the barrier at the flange. The
pouch can be removed without the skin barrier/wafer.
POUCH WAFER
Flange of skin
Flange of pouch barrier/wafer
(flange of wafer (flange of pouch
fits here) fits here)
F. Types of Ostomy Pouch:
1. Drainable pouch = usually has a clamp (called

Bottom
a tail closure) where the end of the pouch is
opening of
folded over the clamp and clipped. This type
pouch
of pouch is usually used by people who need
(tail closure
to empty the pouch more than twice a day.
is folded &
clamped
here)
2. Closed pouch = is often used by people who

have a regular stoma discharge (as in a
sigmoid colostomy) and only have to empty
the pouch 1 or 2 times a day.
134
- Disposable gloves (2 pairs)*
- Two-piece drainable ostomy appliance (wafer & pouch)*
- Pen or pencil*
- Scissors (preferably curved)*
- Tail closure
- Toilet tissue, washcloth & towel
- Stoma measuring guide
- Stomahesive® paste or any skin barrier paste
- Stomahesive® powder (used if there is skin breakdown around stoma)
- Mild non-oily soap (optional)
- Odor-proof plastic bag
 Procedure Guidelines
A. Changing an Ostomy Appliance:
1. Determine the need for an appliance change-
When do you change?
Change when there is a pouch leakage or discomfort @ or around the stoma, change the appliance
___________________________________________________________________________________
___________________________________________________________________________________
2. Select an appropriate time to change the appliance.
▪ Avoid times close to meal or visiting hours. Ostomy odor and stool may reduce appetite or
embarrass the client.
▪ Avoid times immediately after meals or the administration of any medications that may
stimulate bowel evacuation. It is best to change the pouch when drainage is least likely to occur.
3. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol.
Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate.
Provide for client privacy, preferably in the bathroom, where clients can learn to deal with the ostomy
as they would at home.
4. Assemble materials and equipment. Perform hand hygiene and apply clean gloves.
5. Assist the client to a comfortable sitting or lying position in bed or preferably a sitting or standing
position in the bathroom.
6. Empty the pouch and remove the ostomy skin barrier/wafer.
▪ tail closure
Unclamp the ___________________of the drainable pouch and clean it (using soap & water) for
reuse. (refer to picture)
▪ Empty the contents of the drainable pouch through the

bottom opening into a bedpan or toilet. Emptying before
removing the pouch prevents spillage of stool onto the
client’s skin.
135
▪ Peel the skin barrier/wafer off slowly, beginning at the top and working downward, while
holding the client’s skin taut.
▪ Discard the soiled appliance in an odor-proof plastic bag.
7. Remove clean gloves and perform hand hygiene.

8. Assess the following:
▪ Stoma color: The stoma should appear red, similar in color to the mucosal lining of the inner
cheek and slightly moist. A dusky bluish, purplish hue or pale stoma indicates
necrosis
inadequate blood supply a black stoma indicates ____________________.
____________________;
▪ Stoma size & shape: Most stomas protrude slightly from the abdomen. Newly-created stomas
normally appear swollen or edematous, but swelling generally decreases over 2 or 3 weeks or
for as long as 6 weeks.
If the swelling fails to recede after 6 weeks, what does this indicate?
A problem occuring, such as blockage
_______________________________________________________________________________
▪ Stomal bleeding: Touching the stoma normally causes slight bleeding- True? or False?
False
_________
▪ Status of peristomal skin: Any redness and irritation of the peristomal skin – the 5 to 13 cm (2 to
5 in.) of skin surrounding the stoma – should be noted. Transient redness after removal of
adhesive is normal.
▪ Amount & type of feces/effluent: Assess the amount, color, odor, and consistency. Inspect for
abnormalities, such as pus or blood.
▪ Sensations: Since the stoma itself doesn’t have any nerve endings, the client will not feel
anything when the stoma is touched. However, complaints of burning sensation under the skin
barrier may indicate skin breakdown. The presence of abdominal discomfort and/or distention
also needs to be determined.
9. Don a new pair of clean gloves.

