FAR EASTERN UNIVERSITY

INSTITUTE OF HEALTH SCIENCES AND NURSING

DEPARTMENT OF NURSING

NUR 1219 MEDICAL-SURGICAL NURSING 3

SKILLS LABORATORY

CARBOHYDRATE
MODULE 2. TOTAL PARENTERAL • Dextrose provides the carbohydrate content of
NUTRITON PN, up to 75% of the total energy of the
Topic Outline solution. It provides 3.4 kcal/g.
1. Total Parenteral Nutrition • Glucose is the body’s main source of energy.
a. Indications • Concentration is 12.5% (maximum for
b. Composition peripheral introduction) to 25% (total
c. Ordering and Mixing PN Solutions parenteral nutrition)
d. Equipment • Restricted in ventilator patients because
e. Initial Considerations oxidation of glucose produces more carbon
f. General PN Initial Procedures dioxide than does oxidation of fat.
g. Types of Parenteral Nutrition
h. Choice of Nutrition Regimen PROTEIN
i. PN Infusion Rate • Mixture of essential and non-essential amino
j. Monitoring of Nutrition Support acids
k. TPN Procedures • Concentration 3.5 – 15%
• Quantity of amino acids depends on patients
TOTAL PARENTERAL NUTRITION estimated requirements and hepatic and renal
• It is a way of supplying all the function.
nutritional needs directly into
blood stream bypassing FAT
gastrointestinal tract. • Lipid emulsion is a soluble form of fat that
• It is administered outside the allows it to be infused safely into the blood.
digestive tract, intravenously. • Safflower and soybean oil with egg lecithin
used as an emulsifier.
INDICATIONS • Isotonic
1. When individuals cannot or should not get • Significant source of calories.
nutrition through eating. • Usual dose is 0.5 to 1 g/kg/day to supply 20-
2. When the intestines are obstructed, when the 30% of total kcal requirement.
small intestine is not absorbing nutrients • IV fat contraindicated for severe hepatic
properly or a gastrointestinal fistula (abnormal pathology, hyperlipidemia or severe egg
connection) is present. allergies.
3. When the bowels need to rest and not have any
• Used cautiously with atherosclerosis, blood
food passing through them. Bowel rest may be
coagulation disorders.
necessary in Crohn’s disease, pancreatitis,
ulcerative colitis, and with prolonged bouts of
MICRONUTRIENTS
diarrhea in young children.
• Standard multi-vitamin and trace mineral
4. Individuals with severe burns, multiple
preparations added to parenteral solutions to
fractures, and in malnourished individuals to
meet micronutrient needs.
prepare them for major surgery, chemotherapy,
or radiation treatment.
ELECTROLYTE
5. Individuals with aids or widespread infection
(sepsis). • It is dictated by patient’s blood chemistry
values and physical assessment findings.
COMPOSITION OF INGREDIENTS IN BAG
FOR IV DELIVERY ORDERING AND MIXING PN SOLUTIONS
• Usual fluid volume is 1.5 - 2.5L over a 24 hours • The physician writes the order for the TPN
period for most people. prescription.
• Actual infusion depends on: • The pharmacist mixes the TPN solution using
1. Site of infusion aseptic technique.
2. Patient’s fluid and nutrient requirements. • Prescriptions are compounded by mixing the
solutions at a 1:1 dextrose-to-amino acid ratio
and placing in 1-L bags.
1|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
 INTRAVENOUS ACCESS FOR PN INTRA-DIALYTIC
• Intravenous lines for PN may be inserted into a INTRA-DIALYTIC- administered during
number of different veins although the tip hemodialysis
(inner end) of the line will usually be located in Access:
the: 1. Vena cava; or 2. Axillary veins; or 3. • Venous port of hemodialysis tubing (into
Subclavian veins. AV shunts

PN Routes depends on: Indication:

1. Intended duration of nutrition support • Malnourished hemodialysis patients who
2. Patient’s condition are unable to maintain weight and oral/
3. Osmolality of available solution enteral nutrition is not possible or has
4. Any limitations to access (such as trauma or failed.
obstruction)
EQUIPMENTS USED IN TPN
TWO WAYS OF ACCESS ADMINISTRATION
Central Venous Access • Intravenous Access Device
• It means that the fluids are delivered to the • Intravenous Giving Set
superior vena cava or right atrium, or less • Light Protective Covering
commonly the inferior vena cava (from a • Administration Reservoir Containing PN
femorally-inserted line). Solution
• The central position of the line tip is always • Infusion Pump
confirmed chest x-ray. • Syringes for Additives
Peripheral Venous Access INITIAL CONSIDERATIONS
• The tip of the line is usually in the axillary or • TPN should start slowly so that the body has time
subclavian veins. to adapt to both glucose load and the
• Intradialytic PN is another form of peripheral hyperosmolarity of the solution, and to avoid
access. fluid overload.
• A pump controls the infusion rate of the TPN
BLOOD VESSELS COMMONLY USED AS PN solution.
ACCESS SITES/ DELIVERY SITES
CENTRAL VEINS GENERAL PN INITIATION PROCEDURE:
CENTRAL- superior vena cava, right atrium, or 1. Start with 1 liter of TPN solution during the first
inferior vena cava 24 hours (or use 42 cc/hr as a typical start rate).
Access: 2. Increase volume by 1 liter each day until the
• Percutaneous central catheter desired volume is reached.
• Hickman line 3. Monitor blood glucose and electrolytes closely.
• Broviac line 4. Pump administer TPN at a steady rate.
• Groshong line 5. Don’t attempt to catch up if administration gets
• PICC line behind.
• Portacath
TYPES OF PARENTERAL NUTRITION
Indications: PERIPHERAL VEIN IS USED
• Longer-term use • Must be isotonic and therefore low in dextrose
• Short-term use when peripheral solution cannot and amino acids to prevent phlebitis and
meet full nutritional needs or if peripheral route increased risk of thrombus formation.
not available • The need to maintain isotonic solutions of
dextrose and amino acids while avoiding fluid
PERIPHERAL VEINS overload limits the caloric and nutritional value
PERIPHERAL- Any other veins of PPN
Access:
• peripheral cannula Advantages:
• midline catheter 1. Delivers complete but limited nutrition.
• midclavicular catheter 2. The final concentration cannot exceed 12.5%
dextrose – lower concentrations of amino acids.
Indication: 3. Vitamins and minerals are added.
• short-term use (<10-14days) 4. Lipid emulsion may be added to supplement
calories depending on the patients’ tolerance.
5. Provides temporary nutritional support.
2|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
 6. Short - term: 7 – 10 days and do not require
more than 2000 to 2500 kcal per day.
7. May be used for a post-surgical ileus or
anastomotic leak or for patients who require
nutritional support but are unable to use TPN
because of limited accessibility to a central
vein.
8. Sometimes used to supplement an oral diet or
tube feeding or transition from TPN to enteral
intake. Total Parenteral Nutrition (TPN)
SUPERIOR VENA CAVA IS USED
• Hypertonic solutions provide more dextrose
and/or protein but they must be delivered
centrally in a large diameter vein so that they
can be quickly diluted
• Higher concentration is used for TPN due to
more rapid dilution in superior vena cava.
• It is used when nutritional requirements are
high and anticipated need is relatively long 3
liters of 10% dextrose provides only 1020 kcal.
Indications:
1. Severe malnutrition
2. GI abnormalities due to obstruction, peritonitis,
severe acute pancreatitis
3. After surgery or trauma especially that
involving extensive burns, sepsis
4. Need for supplementation of inadequate oral
uptake in patients who are being treated
aggressively for cancer
5. Bone marrow transplantation
CHOICE OF NUTRITION REGIMEN
CONTINUOUS
• Infuses for 24 hours continuously.
• This is the most common type of regimen in the
hospital setting.
• Infusion rates usually range between 40 – 150
ml/h. Choice of Nutrition Regimen
Advantages:
1. Allows the lowest possible hourly infusion rate
to meet nutrient requirements.
2. Better control of blood glucose levels due to
continuous carbohydrate input. 3. May result in
better utilization of nutrients.
Disadvantages:
1. Physical attachment to the pump (may affect
quality of life)
2. Higher risk of biliary stasis (if no oral/enteral
intake)
3. Promotes continuous high insulin levels, which
may increase risk of fatty liver.
CYCLIC / INTERMITTENT
• It is commonly used in long-term parenteral
nutrition
3|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
• The patient is fed for 12 - 18 hours during the
night and fasts during the day or given only on
some days of the week. This gives the long-term
TPN patient freedom from the machinery to
lead a less restricted life during the day.
• It helps prevent hepatotoxicity that can develop
with long-term TPN and the fasting period
allows essential fatty acids to be released from
fat stores.
• Used for home patients
Advantages:
1. Allows greater patient mobility (may improve
quality of life)
2. Mimics physiological feeding / fasting pattern,
which may help to prevent accumulation of fat
in the liver and sludge in the biliary system.
Disadvantages:
1. Compared with continuous nutrition, a higher
infusion rate is required to provide the same
volume of feed. This may be less well-tolerated,
with a higher risk of problems such as:
2. Fluid overload (and frequent urination during
infusion, inconvenient especially at night)
3. Electrolyte Fluctuations
4. Unstable blood glucose levels
PN INFUSION RATE
• All patients require individual assessment for
determining the rate of delivery of nutritional
support, which depends on the patient’s
nutritional requirements and medical condition.
• Typical infusion rates vary between 40-150
ml/h, but cyclic infusions may be delivered at
rates as high as 300 ml/h.
MONITORING OF NUTRITION SUPPORT
PURPOSES OF MONITORING
What should be Monitored, and the Frequency of
Monitoring will depend on Factors such as:
1. Expected duration of treatment
2. Health care setting
3. Patient’s disease state
4. Presence (and severity) of any abnormal results
5. Whether the patient is stable
AREAS OF MONITORING
1. Anthropometry
2. Biochemistry / Hematology
3. Liver tests
4. Iron studies
5. Lipid studies
6. Vitamins, minerals and trace elements
7. Indicators of protein status
8. Clinical assessment and monitoring:
9. Nutritional assessment
10. Dietary intake
 COMMON PROBLEMS
1. Line problems
a. Blocked intravenous line
b. Suspected line infection
2. Blood vessel problems
a. Phlebitis
b. Thrombosis
c. Line displacement
3. Formulation problems
a. Stability problems
b. Drug – nutrient interactions
4. Intolerance
a. Allergic reaction to parenteral nutrition
infusion
b. Nausea or vomiting
c. Appetite problems
d. Constipation
5. Metabolic Abnormalities
a. Re-feeding syndrome
b. Overfeeding
c. Dehydration
d. Fluid overload
e. Abnormal biochemistry
TPN PROCEDURES
PARENTERAL NUTRITION INFUSION
UTILIZING THE PERIPHERAL ACCESS
1. Verify doctor's prescription.
2. Explain the procedure to reassure patient and
significant other (benefits, risks, duration,
changes in volume and flow rate, etc.).
3. Secure consent from patient or/and authorized
member of the family.
4. Prepare parenteral solution and all other devices
needed for the parenteral administration, taking
into consideration the mode of administration
such as:
a. Peripheral access
b. Central access
5. Check the integrity and functionality of the
parenteral solution and IV devices.
6. Observe 10 rights in safe drug administration.
7. Assess patient and choose suitable vein,
location and get baseline vital signs.
8. Do hand hygiene and maintain asepsis
throughout the procedure.
9. Prepare Parenteral Nutrition solution (follow
procedure of IVT Setting Up).
10. Insert IV catheter aseptically (large,
bore0catheter. Follow procedure for IV
insertion).
11. Connect the tubing to the prepared parenteral
solution and regulate flow rate as prescribed.
12. Dress IV sites as per IV standard.
13. Label IV site and solution as per IV standard.
14. Continue to reassure patient and do pertinent
health education.
15. Dispose waste materials according to Health
Care Waste Management (DOH/DENR).
4|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
16. Document procedure and observations with
corresponding nursing intervention in the
patient's chart like I and O , weigh daily, etc.
17. Monitor patient periodically and report unusual
findings if there are signs of infection, hyper
and hypoglycemia, change of color and
consistency of solution, etc.
18. Document observation and intervention as
necessary.
19. Reassure patient.
PARENTERAL NUTRITION INFUSION
UTILIZING CENTRAL VASCULAR ACCESS
1. Follow procedure in Peripheral Access from
steps 1-9.
2. Assist surgeon in Open or Closed Central
Vascular Access Procedures (Maintain asepsis
throughout the procedure).
3. Connect the IV administration set to the central
vascular access catheter aseptically and
regulate flow rate as prescribed.
4. Assess dressing over central vascular access for
swelling, redness, pain and foul-smelling
discharges.
5. Monitor/reassure patient.
6. Document observations and circumstances as
necessary.
7. Discard waste materials according to Health
Care Waste Management (DOH/DENR).
DISCONTINUING PARENTERAL SOLUTION
INFUSION
1. Verify written prescription (Discontinues upon
completion of TPN requirements, (e.g., 24
hours, 12 hours or in the occurrence of any
adverse reaction).
2. Observe 10 rights.
3. Explain procedure to the patient and significant
others.
4. Prepare the necessary materials to be used in
discontinuing TPN utilizing Peripheral /
Central Vascular Access (Prepare sterile
dressing set and stitch scissor for Open Central
Vascular Access).
5. Follow doctor's prescription, e.g. electrolyte;
weight; blood laboratory monitoring.
6. Monitor patient closely and document
observation and intervention.
7. Refer to MD for any unusual observations. 8.
Discard waste materials according to Health
Care Waste Management (DOH/DENR).
 FAR EASTERN UNIVERSITY
INSTITUTE OF HEALTH SCIENCES AND NURSING
DEPARTMENT OF NURSING

NUR 1219 MEDICAL-SURGICAL NURSING 3

SKILLS LABORATORY

MODULE 3 CENTRAL VENOUS PRESSURE • CVP decreases with:

Topic Outline 1. Hypovolemic shock from hemorrhage,
1. Central Venous Pressure fluid shift, dehydration
a. CVP Catheter 2. Negative pressure breathing which
b. Factors Affecting CVP occurs when the patient demonstrates
c. Insertion Sites retractions or mechanical negative
d. CVP Recording pressure which is sometimes used for
i. Using a manometer high spinal cord injuries.
ii. Using a transducer
e. Interpreting Measurements EQUIPMENT
f. Potential Complications • Manometer
• Intravenous Access Device
CENTRAL VENOUS PRESSURE • Transducer

INSERTION SITES
INTERNAL JUGULAR VEIN
• This site is chosen frequently as there is a high
rate of successful insertion and a low incidence
of complications such as pneumothorax
• Internal jugular veins are short, straight and
relatively large allowing easy access, however,
catheter occlusion may occur as a result of head
movement and may cause irritation in conscious
patients.

• It is acquired by threading a central venous
catheter into any of several large veins. ❑It is
threaded so that the tip of the catheter rests in
the lower third of the superior vena cava.
CVP CATHETER
It is an important treatment tool used to:
1. Assess right ventricular function and systemic
fluid status.
2. Allow for rapid infusion.
3. Allow for infusion of hypertonic solutions and
medications that could damage veins.
4. Allow for serial venous blood assessment
FACTORS THAT AFFECT CVP
• Normal CVP is 2 – 6 mm hg.
• The condition of the patient and the treatment
being administered determine how often CVP
measurement should take place.
• CVP is elevated by:
1. Overhydration which increases venous
return
2. Heart failure or PA stenosis which limit
venous outflow and lead to venous
congestion
3. Positive pressure breathing, straining.
5|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
SUBCLAVIAN VEIN
• This site is often chosen as there are more
recognizable anatomical landmarks, making
insertion of the device easier.
• Because this site is positioned beneath the
clavicle there is a risk of pneumothorax during
insertion.
• A subclavian CVC is generally recommended
as it is more comfortable for the patient.
FEMORAL VEIN
• This site provides rapid central access during an
emergency such as a cardiac arrest.
• As the CVC is placed in a vein near the groin
there is an increased risk of associated infection.
• In addition, femoral CVCs are reported to be
uncomfortable and may discourage the
conscious patient from moving.
CVP RECORDING
• It is usually recorded at the mid-axillary line
where the manometer arm or transducer is level
with the phlebotomid axis.
• This is where the fourth intercostal space and
midaxillary line cross each other allowing the
measurement to be as close to the right atrium
as possible.

USING A MANOMETER
1. Explain the procedure to the patient to gain
informed consent.
2. If IV fluid is not running, ensure that the CVC
is patent by flushing the catheter.
3. Place the patient flat in a supine position if
possible. Alternatively, measurements can be
taken with the patient in a semi-recumbent
position. The position should remain the same
for each measurement taken to ensure an
accurate comparable result.
4. Line up the manometer arm with the
phlebostatic axis ensuring that the bubble is
between the two lines of the spirit level.
5. Move the manometer scale up and down to
allow the bubble to be aligned with zero on the
scale. This is referred to as ‘zeroing the
manometer ‘.
6. Turn the three-way tap off to the patient and
open to the manometer.
7. Open the IV fluid bag and slowly fill the
manometer to a level higher than the expected
CVP
8. Turn off the flow from the fluid bag and open
the three-way tap from the manometer to the
patient.
9. The fluid level inside the manometer should fall
until gravity equals the pressure in the central
veins.
10. When the fluid stops falling the CVP
measurement can be read. If the fluid moves
with the patient’s breathing, read the
measurement from the lower number.
11. Turn the tap off to the manometer.
12. Document the measurement and report any
changes or abnormalities.
8. When ‘zeroed’ is displayed on the monitor,
replace the cap on the three-way tap and turn
the tap on to the patient.
9. Observe the CVP trace on the monitor. The
waveform undulates as the right atrium
contracts and relaxes, emptying and filling with
blood.
10. Document the measurement and report any
changes or abnormalities.
INTERPRETING MEASUREMENTS
1. The normal range for CVP is 5-10cm H2O (2-
6mmHg) when taken from the mid-axillary line
at the fourth intercostal space.
2. Many factors can affect CVP, including vessel
tone, medications, heart disease and medical
treatments.
3. A CVP measurement should be viewed in
conjunction with other observations such as
pulse, blood pressure and respiratory rate and
the patients response to treatment.
POTENTIAL COMPLICATIONS
1. Hemorrhage from the catheter site
2. Catheter occlusion
3. Infection
4. Air embolus
5. Catheter displacement

USING A TRANSDUCER
1. Explain the procedure to the patient to gain
informed consent.
2. The CVC will be attached to intravenous fluid
within a pressure bag. Ensure that the pressure
bag is inflated up to 300mmHg.
3. Place the patient flat in a supine position if
possible. Alternatively, measurements can be
taken with the patient in a semi-recumbent
position. The position should remain the same
for each measurement taken to ensure an
accurate comparable result.
4. Catheters differ between manufacturers;
however, the white or proximal lumen is
suitable for measuring CVP.
5. Tape the transducer to the phlebostatic axis or
as near to the right atrium as possible.
6. Turn the tap off to the patient and open to the
air by removing the cap from the three-way port
opening the system to the atmosphere.
7. Press the zero button on the monitor and wait
while calibration occurs.
6|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
 FAR EASTERN UNIVERSITY
INSTITUTE OF HEALTH SCIENCES AND NURSING
DEPARTMENT OF NURSING

NUR 1219 MEDICAL-SURGICAL NURSING 3

SKILLS LABORATORY

MODULE 4 CARE OF CLIENTS WITH brain damaged, or patients with spinal cord
MECHANICAL VENTILATOR injuries
Topic Outline
1. Care of Clients with Mechanical Ventilator INDICATION FOR MECHANICAL
a. Purposes of Mechanical Ventilator VENTILATOR USE
b. Indications 1. Continuous decrease in oxygenation
c. Complications of long-term 2. Increase arterial carbon dioxide
ventilation 3. Persistent acidosis
d. Troubleshooting Ventilator Alarms 4. Respiratory failure:
e. What are the bundles of care to avoid a. Apnea / respiratory arrest
Ventilator-associated Pneumonia b. Inadequate ventilation(acute vs
(VAP)? chronic)
f. Closed system suctioning c. Inadequate oxygenation
g. Plan of Care for Ventilated Patients d. Chronic respiratory insufficiency with
FTT
CARE FOR PATIENT WITH MECHANICAL e. Compromised airway patency
VENTILATOR 5. Cardiac insufficiency
a. Eliminate the work of breathing
b. To reduce the oxygen consumption
6. Neurologic dysfunction
a. Central hypoventilation and frequent
apnea
b. Comatose patient with GCS < 8
c. Inability to protect the airway
7. ABG Results
8. If the patient is under the following conditions:
Patients who can’t breathe, for any reason, need to.be a. Multiple trauma
attached on a mechanical ventilator. This machine helps b. Shock
critically ill patients achieve the needed oxygen to c. Multi-organ failure
survive. The patient is then connected to the ventilator d. Drug overdose
with a tube that passes into the mouth and down to the e. Thoracic or abdominal surgery
trachea. There is some point of complexity on this type f. Neuromuscular disorders
of procedure that is why Nurses who are assigned in the g. Inhalation injury
intensive or critical unit should be competent in caring h. COPD
for the patient with mechanical ventilator.
COMPLICATIONS OF LONG-TERM
PURPOSES OF MECHANICAL VENTILATION VENTILATION
• The patient does not have to work as hard to Infections– A foreign object such as the endotracheal
breathe– their respiratory muscles rest tube in the trachea makes the patient more susceptible
• Helps the patient get adequate oxygen and to bacteria entering the lungs. This is treated with the
clears carbon dioxide use of antibiotics.
• Preserves a stable airway and preventing injury
from aspiration Pneumothorax –This is the condition when the lung/s
• Air is delivered in patients with compromised collapses. It is a complication when the lungs are
ventilation damaged because of gets over-expansion. If this
• Oxygenate the different organs of the body happened, a chest tube is inserted on the collapsed lung
• Expel the carbon dioxide in the lungs to allow it to re-expand and seal the leak.
• Provide comfortable breathing pattern to
patients experiencing shortness of breath Lung damage – The air forced in the lungs can increase
• To breathe for patients who are seriously the risk for injury.
compromised ventilation such as in comatose,
Side Effects of medications– Intubated patients are
most of the time given sedatives to allow easier
7|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
ventilation of the machine. These medications keep the
patient calm and sleepy.
Maintenance of Life– The ventilator sometimes serves
as the only reason why the patient is alive. Organs fail
because the body is dying, this includes the lungs.
VENTILATOR SETTINGS AND CONTROLS
• Tidal Volume (TV) – Air that the client
receives per breathing. Percentage in the
mechanical ventilator is adjusted depending on
client’s needs (40-100%). The normal value of
tidal volume is ½ L or 500 ml.
• Fraction of inspired oxygen (FiO2) – the
oxygen concentration delivered to the client.
ABG is usually determined before adjusting
FiO2 levels. It is adjusted from 40%-100%.
• Peak Flow Rate (PFR)– The peak flow rate is
the maximum flow delivered by the ventilator
during inspiration. Peak flow rates of 60 L per
minute may be sufficient, although higher rates
are frequently necessary.
• Back-up Rate (BUR)– for spontaneous or time
mode ventilator, back-up rate is set so that the
client may receive a minimum number of
breaths per minutes if the client fail to breath. If
the client’s breathing rate is slower, it will cycle
inhale / exhale pressure at the set rate. The usual
setting for BUR ranges from 12-22 breaths per
minute, depending on the physician’s order.
• Pressure end-expiratory pressure (PEEP)– is
exerted during the expiration phase of
ventilation, which improves oxygenation by
enhancing gas exchange and preventing
atelectasis. Not all clients with mechanical
ventilator is attached to PEEP. A typical initial
applied PEEP is 5 cmH2O. However, up to 20
cm H2O may be used in patients undergoing low
tidal volume ventilation for acute respiratory
distress syndrome (ARDS)
• Continuous positive airway pressure (CPAP)
– used for spontaneously breathing clients.
Positive airway pressure is introduced during
the respiratory cycle.
• Sensitivity- used to describe the ventilator’s
responsiveness to the patient’s breathing effort.
Sensitivity adjusts the level of negative pressure
required to trigger the ventilator. With assisted
ventilation, the sensitivity typically is set at -1
to -2 cm H2O.
HOW TO TROUBLESHOOT VENTILATOR
ALARMS?
Alarms are designed to warn nurses that there is
something wrong either to the patient or to the
mechanical ventilator. But sometimes, alarms can give
nurses apprehensions especially if the alarm is non-stop
and we don’t know how to troubleshoot the problem.
8|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
So as a nurse, how will you manage if there’s an alarm?
First, assess the patient if he/she is in distress. Identify
the alarm whether high pressure or low pressure. Some
mechanical ventilators have their own indicators and
shows the cause of the alarm, so it’s important to check
your machine as well.
LOW PRESSURE ALARM
• Low pressures alarm may indicate leak in the
patient’s tube, disconnection of the tube, or the
patient stops to breath.
Interventions
• Check the tube connections.
• Reconnect patient to the ventilator.
• Replace leaking tubes by manually ventilating
the patient.
• Auscultate patient’s lung fields for bilateral
lung sounds.
• Monitor respiratory rate and breathing patterns.
• Evaluate cuff pressure. Reinflate if needed.
HIGH PRESSURE ALARM
• High pressure alarm may indicate displacement
of the ET tube, increased secretions, obstruction
in the tube, bronchospasms, or the patient is
coughing or biting the tube.
Interventions:
• Assess your patient.
• Auscultate lung fields for secretions. This
should be done at least every 2 hours or more.
• Suction secretions as needed. Oxygenate
patient manually before suctioning.
• If patient is biting the tube, provide bite block.
• Sedate patient if necessary especially when
patient is fighting the vent. Make sure this is
ordered by the attending physician or hospitalist
on duty.
• Monitor pulse oximeter continuously if cardiac
monitor and pulse oximeter devices are present.
WHAT ARE THE BUNDLES OF CARE TO
AVOID VENTILATOR-ASSOCIATED
PNEUMONIA (VAP)?
Bundles of care for VAP should be strictly observed by
the Critical Care Nurses or nurses in any department.
• Strict hand washing. The best way to prevent
cross-contamination of any disease is hand
washing.
• Oral hygiene. Nurses should always perform
oral care to patient attached to mechanical
ventilator. Know your hospital policies
regarding your standard oral hygiene
procedures.
• Initiate closed suction system. Change the
system at least every 72 hours or as
indicated/needed.
 • Avoid pressure ulcers. Turn patient to sides
every 2 hours or as needed. Apply cream or
ointment to bony prominences or as indicated
by the physician.
• Elevate head of bed >30 degrees. Always
observe aspiration precaution.
• Assess patient daily for extubation readiness.
Early extubation can greatly prevent VAP.
• Daily interruption of sedation.
CLOSED SYSTEM SUCTIONING
EQUIPMENT
• Sterile Closed Suction Kit
• Normal Saline Irrigation
• Suctioning machine or device: wall or portable
• Oxygen source
• Personal protective equipment
• 10 cc syringe
• Pulse oximeter
• Stethoscope
PROCEDURE
1. Check the guidelines or standard procedure of
your unit for closed-suctioning system.
2. Prepare all needed equipment. Position all
supplies so that they are easily accessible.
Check suction setup for correct functioning.
Read instructions of the closed-suction kit.
3. Explain the procedure to the client. Explain the
benefits of closed-suctioning system and how it
can prevent infection.
4. Assess patient first. Auscultate patient’s lung
fields for abnormal breath sounds. Attach
patient to continuous pulse oximeter
monitoring device.
5. Wear personal protective equipment. Perform
hand hygiene
6. Attach closed suction catheter system between
ventilator circuit and patient airway.
7. Ensure that wall or portable suction is turned on
(no higher than 120 mmHg). Set vacuum setting
according to policy of your unit.
8. Attach suction tubing from setup to suction port
of catheter.
9. Hyper-oxygenate patient to 100% 02 for 2 – 5
minutes.
10. Attach saline to irrigation port. You may use
also a 10 cc syringe for introducing saline
irrigation or depending upon the set-up of your
closed-suction kit.
11. Introduce catheter before instilling saline –
lavage on inspiration.
12. Introduce catheter until a restriction is met or
until you can stimulate cough reflex.
13. Withdraw the catheter slowly while applying
intermittent suction. Suction should not be
applied for more than 15-20 seconds.
9|P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
14. Upon completion of suctioning, withdraw
catheter, ensuring that tip is completely
withdrawn from airway.
15. Rinse suction catheter after each suctioning by
depressing thumb control and squeezing a new
saline irrigation using the 10cc syringe or
depending on the set-up of your close suction
kit.
16. Repeat suctioning process until the patient’s
airway is clear.
17. Discard personal protective equipment and
wash hands.
18. Evaluate patient’s condition by auscultating the
lung fields and by monitoring patient’s
oxygenation using pulse oximeter.
PLAN OF CARE FOR VENTILATED PATIENTS
• Promote effective breathing pattern
• Promoted adequate gas exchange
• Improve the nutritional status that the body
needs
• Prevent patient from developing pulmonary
infection.
• Prevent patient from developing problems
related to immobility.
• Patient and/or family will demonstrate
understanding of the purpose for mechanical
ventilation
References
Hinkle, J.L. & Cheever, K.H. (2018). Brunner &
Suddarth's Textbook of Medical-Surgical
Nursing (14th ed.). Philadelphia: Wolters
Kluwer.
Ignatavicius, D.D., Workman, M.L., & Rebar, C.R.
(2018). Medical-Surgical Nursing: Concepts for
Interprofessional Collaborative Care (9th ed.).
St. Louis: Elsevier.
Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher,
L., & Harding, M.M. (2017). Medical-Surgical
Nursing: Assessment and Management of
Clinical Problems (10th ed.). St. Louis: Elsevier.
 FAR EASTERN UNIVERSITY
INSTITUTE OF HEALTH SCIENCES AND NURSING
DEPARTMENT OF NURSING

NUR 1219 MEDICAL-SURGICAL NURSING 3

SKILLS LABORATORY

MODULE 5 DIALYSIS Types:

Topic Outline 1. Intermittent Hemodialysis
2. Dialysis 2. Peritoneal Dialysis
a. Indications 3. Continuous Renal Replacement Therapy
b. Types (CRRT)
3. Hemodialysis
a. Functions HEMODIALYSIS
b. Complications • Hemodialysis is used for patients who are
4. Peritoneal Dialysis acutely ill and require short-term dialysis for days
a. Continuous Ambulatory Peritoneal to weeks until kidney function resumes and for
Dialysis (CAPD) patients with advanced CKD and ESKD who
b. Automated Peritoneal Dialysis (APD) require long-term or permanent renal
c. Procedures replacement therapy.
d. Complications • It prevents death but does not cure kidney disease
e. Nursing Management and does not compensate for the loss of endocrine
5. Continuous Renal Replacement Therapies or metabolic activities of the kidneys.
(CRRT) • Hemodialysis aims to extract toxic nitrogenous
a. Types substances for the blood and remove excess fluid.
6. Special Considerations Nursing Management • A dialyzer (also referred to as an artificial
of the Hospitalized Patients on Dialysis kidney) is a synthetic semipermeable membrane
through which blood is filtered to remove uremic
OVERVIEW toxins and a desired amount of fluid.
The module provides an overview of the kidney • In hemodialysis, the blood, laden with toxins and
functions as well as the physiology of urine formation. nitrogenous wastes, is diverted from the patient
It focuses on concepts related to dialysis treatment of to a machine via the use of a blood pump to the
patients with chronic kidney disease to support the dialyzer, where toxins are filtered from the blood
learning needs of the nursing students on how to care and the blood is returned to the patient.
for patients undergoing hemodialysis, peritoneal • Dialysate is a solution that circulates through the
dialysis or CRRT. dialyzer, made up of all the electrolytes in their
ideal extracellular concentrations.
DIALYSIS • Principles of hemodialysis: diffusion, osmosis,
A dialysis is a process which separates the solutes in and diffusion
the blood by differential diffusion through a semi-
permeable membrane to affect the removal of toxic
metabolites and excess water.

Figure 1. Dialysis

Indications: for patients with Figure 2. Hemodialysis system. Blood from an artery is pumped
• Fluid overload (A) into a dialyzer, where it flows through the synthetic capillary
tubes (B), which act as the semipermeable membrane (inset). The
• Increasing levels of serum K+ dialysate, which has a particular chemical composition, flows into
• Impending pulmonary edema the dialyzer around the capillary tubes that the blood flows through.
• Increasing acidosis The waste products in the blood diffuse across the semipermeable
• Poisoning or medication overdose membrane into the dialysate solution.
• Uremia
10 | P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
 FUNCTIONS OF HEMODIALYSIS
1. Cleanses the blood of accumulated waste
products
2. Removes the by-products of protein
metabolism (urea, creatinine & uric acid)
3. Removes excessive fluids
4. Maintains or restores the buffer system of the
body
5. Maintains or restores electrolyte levels
HEMODIALYSIS ACCESS
1. Subclavian vein catheter
• Short-term, temporary, up to 6 weeks
• Filled with heparin and capped to maintain
patency between dialysis treatment.
• At risk for infection if left longer than 6
weeks
2. Femoral vein catheter- short-term, temporary
3. External Arteriovenous shunt- direct catheter
insertion at the artery and vein in the forearm or
leg
• Advantages: immediately used, no
venipuncture
• Disadvantages: external danger of
disconnecting and dislodging; risk for
infection and skin erosion
4. Internal Arteriovenous fistula- preferred
method of permanent access for dialysis
• Connects an artery to a vein (anastomosis)
• Needles are inserted into the vessel to
blood flow adequate to pass through the
dialyzer.
• Requires time (2-3 months) to mature
before it can be used
• Uses stress ball for faster maturity
• Maturity is required before the fistula is
used
• Advantages: less danger of clotting and
bleeding, can be used immediately,
decreased incidence of infection, and no
external dressing required
• Disadvantages: cannot be immediately
used after insertion, venipuncture is
required for dialysis, infiltration of needles
(hematoma), aneurysm in the fistula, and
HEMODIALYSIS NURSING MANAGEMENT
arterial steal syndrome
5. Internal Arteriovenous graft
• Can be created by subcutaneously
interposing a biologic, semibiologic, or
synthetic graft material between an artery
and vein
• Usually, a graft is created when the
patient’s vessels are not suitable for
creation of an AVF
11 | P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
• Gore-Tex or bovine carotid artery as artificial
vein for blood flow
• Procedure involves the anastomosis of the graft
to the artery
• Advantages: less danger of clotting and
bleeding, can be used indefinitely, decreased
incidence of infection, and no external dressing
required
• Disadvantages: cannot be immediately used
after insertion, venipuncture is required for
dialysis, infiltration of needles (hematoma),
aneurysm in the fistula, and arterial steal
syndrome
• Common complications: stenosis, infection,
and thrombosis
HEMODIALYSIS COMPLICATIONS
• Chest pain
• Dysrhythmias- may results from electrolyte
and pH changes or from removal or
antiarrhythmic drugs during dialysis.
• Air embolism- rare but can occur if air enters
the vascular system
• Anemia- compounded by blood lost during
hemodialysis)
• Gastric ulcers- may result from the
physiologic stress of chronic illness,
medication, and pre-existing medical
conditions
• Patients with uremia report a metallic taste
• Nausea and vomiting- due to rapid shift of
fluids and hypotension
• Bone pain and fractures- due to poor calcium
metabolism and renal osteodystrophy
• Itchiness- phosphorus deposits in the skin
• Sleep disturbances- due to early morning or
late afternoon dialysis schedules
• Shortness of breath- fluid accumulation in
between dialysis treatments
• Hypotension- occurs when fluid is removed
• Painful muscle cramps- occurs late in the
dialysis when electrolytes rapidly leave the
extracellular space
• Disturbances of lipid metabolism
(hypertriglyceridemia)
• Heart failure, coronary heart disease, angina,
stroke, and peripheral vascular insufficiency
1. Promote Pharmacologic therapy
2. Promote Nutritional and Fluid therapy
• Restriction of dietary protein, sodium,
potassium, phosphorus, and fluid intake
3. Meeting Psychosocial needs
4. Teach patient self-care
5. Continuing of care
 PERITONEAL DIALYSIS
• In PD, the peritoneal membrane that covers the
abdominal organs and lines the abdominal wall
serves as the semipermeable membrane. A
sterile dialysate fluid is introduced into the
peritoneal cavity through an abdominal catheter
at intervals.
• The goals of PD are to remove toxic substances
and metabolic wastes and to reestablish normal
fluid and electrolyte balance.
• PD may be the treatment of choice for patients
with kidney disease who are unable or
unwilling to undergo hemodialysis or kidney
transplantation.
• Patients who are susceptible to the rapid fluid,
electrolyte, and metabolic changes that occur
during hemodialysis experience fewer of these
problems with the slower rate of PD.
• Ultrafiltration (water removal) occurs in PD
through an osmotic gradient created by using a
dialysate fluid with a higher glucose
concentration than the blood.
Figure 3. In peritoneal dialysis and in acute intermittent peritoneal
dialysis, dialysate is infused into the peritoneal cavity by gravity,
after which the clamp on the infusion line is closed. After a dwell
time (when the dialysate is in the peritoneal cavity), the drainage
tube is unclamped and the fluid drains from the peritoneal cavity,
again by gravity. A new container of dialysate is infused as soon as
drainage is complete. The duration of the dwell time depends on the
type of peritoneal dialysis.
CONTINUOUS AMBULATORY PERITONEAL
DIALYSIS (CAPD)
• It is the second most common form of dialysis
for patients with ESKD
• Can be performed in any clean and convenient
place.
• Requires no machinery
• The dialysate is left in the abdomen for up to 8
hours
• The manual exchanges use gravity to drain the
used fluid out of the peritoneal cavity and
replace it with fresh fluid.
• Dialysis takes place while patient continues
normal activities.
• Most CAPD patients need to do 4 bag
exchanges per day.
12 | P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
• 5 to 2.5 liters of fluid per exchange
• Each exchange takes 30-40 minutes
AUTOMATED PERITONEAL DIALYSIS (APD)
• aka Continues Cyclic PD (CCPD)/APD
• Uses a machine to exchange the fluids
• Each session lasts from 10-12 hours
• Usually done at night while patient sleeps
• Machine has 3 main functions:
o Heats PD fluid to body temperature
o Controls time of exchange & amount of
fluid used
o Monitors treatment (safety alarms)
PROCEDURE FOR PERITONEAL DIALYSIS
I. PREPARING THE PATIENT:
1. Explain the procedure & obtain a signed
consent
2. Record baseline vital signs, weight & serum
electrolytes
3. Encouraged to empty bladder &bowel
4. Administer broad-spectrum antibiotic agents as
ordered to prevent infection.
II. PREPARING THE EQUIPMENT:
1. Consult physician re-concentration of dialysate
& medications to be added to it. (Heparin, KCl,
antibiotics etc.)
2. Warm the dialysate to body temperature to
prevent patient discomfort and abdominal pain
and to dilate the vessels of the peritoneum to
increase urea clearance.
3. Assemble the administration set & tubing. Fill
the tubing with the prepared dialysate to reduce
the amount of air entering the catheter and
peritoneal cavity.
III. INSERTING THE CATHETER
• Ideally, the peritoneal catheter is inserted in the
operating room to maintain the surgical asepsis
& minimize the risk of contamination.
IV. PERFORMING THE EXCHANGE
• 1-4 hours, depending on the prescribed dwell
time; involves a series of exchanges or cycles
• Exchange is the entire cycle including the
infusion (fill), dwell, and drainage of the
dialysate.
• Infusion- dialysate is infused by gravity into
the peritoneal cavity for a period of 5-10 mins
to infuse 2L of fluid.
• Dwell- allows diffusion & osmosis to occur
(peaks in the first 5-10 minutes)
• Drainage- the tube is unclamped and the
solution drains from the peritoneal cavity
through a closed system (10 to 30 minutes).
o The drainage fluid is normally
colorless or straw colored and should
not be cloudy. Bloody drainage may be
seen in the first few exchanges after
 insertion of a new catheter but should
not occur after that time.
o The removal of excess water during
peritoneal dialysis is achieved by using
a hypertonic dialysate with a high
dextrose concentration that creates an
osmotic gradient (Dextrose solution of
1.5%, 2.5% and 4.25%)
PERITONEAL DIALYSIS COMPLICATIONS
ACUTE COMPLICATIONS
1. Peritonitis- most common and serious
complication of PD. First symptom is cloudy
dialysate drainage fluid. Diffuse abdominal pain
and rebound tenderness occur much later.
Hypotension and other signs of shock may also
occur with advancing infection
2. Leakage of dialysate through the catheter site
may occur immediately after the catheter is
inserted. Usually, the leak stops spontaneously if
dialysis is withheld for several days. It can be
avoided by using small volumes (500 mL) of
dialysate, gradually increasing the volume up to
2000 to 3000 mL.
3. Bleeding- may be observed occasionally in
young, menstruating women. It is also common
during the first few exchanges after a new
catheter insertion because some blood enters the
abdominal cavity following insertion. Most
often, bleeding stops in 1 to 2 days and requires
no specific intervention. More frequent
exchanges and the addition of heparin to the
dialysate during this time may be necessary to
prevent blood clots from obstructing the catheter.
LONG TERM COMPLICATIONS
1. Hypertriglyceridemia
2. Anorexia
3. Low Back pain
PERITONEAL DIALYSIS CARE
PRE-DIALYSIS CARE
1. Document vital signs
2. Weigh daily or in between dialysis
3. Note BUN, Creatinine, serum electrolytes, pH,
and Hct levels
4. Measure and record abdominal girth
5. Maintain fluid and dietary restrictions as
ordered
6. Have patient empty bladder prior to catheter
insertion
7. Warm the prescribed dialysate solution to body
temperature
8. Explain all procedures and expected outcomes
13 | P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
INTRADIALYSIS CARE
1. Use aseptic technique
2. Add prescribed medication into the dialysate.
Prime the tubing with solution and connect it to
the peritoneal catheter taping connections
securely and avoiding kinks.
3. Instill dialysate into the abdominal cavity over
a period of approximately 10 mins. Clamp
tubing and allow the dialysate to remain in the
abdomen for the prescribed dwell time.
4. Dialysate should flow freely into the abdomen.
5. Troubleshoot for possible problems during
dialysis.
a. Slow dialysate installation- increase the
height of the container, reposition the
patient.
b. Poor dialysate installation
c. Check the abdominal dressing, check
tubing, or catheter obstruction
POST-DIALYSIS CARE
1. Assess vital signs and compare to pre-dialysis
2. Identify the beneficial and adverse effects of the
procedure
3. Time meals to correspond with dialysis outflow
4. Teach the client and family about the procedure.
PERITONEAL DIALYSIS NURSING
MANAGEMENT
1. Meeting Psychosocial Needs
2. Teaching Patient Self-Care
3. Continuing Care
CONTINUOUS RENAL REPLACEMENT
THERAPIES (CRRT)
• Methods used to replace normal kidney function
by circulating the patient’s blood through a filter
and returning it to the patient.
Indications:
• Patients with acute or chronic kidney disease who
are too clinically unstable for traditional
hemodialysis
• Patients with fluid overload secondary to oliguric
(low urine output) kidney disease
• Patients whose kidneys cannot handle their
acutely high metabolic or nutritional needs.
TYPES OF CRRT:
1. Continuous arteriovenous hemodialysis
(CAVHD)-
2. Continuous venovenous hemodialysis
(CVVHD)
3. Slow continuous ultrafiltration (SCUF)
4. Continuous arteriovenous hemodiafiltration
(CAVHDF)
5. Continuous venovenous hemodialfiltration
(CVVHDF)
 SPECIAL CONSIDERATIONS: NURSING
MANAGEMENT OF THE HOSPITALIZED
PATIENTS ON DIALYSIS
1. Protecting vascular access
• Assess the vascular access for patency
• The extremity with the vascular access
must not be used for taking blood pressure
or for obtaining blood specimens
• Tight dressings, restraints, or jewelry over
the vascular access must be avoided
• Evaluate the bruit/ thrill at least every shift.
Absence of palpable thrill or audible bruit
may indicate blockage or clotting in the
vascular access
2. Taking precautions during Intravenous
therapy
• The IV rate must be slow as possible
• Accurate I&O records are essential
3. Monitoring symptoms of Uremia
• As metabolic end products accumulate,
symptoms of uremia worsen. Patients
whose metabolic rate accelerates (those
receiving corticosteroid medications or
parenteral nutrition, those with infections
or bleeding disorders, those undergoing
surgery) accumulate waste products more
quickly and may require daily dialysis.
These same patients are more likely than
other patients receiving dialysis to
experience complications.
4. Detecting cardiac and respiratory
complications
• Cardiac and respiratory assessment must
be conducted frequently. As fluid builds
up, fluid overload, heart failure, and
pulmonary edema develop. Crackles in the
bases of the lungs may indicate pulmonary
edema.
5. Controlling electrolyte levels and diet
6. Managing discomforts & pain
• Complications such as pruritus and pain
secondary to neuropathy must be
managed
• Antihistamines for pruritus and
analgesics for pain
• Keep the skin clean and well
moisturized using bath oils, superfatted
soap, and creams or lotions helps
promote comfort and reduce itching.
• Instruct the patient to keep the nails
trimmed to avoid scratching and
excoriation also promotes comfort.
7. Monitoring blood pressure
• Hypertension in kidney disease is
common. It is usually the result of fluid
overload and, in part, oversecretion of
renin.
• Antihypertensive agents must be
withheld before dialysis to avoid
14 | P a g e
NUR 1219 – MODULE 1
Prepared by CRITICAL CARE FEU Faculty Lecturers 2022
hypotension due to the combined effect
of fluid removal with the dialysis
treatment and the medication
8. Preventing infection
• Patients with ESKD commonly have
low WBC counts (and decreased
phagocytic ability), low RBC counts
(anemia), and impaired platelet
function. Together, these pose a high
risk of infection and potential for
bleeding after even minor trauma
9. Caring for the catheter site
• Recommended daily or 3 or 4 times-
weekly routine catheter site care is
typically performed during showering
or bathing.
• The exit site should not be submerged
in bathwater.
• The most common cleaning method is
soap and water; liquid soap is
recommended.
• During care, the nurse and patient need
to make sure that the catheter remains
secure to avoid tension and trauma.
• The patient may wear a gauze or
semitransparent dressing over the exit
site.
10. Administering medications
• All medications and the dosage
prescribed for any patient on dialysis
must be closely monitored to avoid
those that are toxic to the kidneys and
may threaten remaining renal
function.
• Medications are also scrutinized for
potassium and magnesium content;
those medications that contain them
are avoided.
11. Providing psychological support
LEARNING RESOURCES:
• https://youtube.com/watch?v=EU2skU3bgS8&fe
ature=share
REFERENCES:
Smeltzer, S. Bare, B., Hinkle, J. & Cheever, K
(2010). Brunner & Suddarth’s Textbook
of Medical-Surgical Nursing, 12th ed. Wolters
Kluwer/ Lippincott Williams& Wilkins,
Philadelphia, USA
Sole, M., Klein, D. & Moseley, M. (2013). Introduction to
Critical Care Nursing (6th ed.). Elsevier Inc. St.
Louis, Missouri, USA