NCM104 – FINAL

(LEC)
TRANSTRACHEAL CATHETER

PAIN
o Subjective – symptom
 It only becomes OBJECTIVE if the pain
scale is measured over time, determining the
increase and decrease of the pain.
o Also referred to as the 5th vital sign
o Unpleasant sensory and emotional experience
associated with actual or potential tissue
damage
o Previous pain experience alters pain sensitivity
 Hollow tube inserted within the trachea to deliver o HOW DO YOU ASSESS FOR PAIN?
oxygen.
a. Numeric Rating Scale (NRS) – 1 being the
 Transtracheal Catheter is used with the aid
lowest, 10 being the highest
of Tracheostomy Tube.
TRACHEOSTOMY

b. Wong-Baker Scale – faces/emoji, commonly used

by toddlers

c. Abbey Pain Scale

ABBEY PAIN SCALE

MAIN COMPONENTS:
a. Outer Cannula – it has a cuff that will be inflated
when injected an air by a syringe which will keep the
tube in its place, similar with ET Tube.
b. Inner Cannula – needs to be replaced by a new one
and clean the used.
c. Obturator
TRACHEOSTOMY CARE:
 Inner Cannula Cleaning: Hydrogen Peroxide and
sterile water or Normal Saline depends on
Hospital.
 Trache Tie:
1. Velcro Collar
 Measurement in people who cannot verbalize
(late-stage dementia)
 More on observing the patient
 can also be used for adults who cannot
verbalize their experienced pain properly
 non-verbal cues and facial expressions are
2. Tie Tape – use a square knot needed to be observed and rated it
 Physiological Changes – VS can be altered
due to extreme pain felt by the patient
 Physical Changes – physical injuries
connect to pain.

TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 
Skin tears does not easily associate with Intravascular Space (fluid within the
extreme pain, other interpretations should blood vessels) – blood is found in IVS
still be observed.  arteries, veins, capillaries
PCA PUMP NURSING INTERVENTION Transcellular Space (epithelial lined
space)
 Ex. #1: Heart – there is a
lining. The epicardium is the
outer most layer, surrounds
epicardium is pericardial fluid
which is enclosed in the
pericardial sac/pericardium.
In between the epicardium
and pericardium contains
 PCA – Patient Control Analgesia pericardial fluid – an example
 Analgesia – pain reliever of TRANSCELLULAR
 The patient can add a dose of analgesic if the SPACE.
pain he experiences worsens. He will just press  Ex.: #2: Fluids in Abdomen &
the top of the IV drip for the dose to be added. Peritoneal Cavity – very little
 Patient has still a high chance of overdosing in  Moreover, fluids that are not
this PCA Pump, so the pain nurse’s/ICU nurse’s found inside and in between
responsibility is to adjust the PCA Pump as per the cells are called
doctor’s order. (Max. dose the patient can add TRANSCELLULAR SPACE.
per 15 mins.)  Additional Examples of
 The medication is sometimes given TRANSCELLULAR SPACE:
subcutaneously, instead of through IV. a. Fluids inside ureters that
 Assess for level of sedation and pain are going through the
 Coordination with pain service and pain nurse bladder can be considered
 Standby Naloxone (Narcan) – an antidote; TCS.)
Morphine – if a high dosage of this was given to the b. Sweat
patient, he may experience respiratory depression. c. Saliva
To prevent that from happening, Naloxone is given. d. Seminal Fluids
 Disadvantage: Shortly after Naloxone was Interstitial Fluid (fluid that surrounds
given, the patient will feel body pain again the cell) – found in between the cells
because narcotic analgesics will be in no
effect.
 HOW TO KNOW IF THE PATIENT HAS
RESPIRATORY DEPRESSION?
 Assess VS, RR less than 8 might indicate
that the patient has respiratory depression.
FLUIDS & ELECTROLYTES

 ICF – most amount of water

 ECF – the rest
 Plasma – common division between ECF & ICF; it is
the blood volume/water in the blood that is the
INTRAVASCULAR SPACE.
 INTERSTITIAL SPACE – fluids in between the cells
 CASES: Water inside the blood vessels can go to the
cells. It can also go to the interstitial space, and vice
versa. – FLUID SHIFTING (movement of fluid to
another space) is normal but it should not happen
too much from one compartment to the other.
 Patients with too much interstitial fluid will have
edema.
 Solutes – holds the fluids in place.
o 60% of the body – average amount composed of ELECTROLYTES
water
 Active chemicals that carry charges
 younger – more than 60%
 IONS – charges can be positive or negative
 babies – closer to 65%
 Ex.: Jogging under the heat of the Sun
 older – 55%
It is not only the water being removed
o COMPARTMENTS:
in the body, but also the electrolytes.
A. Intracellular Fluid (2/3) – most of the fluids that This is very dangerous because
a human has in inside his cells. electrolytes are needed for electrical
B. Extracellular Fluid (1/3) – outside of the cells conduction that will help the muscles
move. Lack of electrolytes in the body
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 will result to abnormal movement of  Pressure created by the weight of fluid against
current to the muscles, as well as in the the wall that contains it.
brain and heart.  The more water there is, the more pressure
ELECTROLYTES ENABLE THE is present, and the stronger the pushing
ELECTRICITY TO TRAVEL IN THE force is. In the human body, if the blood
HUMAN’S BODY. vessels have more fluids, the stronger the
Muscles will only contract if there is an pushing force is. To conclude, the more fluid
enough electricity that travels in the present in the body, the higher the blood
body. pressure will be.
CASE: Excessive electrolytes will also  PHYSIOLOGY: More fluid = ↑
make excessive contractions in the Blood Volume = ↑ Cardiac Output
muscles that is very dangerous. = ↑ Blood Pressure
2 MAIN TYPES OF ELECTROLYTES:  Best Example: Mineral Water Gallon &
1. Cations (+) Na, K, Ca, Mg, H – positively charged Beer Tower
ion ONCOTIC PRESSURE
 WHICH HAS A HIGHER CONTENT IN
THE BLOOD? K+ or Na+?
Blood is found in ECF
(intravascular space), so Na+ has
a higher content in the blood.

 Albumin as water magnet – pulling force in the

intravascular space.
 ↑ Solute Content = ↑ Oncotic Pressure
 Fluid Shifting – to enter the blood vessel
 Ex.: More Albumin in the blood attracts
more water inside the blood vessel. Lesser
Albumin in the blood will shift out the water
others: (Fe2+), Zinc (Zn2+), Copper in the blood vessel. People with damaged
(Cu2+), and Manganese (Mn2+), which kidney has no albumin that attracts water
are involved in various metabolic inside the blood vessel shifts out and goes to
processes in the body. the interstitial fluids which result to having
 Almost all the cations have a relation with an edema.
muscle movement and contraction. 4 FLUID DYNAMICS
 pH – means the power of hydrogen; 14 –
alkaline, 1 – acid; 7 – neutral (neither an
acid nor an alkaline)
2. Anions (-) HCO3, SO4 – negatively charged ion

 Capillary Hydrostatic Pressure & Interstitial

Oncotic Pressure – move out of capillaries
 Plasma Oncotic & Interstitial Hydrostatic
Pressure – move into capillaries
TONICITY

HYDROSTATIC PRESSURE

TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 SPACING TYPES
1. First Spacing
Normal fluid distribution (ICF & ECF)
2. Second Spacing
Abnormal accumulation of Interstitial
Fluid (edema)
 dehydration
3. Third Spacing
Abnormal fluid accumulation in
Transcellular Space
 Abnormal accumulation of fluid
in a non-functional space or
 Concentration of solutes in a solution compartment, outside of the
HYPERTONIC SOLUTION: intracellular fluid (ICF) and
extracellular fluid (ECF)
compartments
 Ex.: Pleural Cavity (around the
lungs), the peritoneal cavity
(around the abdominal organs),
and the pericardial cavity
(around the heart)
CENTRAL VENOUS PRESSURE (CVP)
MEASUREMENT

High solute concentration (“malapot”)

 The solution that is “malapot”, the water
will go into it because it has a higher
oncotic pressure.
HYPOTONIC SOLUTION:

Low solute concentration (“malabnaw”)

Example #1: If the patient is edematous, then he/she
will be given a hypertonic solution via IV. As the
hypertonic solution goes to the blood, it will become
highly concentrated and attract the fluids from the
interstitial space to go to intravascular space. Edema
will lessen.
 Example #2: Cerebral Edema (edema in the brain) –
the doctor will give a hypertonic solution to make the
blood highly concentrated and pull excess fluids from
the interstitial and intracellular, then it will go to
intravascular space. CVP – pressure found in the large
ISOTONIC SOLUTION: veins like IVC & SVC
 Fluid status assessment and guide for fluid
replacement utilizing a CVP manometer.
 Normal CVP: 4 to 12 cm H2O or mmHg
(Brunner)
o The more blood volume that a person has,
the higher the CVP. The higher the CVP,
the higher the hydrostatic pressure.
HORMONAL INFLUENCE OF FLUID &
ELECTROLYTES
1. ADH (anti-diuretic hormone)
 Same concentration as body fluids ↓ water loss
 The concentration of the isotonic is the same o diuretic – urination; losing fluids
with the concentration of the blood. o anti-diuretic hormone – prevents the
 Tonicity of the Isotonic Solution = Tonicity
person from urination; less water loss;
of the Blood (NO FLUID SHIFTING)
retaining of fluids.
 Example: NSS (No Saline Solution) 0.9%
2. Aldosterone
NaCl = equal tonicity with the blood
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 Controls Na levels in ECF.
Sodium attracts water.
o RAAS – Renin – Angiotensin –
Aldosterone System
o Aldosterone is related to control of
sodium. Retaining of Sodium, attracts
water because too much sodium in
blood will act as extra solute and
results to pulling of water going inside
the blood vessel. Blood Pressure will ↑.
o WHY SALTY FOODS ARE NOT
ALLOWED FOR HYPERTENSIVE
CLIENTS?
 Salty foods are rich in sodium
that attracts water – increase
blood volume – increase Blood
Pressure.
3. Natriuretic Peptide
Counteracts effect of Renin secretion.
CRYSTALLOIDS
 Poor excretion of waste products
4. ↓ Thirst Reflex
 Fluid intake
POINTS TO REMEMBER:
A. Vein Selection
- Distal veins first, subsequent IV starts
should be proximal to the previous site.
- Client’s non-dominant hand if possible.
B. Vein that are:
- Easily palpated and feels soft and full
- Naturally splinted by bone
- Large enough to allow adequate circulation
around the catheter
NURSE PHLEBOTOMIST


Venipuncture – process of collecting or
“drawing” blood from a vein and the most
common way to collect blood specimens for
laboratory testing.
VENIPUNCTURE MATERIALS:
 Vacutainer Needle/Venipuncture Needle

 Water + added electrolytes  Vacutainer Holder/Blood Collection Tube Holder

 E.g. PNSS, Plain LR, D5
COLLOIDS

 Alcohol Swab

 Vacutainer/Blood Collection Container

 “Volume expanders” (usually more concentrated
solutions)
 Substance with solid particles microscopically
dispersed in liquid
 Voluven – Hydroxyethyl starch
o When given through the IV, the water from
the interstitial space will go to the blood
vessel and the expand it which raises the
blood pressure. Voluven helps increase the
blood pressure of clients and maintain it in
its normal value.
GERIATRIC CONSIDERATION IN FLUIDS &  Phlebotomy Tourniquet
ELECTROLYTES
1. Loss of Skin Elasticity
 Unreliable indicator of fluid status
2. ↓ Skin Turgor
 Dry, easily damaged skin
3. ↓ Glomerular Filtration
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 a. EEG – recording of the stages of
sleep and any episode of apnea
 electrical brain activity
 The waves of a human differs
when he is awake or asleep.
 The brain waves slow down
when the human is about to
fall asleep.
 CASES: There are some
patients who are about to fall
VENIPUNCTURE STEPS: asleep have brain waves that
1. Place the tourniquet around the arm about 3-4 are patterned for people like
inches above the intended venipuncture site. he is still awake, and vice
2. Cleanse the site with an alcohol swab and let it versa.
dry. b. Electroculogram – detects eye
3. Antecubital site insertion: Insert the needle at a movement
30-degree angle.  also detects REMs (Random
4. Release the tourniquet before removing the Eye Movement)
needle.  deep sleep = REM sleep (the
ORDER OF DRAW OF BOTTLES/VACUTAINERS: eye moves)
1st: Blood culture collection bottles (anaerobic & aerobic)  CASES: There are some
2nd: Light blue vacutainer (coagulation studies like PT, people who have no REM
PTT) sleep, very short REM sleep,
3rd: Red Vacutainer/Yellow (Laboratories like Sodium, or very long REM sleep.
Potassium, BUN, and Creatinine) c. Electromyographic Recording –
4th: Lavender tap (CBC) muscle movement
 excess muscle movements
while asleep
d. ECG – detect any cardiac
arrhythmias
 heart
 some electrical conduction of
the heart like irregular
heartbeats appears when
asleep.
SLEEP LABORATORY:
SLEEP
 The patient will be put into sleep and there are
PHYSIOLOGICAL SLEEP MECHANISMS attached monitoring equipment in his body to
 Circadian Rhythm – 24-hour cycle “internal evaluate the sleep of the patient wherein it can show
clock” the sleep problems/concerns present.
o this tells us when we should be asleep or
SLEEP DISORDERS
awake
o should be a regular cycle  Dyssomnia
 Melatonin – linked with environmental light-dark  Problems associated with initiating or
cycle; night-time release maintaining sleep
o Prepares the person to sleep  Disorders under:
o dim or night lights can help improve sleep a. Narcolepsy
- Excessive sleepiness but
SLEEP CYCLE
may experience fragmented
A. NREM (Non-Random Eye Movement) sleep.
75%-80% of sleep - With or without cataplexy –
Stage 1: Beginning of Sleep muscle weakness less than
Stage 2: Most of Night; HR & Temp ↓ 2 mins.
Stage 3: Slow wave sleep/Deep sleep o disease
B. REM (Random Eye Movement) o narcoleptic patients should not be
20%-25% of sleep doing
“vivid dreams occurs” – clear look of the o certain procedures because it will be
dreams
very dangerous for the people around
 deep sleep them if they suddenly fall asleep
 relaxes the brain o severe form and rare case: being asleep
 dreams remove stress emotionally,
for months like a comatose patient, in
psychologically
this case he should be provided food via
 body is being recharged
NGT or IV.
 Do not wake up the patient during
b. Insomnia
deep sleep.
- Difficulty falling asleep or
SLEEP DISORDERS DIAGNOSTICS maintaining it for more than
 Polysomnography 3 nights per week.
 Physiologic measures of brain waves, - Manifestations:
eye movements, and muscle tone. 1. Long sleep latency
 Sleep Study consists of: (difficulty falling asleep)
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 2. Fragmented awakening
(frequent awakenings)
3. Waking up too early and
can’t sleep anymore
o You feel awake
enough not to
sleep anymore
but not awake
enough to do
anything
meaningful.
4. Non-restorative sleep
(unrefreshed)
o commonly happens now a days due to 2. Uvulopalatopharyngopla
smartphone and Wi-Fi excessive use sty (UPPP) – excision of
o BLUE LIGHT mechanism in tonsillar pillar, uvula and
smartphones: Keeps us awake because posterior soft palate
it signals the brain that it is morning.
Melatonin will not be released because
it is for dark or night light, which
causes the person not to fall asleep
easily.
c. Obstructive Sleep Apnea
- sleep-disordered breathing
- partial or complete upper
airway obstruction during
sleep
 last 10-90
secs
(hypoxemia
occurs)
 O2 level in
the blood
drops – d. Periodic Limb Movement Disorder
daytime - Involuntary continual
sleepiness movement of the legs
is common and/or arms during sleep
- CPAP: Positive pressure (5 - Movement: Every 0.5 – 10
to 25 cm H2O) in the airway seconds
during inspiration and - Interval: 5 – 90 seconds
expiration to prevent airway - Treatment: Pramipexole
collapse (Mirapex) – Dopamine
agonists
o Dopamine – a happy
hormone but also a
neurotransmitter that
inhibits excessive
movements like
tremors. It gives a
purposeful movement.
PARASOMNIAS:
 Unusual and often undesirable behaviors
that occur while falling asleep
- Keeps alveoli partially  Types:
inflated during inspiration 1. Somnambulism (sleepwalking)
- Treatment: o very dangerous for the safety of the
1. BIPAP – delivers higher patient if it happens outside of the
respiratory pressure home.
than CPAP 2. Sleep terrors & nightmares
o can be psychological related
3. Somniloquy – sleep talking, due to
emotional stress (e.g., sleep terror)
o deepest darkest secrets of a person that
sleep talks will not be spilled out
 Cliomania – excessive desire to stay in bed
o the patient stays in bed for days without
doing anything
 Nocturnal Leg Cramps
 Unknown pathophysiology
- F & E imbalance
- May last for 30 mins
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
  Prevention: Vitamin B
NOCTURNAL EMISSION
 “wet dreams”
 orgasm and emission of semen during sleep
o common in younger men
o for older men: can be due to medicine-
related intake like anabolic steroids
SLEEP HYGIENE
 interventions to promote sleep
FACTORS:
1. environment
2. medication – can help patient sleep like Iterac,
Valium, and other anxiolytic medications.
3. diet – too much carbs make you fall asleep; keto-diet
– full of energy.
4. disease
INTERVENTION:
1. lighting (night light)
2. bed positioning – depending on the patient’s
comfortability
3. loose clothing
4. hygiene measures – brushing teeth before going to
sleep
5. bed linen – to make the patient feel comfortable as
he sleeps
6. voiding pre-bedtime – urination before sleeping,
most specially for those who are under medications
NOCTURNAL PENILE TUMESCENCE
 “Morning wood”
 spontaneous erection of the penis during sleep
or when waking up
o it happens due to the parasympathetic
response
o this is normal
RICHMOND AGITATION & SEDATION SCALE
(RASS)

TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 through an incision (cut) made on the
outside of the abdomen.
 starts from the mouth
 enteral nutrition is applicable for patients who
cannot digest food due to:
a. obstruction in esophagus
b. failure in continuity of peristaltic movement

peristalsis - is a series of wave-like

muscle contractions that move food
through the digestive tract. It starts in
the esophagus where strong wave-like
motions of the smooth muscle move
balls of swallowed food to the stomach.
c. tumor presence
d. atresia - means that a body part that is
tubular in nature does not have a normal
opening, or lacks the ability to allow material
to pass through it.
 jejunal atresia - is a rare type of
obstruction of the small bowel affecting
newborns. Patients with this disorder
are born with complete mechanical
obstruction of the proximal small
intestine.
Surgery: Exploratory
Laparotomy – jejunum is being
cut.
DEFINITION:
o Alternative feeding methods that ensure
adequate nutrition that includes enteral (through
GI system).
NCM104 – FINAL o Other term: Total enteral nutrition (TEN)
o Provided to clients who cannot digest foods of

(LAB) the upper GI tract is impaired and the transport

of food to the small intestines are interrupted.
ENTERAL NUTRITION ENTERAL ACCESS DEVICES (SITES)
Enteral
 related to gastrointestinal system (GI Tract)
 Gastrointestinal System – long tube
from mouth → esophagus → stomach
→ small intestine → large intestine →
rectum
 used for drug, medication, and gavage

 gavage – a way of giving medicines and

liquids, including liquid foods, through a
small tube placed through the nose or
mouth into the stomach or small
intestine. Sometimes the tube is placed
into the stomach or small intestine
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 A tube inserted through the wall of the
o
abdomen directly into the stomach.
o It allows air and fluid to leave the
stomach and can be used to give drugs
and liquids, including liquid food, to the
patient.
o Giving food through a gastrostomy tube
is a type of enteral nutrition.
o Also called PEG tube and percutaneous
endoscopic tube.
PEG (PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY):

1. Nasogastric/Nasointestinal/Nasoenteric Tube

A tube that is inserted through the nose,

o
A percutaneous endoscopic gastrostomy
o
down the throat and esophagus, and
into the stomach. (PEG) is a procedure to place a feeding
o It can be used to give drugs, liquids, tube.
o These feeding tubes are often called PEG
and liquid food, or used to remove
substances from the stomach. tubes or G tubes.
o Giving food through a nasogastric tube o The tube allows you to receive nutrition
is a type of enteral nutrition. directly through your stomach.
o Also called gastric feeding tube and NG  connected to feeding formula:
 Types of Enteral Formulas:
tube.
 opening of nares (inserted in only 1
nares)
 correct measurement: tip of nose –
earlobe – xiphoid process
correct measurements is
needed to ensure that it is really
inserted in stomach.
 it is very fatal and crucial if the NGT is
misplaced.
can cause asphyxia or even
death.
2. Gastrostomy Tube
 osteorized feeding formula
 made by the nutritionist
 ex: blended bread and orange
 equivalent to only 1 complete meal
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier

3. Jejunostomy Tube
Jejunal feeding may be initiated for a
o stomach.
patient of any age.
o Jejunal feeding is indicated in patients
with gastric outlet obstruction,
gastroparesis, pancreatitis, severe
reflux with faltering growth, and known
reflux with aspiration of gastric
contents, where continuous gastric
feeding has been trialed and
unsuccessful.
o While onerous, jejunal feeding is safer
and less expensive than parenteral
nutrition (PN).
SKILL: NASOGASTRIC TUBE (NGT)
INSERTION – PT. 1
o Larger than 12F is placed into the stomach.
o The larger the lumens allow the delivery of
liquids to the stomach or removal of gastric
contents.
o Softer, more flexible, and less irritating small-
bore feeding tubes.
 12F – unit for measurement of NGT
 lumen – diameter of tube
 possible case – restriction of water for
some patients
 NGT insertion is a dependent nursing
intervention and needs to follow the
physician’s order.
 NGT is sometimes dipped in warm water
for easy insertion.
 Rationale: This increases the stiff
tube’s flexibility by coiling it
around the gloved fingers for a few
seconds or dipping it into a warm
water.
PURPOSE OF INSERTING A NASOGASTRIC
TUBE:
 To administer tube feedings and medications to
clients unable to eat by mouth or swallow a
sufficient diet without aspirating foods or fluids
into the lungs.
 Sample Case #1: Aspiration Pneumonia
 a common complication
 tube is misplaced so the food
enters into the lungs
 lungs become inflamed
 Sample Case #2: Breastfeeding a Baby
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C)
Javier
 breast milk entered the lungs of
the baby due to the wrong body
position while the mother
breastfeeds the baby
 To establish a means for suctioning stomach
contents to prevent gastric distention, nausea,
and vomiting.
 Sample Case: Irritable Bowel Movement
 problem in defacation
 suctioning using NGT
 gavage - is feeding (food, water, fluid) a
patient employing a tube directed into the
 lavage - is also known as therapeutic
irrigation, a medical term for cleaning or
rinsing (gas, secretions, poisons, toxic
materials).
 To remove stomach contents for laboratory
analysis.
 acidosis
 To lavage the stomach in case of poisoning or
overdose of medications.
 lavage – washing out the stomach by
introducing liquids and removing them
ASSESSMENT:
 Check for history of surgery or deviated septum.
Assess patency of nares.
 check anatomical structure of the nose
 patency – check for secretions/mucous
 Determine presence of gag reflex.
 for comatose patients, no gag reflex
 Assess mental status or ability to participate in
the procedure.
 because inserting NGT is somehow painful
 Verify Doctor's order for formula, rate, route, and
frequency.
 NGT is a dependent nursing intervention so
the doctor’s order is needed to be followed.
 Identify patient using two identifiers (e.g. name
and birthday or name and medical record
number) according to agency policy.
 Assess patient for food allergies or intolerances.
 Perform physical assessment of abdomen.
PLANNING:
1. Gather the equipment and bring them to the
bedside.
 bring stethoscope and gloves
NOTES TO REMEMBER:
- introduction of air to the NGT may
cause abdominal distention
- extract gastric content and then test
using a litmus paper
 pH 5↓ = acidic (means that the
NGT is in correct location)
 no extraction of gastric
secretions = wait for another
10 mins, then test again.
 if still no extraction, position
the patient in left lateral
recumbent = 20 ml of water,
stay for 5 mins, then extract.
 no extraction at all = let the
patient undergo X-Ray
Bowel Sounds: 5-10 secs (normal)
Hypermobility: 5-15 secs
Hypomobility: within 15 seconds
no movement, extend for 1-3 mins
2. Explain the procedure to patient.
 if the patient is conscious, explain it to
him/her.
SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
  if not, explain to the relative.
 also to teach the relatives on what
are the stuffs to check for the
patient in the use of NGT.
3. Provide patient privacy.
 close the door or curtain
4. Performs hand hygiene and apply clean gloves.
IMPLEMENTATION:
1. Place the patient in High Fowler’s position or
elevate head of bed preferably 45 degrees for
some patients.
2. Prepare the tube:
a. SMALL BORE TUBE – ensure stylet or
guidewire is secured in a position.
b. LARGE BORE TUBE – Place in a basin to
become more pliable and flexible
3. Determine how far to insert the tube.
o Measurement length: TIP OF CLIENT’S
NOSE-TIP OF EARLOBE-TIP XIPHOID
PERFORMANCE:
 Lubricate the tip of the tube well with water-
soluble lubricant.
o RATIONALE: If the nasogastric tube is
not properly lubricated, it will have a
difficult time curving with the body's
anatomy and may not make it to its
destination without a great deal of internal
damage to the patient.
 Insert the tube with its natural curve downward,
into the selected nostrils.
 Ask the client to hyperextend the neck and
gently advance the tube towards the
nasopharynx.
 Direct the tube along the floor of the nostrils and
toward the midline.
 Slight pressure and a twisting motion are
sometimes required to pass the tube into the
nasopharynx.
 If the tube meets resistance, withdraw it.
Relubricate it and insert in the other nostrils.
 Once the tube reaches the oropharynx , the
client will feel the tube in the throat and may
gag. Ask the client to tilt the head forward.
 If the client gags, stop passing the tube
momentarily.
 In cooperation with the client, pass the tube 5 to
10cm with each swallow until the indicated
length is inserted.
o swallow or introduce water
o every swallow = move the tube
 Ascertain the correct placement of the tube.
 Check the pH – 1 to 5.
 extract secretions
DOCUMENT & EVALUATE:
a. Client’s tolerance of the NGT
b. Correct placement
c. Client’s understanding of restrictions, color, and
amount of gastric contents
SKILL: FEEDING THROUGH NGT – PT. 2
ASSESSMENT:
 Verify Doctor's order for formula, rate, route and
frequency.
 Identify patient using two identifiers.
 full name
 birthdate
 Assess patient for food allergies or intolerances.
 Perform physical assessment of abdomen.
PLANNING:
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C)
Javier
1. Gather the equipment and bring them to the
bedside.
 bring stethoscope, clean gloves, formula
2. Prepare feeding container and formula:
a. Check expiration date of formula and
integrity of container.
b. Have tube feeding at room temperature.
c. Shake formula well.
3. Explain the procedure to patient.
 tell the patient that this is a nutritional
requirement for him/her
4. Provide patient privacy.
 close the door or curtain
5. Performs hand hygiene and apply clean gloves.
IMPLEMENTATION:
1. Place the patient in High Fowler’s position or
elevate head of bed preferably 45 degrees for
some patients.
 45º - 90º - depending on the patient’s
capability to stay on that position while
performing the procedure
2. Verify tube placement:
o Nasogastric tube:
a. Attach syringe and aspirate 1mL of
gastric contents.
b. Observe the appearance of aspirate and
note pH (if available).
3. Check for gastric residual volume (GRV) before
each feeding – for bolus and intermittent
feedings every 4 to 6 hours in non- critically ill
patients.
a. Connect asepto syringe to the end of
feeding tube. Remove bulb and flush tube
with air (negative pressure). Put down slowly
to aspirate total amount of gastric contents
and measure.
b. If 100 ml (or more than the last feeding) is
withdrawn refer to agency policy before
proceeding. (at some agencies a feeding is
delayed when the specified amount or more
formula remains in the stomach).
c. Re-instill the gastric contents into the
stomach if this is the agency policy.
4. Auscultate for gurgling sounds.
5. Initiate feeding:
o Syringe for Intermittent Feeding
a. Pinch proximal end of feeding tube
b. Remove plunger from syringe and
attach tip of syringe to end of tube.
c. Fill syringe with measured amount
of formula.
d. Release tube, elevate syringe to no
more than 45 cm(18inches) above
insertion site, and allow it to empty
gradually by gravity.
6. Flush with 30ml water every 4 hours before and
after an intermittent feeding.
AFTER CARE & EVALUATION:
After Care –
 Keep patient in Fowler's position for 30 minutes.
 Secure tubing to patients’ gown.
 Washes equipment used and store in the
designed area.
Evaluation –
 Perform a follow-up examination of the following:
a. tolerance of feeding
b. bowel sounds
c. regurgitation and feelings of fullness after
feedings
DOCUMENTATION:
SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
 a. Record amount and type of feeding instilled,
patient’s response to tube feeding, patency of
tube, condition of naris and any side effects.
b. Document your evaluation of patient learning.
SKILL: REMOVAL OF NGT – PT. 3
Removing –
1. Verify health care provider's order for removal.
2. Gather equipment, explain procedure to patient.
3. Perform hand hygiene, apply gloves.
4. Position patient in high-Fowler's if possible.
5. Place towel on patient's chest.
6. Disconnect tube from administration set if
appropriate.
7. Remove tape partially.
8. Coil end of tubing until the nose.
9. Instruct patient to take deep breath and hold it.
Pull tube out smoothly. Dispose tube properly by
wrapping the coiled tubing with gloves.
10. Offer tissue to patient to blow nose. Clean naris,
provide oral care.
11. Perform hand hygiene.
Evaluation –
a. Inspect naris and oropharynx for irritation.
b. Ask if patient is comfortable.
c. Observe patient for difficulty breathing,
coughing, or gagging.
MEDICATION ADMINISTRATION
o A medication is a substance used in the
diagnosis, treatment, cure, relief, or prevention
of health problems.
 medication administration is done in all
settings
 this is an independent nursing intervention
by a nurse but based on a doctor’s order
 medication administration is also a way to
prevent health problems:
a. vaccines
prophylaxis – live virus;
these are non-continuated
vaccines (Pfizer);
regarded by the T-cells
and acts as non-foreign
body.
dead virus – tetanus
b. antibiotics
pseudomonas – caused by
nosocomial/hospital
infection; patients are
asked to drink antibiotics
before being exposed to a
patient/surrounding with
suspected pseudomonas;
there is no prophylaxis
for COVID-19.
for relief – analgesia as
pain reliever; anti-
hypertensive.
cure – antibiotic,
antibacterial, antivirus.
diagnosis – helps in
ruling out the alteration
of body function (Varium
– chemical administered
through rectum to check
GI organs in ultrasound)
 the nurse will have to:
a. prepare the medicine, administer it,
and evaluate the client’s response
after administering the procedure
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C)
Javier
b. have the concepts of computation
(tab, vial, ampule)
 COMMON SITES FOR INTRAMUSCULAR
INJECTION: deltoid, gluteus maximus,
gluteus minimus
o dangerous site: g. maximus and
minimus because sciatic nerve is
there and the client may be
paralyzed kapag natamaan.
o safest site: ventrogluteal
SCIENTIFIC KNOWLEDGE – BASED
 To safely and accurately administer medications,
you need knowledge related to:
 Legal aspects of health care – NCLEX-
based; safe and effective
 Pharmacology
 Pharmacokinetics – action of medication
 Physiology – normal function of the body
 Pathophysiology – altered normal function
of the body
 Human anatomy
 Mathematics
MEDICATION LEGISLATION & STANDARDS
 Federal Regulations
o Pure Food and Drug Act – all medicines
should be free from impurities
o Food and Drug Administration (FDA) –
to ensure all medicines have undergone
vigorous testing before being released in the
market
BFAD – PH setting of FDA
cosmetics and supplements
“No therapeutic claim” – not yet
BFAD approved
Medicines should be FDA
approved
o MedWatch program – nurses will report
medication errors
o State and Local Regulations – there is a
specific policy per hospital
In US, Intracardiac is only for
doctor’s intervention.
In PH, gluteus minimus site of
injection is only for doctor’s
intervention.
 Healthcare institutions and medication laws
o Generic Act – not prescribing medicines
without generic
 Medication regulations and nursing practice
(Nurse Practice Acts)
o REQUIREMENT FOR NURSES: PRC
license for nursing practice; ANSAP card
for IV Therapy
o STRICTLY “NO LICENSE, NO
ADMINISTRATION”!
PHARMACOLOGICAL CONCEPTS
 Medical Names:
SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
 o chemical – exact description
medication’s composition.
prepared by pharmacists
acetaminophen – tyenol, advil,
panadol
paracetamol – tempra, biogesic
o generic – the manufacturer who first
develops the drug assigns the name,
and it is then listed in the U.S.
Pharmacopeia.
o trade – brand/proprietary name. This is
the name under which a manufacturer
markets the medication.
 Classification
o Effect of medication on body system
diuretics – for urination
laxatives – for increasing bowel
movements
o Symptoms the medication relieves
o Medication’s desired effect
Examples: to lower body
temperature, blood pressure,
sugar, etc.
 Medication Forms – solid, liquid, other oral
forms; topical, parenteral; forms for instillation
into body cavities
o solid – tablets, capsules
o liquid – syrup, suspension (more viscous),
inhalers
o topical – ointment, jellies
o parenteral – through syringes
o instillation – through eyes, nose, ears,
rectum, vagina
PHARMACOKINETICS AS THE BASIS OF
MEDICATION ACTIONS
 The study of how medications:
 Enter the body (Absorption)
 are absorbed and distributed into cells,
tissues, or organs (distribution)
 Reach their site of action
 Alter physiological functions
 Are metabolized (metabolism)
 Exit the body (excretion)
REMEMBER:
 absorption – medication enters body
 sublingual – dissolves easily
 EMERGENCY SITUATION for Hypertensive
patient: NIFEDIPINE sublingually administered
and placed through Wharton Ducts or submaxillary
ducts.
 Half Life – medicines are considered half-life so the
patient needs to take meds again to sustain the
function of it to the body.
o Example: PARACETAMOL has low half-
life that is why it is given every 4hours.
 Metabolized: alters metabolism of the drug if the
patient has liver disease
 Excretion: kidney failure – toxic effect cannot be
excreted
TYPES OF MEDICATION ACTION
A. Therapeutic Effect – expected or predicted
physiological response
B. Adverse Effect – unintended, undesirable, often
unpredictable
 Side effect: Predictable, unavoidable
secondary effect
S/Sx during the testing of the
medicine should appear
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C)
Javier
of  Toxic effect: Accumulation of medication
in the bloodstream
in the bloodstream, iron toxicity
that were not excreted in urine will
corrode the blood vessel
 Idiosyncratic reaction: Overreaction or
underreaction or different reaction from
normal
Inflames a body part or either no
reaction at all
C. Allergic Reaction – unpredictable response to a
medication
 Skin Test – testing for allergies through
intradermal administration
D. Medication Interactions – when one medication
modifies the action of another
 food and medicine combination
ORANGE JUICE & Ferrous
Sulfate combination
DRUG STUDY
ROUTES OF ADMINISTRATION
A. Oral Routes – oral medications have slower onset
action but a more prolonged effect
sublingual administration – under the

tongue; instruct patient not to swallow/drink
while the medicine is being administered
 buccal administration – between the gum
and the cheek
B. Parenteral Routes
 Four Major Sites of Injection
intradermal – dermis, located
between the epidermis and
hypodermis
subcutaneous – below dermis
intramuscular – muscle
intravenous – vein
 Other Routes
epidural – for painless birth
intraosseous – directly into the
bone
intraperitoneal – into the
peritoneum (body cavity)
intrapleural – needle passes
through intercostal muscles and
parietal pleura on its way to the
pleural space
SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
 intraarterial – joint injection;
symptomatic relief for
osteoarthritis
 Routes Usually Limited to Physicians
ONLY:
intracardiac – injections given
directly into the heart muscles or
ventricles; used in emergency
intraarticular – treatment for oEXCESS: 0.6 ml should be stored in a
inflammatory joint conditions like refrigerator, for consumption within 24hrs.
gout, tendinitis, carpal tunnel after 24hrs, dispose.
syndrome, rheumatoid arthritis,
and osteoarthritis HEALTH CARE PROVIDER’S ROLE
C. Topical Administration 
Prescriber can be physician, nurse practitioner,
 skin or physician’s assistant.
 mucous membranes  Orders can be written (hand or electronic),
D. Inhalation Route verbal, or given by telephone.
 for asthmatic patients; local & systemic  Telephone Orders for medication should be
effect signed within 24hrs.
E. Intraocular Route  The use of abbreviations can cause errors; use
 medications for eyes like contact lenses caution.
SYSTEMS OF MEDICATION MEASUREMENT MEDICATION ABBREVIATIONS:
 Require the ability to compute medication doses Abb. Meaning Abb. Meaning
SL sublingually PR per rectum
accurately and measure medications correctly
ORAL by mouth PV per vagina
 Metric system SC/SUBCUT subcutaneous PRN as necessary
 Most logically organized 1 mg not 1.0 mg IM intramuscular OD once a
o Meter, liter, gram day/once daily
IV intravenous BID twice a day
 Household system
ID intradermal TID thrice a day
o Most familiar to individuals – 1 tbsp., 1 NG nasogastric QID four times a
tsp. day
o Disadvantage: inaccuracy HS hours of sleep OD right eye
use measuring cup instead PC after meal OS left eye
AC before meal OU both eyes
 Solution
ANST after negative AD right ear
REMEMBER: FOR PEDIATRIC DOSES, DOCTOR’S ORDER skin test
ARE NEEDED TO BE FOLLOWED. AS left ear ATC around the
clock
DOSE CALCULATION METHODS AU each ear/both RTC round the
 Verify medication calculations with another ear clock
nurse to ensure accuracy. gtts drops Rx to take
 The ratio and proportion method REMEMBER:
o Example: 1:2 = 4:8  OD (once daily) – same time of the day
 Formula Method: [Mon 8am = Tues 8am]
 BID (twice a day) – same time of the day
[8am & 6pm]
 QID (four times a day) – same time of the day
 Easier Formula Method:
[6am = 12pm = 6pm = 12mn]
 HS (hours of sleep) – laxatives; sleep
enhancers; usually given at 10pm
 ANST (after negative skin test)
Where:
D – desired/doctor’s order  Distinction between OD: once a day & right eye
S – stock/availability of medicine
Q – quantity
SAMPLE PROBLEMS:
 Cotrimoxazole: 500mg = 1 tablet q12 = Stock  Distinction between PRN & RTC:
1000mg/tablet

HOW TO READ A PRESCRIPTION?

o Prescriber
o Patient’s Data
 Morphine: 30mg/ampule = Stock 10mg/ampule o Superscription- Rx
o Inscription- Main part
o Subscription – Direction
o Signature
REMEMBER:
 Ampicillin: 350mg/ml q6hours = Stock 500mg/ml =  Prescriptions are only valid for 7days.
Diluent is 2ml  Rx means “to take”.

TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 b. right dose
c. right patient
d. right route
e. right time
f. right documentation
MAINTAINING PATIENT’S RIGHTS:
 a patient has the right:
o To be informed about a medication
o To refuse a medication
o To have a medication history
o To be properly advised about
experimental nature of medication
o To receive labeled medications safely
TYPES OF ORDERS IN ACUTE CARE o To receive appropriate supportive
AGENCIES therapy
o To not receive unnecessary medications
o To be informed if medications are part of
a research study
ADMINISTRATION APPLICATION ON
DIFFERENT ROUTES
ORAL ADMINISTRATION:

REMEMBER:
 Single (Ex: deworm) 
Easiest and most desirable route.
 Take anti-histamine first to tame the 
Food sometimes affects absorption.
parasites. If parasites were not tamed, it will 
Aspiration precautions.
go out to different routes of the body. 
Enteral or small-bore feedings:
 STAT (more important than now)  Verify that the tube location is
 If order was given at 10:10, the medication compatible with medication absorption.
should be administered by 10:11.  Use liquids when possible.
 Now – ranges from 1 ½ hours up to 3 hours; within  If medication is to be given on an empty
90 minutes given. stomach, allow at least 30 minutes
before or after feeding.
MEDICATION ADMINISTRATION – ROLES &
 Risk of drug-drug interactions is higher.
SYSTEMS
TOPICAL MEDICATION:
A. Pharmacist’s Role – Prepares and distributes
medication
B. Nurse’s role
o determining medications ordered are
correct, assessing patient’s ability to
self-administer, determining whether
patient should receive medications at a
given time, administering medications 
Skin application
correctly, and closely monitoring effects  Use gloves and applicators; clean skin
o cannot be delegated first.
o Includes patient teaching  Use sterile technique if the patient has
C. Distribution Systems an open wound.
o unit dose systems  Follow directions for each type of
o automatic medication dispensing system medication.
(AMDS)  Transdermal patches:
MEDICATION ERRORS a. Remove old patch before
applying new.
 Report all medication errors.
b. Document the location of the
 Patient safety is top priority when an error
new patch.
occurs. c. Ask about patches during the
 Documentation is required. medication history.
 The nurse is responsible for preparing a written d. Apply a label to the patch if it is
occurrence or incident report: an accurate, difficult to see.
factual description of what occurred and what e. Document removal of the patch
was done. as well.
 Nurses play an essential role in medication NASAL INSTILLATION:
reconciliation.
CRITICAL THINKING
 6 Rights:
a. right medication
TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 ADMINISTERING MEDICATIONS BY
INHALATION
 spray
 drops
 tampons

EYE INSTILLATION:

 Pressurized metered-dose inhalers (PMDIs) –

need sufficient hand strength for use
 Breath-actuated metered-dose inhalers (BAIs) –
 OPTIC release depends on strength of patient’s breath
 Instillation  Dry powder inhalers (DPIs) – activated by
 Avoid the cornea. patient’s breath
 Avoid the eyelids with droppers or tubes ADMINISTERING MEDICATIONS BY
to decrease the risk of infection. IRRIGATION
 Use only on the affected eye.
 Never share medications.
 Intraocular instillation
 Disk resembles a contact lens.
 Teach patients how to insert and
remove the disk.
 Teach about adverse effects.
EAR INSTILLATION:
 Irrigations cleanse an area, instill a medication,
or apply hot or cold to injured tissue.
 Irrigations most commonly use sterile water,
saline, or antiseptic solutions on the eye, ear,
throat, vagina, and urinary tract.
 Use aseptic technique if there is a break in the
skin or mucosa.
OTIC solution  Use clean technique when the cavity to be
irrigated is not sterile, as in the case of the ear
Instill eardrops at room temperature.
canal or vagina.
Use sterile solutions.
Check for eardrum rupture if patient has ear PARENTERAL ADMINISTRATION OF
drainage. MEDICATIONS
 Eardrum rupture – white with blood  Equipment
drainage
 Otitis Media – yellow with foul smell
drainage
 Never occlude the ear canal.
VAGINAL INSTILLATION:

 syringes
a. Luer – Lok
b. Non – Luer – Lok
 Needles
RECTAL INSTILLATION:

TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 VASTUS LATERALIS –

 hub
 shaft
 bevel
PREPARING AN INJECTION FROM AN AMPULE: 
Used for adults and children
 Snap off ampule neck 
Use middle third of muscle for injection
 Aspirate medication into syringe using filter 
Often used for infants, toddlers, and children
needle receiving biologicals
 Replace filter needle with an appropriate size DELTOID –
needle or needless device
 Administer injection
PREPARING AN INJECTION FROM A VIAL:
 If dry, use solvent or diluent as needed
 Inject air into vial
 Label multidose vials after mixing
 Refrigerate remaining doses if needed
MINIMIZING PATIENT DISCOMFORT:
 Use a sharp-beveled needle in the smallest USE OF THE Z – TRACK METHOD INJECTIONS –
suitable length and gauge; position patient
comfortably.
 Select the proper injection site.
 Apply a vapocoolant spray or topical anesthetic.
 Divert the patient’s attention from the injection.
 Insert the needle quickly and smoothly.
 Hold the syringe steady while the needle
remains in tissues. Zigzag path seals needle track
 Inject the medication slowly and steadily. Medication cannot escape from the muscle
SUBCUTANEOUS INJECTIONS – tissue
INTRADERMAL INJECTIONS –
 Used for skin testing (tuberculosis [TB],
allergies)
 Slow absorption from dermis
 Skin testing requires the nurse to be able to
clearly see the injection site for changes
 Use a tuberculin or small hypodermic syringe for
skin testing
 Angle of insertion is 5 to 15 degrees with bevel
up
oMedications placed into loose connective tissue  A small bleb will form
under dermis SAFETY IN ADMINISTERING MEDICATIONS BY
INTRAMUSCULAR INJECTIONS – INJECTION
 Faster absorption than subcutaneous route
 No interruption policy
 Many risks, so verify the injection is justified
 Handwashing
 Angle of administration: 90 degrees
 Clean Gloves
 Body mass index (BMI) and adipose tissue
influence needle size selection  Draping (sites)
 Amounts:  Return to the room after 15-30 minutes
 Adults: 2 to 5 mL (4 to 5 mL unlikely to (ID/SQ/IM)
be absorbed properly)  Tuberculosis Test (48-72hours)
 Children, older adults, thin patients: up  Aspirate (5-10s)
to 2 mL  10 seconds before withdrew
 Small children and older infants: up to 1  Do not massage
mL  Teach-Back
 Smaller infants: up to 0.5 mL  Needless Devices
VENTROGLUTEAL –
 Gluteus medius
 Deep and away from major nerves and blood
vessels
 Preferred and safest site for all adults, children,
and infants
 Recommended for volumes greater than 2 mL

TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier
 o Most needlestick injuries are
preventable
o Needlestick Safety and Prevention Act
o Safety syringes
 Dispose of sharps in marked containers

o Use puncture- and leak-proof containers

o Never force needles into receptacle
o Never place used needles into
wastebaskets, your pockets, or patient’s
tray or bedside

TRANSES BY: ALCANTARA, Princess June P. (1 BSN C) SOURCES: PPT Presentations & Discussions of Prof. Cabale, Manlangit, &
Javier