10. Clean and dry the peristomal skin and stoma.
▪ Use toilet tissue to remove excess stool.
▪ Use warm water, mild soap (optional), and a washcloth to clean the skin and stoma.
▪ Dry the area thoroughly by patting with a towel.
▪ Apply Stomahesive® powder on weeping areas of peristomal skin as indicated for skin
breakdown.
11. Place a piece of tissue or gauze over the stoma, and change it as needed. This absorbs any seepage
from the stoma while the ostomy appliance is being changed.
12. Use the measuring guide to determine stoma size [see illustration below].
13. For appropriate size, choose a circle on the measuring guide 1/16 to 1/8 inch larger than client’s actual
stoma size (usually 1 to 2 circles or sizes bigger than client’s stoma size on the measuring guide)
14. After choosing the appropriate size on the measuring guide, trace pattern or appropriate circle
carefully onto paper backing of wafer using pen or pencil [see illustration below].
15. Cut the circular opening in the skin barrier. Bevel the edges to keep them from irritating the patient.
[as shown below].
16. Remove the paper backing from the wafer and moisten it or apply Stomahesive® paste, as needed,
along the edge of the circular opening [see illustration].
17. Remove tissue or gauze from stoma.
18. Center the wafer over the stoma, adhesive side down, and gently press it to the skin. Continue
applying pressure to peristomal skin for 60 seconds (1 minute) to ensure adherence of wafer to skin
and to allow drying of Stomahesive® paste [as shown below].
19. Gently press the flange of the pouch to the flange of the wafer until it snaps into place [as shown].
20. Fold the bottom opening of drainable pouch once onto the bar of the tail closure. Clamp by joining the
bar & hinge of the tail closure and lock by applying pressure on the finger tab [see illustration below].
Finger Tab
Bar
Hinge
21. Discard of used equipment, remove gloves and perform hand hygiene.
B. Emptying a Drainable Ostomy Pouch:

1. Empty the pouch when it is 1/3 to 1/2 full of stool or gas. If the pouch is allowed to get more than half
full of stool, the weight of the effluent will pull on the pouch and weaken the seal of the skin barrier.
2. Don clean gloves.
3. Hold the pouch over a bedpan or toilet. Lift the lower edge up.
4. Unclamp or unseal the pouch.
5. Drain the pouch.
6. Clean the inside of bottom opening of pouch with a tissue or a pre-moistened towelette.
7. If desired, the bottom portion of the pouch can be rinsed with cool tap water. Don't aim water up near
the top of the pouch because this may loosen the seal on the skin.
8. Apply the tail closure and seal the pouch.
9. Dispose of used supplies.
10. Remove clean gloves. Perform hand hygiene.
▪ Most clinicians agree that an ostomy appliance should be changed at least once a week. If the skin is
erythematous, eroded, denuded, or ulcerated, the pouch should be changed every 24 to 48 hours to
allow appropriate treatment of the skin. More frequent changes are recommended if the client
complains of pain or discomfort.
▪ A drainable pouch should be used for all colostomies or Ileostomies, especially during the first 8 weeks
after surgery.
▪ Provide the following interventions for odor control:

- Encourage pouch hygiene through rinsing, keeping pouch tail free of effluent, airing of reusable
pouches, discarding odor-impregnated pouches.
- Recommend the use of pouch deodorants (such as spray deodorants & chlorophyll tablets),
room deodorizers, and oral deodorizers (such as buttermilk, yogurt & parsley).
- Never make a pinhole in a pouch to release gas which destroys the odor-proof seal.
- Instruct to minimize intake of food that increase odor of effluent: Enumerate as many as you
can-
fish, eggs, bear, and spices (garlic, onions)
_______________________________________________________________________________
_______________________________________________________________________________
▪ Provide the following interventions for gas control:

- Suggest avoidance of straws, excessive talking while eating, chewing gum, and smoking to
reduce swallowed air.
- Beans and cabbage as well as carbonated beverages and eliminate
Instruct about gas-forming foods: ___________________________________________________
when appropriate. It takes about 6hrs for gas to travel from mouth to colostomy
_______________________________________________________________________________
_______________________________________________________________________________
- Recommend using arm over stoma to muffle gas sounds when appropriate.
▪ Provide the following interventions to prevent ostomy blockage:

- Instruct patient to chew food well.
- Instruct to refrain from eating the following:
✓ Green leafy vegetables (spinach, collards, mustards)
✓ Cole slaw, sauerkraut
✓ Celery
✓ Corn, popcorn
✓ Foods with non-digestible peels (apples, grapes, potatoes, membranes on citrus fruits)
✓ Coconut
✓ Mushrooms
✓ Nuts
✓ Dried fruits (raisins, figs, apricots)
✓ Chinese vegetables
✓ Meats with casings (sausage, hot dogs, bologna)
▪ Encourage patient to verbalize feelings regarding the ostomy, body image changes, and sexual issues.
▪ Inform patient of community resources, local and mail-order ostomy supply dealers, ostomy specialty
nurses, etc.
▪ Colostomy irrigation is done to regulate bowel movements at a regular time. Candidates for
colostomy irrigation are those with more formed stool (descending or sigmoid portion of colon)

Learning.
Corporation.
Williams & Wilkins.
F.A. Davis Company.

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VELEZ COLLEGE – COLLEGE OF NURSING (Nursing Care Management 112 Skills Lab)

SKILLS LABORATORY MODULE NO. 1

 Important Information related to this Module:

▪ Hypoxemia (or insufficient oxygenation of arterial blood) resulting from a respiratory or

B. Oxygen Delivery Devices:

• if this problem occurs, the nurse increases the liter

C. Parts of an Oxygen Setup:

▪ In-Line/Wall Unit (oxygen is supplied from piped-in oxygen)

D. Parts of a Bag-Valve-Mask Resuscitator (Ambu®-Bag):

▪ Administering Oxygen Therapy:

▪ Performing Bag-Valve-Mask (Ambu®-Bag) Ventilation:

B. Performing Bag-Valve-Mask (Ambu®-Bag) Ventilation:

 References & Suggested Readings:

 Important Information related to this Module:

A. Benefits of Incentive Spirometry:

B. Types of Incentive Spirometers:

▪ Volume Oriented Spirometer

 Nursing Skill to Develop in this Module & Materials/Equipment Needed:

 Special Considerations for Incentive Spirometry:

A preoperative evaluation will also help in establishing a postoperative therapeutic goal.

 References & Suggested Readings:

SKILLS LABORATORY MODULE NO. 3

 Important Information related to this Module:

B. Contraindications of Chest Physiotherapy:

 Nursing Skills to Develop in this Module & Materials/Equipment Needed:

* Affected Lung Segment: Lower Lobes – Posterior Basal Segments

* Affected Lung Segment: Lower Lobes – Lateral Basal Segments

* Affected Lung Segment: Lower Lobes – Superior Segments

* Affected Lung Segment: Upper Lobes – Anterior Segments

* Affected Lung Segment: Upper Lobes – Apical Segments

* Affected Lung Segment: Upper Lobes – Posterior Segments

 Special Considerations for Chest Physiotherapy:

 References & Suggested Readings:

SKILLS LABORATORY MODULE NO. 8

 Important Information related to this Module:

▪ Administering Nebulized Medications through an Aerosol Mask:

▪ Administering Nebulized Medications through a Metered-Dose Inhaler:

B. Administering Nebulized Medications through a Metered-Dose Inhaler

 References & Suggested Readings:

SKILLS LABORATORY MODULE NO. 6

 Indications for Thoracentesis:

 Materials to Bring for this Module:

 Nursing Skill to Develop in this Module:

- Sterile towels & drapes

10. Remind the patient ______________________________________________ during the procedure to

 Special Considerations in Thoracentesis:

 References & Suggested Readings:

SKILLS LABORATORY MODULE NO. 7

 Important Information related to this Module:

B. Sites for Chest Tube Placement:

C. Chest Tube Drainage Systems:

 Materials to Bring for this Module:

 Nursing Skills to Develop in this Module:

 Special Considerations in Maintaining a Chest Tube Drainage System:

B. Assisting with Chest Tube Removal 43

4. Perform hand hygiene.

 References & Suggested Readings:

SKILLS LABORATORY MODULE NO. 7

 Important Information related to this Module:

D. Parts of a Suction Set-up:

E. Appropriate Suction Pressure [per age group]

 Nursing Skills to Develop in this Module:

16. For nasal insertion:

17. For oral insertion: