Wa0009.

Faculty of Nursing
Critical Care and Emergency Nursing
DY1
2023/2024
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Prepared by:
1. TA/Asmaa Hamed.
2. AL/ Gehad Diaa.
3. AL/ Menattallah Mohamed.
4. TA/ Sabreen Ahmed.
5. TA/ Ahmed Abdelaziz.
6. TA/ Gerges Nady.
7. TA/ Nouhem Refaat.
Under Supervision:
- Prof. Manal Ismail.
Head of Department
- Associate. Prof. Marwa Fathallah.
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Index
NO. List of Procedures Page
1 Crash Cart 4
2 Endotracheal Intubation 7
3 Oropharyngeal Airway Insertion and care 23
4 Suctioning 29
5 Endotracheal Tube Care 47
6 Tracheostomy Care 60
7 O2 Therapy 71
8 Inhalation Therapy) Nebulizer 81
9 Chest tube drainage system 90
10 Arterial puncture and arterial blood gases 99
11 Pulse Oximeter 107
12 ECG & Initiating cardiac monitoring 113
13 Central venous Catheter 121
14 Central venous Pressure 133
15 Central venous Catheter change dressing 140
16 Defibrillation &Cardioversion 149
17 Enteral Feeding 168
18 Total Parenteral Nutrition 173
19 Gastric Lavage 179
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Crash Cart Drawers Content
1st Drawer
(High-Alert or Emergency Medications)
• 50% Dextrose 50ml • Dobutamine 250mg in 5ml or

• Adenosine 3 mg/ml 20ml-2
• Adrenaline 1mg/ml • Dopamine 40 mg/ ml
• Amiodarone 150 mg vial • Epinephrine: EpiPen,
• Atropine 8 mg/20 ml vial Epinephrine 1:1,000
• Benadryl 50mg • Lidocaine 100 mg
• Dextrose 50% and 25% in pediatric • Lopressor 10 mg
wards. • Midazolam 50 mg/10 ml vial
• Diazepam 50 mg/10 ml • Naloxone, Narcan 1 mg/ml.
• Vasopressin 20u/ml
2nd Drawer
(Intravenous Supplies)
• Syringes: 3/5/10/20/50 cm - Ryle Extension line- Arterial line - 3 way –

syringe – Different Cannula sizes - different identification bracelets -
Gauze bandage - Bandage - Sterile gel laboratory tubes - Sterile Gloves -
- Tongue depressor- IV sets – Clean electrocardiogram paper - electrode
Gloves. bag for the monitor.
3rd Drawer
(Airway Supplies)
Laryngoscope - Endotracheal tubes sizes – Oxygen mask – Nasal cannula –

Airway tube sizes – Ambu bag mask. Oxygen mask- Extra batteries.
4th Drawer
(Procedure Supplies)
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Nasogastric tubes - Urinary catheter - Sterile scissors and forceps - CVC
Suction Catheter - Urine collection bag - catheter - Different sutures - surgical
chest tube + jar. scalpel.
5th Drawer
(All IV fluids)
• 1,000 ml dextrose 5% in water • 1,000 ml lactate solution,

solution, D5W Lactate’s Ringer or LR 500 ml
• 1,000 ml normal saline solution, NS of D5W and NS
100 ml of NS-2
5
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Endotracheal Intubation Procedure
Procedure of Performing Endotracheal Intubation
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Definition of endotracheal tube:
- An endotracheal tube is a flexible tube that is placed in the

trachea (windpipe) through the mouth or nose. It can be used
to assist with breathing during surgery or to support breathing
in patients with lung disease, chest trauma, or airway
obstruction.
Components of endotracheal tube:
Purposes of performing endotracheal intubation :
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• Establish and maintain a patent airway.
• Facilitate oxygenation and ventilation.
• Reduce the risk of aspiration.
• Assist with the clearance of secretions.
Indications of performing endotracheal intubation:
• Inadequate oxygenation and ventilation.

• Altered mental status (e.g., head injury, drug overdose) for
airway protection.
• Anticipated airway obstruction (e.g., facial burns, epiglottitis,
major facial or oral trauma).
• Upper airway obstruction (e.g., from swelling, trauma, tumor,
bleeding).
• Apnea.
• Ineffective clearance of secretions (i.e., inability to maintain
or protect airway adequately).
• High risk of aspiration.
• Respiratory distress, respiratory failure.
Equipment:
• Personal protective equipment.
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• Endotracheal tube with intact cuff (women, 7-mm to 7.5-mm
tube; men, 8-mm to 9-mm tube).
• Laryngoscope handle with fresh batteries.
• Laryngoscope blades (straight and curved).
• Self-inflating manual resuscitation bag-valve-mask device
with tight. fitting face mask connected to supplemental oxygen
(15 L/min).
• Oxygen source.
• 10-mL syringe for cuff inflation.
• Water-soluble lubricant.
• Rigid pharyngeal suction-tip (Yankauer) catheter.
• Suction apparatus (portable or wall).
• Suction catheters.
• Oropharyngeal airway.
• Endotracheal tube–securing apparatus or appropriate tape.
• Adhesive tape (6 to 8 inches long).
• Stethoscope.
• Monitoring equipment: cardiac monitor, pulse oximetry, and
sphygmomanometer.
• Drugs for intubation as indicated (induction agent, sedation,
paralyzing agents, lidocaine, atropine).
• Additional equipment, such as local anesthetic jelly (nasal
approach), mechanical ventilator.
Procedure of Performing Endotracheal Intubation
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No. Steps Rational
Pre-Procedure
1. Verify physician prescription. To avoid any mistakes
2. Wash Hands. To maintain infection control
3. Prepare needed Equipment. To save time and effort
4. Introduce yourself. To avoid mistakes
5. Verify the patient by 2 Nurses. To increase patient trust and help prevent error
6. Explain procedure to the patient. To increase patient’s cooperation
7. Keep patient privacy. Patient right (to decrease patient
embarrassment)
8. Before intubation, initiate intravenous Readily available intravenous access may be
access. necessary if the patient needs to be sedated or
paralyzed or needs other medications because
of a negative response to the intubation
procedure.
9. Attach patient to monitoring equipment Provides continuous patient monitoring during
including cardiac and blood pressure intubation.
monitor and pulse oximeter.
10. Set up suction apparatus and connect Prepares for oropharyngeal suctioning as
rigid suction-tip catheter to tubing. needed
11. Assess patient’ s airway to determine Use of LEMON mnemonic can assist in
whether a difficult intubation is determination of difficult intubation.
anticipated.
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12. Position the patient’ s head by flexing Allows for visualization of the vocal cords with
the neck forward and extending the alignment of the mouth, pharynx, and trachea.
head, in sniffing position (only if neck
trauma is not suspected;Fig.1). If spinal
trauma is suspected, request that an
assistant maintain the head in a neutral
position with in-line spinal

immobilization.
Fig. 1
13. Check the mouth for dentures and Dentures should be removed before oral
remove if present. intubation is attempted but may remain in
place for nasal intubation.
During Procedure
Suction the mouth and pharynx as Provides for a clear view of the posterior
14. needed if copious secretions are pharynx and larynx.
visualized.
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Insert oropharyngeal airway if Assists in maintenance of upper airway
indicated (Fig.2). patency. Helps to improve ability to ventilate
during bag-valve-mask ventilation.
15.
Preoxygenate for 3–5 minutes, with Helps prevent hypoxemia. Gentle breaths
100% oxygen via a self-inflating manual reduce incidence of air entering stomach
16. resuscitation bag-valve mask device. (leading to gastric distention, aspiration),
decrease airway turbulence, and distribute
ventilation more evenly within the lungs.
17. Premedicate patient as indicated. Sedates and relaxes the patient, allowing easier
intubation.
18. Remove oropharyngeal airway if Clears the airway for advancement of the
present. laryngoscope blade and endotracheal tube.
Orotracheal intubation:
19. Grasp laryngoscope (with blade in place Prepares for efficient blade placement.
and illuminated light on) in left hand.
20. Use fingers of right hand to open the Provides access to oral cavity.
mouth.
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21. Using a controlled motion, slowly insert Displaces the tongue to the left, increasing
the blade into the right side of the visualization of the glottic opening (Fig.4)
patient’ s mouth, using it to push the Fig. 4
tongue to the left (Fig.3). Advance the
blade inward and toward midline past
the base of the tongue.
Fig. 3
22. Visually identify the epiglottis and Identification of anatomical landmarks
vocal cords. provides landmarks for successful intubation.
23. Carefully advance the blade toward the Identification of epiglottis is key for
epiglottis in a well-controlled manner. successful direct laryngoscopy intubation.
A. With a curved blade, advance tip Exposes the glottic opening. This lifting
into vallecula (area between the motion elevates the epiglottis, keeping the
base of the tongue and the tongue out of the way, allowing for maximal
epiglottis) and exert outward and exposure of the glottis (Fig.5).
upward gentle traction at a 45-
degree angle. Lift the
laryngoscope in the direction of
the handle to lift the tongue and
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posterior pharyngeal structures
out of the way, allowing for
exposure of the glottis opening.
Do not allow the handle to lever
back, causing the blade to hit the
teeth.
B. With a straight blade, advance
tip just beneath the epiglottis and
exert gentle traction outward and
upward at a 45-degree angle to
the bed. Blade may be inserted to
the right of the tongue into the
natural gutter between the lower
molars (paraglossal technique)
or midline. 15 Do not allow the
handle to lever back, causing the
blade to hit the teeth.
24. Lift the laryngoscope handle up and Allows for correct placement of tube into
away from the operator (at a 45- to 55- trachea (Fig. 6).
degree angle from the trachea) until the
vocal cords are visualized.
25. With use of direct vision, gently insert Tube must be seen passing through the vocal
tube from right corner of mouth cords to ensure proper placement. Advance
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through the vocal cords (Fig. 4) until tube 1.25–2.5 cm farther into the trachea.
the cuff is no longer visible and has When correctly positioned, the tip of the tube
passed through the vocal cords (Fig. 5). should be halfway between the vocal cords
Do not apply pressure on the teeth or and the carina.
oral tissues.
(Fig. 8)
(Fig. 7)
26. When the tube is correctly placed, Firmly holding tube at the lips provides
continue to hold it securely in place at stabilization and prevents inadvertent
the lips with right hand while first extubation.
withdrawing the laryngoscope blade
and then the stylet with left hand.
27. Inflate cuff with 5–10 mL of air Keep cuff pressure between 20 and 30 mmHg
depending on the manufacturer’ s to decrease risk of aspiration and prevent
recommendation. Do not overinflate the ischemia and decreased blood flow.
cuff.
28. Confirm endotracheal tube placement Ensures correct placement of endotracheal
while manually bagging with 100% tube.
oxygen:
a) Auscultate over epigastrium.
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b) Auscultate lung bases and apices
for bilateral breath sounds.
c) Observe symmetrical chest wall
movement.
d) Evaluate oxygen saturation
(Spo2) with noninvasive pulse
oximetry.
29. Connect endotracheal tube to oxygen Reduces motion on tube and mouth or nares.
source via self-inflating manual
resuscitation bag-valve device, or
mechanical ventilator.
30. Insert oropharyngeal airway along the Prevents the patient from biting down on the
endotracheal tube, with oral intubation endotracheal tube.
if indicated.
31. Secure the endotracheal tube in place Prevents inadvertent dislodgment of
(according to institutional standard). tube.
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32. Use of Commercially Available Allows for secure stabilization of the tube,
Endotracheal Tube Holder (Fig.9) decreasing the likelihood of inadvertent
A. Apply according to extubation.
manufacturer’ s directions.
(Fig. 9)
Use of Adhesive Tape
A. Prepare tape as shown in (Fig. 10)
B. Secure tube by wrapping double-
sided tape around patient ’ s head
and torn tape edges around

endotracheal tube.
Fig.10
33. Reevaluate for correct tube placement. Verifies that the tube was not inadvertently
displaced during the
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securing of the tube.
34. Note position of tube at teeth or gums Establishes a baseline for future assessment
(use centimeter markings on tube). of possible endotracheal tube migration, in
or out.
Nasotracheal Intubation
35. Follow Steps 1 through 14. To detect any abnormality.
36. Lubricate tube with local anesthetic Allows for smooth passage of tube
jelly.
37. Slowly insert tube into selected naris, Tube is introduced into airway channel
and guide tube up from the nostril, then
backward and down into the
nasopharynx.
38. Gently advance the tube until maximal Tube is located at opening of trachea.
sound of moving air is heard through
the tube.
39. While listening, continue to advance Facilitates movement of tube through glottic
tube during inspiration. opening.
40. When endotracheal tube is placed, A properly inflated cuff will minimize
inflate cuff. secretion aspiration and facilitate stabilization
in the trachea.
41. Follow Steps 25-28 and 30-34 to For nasotracheal intubation note position of
evaluate tube placement and secure tube tube at nares.
in place.
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Post Procedure
42. Assist the patient to a comfortable Ensures patient comfort. Proper positioning
position. Raise the bed rail and place the with raised side rails and proper bed height
bed in the lowest position. provides for patient comfort and safety.
43. Dispose of equipment appropriately. To reduce risk of transmission of

microorganisms.
44. Remove used gloves &discard in the To maintain infection control.
proper bag (Red).
45. Wash hands. To maintain infection control.
46. Record depth of the endotracheal tube To maintain legal principles.
from teeth or lips; the amount,
consistency, and color of secretions
suctioned; presence of any skin or
mucous membrane changes or pressure
ulcers; and your before and after
assessments, including lung sounds,
oxygen saturation, skin color, cuff
pressure, and chest symmetry.
47. Report any abnormalities. To detect any abnormality.
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Related Video:
https://youtu.be/SUOAnZLO2Os
The LEMON mnemonic can be used to determine whether a difficult

intubation is anticipated:
• L = Look Externally: look for features associated with a difficult

intubation such as a short neck, prominent incisors, broken teeth, a large
protruding tongue, a narrow or abnormally shaped face.
• E = Evaluate using the 3-3-2 rule: These three rules help to determine
whether there will be alignment of the pharyngeal, laryngeal, and oral
axes.
- Three fingers: distance between upper and lower incisors in the
mouth opening.
- Three fingers: distance between tip of chin and chin-neck
junction (hyoid bone).
- Two fingers: distance between thyroid cartilage and mandible
• M = Mallampati Grade: This scoring system provides an estimate of
the space available for oral intubation using direct laryngoscopy. It
relates the amount of mouth opening to the size of the tongue. Classes1
and 2 predict a routine laryngoscopy, class 3 predicts difficulty, and
class 4 predicts extreme difficulty.
• O = Obstruction: Look for causes that might interfere with intubation,
such as tonsillar abscess, epiglottitis, trauma, tumors, swollen tongue,
and obesity.
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• N = Neck Mobility: Look for conditions that might limit neck range
of motion such as a hard cervical collar (trauma), previous neck
surgery, and rheumatoid arthritis. If trauma is not suspected, ask the
patient to touch his or her chin to his or her chest and extend the neck
to the ceiling.
Complications from endotracheal intubation:
• Intubation of esophagus or right main-stem bronchus

(improper tube placement).
• Accidental extubation.
• Cardiac dysrhythmias because of hypoxemia and vagal
stimulation.
• Broken or dislodged teeth.
• Leaking of air from endotracheal tube cuff.
• Oral or nasal trauma with bleeding.
• Tracheal injury at tip of tube or at cuff site.
• Laryngeal edema.
• Vocal cord trauma.
• Suctioning of gastric contents or food from endotracheal tube
(aspiration).
• Obstruction of endotracheal tube.
References:
Goodrich, C. (2019) Endotracheal Intubation (Perform). Available from:

https://www.elsevier.com/__data/assets/pdf_file/0008/270980/ch0002.pdf
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…………………….
Oropharyngeal Airway Insertion and Care

Procedure
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Oropharyngeal Airway Insertion and Care
Definition:
An oropharyngeal airway (also known as an oral airway, or Guedel

pattern airway) is a rigid plastic tube which sits along top of mouth
and ends at base of tongue (an adjunct to help keep airway open).
Purpose:
• To maintain or open a patient's airway.

• To exhibit oxygen saturation within acceptable parameters or
greater than 95%.
• To remain patient free of aspiration and injury.
Indications:
• Unconscious patients.
• Patients are at risk of airway obstruction due to relaxed upper
airway muscles or blockage of the airway by the tongue.
Equipment:
• Oropharyngeal airway of appropriate size.
• Disposable Gloves.
• Hand disinfectant.
• Stethoscope.
• Penlight if needed.
• Suction equipment.
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• Face mask if needed.
Procedure of Oropharyngeal Airway Insertion and Care
No. Steps Rational

Pre-Procedure
5. Verify the patient by 2 Nurses. To increase patient trust and help
prevent error
7. Keep patient privacy. Patient right( to decrease patient
embarrassment )
8. Disinfect your hand. To maintain infection control
9. Wear disposable gloves and face mask. To maintain infection control
During Procedure (oropharyngeal airway insertion)

10. Measure the oropharyngeal airway for correct Correct size ensure correct insertion
size. Measure the oropharyngeal airway by and fit and allow for conformation of
holding the airway on the side of the patient’s airway to curvature of palate.
face. The airway should reach from the opening
of the mouth to the back angle of the jaw.
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11. Assess mouth for any loose teeth, dentures, or To prevent aspiration or swallowing of
other foreign material. Remove dentures or objects.
material if present.
Position patient in semi-Fowler’s position. To facilitate airway insertion and help
12. prevent tongue from moving back
against posterior pharynx.
Suction patient, if necessary. To remove excess secretions and help
13.
maintains patent airway
Open patient’s mouth by using your thumb and To advance tip of airway past tongue
index finger to gently pry teeth apart. Insert the toward back of throat.
14.
airway with the curved tip pointing up toward the
roof of the mouth.
15. Slide the airway across the tongue to the back of To shift tongue anterior and allow
the mouth. Rotate the airway 180 degrees as it patient to breathe through and around
passes the uvula. The tip should point down, and
the curvature should follow the contour of the
roof of the mouth. A penlight can be used to
confirm the position of the airway with the curve
fitting over the tongue.
airway.
16. Ensure accurate placement and adequate If airway placed correctly lung sound
ventilation by auscultating breath sounds. should audible and equal in all lobes.
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17. Position patient on his or her side when airway is Help keep tongue out of posterior
in place. pharynx area and help to prevent
aspiration if unconscious patient
should vomit.
Oropharyngeal Airway Care
18. Provide meticulous oral care every 2–4 hours Decreases secretions, encrustations,
and as needed. oral infections, and airway port
occlusions
19. Oxygenate and suction as necessary, per Retained secretions increase the
assessment. potential for airway obstruction and
pulmonary infections.
20. Monitor respiratory status every 2–4 hours. Change in respiratory status may
indicate displacement of airway or
worsening respiratory condition.
21. Follow institution standard for assessing pain. Identifies need for pain interventions.
Administer analgesia as prescribed.
Post Procedure
microorganisms.
23. Remove used gloves, face mask and discard in To maintain infection control.
the proper bag (Red).
25. Remove the airway for a brief period every 4 Tissue irritation and ulceration can
hours, or according to facility policy. result from prolonged use of airway.
26. Record placement of airway, size, assessment To maintain legal principles.
before and after oxygen saturation.
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Complications:
• Vomiting which may lead to aspiration.
• Worsen airway obstruction if an inappropriately sized airway is used
(i.e., too small).
• Laryngospasm (i.e., too big size).
• Damage to the oral structures or dentition can also result from
oropharyngeal airway inserti
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Nasopharyngeal, Nasotracheal and
Endotracheal /Tracheostomy Suctioning
Procedure
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Nasopharyngeal, Nasotracheal and Endotracheal
/Tracheostomy Suctioning Procedure
Definition of suctioning:
Suctioning is defined as a sterile invasive procedure which is used for

mechanical aspiration of pulmonary secretions from a patient with an artificial
airway passage via nose or mouth or through endotracheal or tracheostomy
tube by using catheter connected to a suction machine or wall suction outlet.
Purposes:
• Maintain patent airway by removing the accumulation of secretion.

• Treat hypoxia caused by accumulation of secretion.
• Prevention of respiratory tract infection.
• To obtain sputum diagnostic sample.
• To prevent respiratory distress (S&S of respiratory distress include;
agitation, tachypnea, tachycardia, use of accessory muscles of
breathing).
Indications:
Therapeutic uses:
• Auscultation of adventitious lung sounds (rhonchi) or crackles over the

trachea, mainstem bronchi, or both.
• Gradual or sudden decrease in oxygen saturation.
• Increase in peak airway pressures when the patient is receiving
mechanical ventilation.
• Increased respiratory rate, frequent coughing, or both.
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• Secretions in the artificial airway.
• Sudden onset of respiratory distress when airway patency is obstructed.
• Suspected aspiration of gastric or upper-airway secretions.
Diagnostic uses:
• to obtain a sputum specimen/ETA (Endo Tracheal Aspiration) for

bacteriological or microbiological investigations.
Pre-suctioning Instructions
• Encourage the patient to do breathing and coughing exercises if

he/she is conscious.
• Chest physiotherapy.
• Increase warm fluid if no restriction.
• Change patient position frequently if allowed.
• Explain to the patient that suctioning may be uncomfortable,
causing temporary shortness of breath or coughing.
• Explain to the patient how to use nonverbal cues to assist the
health care team with understanding what the patient may be
experiencing.
• Encourage questions and answer them as they arise.
Equipment:
• Portable suction machine (if wall suction is not available).

• Suction kit (sterile suction catheter, sterile gloves, sterile
disposable container).
• Stethoscope.
• Clean gloves.
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• Towel or disposable pad.
• Normal saline.
• Face Mask, goggles or face shield.
• Water soluble lubricant for nasopharyngeal and nasotracheal
suctioning.
• Ambu bag.
• Assistant (optional).
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Nasopharyngeal, Nasotracheal and Endotracheal /Tracheostomy
Suctioning Procedure
# Steps Rational
1. Verify physician prescription. To ensure safety.
2. Wash hands. To prevent transmission of

microorganisms
3. Prepare equipment. To save time and effort.
4. Introduce yourself to the patient. To build trust.
5. Identify the patient using two identifiers, To ensure that, the right patient
such as the patient’s name and birth date or receives the intervention.
name and medical record number,
according to your agency’s policy .
6. Explain procedure to the patient. To facilitate cooperation and decrease

patient’s anxiety.
7. Keep patient’s privacy. To minimize embarrassment.
8. Adjust the height of bed. To maintain comfort during

procedure.
9. Lower side rail on side nearest you. To minimize nurse’s muscle strain.
10. Disinfect your hands. To prevent transmission of

microorganisms.
11. Apply clean gloves. To prevent transmission of

microorganisms
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12. Assess for clinical signs indicating the To provide baseline data to identify
need for suctioning: tachypnea, gurgling need for
breath sounds, nasal secretions, dyspnea, suctioning and measures the
restlessness, coughing without clearing effectiveness of suction procedure.
airway secretions, decrease (SpO2) to
lower than 90%, tachycardia, decrease
level of consciousness and cyanosis (late
sign of hypoxia).
13. Positioning of the patient:
o If conscious, place patient in semi- o Semi-fowler’s position helps

fowler’s position. patient to cough and breathing
o If unconscious, place patient in lateral easier.
position, facing at you. o Lateral position prevents airway
o If conscious or unconscious, place from obstruction and promotes
patient in semi-fowler’s position for drainage of secretion.
endotracheal tube (ETT) or
tracheostomy suction.
14. Put towel or waterproof pad over the To keep patient clothes clean and dry.
patient's chest.
15. Plug the suction machine into the electrical To ensure the suction machine is
outlet ( portable suction). functioning well.
16. Connect suction tubing and jar (receptacle To ensure the suction machine is
container). connected together well.
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17. Turn on the suction machine and occlude To check suction for function.
the suction tubing by your thumb.
18. Adjust suction to appropriate pressure: Higher pressures cause mucosal

trauma and hypoxemia.
• Wall unit for an adult patient: (100-150)
mm Hg (Fig. 1).
• Portable unit for an adult patient: (10-
15) cm Hg.
Fig. 1
19. Remove gloves and discard it. To prevent transmission of infection.
20. Disinfect your hands. To prevent transmission of infection.
21. Open the suction kit without To prevent transmission of infection.

contaminating the content, follow non-
touching technique.
22. Pour 100 ml sterile normal saline into the Normal saline is used to clear the
container. catheter between suction attempts.
23. Wear face mask, goggles or face shield. To protect from microorganisms.
25. Wear sterile gloves. To maintain sterility during

procedure.
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26. Pick up the suction catheter with dominant To maintain sterility of suction
hand. catheter.
27. Connect suction catheter to the suction To maintain sterility of suction

tubing by non-dominant hand. catheter.
28. Place the catheter tip in the saline and To ensure equipment function and
occlude the suction vent. Suction a small lubricate internal catheter and tubing.
amount of normal saline solution from
basin.
Nasopharyngeal and Nasotracheal suctioning:
29. Encourage the patient to take several deep To decrease risk of hypoxemia.
breaths if able, or increase oxygen flow rate
with delivery device through cannula or mask
(if ordered).
30. Lubricate 6–8 cm of suction catheter with

water-soluble lubricant.
31. Remove oxygen-delivery device, if

applicable, with non-dominant hand.
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32. Nasopharyngeal: Never apply suction during
insertion to avoid mucosal trauma.
Without applying suction, gently insert the
catheter through the nasopharyngeal airways Fig. 2
(Fig. 2) or directly by naris toward back of
pharynx (distance from tip of nose to angle of
mandible; approximately 16 cm).
33. Nasotracheal: During patient inhalation,

epiglottis is open. Do not insert
Without applying suction, gently insert the
during swallowing as catheter will
catheter through the naris toward trachea
most likely enter esophagus.
during patient inhalation (approximately 20
cm).
34. If resistance is met during insertion, try the To prevent mucosal damage.
other naris. Do not force the catheter up the
nares.
Endotracheal/ Tracheostomy suctioning:
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35. Hyper-oxygenate the patient with 100% Pre-oxygenation decreases risk of
oxygen for at least 30 to 60 seconds before decreased arterial oxygen levels
suctioning by; while ventilation or oxygenation is
interrupted.
• Pressing suction hyperoxygenation button
on ventilator OR ,
• Increasing baseline fraction of inspired
oxygen (FiO2) level on mechanical
ventilator OR,
• Disconnecting ventilator, attach the
resuscitation apparatus connected with the
oxygen source to tube with non-dominant
hand and give 5–6 breaths over 30 seconds
(or have assistant do this) (Fig 3). Fig. 3
36. Without applying suction, gently insert Resistance usually means that the
catheter into artificial airway using dominant catheter tip has reached the
thumb and forefinger. Advance catheter about bifurcation of the trachea.
0.5 to 1 cm past the distal end of the tube or Withdrawing the catheter will
until the patient coughs (Fig. 4). If you feel prevent damaging the mucous
resistance, withdraw the catheter about 1 to 2 membranes at the bifurcation.
cm before applying suction. Fig. 4
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37. Apply intermittent suction by placing and Suction time greater than 15
releasing seconds increases risk for suction
non-dominant thumb over vent of catheter; induced hypoxemia. Intermittent
slowly withdraw catheter while rotating it suction and rotation of catheter
between dominant thumb and forefinger. Do prevent injury to tracheal mucosa.
not use suction for greater than 15 seconds.
38. Reapply oxygen-delivery device and To prevent risk of hypoxemia.

encourage patient to take some deep breaths,
if able. If patient is receiving mechanical
ventilation, hyper-oxygenate patient for 30–
60 seconds.
39. Flush catheter and connecting tubing with To remove catheter secretions.
saline.
40. Assess effectiveness of suctioning and repeat, To determine patient need to

as needed. additional suction or not.
41. Provide 30 seconds of rest between each To allow for re-ventilation and re-
suction attempt. oxygenation of airway
42. Provide 10 minutes between suctioning To prevent elevations in

procedures in brain injured patients intracranial pressure (ICP)
43. Do not perform more than two suctions per To prevent complications e.g.,
suctioning episode. mucosal trauma and hypoxemia.
44. Roll catheter around fingers of dominant To prevent transmission of

hand. Remove the gloves and enclose the microorganisms.
39
suction catheter in an inverted glove and
discard in appropriate receptacle.
45. Turn off suction.
46. Return patient to comfort position. To maintain comfort and safety.
47. Place bed in the lowest position. To maintain comfort and safety
48. Wear clean gloves. To prevent transmission of

infection.
49. Apply oral care after suctioning. To provide cleaning and comfort.
50. Reassess the patient respiratory status, To assess effectiveness of

including respiratory rate, effort, oxygen suctioning.
saturation, and lung sounds.
51. Dispose used supplies follow hospital policy. To maintain organization.
52. Remove gloves. To prevent transmission of

infection.
53. Wash hands. To prevent transmission of

infection.
54. Record the following items: Documentation provides ongoing

data.
Procedure’s date, time, nurse’s signature.
Amount, color and viscosity of secretions.
Pre-suctioning and post-suctioning vital

signs and SpO2. Patient’s tolerance of the
40
procedure. Number of passes of the suction
catheter. Pain assessment and management.
Unexpected outcomes and related

interventions.
55. Report any abnormalities: To ensure patient safety.
e.g., decreased SpO2, continued tachypnea,

continued
increased work of breathing, and cardiac
dysrhythmias.
Oropharyngeal Suctioning Procedure
# Steps Rational
1. Verify physician prescription. To ensure safety.
2. Wash hands. To prevent transmission of microorganisms
3. Prepare equipment. To save time and effort.
5. Identify the patient. To ensure that, the right patient receives the
intervention.

patient’s anxiety.
7. Keep patient’s privacy. To minimize embarrassment.
41
8. Adjust the height of bed. To maintain comfort during procedure.
9. Lower side rail on side nearest you. To minimize nurse’s muscle strain.
10. Disinfect your hands. To prevent transmission of microorganisms.
11. Apply clean gloves. To prevent transmission of microorganisms
12. Assess for clinical signs indicating the To provide baseline data to identify need for
need for oropharyngeal suctioning: suctioning and measures the effectiveness of
obvious excessive oral secretions, suction procedure.
drooling, gastric secretions or vomitus in
mouth and restlessness.
13. Positioning of the patient:
o If conscious, place patient in semi- o Semi-fowler’s position helps patient to

fowler’s position. cough and breathing easier.
o If unconscious, place patient in o Lateral position prevents airway from
lateral position, facing at you. obstruction and promotes drainage of
If conscious or unconscious, place secretion.
patient in semi-fowler’s position for
patient with endotracheal tube (ETT)
or tracheostomy tube.
14. Put towel or waterproof pad over the To keep patient clothes clean and dry.
patient's chest.
15. Plug the suction machine into the

electrical outlet ( portable suction).
42
16. Connect suction tubing and jar
(receptacle container).
17. Turn on the suction machine and occlude To check suction for function.
the suction tubing by your thumb.
18. Adjust suction to appropriate pressure: Higher pressures cause mucosal trauma and
hypoxemia.
• Wall unit for an adult patient: (100-
150) mm Hg.
• Portable unit for an adult patient: (10-
15) cm Hg.
19. Pour 100 ml sterile normal saline into the Normal saline is used to clear the catheter
container. between suction attempts.
20. Wear face mask, goggles or face shield. To protect from microorganisms.
21. Connect the suction catheter or Yankauer

to the suction tube (Fig. 1).
Fig. 1
22. Place the catheter tip in the saline and To ensure equipment function and lubricate
occlude the suction vent. Suction a small internal catheter and tubing.
amount of normal saline solution from
basin.
43
23. Remove patient’s oxygen mask if present. Allows access to mouth. Reduces chance of
Nasal cannula may remain in place. Keep hypoxia.
oxygen mask near patient’s face.
24. Insert catheter through oropharyngeal Directing the catheter along the side prevents
airway (Fig. 2) or into mouth directly gagging.
along gum line to pharynx (about 10 to 15
cm).
Fig. 2
25. Move catheter around mouth and beneath Coughing moves secretions from lower
the tongue until secretions have cleared. airway into upper airway and mouth.
Encourage patient to cough.
26. Replace oxygen mask. To prevent hypoxia.
27. Flush catheter and connecting tubing with To remove catheter secretions. Secretions
saline. left in tubing decrease suctioning efficiency
and provide environment for microorganism
growth.
28. Apply oral care after suctioning. To provide cleaning and comfort.
29. Wash face if secretions are present on To prevent skin breakdown.

patient’s skin.
44
30. Dispose used supplies follow hospital To maintain organization
policy.
31. Remove gloves. To prevent transmission of infection.
32. Wash hands. To prevent transmission of infection.
33. Record the following items: Documentation provides ongoing data.
• Procedure’s date, time, nurse’s

signature.
• Amount, color and viscosity of
secretions.
• Pre-suctioning and post-suctioning
vital signs and SpO2.
• Patient’s tolerance of the procedure.
Number of passes of the suction
catheter. Pain assessment and
management. Unexpected outcomes
and related interventions.
34. Report any abnormalities: To ensure patient safety.
e.g., decreased SpO2, bloody secretions.
45
Complications:
• Hypoxemia.
• Pulmonary hemorrhage or bleeding.
• Arrhythmias (tachycardia, bradycardia, heart blocks).
• Increased intracranial pressure.
• Bronchospasm.
• Atelectasis.
• Hypertension or hypotension.
• Cardiac arrest or Respiratory arrest
References:
• La Vita, C.J. (2021). Chapter 37: Airway management. In R.M.

Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of
respiratory care (12th ed., pp. 748-787). St. Louis: Elsevier.
• Elenbaas, M. and Kathleen M. 2020. Suctioning: Artificial Airway
During Mechanical Ventilation (Respiratory Therapy). Available from:
https://www.elsevier.com/__data/assets/pdf_file/0006/996756/Suction
ing-Artificial-Airway-During-Mechanical-Ventilation-Respiratory-
Therapy-Skill_085020.pdf (Accessed: 16 January 2023).
• Potter, P. (2018). Clinical nursing skills & techniques (9th ed.) Missouri:
Elsevier, Pp 674- 677.
• Berman. A., Snyder, S. & Frandsen, G (2016). FUNDAMENTALS
OF NURSING Concepts, Process, and Practice (3rd ed.) Boston:
PEARSON, Pp 1270.
x
46
Endotracheal Tube Care and Securing
Procedure
47
Endotracheal Tube Care and Securing
Definition:
Endotracheal tube care and securing refers to the maintenance

and proper placement of a tube that is inserted through the mouth or
nose and into the trachea to assist with breathing.
Purposes:
• To maintain patency of endotracheal tube.

• To prevent buccal, oropharyngeal, and tracheal trauma from the
tube and cuff.
• To provide oral hygiene.
• To decrease potential trauma to the trachea and prevent
aspiration of secretions.
• To keep the endotracheal tube in place and the patient maintains
bilaterally equal and clear lung sounds.
• To remain the patient’s skin intact, oxygen saturation remains
within acceptable parameters, or greater than 95%; chest rises
symmetrically, and airway remains clear.
48
Indications:
• Excessive secretions (oral or tracheal).

• Dry oral mucosa.
• Debris in the oral cavity.
• Plaque buildup on teeth.
• Soiled tape or ties or commercial device.
• Patient biting or kinking tube.
• Pressure areas on nares, corner of mouth, or tongue.
• ETT moving in and out of mouth.
• Patient able to verbalize or audible air leak around ETT.
Equipment:
• Assistant (nurse or respiratory therapist).

• Portable or wall suction unit with tubing.
• Sterile suction catheter with Y-port.
• Disposable gloves.
• Mask and goggles or face shield.
• Sterile suctioning kit.
• Two 3-mL syringes or tongue blade.
• Scissors or Razor (optional).
• Towel.
• Oral airway if needed.
• Adhesive or twill tape; commercial ETT holder.
• 2 × 2 gauze or cotton swab for cleaning around the nares.
• Normal saline solution.
49
• Soft adult toothbrush or suction toothbrush.
• Foam oral swab or oral suction swab.
• Oral cleansing solution (e.g., 1.5% H 2 O 2 , chlorhexidine,
cetylpyridinium chloride, toothpaste).
• Handheld pressure gauge
50
Procedure of Endotracheal Tube Care and Securing
No. Steps Rational

Pre-Procedure
2. Wash hands. To maintain infection control
3. Prepare needed equipment. To save time and effort
5. Verify the patient by 2 Nurses. To increase patient trust and help prevent
error
7. Keep patient privacy. Patient right (to decrease patient
embarrassment )
8. Assess for signs and symptoms that Assessment provides for early
indicate that oral cavity and ETT care is recognition that oral or ETT care is
necessary. needed.
9. Administer pain medication or sedation, Re-taping the endotracheal tube can
as prescribed, before attempting to re- stimulate coughing, which may be
tape endotracheal tube. painful for patients, particularly those
with surgical incisions.
10. Ensure that ETT is connected to the Decreases pressure exerted by ventilator
ventilator. tubing on the ETT.
11. Obtain the assistance of a second person This prevents accidental extubating.
to hold the endotracheal tube in place
while the old tape removed and the new
tape placed.
51
Adjust the bed to a comfortable working Having the bed at the proper height
12.
position, Lower side rail closest to you. prevents back and muscle strain.
Position of patient: Sitting position helps the patient to cough
If conscious, place the patient in a and makes breathing easier. Gravity also
semi-fowler’s position. facilitates catheter insertion.
13.
If unconscious, place the patient in the The lateral position prevents the airway
lateral position, facing you. from becoming obstructed and promotes
drainage of secretions.
14. Put on face shield or goggles and mask. PPE prevents exposure to contaminants.

Put on disposable gloves. Have the Gloves protect hands from exposure to
16.
assistant put on gloves as well. contaminants.
During Procedure
If suctioning is clinically indicated, Removes secretions that may obstruct
17. hyper-oxygenate via the ventilator before tube.

ETT suction and between attempts.
If patient is nasally intubated, clean Removes secretions that could cause
18. around ETT with saline solution–soaked pressure and subsequent skin breakdown.
gauze or cotton swabs.
If patient is intubated orally, remove Oropharyngeal airway prevents the
19. oropharyngeal airway before proceeding patient from biting down on the ETT and
with oral hygiene. occluding airflow.
Initiate oral hygiene with adult (soft) To reduce oropharyngeal colonization
toothbrush, at least twice a day. Gently and dental plaque, which is associated
20.
brush patient ’ s teeth to clean and with VAP.
remove plaque from teeth.
52
Suction oropharyngeal secretions after
brushing. Use toothpaste or a cleansing
solution that assists in the breakdown of
Debris.
In addition to brushing twice daily, use To improve oral health and reduce the
oral swabs with a 1.5% hydrogen risk of healthcare acquired pneumonia.
21.
peroxide solution to clean mouth every
2–4 hours.
After each cleansing, apply a mouth To prevent dryness of the oral mucosa.
22. moisturizer to the oral mucosa and lips to

keep tissue moist.
After oral hygiene is completed, change The securing mechanism should be
the ETT securing mechanism with new changed if using tape and/or moved at
tape, ties, or commercial device, as least once daily to provide an opportunity
23.
needed, according to institutional for assessment and repositioning of the
standard. ETT to reduce the risk of a pressure skin
injury.
24. Measure a piece of tape for the length Extra length needed so that tape can
needed to reach around the patient’s neck wrapped around the endotracheal tube.
to the mouth plus 8 inches. Cut tape. Lay
it adhesive-side up on the table.
25. Cut another piece of tape long enough This prevents the tape from sticking to
to reach from one jaw around the back the patient’s hair and the back of the
of the neck to the other jaw. Lay this neck.
piece on the center of the longer piece
53
on the table, matching the tapes
adhesive sides together.
26. Take one 3-mL syringe or tongue blade This helps the nurse or respiratory
and wrap the sticky tape around the therapist to manage the tape without it
syringe until the non-sticky area sticking to the sheets or the patient’s hair.
reached. Do this for the other side as
well.
27. Take note of the ‘cm’ position markings Assistant should hold the tube to prevent
on the tube. Begin to unwrap old tape accidental extubation. Holding the tube
from around the endotracheal tube. After as close to lips or nares as possible
one side is unwrapped, have assistant prevents accidental dislodgement of tube.
hold the endotracheal tube as close to the
lips or nares as possible to offer
stabilization.
28. Carefully remove the remaining tape The endotracheal tube may cause
from the endotracheal tube (Fig. 1). pressure ulcers if left in the same place
After tape is removed, have assistant over time. By moving the tube, the risk
gently and slowly move endotracheal for pressure
tube (if orally intubated) to the other ulcers is reduced.
side of the mouth (Fig. 2).
54
Assess mouth for any skin breakdown.
Fig. 1
Before applying new tape, make sure
that markings on endotracheal tube are
at same spot as when re-taping began.
Fig. 2
29. Remove old tape from cheeks and side To prevent skin breakdown, remove old
of face. Use adhesive remover to adhesive. Shaving helps to decrease pain
remove excess adhesive from tape. when tape removed. Cheeks must be dry
Clean the face and neck with washcloth before new tape applied to ensure that it
and cleanser. If patient has facial hair, sticks.
consider shaving cheeks. Pat cheeks dry
with the towel (Fig. 3).
Fig. 3
55
30. Apply skin barrier to patient’s face Skin barrier protects the skin from injury
(under nose, on cheeks, and lower lip) with subsequent tape removal and helps
where the tape will sit. Unroll one side the tape adhere better to the skin. The
of the tape. Ensure that nonstick part of tape should be snug to the side of the
tape remains behind the patient’s neck patient’s face to prevent accidental
while pulling firmly on the tape. extubation.
Place adhesive portion of tape snugly
against the patient’s cheek. Keep track
of the pilot balloon from the
endotracheal tube, to avoid taping it to
the patient’s face.
Split the tape in half from the end to the
corner of the mouth.
31. Place the top-half piece of tape under the By placing one piece of tape on the lip
patient’s nose (Fig.4). Wrap the lower and the other piece of tape on the tube,
half around the tube in one direction, the tube remains secure. Tab makes tape
such as over and around the tube. Fold removal easier.
over tab on end of tape.
Fig. 4
56
32. Unwrap second side of tape. Split to Alternating the placement of the top and
corner of the mouth. Place the bottom- bottom pieces of tape provides more
half piece of tape along the patient’s anchorage for the tube. Wrapping the
lower lip (Fig. 5). tape in an alternating manner ensures that
Wrap the top half around the tube in the the tape will not accidentally be
opposite direction, such as below and unwound.
around the tube. Fold over tab on end of
tape. Ensure tape is secure.
Fig. 5
33. Auscultate lung sounds. Assess for If the tube has moved from original place,
cyanosis, oxygen saturation, chest the lung sounds may change, as well as
symmetry, and endotracheal tube oxygen saturation and chest symmetry.
stability. Again, check to ensure that the The tube should be stable and should not
tube is at the correct depth. move with each respiration cycle.
57
34. If the endotracheal tube cuffed, check To maintain the normal ETT cuff
pressure of the balloon by attaching a pressure within 20-30 cm H2O.
handheld pressure gauge to the pilot ETT cuff pressure more than 30 leads to
balloon of the endotracheal tube (Fig. 6). excessive pressure on tracheal mucosal
wall and surrounding structures.
Fig. 6
Post Procedure
35. Assist the patient to a comfortable Ensures patient comfort. Proper
position. Raise the bed rail and place the positioning with raised side rails and
bed in the lowest position. proper bed height provide for patient
comfort and safety.
microorganisms.
37. Remove used gloves &discard in the To maintain infection control.
proper bag (Red).
39. Record depth of the endotracheal tube To maintain legal principles.
from teeth or lips; the amount,
consistency, and color of secretions
suctioned; presence of any skin or
mucous membrane changes or pressure
ulcers; and your before and after
58
assessments, including lung sounds,
oxygen saturation, skin color, cuff
pressure, and chest symmetry.
Complications:
• Dislodged ETT
• Occluded ETT
• ETT cuff leak
• Pressure ulcers in mouth or on the lip or nares
• Ventilator associated pneumonia (VAP).
References:
• Quinn, B. and Ruble, C. (2020). Endotracheal Tube Care and Oral Care
Practices for Ventilated and Non-ventilated Patients. Available from:
https://www.elsevier.com/__data/assets/pdf_file/0007/1357360/Chapt
er0003.pdf
59
Tracheostomy Care Procedure
60
Procedure of Tracheostomy Care
Definition of Tracheostomy:
Tracheostomy is a surgical opening made into the trachea through

which a curved tube, called tracheostomy tube, is inserted. The
tube may be temporary or permanent.
Purposes:
- Maintain airway patency by removing mucus and encrusted

secretions. - Promote cleanliness and prevent infection and skin
breakdown at stoma site.
Indications:
Mnemonic of IOS:
I=Insufficiency (respiratory Insufficiency)
O=Obstruction (respiratory obstruction)
S=Secretions retained
61
Equipment:
• Sterile tracheostomy care kit containing:

- Two basins.
- Small brush or pipe cleaners.
- 4" × 4" gauze.
- Commercially available tracheostomy dressing.
- Tracheostomy ties.
• Hydrogen peroxide.
• Normal saline.
• Sterile gloves.
• Scissors.
• Tracheostomy suction supplies.
• Face mask.
62
Procedure of Tracheostomy Care
No Steps Rational
Pre-procedure
1. Confirm the doctor’s order in the medical Verifying the medical order ensures
record. that the correct intervention is
administered to the right patient.
2. Gather equipment. Assembling equipment provides for an

organized approach to the task.
3. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent the
indicated. spread of microorganisms.
4. Identify the patient by 2 nurses. Identifying the patient ensures the right
patient receives the intervention and
helps prevent errors.
5. Explain procedure to the patient. Discussion promotes reassurance and

provides knowledge about the
procedure. Dialogue encourages
patient participation and allows for
individualized nursing care.
6. Close the curtains around the bed and close the This ensures the patient’s privacy.
door to the room, if possible.
7. Assemble equipment on over bed table within Arranging items nearby is convenient,
reach. saves time, and avoids unnecessary
stretching and twisting of muscles on
the part of the nurse.
8. Adjust the bed to a comfortable working height, It prevents back and muscle strain.
usually elbow height of the caregiver.
63
9. Assist the patient to a comfortable position in This provides adequate visualization.
semi- to high Fowler's position
10. Disinfect the hand. To maintain infection control

11. Wear disposable gloves. Gloves prevent contact with blood and
body fluids.
During procedure
12. Remove soiled dressing. To facilitate changing of the dressing
and visualize for signs of infection.
13. Assess the condition of dressing and skin To facilitate changing of the dressing
around the tracheotomy tube. and visualize for signs of infection
14. Remove glove and disinfect hand. To maintain infection control

15. Open tracheostomy kit using aseptic technique. Use of aseptic technique ensures
sterility and prevents spread of
microorganisms.
16. Pour normal saline and hydrogen peroxide in a

separate container.
17. Wear sterile gloves. Gloves prevent contact with blood and
body fluids.
64
18. Remove oxygen source (The hand that
touches the oxygen source is no longer
sterile).
19. Place sterile towel over the patient chest. To maintain sterile field and to comply
with maximal barrier precaution
20. Unlock inner cannula by turning

counterclockwise. Remove inner cannula.
21. Carefully drop inner cannula in the basin with

the hydrogen peroxide.
22. Remove the inner cannula from the soaking

solution. Moisten the brush or pipe cleaner in
saline and insert into tube, using a back-and
forth motion to clean
65
23. Rinse inner cannula in a container with saline. To ensure that the inner cannula is
devoid of mucus or secretions.
24. Dry inner cannula (wipe out excess solution Dried secretions are a good medium for
using 4x4 cm sterile gauze). bacterial growth
25. Re- inserts the clean inner cannula.
26. Clean around the stoma site with gauze Dried secretions are a good medium for
moistened with saline in one direction with
bacterial growth
cotton buds
27. Dry the skin with 4x4 cm sterile gauze. Moist surfaces support growth of
microorganisms and skin excoriation.
66
28. Place dry, sterile, precut V-shape Frayed cotton fibers from cut gauze
tracheostomy dressing around tracheostomy
could be aspirated into the trachea.
stoma and under faceplate. Do not uses cut 4"
× 4" gauze.
29. If tracheostomy ties are to be changed, have To stabilize the tube and prevent
an assistant wear sterile glove and hold the accidental dislodgment and keep
tracheostomy tube in place. coughing due to minimal manipulation.
30. Cut a 12-inch slit approximately 1 inch from The tie is secured to the faceplate
one end of both clean tracheostomy ties. This without using knots. Knots are difficult
is easily done by folding back on itself 1 inch to undo when ties become crusted with
of the tie and cutting a small slit in the middle. secretions.
31. Remove and discard soiled

tracheostomy ties.
32. Thread end of tie through cut slit in tie. Pull

tight.
67
33. Bring both ties together at one side of the Ties must be taut enough to prevent
accidental dislodging of tracheostomy
patient's neck. Assess that ties are only tight
tube but loose enough not to cause
enough to allow one finger between tie and choking or pressure on the jugular veins.
Ties at side of neck are more
neck. Use two square knots to secure the ties.
comfortable for the client.
Trim excess tie length.
Note: Assess tautness of tracheostomy ties
frequently in clients whose neck may swell
from trauma or surgery.
34. While an assisting nurse holds the faceplate,

gently pull the Velcro tab and remove the
collar on one side. Insert the new collar into
the opening on the faceplate and secure
the Velcro tab
68
35. Hold faceplate in place as the assisting nurse
repeats step on the second side
36. Remove the old collar and ensure that the new
collar is securely in place.
37. Return patient in a comfortable position.
Post procedure
38. Remove equipment and discard syringe in Proper disposal of equipment prevents
appropriate receptacle. transmission of microorganisms.
39. Remove gloves and additional PPE, if used. Removing PPE properly reduces the risk
for infection transmission and
contamination of other items.
40. Perform hand hygiene. Hand hygiene prevents the spread of

microorganisms.
69
41. Assess the patient’s response to the procedure. This provides accurate assessment of the
patient’s response to the procedure.
42. Record procedure. To maintain legal principles.

Complications:
• Skin infection.
• Tracheal erosion and necrosis.
• Dislodgement of the tube.
• Occlusion of the tube by hardened sputum that obstruct the
airway.
References:
• Lynn, P.P. Taylor’s clinical nursing skills : a nursing process

approach (3rd edit.) Phadelphia, Wolters Kluwer, p.756-760
• Techniques for Performing Tracheostomy. Respir Care;50(4):488
– 496.
• Tracheostomy (2022) NHS choices. NHS. Available at:
https://www.nhs.uk/conditions/tracheostomy/ (Accessed: January 21,
2023).
70
Administering Oxygen Therapy
71
Administering Oxygen Therapy
Definition:
Oxygen therapy is a treatment that delivers extra
oxygen to the lungs when the level of oxygen in the
blood is too low (hypoxia). Oxygen is
supplemented in higher percentages than that of
atmospheric air.
Purpose:
• Relieve hypoxemia.
• Maintain adequate oxygenation of tissues and vital organs.
• Enhance the respiratory rate and depth within acceptable ranges.
• Reduce the extra work of the heart.
Indications:
• Chronic obstructive pulmonary disease (COPD)
• Pneumonia
• Asthma
• Bronchopulmonary dysplasia, underdeveloped lungs in newborns
• Heart failure
• Cystic fibrosis
• Sleep apnea
• Lung disease
• Trauma to the respiratory system
Complications:
• Lung damage
• Fluid buildup or bursting (rupture) of the middle ear
• Sinus damage
• Changes in vision, causing nearsightedness, or myopia
• Oxygen poisoning, which can cause lung failure, fluid in the lungs, or
seizures
Oxygen therapy is generally safe, but it can cause side effects. They
include a dry or bloody nose, tiredness, and morning headaches.
72
Contraindication:
• Oxygen treatment is contraindicated in all patients with unfavorable

ventilation response to oxygen treatment.
• There is currently only one absolute contraindication to hyperbaric
oxygen therapy (HBOT) (100% O2): untreated pneumothorax.
• Not indicated in patients who continue smoking cigarettes because of
the significant risk of fire.
• Carbon dioxide narcosis occurs; over-administration of oxygen may
reduce the respiratory drive. This reduction can result in further
hypercarbia.
Equipment:
• Oxygen source (wall unit, cylinder, etc.)

• Oxygen flow meter.
• Adapter, if using a wall unit, or a pressure-reduction gauge, if using a
cylinder.
• Delivery device as prescribed (nasal cannula, simple mask, none-breather
mask, etc.)
• Humidifier with sterile, distilled water if indicated
• Oxygen tubing.
• Sterile water for humidifier.
73
• “Oxygen in use” sign.
• Stethoscope, pulse oximeter.
• Gauze to pad elastic band.
• PPE, as indicated.
74
Procedure of Administering Oxygen Therapy by Nasal
Cannula
# Steps Rational
5. Verify the patient by 2 Nurses. To increase patient trust and help
prevent error
embarrassment )
8. Put patient in comfortable position. To facilitates administering of oxygen
10. Wear disposable gloves. To maintain infection control
11. Assess patient’s respiratory status To provide a baseline for evaluation
(respiratory rate, rhythm, effort, and the effectiveness of oxygen therapy.
lung sounds), any signs of respiratory
distress as tachypnea, nasal flaring, use
of accessory muscles, or dyspnea.
12. Assess patient's oxygen saturation level To provide a baseline for evaluation
before starting oxygen therapy. the effectiveness of oxygen therapy.
75
Connect flow meter with oxygen supply To obtain oxygen through adjusted
13.
rate.
Connect humidifier to the flow meter To prevent dehydration of the mucous

contains suitable amount of sterile, membranes.
distilled water.
14.
Open oxygen supply before connecting To check the function of the oxygen
15. nasal cannula tubing. source and flow meter.
16. Connect the nasal cannula tubing to the To check oxygen is flowing out of
oxygen supply with humidification and prongs.
Adjust flow rate as prescribed.
76
17. Place prongs in patient’s nostril: Correct placement of the prongs
facilitates oxygen administration and
a. Place tubing over and behind each patient comfort. Pads reduce irritation,
ear with adjuster comfortably under pressure and protect the skin.
chin.
b. Alternately the tubing may be placed
around the patient’s head, with the
adjuster at the back or base of the
head.
c. Place gauze pads at ear beneath the
tubing, as necessary
18. Adjust the fit of the nasal cannula To maintain proper adjustment of the
Tubing should be snug but not tight prongs in the patient’s nostrils.
against the skin.
19. Encourage the patient to breathe Nose breathing provides for optimal
through the nose with the mouth delivery of oxygen to the patient.
closed.
20. Check nasal cannula every 8 hours and To ensure patency of cannula and
Keep humidification container filled at oxygen flow.
all time.
77
21. Place “Oxygen in use” sign on wall To alert visitors and care providers that
behind bed and at entrance to room. oxygen is in use.
22. Reassess the patient’s respiratory status, To assess the effectiveness of oxygen
including respiratory rate, effort, and therapy.
lung sound. Note any signs of respiratory
distress, such as tachypnea, nasal flaring,
use of accessory muscles, or dyspnea.
microorganisms.
24. Remove used gloves and discard in the To maintain infection control.
proper bag (Red).
26. Record assessment before and after To maintain patient’s safety and keep-
intervention: amount of oxygen applied, documented source helps in following
date, time, the patient’s respiratory patient’s status.
status, oxygen saturation, and lung
sounds.
78
Procedure of Administering Oxygen Therapy by Face Mask
# Steps Rational
Follow steps from 1 to 15
1. Connect the face mask tubing to the To check oxygen is flowing out of mask.
oxygen supply with humidification and To avoid pushing of high flow oxygen and
Adjust flow rate as prescribed. prevent mucus membrane injury, and a
feeling of suffocation
2. Gently place the face mask on the To direct oxygen delivering to patient’s
patient's face, applying it from the bridge nose.
of the nose to under the chin.
3. Secure the elastic bend around the back ofTo avoid loose or poorly fitting of the mask.
the patient's head. Make sure the mask
fits snugly but comfortably.
4. If the patient reports irritation or you Pads reduce irritation and pressure and
note redness, use gauze pads under the protect the skin.
elastic strap at pressure points to reduce
irritation to ears and scalp.
5. Place “Oxygen in use” sign on wall To alert visitors and care providers that
behind bed and at entrance to room. oxygen is in use.
79
6. Reassess the patient’s respiratory status, To assess the effectiveness of oxygen
including respiratory rate, effort, and lung therapy.
sound. Note any signs of respiratory
distress, such as tachypnea, nasal flaring,
use of accessory muscles, or dyspnea.
microorganisms.
proper bag (Red).
10. Record assessment before and after To maintain patient’s safety and keep-
intervention: amount of oxygen applied, documented source helps in following
date, time, the patient’s respiratory status, patient’s status.
oxygen saturation, and lung sounds.
12. Remove mask and dry the skin every 2 or The tight-fitting mask and moisture from
3 hours if oxygen is running condensation can irritate the skin on the
continuously face.
Dose not use powder around mask. There is danger of inhaling powder if it is
placed on the mask.
Procedure Video Links:

https://youtube.com/watch?v=Nc2zl2SeQNo
https://www.youtube.com/watch?v=GPqPpW6jSeo
References:
− Lynn, P., 2019. Taylor’s clinical nursing skills: A nursing process
approach, Philadelphia, PA: Wolters Kluwer Health.
− Perry, A.G., Potter, P.A., Ostendorf, W.R. and Laplante, N.,
2021. Clinical nursing skills and techniques-E-Book. Elsevier Health
Sciences.
− https://www.ncbi.nlm.nih.gov/books/NBK551617/
80
Nebulization Therapy Procedure
81
Nebulization Therapy
Nebulization:
Is the process of medication administration via inhalation. It utilizes a
nebulizer which transports medications to the lungs by means of mist
inhalation.
Purposes:
The goal of nebulization therapy can be briefly summarized as
“SHAPE”:
• S (Relief airway Spasm): to relieve bronchospasm, coughing
and wheezing:
• H (Humidify): to humidify airway.
• An (Anti-inflammation): to achieve an anti-inflammatory
effect.
• P (Prevent): to prevent respiratory complications such as
airway inflammation, obstruction, atelectasis, infection, and

asphyxia.
• E (Expectorant): promote expectoration.
Indication:
Nebulization therapy is used to deliver medications along the respiratory
tract and is indicated to various respiratory problems and diseases such as:
▪ Bronchospasms
▪ Chest tightness
▪ Excessive and thick mucus secretions
▪ Respiratory congestions
▪ Pneumonia
▪ Atelectasis
▪ Asthma
82
Contraindications:
In some cases, nebulization is restricted or avoided due to possible
untoward results or rather decreased effectiveness such as:
▪ Patients with unstable and increased blood pressure
▪ Individuals with cardiac irritability (may result to dysrhythmias)
▪ Persons with increased pulses
▪ Unconscious patients (inhalation may be done via mask but the
therapeutic effect may be significantly low)
Equipment:
• Nebulizer and nebulizer connecting tubes.
• Compressor oxygen tank
• Mouthpiece/mask
• T-piece connector.
• Respiratory medication to be administered.
• Normal saline solution
• Stethoscope.
• Disposable gloves (PPE as indicated).
Complications:
Possible effects and reactions after nebulization therapy are as follows:
• Palpitations
• Tremors
• Tachycardia
• Headache
• Nausea
83
• Bronchospasms (too much)
Nebulizer Parts
84
Nebulization Procedure
# Steps Rational
Pre-procedure
3. Prepare needed equipment. To save time and effort
5. Verify the patient by 2 Nurses. To ensure that, right patient receives
intervention.
6. Explain procedure to the patient. To decrease patient's anxiety and
increase patient’s cooperation
embarrassment )
8. Position the patient appropriately, allowing To facilitate the administration of the
optimal ventilation. medication.
Sit up straight on a comfortable chair.
Using a mouthpiece is preferred. When
using a mouthpiece, place the mouthpiece
between the teeth and ask the patient to seal
his/her lips around it.
If the patient is using a mask, position it
comfortably and securely on the face.

10. Wear disposable gloves. To maintain infection control
During procedure
11. Assess and record breath sounds, To provide a baseline for evaluation
respiratory status, pulse rate and other the effectiveness of nebulization
significant respiratory functions. Ask the therapy.
patient about allergies.
12. Check the doctor’s orders for the To avoid any mistakes.
medication, prepare thereafter.
85
Place the premeasured medication in the To get enough volume to make a fine
bottom section of the cup or use a dropper mist that can be inhaled.
to place medication. Add prescribed diluent
(usually Saline) if ordered.
13.
Screw the top portion of the nebulizer cup Air or oxygen must be forced through
back in place and attach the cup to the the nebulizer to form a fine mist.
nebulizer. Attach one end of the tubing to To secure the passage of aerosol mist
the stem on the bottom of the nebulizer cuff to the lungs.
and the other end to the air compressor or
oxygen source.
14.
For patient on mechanical Ventilator: To deliver medicine by using high-

frequency vibrations to convert the
1. Unhook the ventilator tubing and insert liquid into an aerosol and do not
the T-piece into the ventilator tubing on increase patient tidal volume during
the inhalation side.
2. Insert the nebulizer cup into the T-piece
that is now in line with the ventilator
15.
circuit.
3. Connect one end of the tubing to the
bottom of the nebulizer and the other
end to the aerosol/nebulizer machine.
4. Once nebulizer is done, suction the trach
to remove secretions. inhalation.
86
16. Turn on the air compressor or oxygen. To prevent any leakage while receiving
Check that a fine medication mist is the medication.
produced by opening the valve. Have the
patient place the mouthpiece (or Mask) into
the mouth and grasp securely with teeth and
lips.
17. Offer the nebulizer to the patient, help until To assess patient ability to receive the
she/he can perform proper inhalation (if medication and to start medication on
unable to hold the nebulizer, replace the time.
mouthpiece with mask)
18. Instruct the patient to inhale slowly and To let the medication come in contact
deeply through the mouth. A nose clip may with respiratory tissues and can be
be necessary if the patient is also breathing absorbed. The longer the breath is held,
through the nose. Hold each breath for a the more medication can be absorbed.
slight pause, before exhaling.
19. Continue the inhalation technique until the For optimal delivery of medication to
all medication in the nebulizer cup has been the
aerosolized (about 5 to 15 minutes). patient.
20. Observe for any possible side effects or To prevent any complications and
inhalation reactions. reporting it in timely manner.
21. When the medication is completely To avoid oral fungal infections due to
aerosolized, the cup will be empty. Have inhaled steroids.
the patient remove the nebulizer from the Rinsing removes medication residual
mouth and gargle and rinse with tap water, from the mouth.
as indicated.
87
22. Reassess patient status from breath sounds, To ensure the effectiveness of the
respiratory status, pulse rate and other medication given and to write down
significant respiratory functions needed. any changes or differences in the
Compare and record significant changes patient’s condition. Lung sound,
and improvements. Refer if necessary. Oxygen saturation level may improve
after nebulizer use. Respiration may
decrease as well.
Post procedure
microorganisms.
24. Clean the nebulizer and take it apart and To kill bacteria and remove build-up.
wash all of the parts in warm, soapy water.
Store nebulizer and equipment according to
facility’s policy.
proper bag (Red).
27. Record patient's assessment before and To maintain patient’s safety and keep-
after intervention, medication dosage and documented source helps in following
name, date, time, oxygen saturation. patient’s status.
28. Report any abnormalities to the physician To take necessary actions.
such as allergic reactions or pain.
Procedure Video Links:

https://www.youtube.com/watch?v=V44OI-FjBCk&t=4s
https://youtube.com/watch?v=Z5Lx--xlj28
https://youtube.com/watch?v=afSqRIdwwdM
References:
− Lynn, P., 2019. Taylor’s clinical nursing skills: A nursing process
approach, Philadelphia, PA: Wolters Kluwer Health.
− Perry, A.G., Potter, P.A., Ostendorf, W.R. and Laplante, N.,
2021. Clinical nursing skills and techniques-E-Book. Elsevier Health
Sciences.
88
− https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6803223/#:~:text=Nebul
ization%20therapy%20can%20be%20used,airway%20management%20i
n%20other%20diseases.
− https://www.urmc.rochester.edu/childrens-hospital/tracheostomy-
ventilator-program/ventilator/nebulizer-
treatments.aspx#:~:text=Place%20the%20medicine%20in%20the,line%2
0with%20the%20ventilator%20circuit.
89
Chest Tube Care Procedure
90
Chest Tube Care Procedure
Definition:
A chest tube is a hollow plastic tube that is surgically inserted into the chest
cavity to drain air or fluid. Different types of fluid, such as blood, pus, or
cancer cells, can accumulate in the chest due to trauma, surgery, cancer, or
infection.
Indication:
• A collapsed lung
• A lung infection with pus collection
• Pneumothorax, which is air around or outside the lung
• Hemothorax, which is bleeding around the lung
• Fluid buildup due to another medical condition, like cancer or
pneumonia
• Breathing difficulty due to a buildup of fluid or air
• Surgery, especially lung, heart, or esophageal surgery
Purpose:
• To prevent infection.
• To identify any complications (bleeding – emphysema)
Equipment:
• Sterile gloves.
• Draw sheet.
• Biohazard bag.
91
• Adhesive tape.
• Antiseptic solution as doctor order.
• Normal saline.
• Sterile kit (sterile gauze, sterile dressing "V cut shape", clamp, 2 small
cups).
Complications:
The complications of chest tube placement may include:
• Bleeding: Sometimes blood vessels are "nicked" during chest tube
insertion. If bleeding persists, surgery may be needed to cauterize the
vessels.2
• Infection: Any time an instrument is introduced through the skin, there
is a small risk of infection. The risk of infection increases the longer the
tube is left in place.
• Pain: Sometimes a chest tube may cause pain, pressure, or
discomfort.4 Talk to your doctor about any discomfort that you are
having.
• Untreated fluid collection: Some pleural effusions are loculated, which
means they have several small collections of water, pus, or blood. When
this is the case, a chest tube may only drain that collection of fluid in
the area where the chest tube is placed.
• Pneumothorax: A chest tube may puncture the lung, resulting in
apneumothorax.4 A lung that has collapsed may also collapse again
when the tube is removed.
• Injury: Other structures in the vicinity of the chest tube may be injured,
such as the esophagus, stomach, lung, or diaphragm.
92
Procedure of Chest Tube Care
# Steps Rational
1. Verify physician prescription. Validates the correct plan and correct
procedure.
2. Wash your hands. To prevent the spread of microorganisms.
3. Prepare needed equipment To promote efficient time management.
5. Identify the patient. To keep patient's safety.
6. Explain the procedure to the patient. To enhance patient's cooperation.
7. Keep patient’s privacy. To gain patient trust.
8. Disinfect your hands. To prevent the spread of microorganisms.
9. Wear disposable gloves. To reduce transmission of microorganism.
10. Put patient in comfortable position. To provide comfort.
11. Expose patient’s area of chest tube To protect underlying surfaces.
insertion site.
12. Place a waterproof pad under chest To protect underlying surfaces.
tube site.
13. Assess the patient: To detect any abnormalities.
• Auscultate chest sound.
• Air entry.
• Respiratory rate.
• Skin color of the patient.
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14. Palpate and inspect gently around the To detect any abnormalities.
insertion site.
15. Check that all drainage system Improper placement of the tube or an air leak
connections are securely tape. can cause discomfort to the patient.
16. Check chest tube and drainage system Loops or kinks can prevent the tube from
to ensure that there is no loops or draining appropriately.
kinks.
17. Check position of drainage collection
device below the tube insertion site and
the tube itself should be connected and
below the distilled water level in under
water seal.
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18. Assess the water-seal chamber for Fluctuation of the water level in the water-
fluctuation of the water level with the seal chamber with inspiration and expiration
patient inspiration and expiration.
is an expected and normal finding.

19. Assess the amount, color and content Allow for accurate intake and output
of the drainage. measurement and assessment of the
effectiveness of therapy.
20. Measure drainage out-put at the end of Contributes to the decision to remove the
each shift by marking the level on the tube.
container (or placing a small piece of
tape at the drainage level)
Change Dressing.
21. Remove adhesive tape toward the
dressing.
22. Assess dressing for presence any To detect any abnormalities
drainage (amount, color, and odor).
23. Discard the soiled dressing at To prevent the spread of microorganisms
biohazard bag.
95 | P a g e
24. Assess site of insertion for the presence of irritation or infection should
inflammation, redness, oozing pus or be documented
any abnormalities.
25. Dispose clean gloves. To reduce transmission of microorganism
26. Disinfect your hands. To reduce transmission of microorganism
27. Open sterile kit (Dressing tray).
28. Pour normal saline and antiseptic
solution (As prescribed) following non-
touching technique.
29. Wear sterile gloves. To reduce risk for spreading microorganisms
30. Use separate gauze for each wipe. To ensure cleaned area is not contaminated
again
31. Disinfect site in circular motion around To ensure cleaning occurs from the least to
tube. most contaminated area and previously
cleaned area is not contaminated again
32. Apply antiseptic solution by same
technique if prescribed.
33. Use dry gauze to dry with same To prevent moisture media for growth
technique used for cleansing. microorganisms
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34. Place V-Cut gauze carefully and apply To additional protection against
additional layer of gauze if needed. microorganisms and increased absorption of
drainage
35. Remove and discard gloves.
36. Secure site with adhesive tape.
37. Label with (date, time and signature). To provides communication and
demonstration adherence to plan of care
38. Return patient to a comfortable To promote safety and comfort
position.
39. Wear clean gloves.
40. Dispose used supplies and remove To prevent the spread of microorganisms
gloves.
41. Wash hands. To prevent the spread of microorganisms
97 | P a g e
42. Document the (date and time of care, To ensure continuity of care
level of drainage, and color)
43. Report about any abnormalities To ensure continuity of care
detected during procedure as absence
of oscillation, abnormal color, presence
of subcutaneous emphysema and if
amount of drainage exceeds 50ml/hr.
Reference:
• Burt BM, Shrager JB. Prevention and management of postoperative air

leaks. Ann Cardiothorac Surg. 2014;3(2):216-8
• Cunningham JP, Knott EM, Gasior AC, et al. Is routine chest radiograph
necessary after chest tube removal? J Pediatr Surg. 2014; 49(10):1493-
5.
• Teixeira LR, Vargas FS. Reexpansion pulmonary edema after
therapeutic thoracentesis. Clinics (Sao Paulo). 2010;65(12): 1387-9.
• Kane CJ, York NL, Minton LA. Chest tubes in the critically ill patient.
Dimens Crit Care Nurs. 2013;32(3):111-7.
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Arterial Blood Gases procedure
99 | P a g e
Definition:
It is the withdrawal of blood from an artery by syringe for a diagnostic

purpose.
Indications:
• Respiratory compromise, which leads to hypoxia or diminished

ventilation.
• Peri- or post cardiopulmonary arrest or collapse.
• Medical conditions that cause significant metabolic derangement,

such as sepsis, diabetic ketoacidosis, renal failure, heart failure, toxic
substance ingestion, drug overdose, trauma, or burns.
Purposes:
• To assess patient’s oxygen and carbon dioxide levels in arterial blood.
• To detect respiratory and metabolic disturbances.
100 | P a g e
Equipment:
• 3-mL syringe.
• Heparin (Ampoule)
• 2 × 2 gauze pad
• Band-Aid
• Alcoholswab
• Label with complete patient identifiers.
• Cup or plastic bag with crushed ice.
• Clean gloves.
• Rolled towel.
Complications:
• Bleeding or bruising at the puncture site
• Feeling faint
• Blood accumulating under the skin
• Infection at the puncture site
• Hematoma
• Nerve damage
• Fainting
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# Steps Rational
Pre-procedure
1. Verify blood sample request. To ensure accurate blood sample.
3. Prepare all needed equipment. To save time.
5. Identify the patient. To ensure that right patient receives
intervention.
6. Explain procedure to the patient. To decrease patient's anxiety and enhance
patient's cooperation.
7. Keep the patient privacy. Patient's right.
8. Place the patient in comfortable position. To have access to the site and provides
patient comfort and safety.
9. Place sheet under the patient hands. To keep the area clean.
10. Disinfect your hands. To maintain infection control.
11. Wear disposable gloves. To maintain infection control.
During Procedure
12. Perform Allen’s test before obtaining a Allen’s test assesses patency of the ulnar
specimen from the radial artery. and radial arteries.
a. Have the patient clench the wrist to
minimize blood flow into the hand.
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b. Using your index and middle fingers,
press on the radial and ulnar arteries.
Hold this position for a few seconds.
c. Without removing your fingers from

the arteries, ask the patient to unclench
the fist and hold the hand in a relaxed
position. The palm will be blanched
because pressure from your fingers has
impaired the normal blood flow.
d. Release pressure on the ulnar artery. If

the hand becomes flushed, which
indicates that blood is filling the
vessels, it is safe to proceed with the
radial artery puncture. This is
considered a positive test. If the hand
does not flush, perform the test on the
other arm.
13. Locate the radial artery and lightly palpate it If you push hard during palpation, the
for a strong pulse. radial artery will be obliterated and hard
to palpate.
103 | P a g e
14. Disinfect the patient’s skin at the puncture Site disinfection prevents potentially
site with the alcohol swab and let alcohol to infectious skin flora from being introduced
dry. into the vessel during the procedure
15. Stabilize the hand with the wrist extended

over the rolled towel, palm up.
16. Palpate the artery above the puncture site Stabilizing the hand and palpating the
with the index and middle fingers of your artery with one hand while holding the
non-dominant hand while holding the syringe syringe in the other provides better access
over the puncture site with your dominant to the artery. Palpating the area to be
hand. Do not directly touch the area to be punctured would contaminate the clean
punctured. area.
17. Hold the needle bevel up at a 45- to 60-degree The proper angle of insertion ensures
angle at the site of maximal pulse impulse. correct access to the artery. The radial
artery is shallow and does not require a
deeper angle to penetrate.
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18. Puncture the skin and arterial wall in one The blood should enter the syringe
motion. Watch for blood backflow in the automatically due to arterial pressure.
syringe. Pulsating blood will flow into the
syringe. Do not pull back on the plunger. Fill
the syringe to the 5-mL mark.
19. After collecting the sample, withdraw the If insufficient pressure is applied, a large,
syringe while your non-dominant hand is painful hematoma may form, hindering
beginning to place pressure proximal to the future arterial puncture at the site.
insertion site with the 2 × 2 gauze. Press a
gauze pad firmly over the puncture site until
the bleeding stops—at least 5 minutes.
Post-procedure
20. Discard disposable needle into safety box. To prevent transmission of
microorganisms.
21. Remove gloves. To prevent transmission of
microorganisms.
22. Wash your hands. To prevent transmission of
microorganisms.
23. Label blood sample with date, time patient To ensure accurate reporting of results.
name and hospital number (according to
policy of hospital).
105 | P a g e
24. Send immediately the blood sample with lab
request to laboratory.
25. Documents (date and time of sampling, and To ensure continuity of care.
time of transport to the laboratory).
26. Report any abnormalities to the physician To take necessary actions.
such as hematoma formation.
Reference:
Procedure Manual for High Acuity, Progressive, and Critical Care, 7th
Edition
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Using Pulse Oximeter procedure
107 | P a g e
Using Pulse Oximeter procedure
2023-2024
Pulse oximetry: is a noninvasive technique that measure the arterial

oxyhemoglobin saturation (SpO2) of arterial blood.
Indications:
- Monitoring patients receiving oxygen therapy.

- Monitoring patients at risk for hypoxia and hypoventilation (opioid use,
neurologic compromise)
- Postoperative patients.
Purpose:
To assess arterial blood oxygenation toward respiratory status during

ventilation, acute illness, activity, and sleep and to evaluate the effectiveness
of therapeutic interventions.
Equipment:
• Pulse oximeter with appropriate sensor or probe.
• Disposable Gloves.
• Alcohol swab.
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Procedure of Using Pulse Oximeter
# Steps Rational
1 Review health record for any health problems Identifying influencing factors aids in
that would affect the patient’s oxygenation interpretation of results.
status.
2 Perform hand hygiene. To prevent the spread of microorganisms.
3 Prepare needed Equipment. To save time and effort
4 Introduce yourself to patient To build trust.
5 Identify the patient To ensure that the right patient receives
the intervention and helps prevent errors.
6 Explain procedure to the patient. To increase patient’s cooperation and
relieve anxiety.
7 Keep patient privacy. Patient right( to decrease patient
embarrassment )
8 Disinfect your hand and wear disposable To maintain infection control
gloves.
9 Select adequate site for application of sensor. Inadequate circulation can interfere with
oxygen saturation reading.
a. Use patient index, middle or ring Fingers are easily accessible.

finger.
b. Check proximal pulse and capillary

refill at pulse closest to site.
109 | P a g e
Capillary refill and strong pulse indicate
adequate circulation to site.
c. If circulation to site inadequate

consider using earlobe, forehead,
bridge of nose and use appropriate
oximetry sensor for chosen site.
d. Use toe only if lower extremity
circulation not compromised.
Use of appropriate equipment is vital for

accurate results.
Peripheral vascular disease is common in

lower extremities.
10 Use probes appropriate for patient’s age and Inaccurate readings can result if the probe
size or sensor is not attached correctly.
11 Prepare the monitoring site: Skin oils, dirt, or grime on the site can
a. Clean selected site with alcohol swab. interfere with passage of light waves.
Allow area to dry.
Attach probe securely to skin and make sure Secure attachment and proper alignment
that light emitting sensor and light receiving promote satisfactory operation of
12
sensor are aligned opposite each other (not equipment and an accurate recording of
necessary to check if placed on forehead or SpO2.
bridge of nose).
110 | P a g e
Connect sensor probe to pulse oximeter,
turn oximeter on and check operation of
equipment.
13
Set alarms on pulse oximeter and check To provides additional safeguard and
14
manufacturer’s alarm limits for high and low signals when high or low limits have been
pulse rate setting. surpassed.
15 Check oxygen saturation at regular intervals. To provide ongoing assessment of
patient’s condition
16 Remove sensor on regular basis and check Prolonged pressure may lead to tissue
skin irritation or signs of pressure. necrosis and adhesive sensor may cause
skin irritation.
17 Clean non-disposable sensors according to To reduce spread of microorganisms.
manufacturer’s directions.
18 Remove used gloves and discard in the To maintain infection control.
proper bag (Red).
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19 Wash hands. To maintain infection control.
20 Record type of sensor, location used, pulse To maintain legal principles.
oximeter reading.
21 Report any abnormalities. To take the immediate action as soon as
possible in proper time.
References:
• Lynn., P (2019) Taylor’s Clinical Nursing Skills: A Nursing Process Approach. 5th
ed. Philippine: Wolters Kluwer.
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Electrocardiogram (ECG) procedure
113 | P a g e
Electrocardiogram (ECG) procedure
DY1 2023-2024
Definition:
Electrocardiogram is a medical device used to monitor electrical functions not

muscular reactions of the heart into line tracings on paper. It’s a noninvasive and
painless procedure.
Indications:
• Symptoms are the foremost indication of the ECG, including palpitation,

dizziness, cyanosis, chest pain, syncope, seizure, and poisoning
• Symptoms or signs associated with heart disease include tachycardia,

bradycardia, and clinical conditions including hypothermia, murmur, shock,
hypotension, and hypertension
• To detect myocardial injury, ischemia, and the presence of prior infarction
• Rheumatic heart disease.
Contraindications:
There are no absolute contraindications for an electrocardiogram. The relative

contraindications to its use include:
• Patient refusal.
• Allergy to the adhesive used to affix the leads.
Equipment:
• ECG machine
114 | P a g e
• Recording paper
• Conductive gel/ disposable electrodes
• Bath blanket
• 4x4 gauze pads
• Skin cleanser and water
•Tissue paper
 Steps Rational
Pre procedure:
 Verify physician prescription This ensures that the correct intervention is
performed.
 Wash hands To maintain infection control.
 Prepare equipment (check the To save time
functioning of the ECG machine)
 Introduce yourself to patient To build trust.

 Identify the patient To ensure that the right patient receives the
intervention and helps prevent errors.
6 Explain procedure to the patient -To relieve anxiety and facilities
• Tell the patient that the test records cooperation.
the heart’s electrical activity and it may -Possible allergies may exist related to
be repeated at certain intervals. adhesive on ECG leads.
115 | P a g e
• Emphasize that no electrical current
will enter his or her body.
• Tell the patient the test typically takes
about 5 minutes
• Ask the patient about allergies to
adhesive, as appropriate.
7 Keep patient privacy ( close curtains It's patient's right.
around the bed and close the door to the
room if possible)
8 Disinfectant your hands and wear To maintain infection control
disposable gloves
9 Place the ECG machine close to the Having equipment available saves time and
patient bed, and plug the power cord facilities accomplishment of the procedure.
into the wall outlet.
10 Raise the bed to comfortable working Having the bed at the proper height prevents
height, usually elbow height of the care back and muscle strain
giver.
During procedure
11 -Ask the patient to lie in supine Proper positioning helps increase patient
position, in the center of the bed with comfort and will produce a better tracing.
the arms at the sides. -Raise the
head of the bed if necessary to promote
comfort.
12 Expose the patient’s arms, legs, and To put the electrode
chest and drape appropriately. To keep privacy
116 | P a g e
13 Encourage patient to relax the arms and Proper positioning and relaxation of the arms
legs and make sure the feet do not touch and legs minimizes muscle tension and
the bed’s food board. trembling and electrical interference.
To avoid any external interference.
14 Prepare the skin for electrode Shaving causes injury that lead to (infection)
on the chest skin. Oils and excessive hair
placement.
interfere with electrode contact and function.
- If an area is excessive hairy, clip the
hair. Do not shave the hair.
- Clean excess oil or other substances
from the skin with skin cleanser and
water and dry it completely.
15 Apply the limb electrodes. The tip of Use of recommended standard sites for limb
electrode is essential to obtain accurate ECG
each lead wire is lettered and color
recording.
coded for easy identification.
• The red or RA lead goes to the right
arm, just above the rest bone.
• The black or RL lead to the right leg,
just above the ankle bone.
• The yellow or LA lead to the left arm,
just above the rest bone.
• The green or LL lead to the left leg,
just above the ankle joint.
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16 Apply the chest electrodes. The tip of
each lead wire is lettered and color
coded for easy identification.
The V1 to V2
• V1: Forth intercostal space at right
sternal border.
• V2: Forth intercostal space at left
sternal border.
• V3: Exactly midway between V2 and
V4.
• V4: Fifth intercostal space at the left
mid-clavicular line
• V5: left anterior axillary line, same
horizontal plane as V4 and V6
• V6: left mid axillary line, same
horizontal plane as V4 and V5
17 • After the application of all the leads, Minimizes electrical artifact and improves
quality and accuracy of the ECG.
ensure that the cables are not pulling on
the electrodes or lying over each other.
• Make sure the paper speed selector is
set to the standard 25 m/second and
that the machine is set to full voltage.
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18 If necessary, enter the patient This allows for proper identification of the
identification data into the machine. ECG strip.
19 Ask the patient to relax and breathe Lying still and not talking produce a better
normally and avoid movement or tracing.
talking while recording the ECG
20 Press the Auto button. Observe the
tracing quality.
The machine will record all 12 leads
automatically; some machines have a
display screen so you can preview wave
forms before the machine records them
on paper.
Adjust waveform, if necessary.
21 When the machine finishes recording To promote patient's comfort.
the 12-leads ECG, remove the electrode
and clean the patient's skin.
22 After disconnecting the lead wires from To promote patient's comfort.
the electrodes, return the patient to
comfortable position.
Post procedure
119 | P a g e
23 Remove gloves To maintain infection control.
24 Wash hands To maintain infection control.
25 label the ECG with the patient's name, Accurate labeling ensures the ECG is
age, location, date and time of recording recorded for the correct patient.
26 Report any abnormality. To take the immediate action as soon as
possible in proper time.
27 Clean the ECG machine according to To decrease the risk for transmission of
hospital policy microorganisms.
References:
• Lynn., P (2019) Taylor’s Clinical Nursing Skills: A Nursing Process Approach. 5th
ed. Philippine: Wolters Kluwer.
120 | P a g e
Central Venous Catheter (CVC)
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Assisting Central Venous Catheter (CVC) Insertion
Introduction
A central venous catheter (CVC), also known as a central line, central venous line, or
central venous access catheter, is a catheter placed into a large vein and is not routinely
procedure. It could be placed in veins in the neck (internal jugular vein), chest
(subclavian vein or axillary vein), groin (femoral vein), or through veins in the arms
(peripherally inserted central catheters) and the tip of a CVAD is placed in the lower
third of the superior vena cava near the junction of the
right atrium
Indications of CVAD:
• A person needs a combination of:
- long-term fluid replacement
- nutritional support
- IV medication
• A person has poor peripheral venous access.
• A person requires monitoring of the central venous pressure.
Purpose of insertion:
• Volume resuscitation
• Emergency venous access
• Nutritional support
• Administration of medications (vasopressors and sclerosing agents)
• Central venous pressure monitoring
• Transvenous pacing wire introduction.
• Hemodialysis
Contraindications to CVC:
• Inexperience, unsupervised operator
• Local infection
• Distorted local anatomy
• Coagulopathy
• Previous radiation therapy
• Suspected proximal vascular injury
• Traumatized site (eg. clavicle fracture and subclavian line)
122 | P a g e
• Burned site
Equipment:
1. Materials required for CVC insertion.
• Hair clippers
• Central vascular access insertion tray to
include appropriate-length catheter and
introducer needle, sterile gauze, sterile
drapes, and disposable tape measure.
• Maximum barrier supplies to include
head covering, sterile gowns, masks,
sterile gloves (powder free), antiseptic
solution (alcoholic chlorhexidine solution
preferred, 70% alcohol, povidone-iodine
for chlorhexidine sensitivities), large full-
body sterile drape with fenestration.
• Protective eyewear
• Nonsterile gloves
• Gauze pads
• Surgical towels
• 1% lidocaine (Xylocaine) for use as local
anesthetic as ordered by health care
provider.
• 3-mL syringe and small-gauge needle for
anesthetic administration
• 10-mL syringe
• Transparent semipermeable membrane
(TSM) or gauze 4 × 4 dressing for
catheter insertion site
• Engineered stabilization device.
• Needleless connector for each lumen
• Polymer-based skin protectant swab
(optional) sterile tape.
2. Ancillary equipment for CVC
123 | P a g e
• Oxygen supply
• Pulse oximeter and Blood pressure cuff
• Crash cart with cardiac monitor
Complications of central venous cannulation

Immediate
• Pneumothorax
• Haemothorax
• Retroperitoneal hematomas
• Arterial puncture
• Local haematoma
• Guidewire-induced arrhythmia
• Thoracic duct injury
• Air embolism
Late
• Vascular erosion
• vessel stenosis
• thrombosis
• osteomyelitis of clavicle (subclavian access)
Remember to:
• Sometime the procedure is guided by Ultrasound.
Ultra-sonographic features which distinguish the internal jugular vein from the
carotid artery to reduce the risk of insertion related complication.
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Assisting Central Venous Catheter (CVC) Insertion procedure
# Steps Rational
Pre procedure:
1. Wash hands To minimize infection
2. Prepare equipment To save time
3. Introduce youreslf to patient To build trust
4. Identfiy the patient To ensure that is the right patient
5. Explain procedure to the patient The patient may be very anxious and it is
important that the nurse gives a clear
explanation and reassurance before, during and
after the procedure.
6. Keep patient privacy To minimize embarrassment
7. Positions patient in Trendelenburg's To encourage venous engorgement, which
Position unless contraindicated (10- makes it easier to puncture the vein and reduce
15); In case of internal jugular and
subclavian CVL and places rolled
towel or bath blanket between
patient's shoulder blades.
the risk of air embolism
8. Put disposable pad /dressing under the To prevent infection transmission.

venous access.
Monitor heart rate & rhythm, respiratory rate &
Then Attach patient to cardiac patient response throughout the procedure.
monitor and pusle oximeter if avalable Watch cardiac monitor closely as guidewire &
catheter are inserted & notify physician
immediately if dysrhythmia occurs.
10 Perform hand hygiene using antiseptic Handwashing technique removes transient and
soap for 60 seconds. resident bacteria from skin.
11 Perpare a sterile field on the bed side To prevent infection transmission to the
table. insertion site
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12 Physician and nurse apply cap, mask, To prevent infection transmission to the
eyewear, surgical gown, and powder- insertion site
free
sterile gloves.
During procedure :
13 Perform skin antisepsis with Allow any skin antiseptic agent to fully dry for
antiseptic solution using friction in complete antisepsis to prevent infection
back-and-forth motion or in a transmission to the insertion site.
scrubbing motion for 30 seconds and
allow to dry completely. To ensure patient comfort during the procedure.
• Explain what is happening

throughout the procedure
While the physician
disinfecting the area.
14 After cleaning site, physician and Gloves become contaminated from surface
nurse remove gloves. Physician bacteria
changes into second pair of sterile picked up in solution. Nurse functions as
gloves, and nurse performs hand nonsterile
hygiene. circulator (non sterile gloves) whose primary
role is to ensure sterility of insertion field.
• (Check agency policy because
some agencies require strict
precautions.)
15 Ensure that physacian drapes the To sterile field and to comply with maximal
patient with large sterile drapes and barrier percaution.
finds anatomical landmarks and places
sterile fenestrated drape appropriately
over
proposed insertion site.
16 Nurse sets up IV bag, primes and fills IV tubing is ready to be connected to IV catheter.
tubing, and covers end of tubing with
sterile
cap
17 A Nurse scrubs top of 1% lidocaine Removes surface bacteria; allows physician to
bottle with antiseptic swab, allowing withdraw lidocaine while maintaining asepsis.
126 | P a g e
to dry completely, and holds bottle
upside down if not in insertion kit.
Minimizes discomfort patient feels during
• Physician injects needle into venipuncture. Site has been documented to be
bottle and withdraws safer for
approximately 3 to 4 mL bedside insertion and ability to use ultrasound-
lidocaine. guided
insertion
• He or she injects needle into site

for internal jugular puncture
and anesthetizes venipuncture
site, waiting 1 to 2 minutes for
effect to take place.
127 | P a g e
CVC Insertion Steps by Physician(seldinger)
128 | P a g e
129 | P a g e
18 Monitor heart rate & rhythm, To prevent complication during insertion
respiratory rate & patient
response throughout the
procedure. observe cardiac
monitor closely as guidewire &
catheter are inserted & notify
physician immediately if
dysrhythmia occurs.
19 Assist physician with flushing of Determines patency of device. Use of heparin,

catheter ports with normal saline. flush
volume, and concentration vary by agency.
Physician determines patency of line
by withdrawing blood with 10-mL
syringe,
flushing with 0.9% sodium chloride,
and placing needleless connectors on
hub of
each lumen.
20 Assist physician with Secure catheter

by suture by handlining the needle by
needle holder
130 | P a g e
21 Secure catheter by CVC transparent
Dressing
22 Label the dressing with data , the time To ensure proper identification and
and your intials of physicain. documentation.
23 Mak sure that all lumen clamps are To prevent air embolism
closed
24 Physician removes sterile drapes and Measurement allows for comparison if
completes procedure. External dislodgement of
catheter length is measured. CVAD is suspected.
25 Return patient in comfort position To promot patient comfort
26 Intiate IV therapy if perscribed after
an X rays comfirms correct
placement in the superior vena cava
27 Reasses patient patient after 30 mins To assess any signs of insertion related
commplication
Post procedure:
28 Dispose any used material To reduce infection
29 Remove gloves To reduce infection
30 Wash hands To reduce infection
131 | P a g e
31 Record the procedure Documentation provides ongoing data
32 Report any abnormalitis To ensure patient safety
Reference:
- Delves-Yates, C. ed., 2018. Essentials of nursing practice. Sage.

- Lynn, P., 2018. Skill Checklists for Taylor's Clinical Nursing Skills. Lippincott
Williams & Wilkins.
132 | P a g e
Central Venous Pressure (CVP) Measuring
Procedure
133 | P a g e
Central Venous Pressure (CVP) Measuring Procedure
Introduction and definition:

Central venous ressure (CVP) is the pressure in the thoracic vena cava near the right
atrium (therefore CVP and right atrial pressure are essentially the same).
Indications:
CVP is an important procedure for patient with critical condition as it is a major

determinant of the preload of the right ventricle.
Purposes:
1. To estimate the preload and right atrial pressure.

2. To predict the cardiac output response resulting from fluid administration.
3. To establish “limit/ increase” for fluid administration.
CVP Equipment Needed:

1 Infusion solution (0.9% NaCl)
2 Infusion set
134 | P a g e
3 Stopcock (3 way)
& Extension line if needed
4 CVP manometer
5 IV stand
6 Disposable gloves
7 Alcohol swabs
135 | P a g e
8 Water proof sheet
Central Venous Pressure (CVP) Measuring Using a Water Manometer

Procedure
# Steps Rational
Pre procedure:
1. Varify medical prescription / hospital policy To ensure safety.
2. Wash hands. To prevent transmission of infection.
3. Prepare equipment. To promote efficient time management
and an organized approach to the task.
4. Introduce youreslf to patient. To build trust.
5. Identfiy the patient. To ensure that, right patient receives the
intervention.
anxiety.
7. Keep patient privacy. To minimize embarrassment.
8. Place waste bag in proper place to use during To ease discarding of soiled dressing.
the procdure
9. Adjust bed height to commfortable position To prevent back strain
for the nurse.
10 Disinfect your hands. To prevent transmission of infection.
11 Wear clean gloves. To prevent transmission of infection.
During procedure :
12 Place the patient flat in a supine position if To ensure an accurate comparable
possible. Alternatively, measurements can be result.
taken with the patient in a semi-
fowler's position. The position should remain
the same for each measurement taken.
13 Place sheet under CVC site. To minimize soiling of bed linen and
prevent transmission of infection.
136 | P a g e
14 Flush CVC by normal saline 0.9% if IV fluid To ensure that the CVC is patent.
is not running.
15 Make a small ink mark on the skin at the To ensure consistent use of the site and
phlebostatic axis. The zero point for placing accurate comparable results.
the manometer zero (Where the 4th intercostal
space and mid-axillary cross other allowing
the measurement to be close to the right atrium
as possible.)
16 Ensure all intravenous infusions running are Intravenous infusion increases CVP.
stopped.
17 Prepare 0.9% saline with IV set. Prime IV To evacuate air from line and prevent air
infusion set with 0.9% saline. embolism when connect to patient.
18 Attached IV set to manometer and the patient To perpare for CVP measuring
using Stopcock (3 way).
19 Line up the zero point of the manometer to To ensure the atmospheric pressure at
patient phlebostatic axis (Where the 4th the point of measurement is read as
intercostal space and mid-axillary cross other zero.
allowing the measurement to be close to the
right atrium as possible.)
Phlebostatic axis
20 Turn the stopcock (3 way); close to patient, To allows the IV solution flow into the
open to IV solution and manometer manometer.
137 | P a g e
21 Allow the manometer to fill with fluid into A wet filter will resist air entry, giving a
measuring chamber to a level beyond the falsely high reading.
expected pressure. Do not fill the line so far
that the air filter becomes wet.
22 Turn stopcock; open to patient and manometer To allow the IV solution in manometer
and close to IV solution. flows into patient.
23 Observe the fall in height measuring chamber Gravity will cause the water level to fall
(the column of fluid in manometer). until resistance from the patient’s CVP
matches the pressure of gravity.
24 Assess swinging pattern (the fluid in the Changes in pressure caused by the
manometer will fluctuate slightly on patient’s respiratory pattern (usually
respiration), until it oscillates between two about 1cm).
points.
25 Record the higher point/reading (at the end of When intrathoracic pressure has
expiration). If the patient is mechanically negligible effect (that it may safely be
ventilated, subtract the PEEP (Positive End- neglected or disregarded)
Expiratory Pressure) value from measuring
reading.
26 Turn the stopcock again (open to patient, and To resume IV infusion if needed
close to manometer) and open to IV infusion.
27 Adjust the IV drip rate as required. To resume accurate IV infusion rate.
28 Return the patient to a comfortable position. To maintain patient comfort.
Post procedure:
29 Dispose any used material. To prevent transmission of infection.
30 Remove gloves. To prevent transmission of infection.
31 Wash hands. To prevent transmission of infection.
138 | P a g e
32 Document patient's CVP reading and mention To maintain continuity of care.
any factors could affect the reading (IV fluids
remaining during measurement, mechanical
ventilator, viscous drugs and the position
while measurement taken) and patient
tolerance to the procdure.
33 Report any abnormalities. To take necessary action if needed in
the next time of measurement.
References:
➢ Shojaee, M., Sabzghabaei, A., (2017). Effect of Positive End-Expiratory

Pressure on Central Venous Pressure in Patients under Mechanical
Ventilation. Pub Med central journal [online], January, vol. 5, no 1, pp.1-20
Available
from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5325877/.[Accessed6th
February 2018]
➢ Lynn,P.,(2019).Taylor’s clinical nursingskills,4thed.,London:Wolters Kluwer
➢ WNHS, 2019. Central venous pressure (CVP). [Online]
Available at:
https://www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For%20h
ealth%20professionals/Clinical%20guidelines/OG/WNHS.OG.CVPMeasurem
ent.pdf
[Accessed 12 1 2021].
139 | P a g e
Central Venous Catheter (CVC) Dressing
change
140 | P a g e
Central Venous Catheter (CVC) Dressing change
Introduction:
Dressing is placed to cover the site and prevent the introduction of microorganisms
into the bloodstream. Moreover, minimize catheter movement and prevent
dislodgement. Various access techniques and devices were developed for many
indications,
including total parenteral nutrition administration, dialysis, plasmapheresis,
medication administration, and hemodynamic monitoring, and to facilitate further
complex interventions such as transvenous pacemaker placement.
A. Dressing change:
Purposes:
1- Minimize contamination of the insertion site
2- Provide stability to the central venous catheter
Equipment needed:
• Sterile Gloves.
• TSM dressing, 4 × 4 gauze pads.
• Two Face mask according mask hospital policy.
• Antiseptic solution (alcoholic chlorhexidine solution preferred, 70%
alcohol, or povidone-iodine).
• Tape measure, sterile tape, label.
• Disposable pad.
B. Flushing CVC:
Purposes
1- Preventing blood clotting
2- ensuring that the catheter is patent
3- reducing the risk of mixture between substances by cleaning the inner lumen
of the catheter
4- preventing bacterial colonization of the catheter.
141 | P a g e
Equipment needed:
• Clean gloves
• 1 (10-mL) 0.9% NS flush per lumen
• 1 heparinized flush per lumen, as per facility policy
• 2 chlorhexidine or 70% isopropyl alcohol wipes for each lumen
• Disinfectant cap for each lumen
C. Removal of CVC:
Indications:
1- if signs of infection are present
2- if medications are discontinued or patient is discharged
3- if the CVC line is blocked or not patent
4- presence of sepsis
Equipment needed:
• Personal protective equipment as indicated (goggles, gown, mask, and clean
gloves)
• CVAD dressing change kit, which includes sterile gloves, mask, antiseptic
swabs for skin disinfection, TSM dressing, 4 × 4 gauze pads, tape measure,
sterile tape, label.
• Petroleum-based ointment or petroleum-based gauze, sterile
• Suture removal kit (if sutures are in place)
142 | P a g e
Changing Central Venous Catheter (CVC) Dressing procedure
# Steps Rational
A. Changing dressing.
Pre procedure:
.1 Varify medical prescription / facility policy To ensure correct intervention for
(determine the need for dressing change or CVC correct patient
flushing )
.2 Wash hands To reduce infection
.3 Prepare equipment To promote efficient time
management and an organized
approach to the task
.4 Introduce youreslf to patient To build trust
.5 Identfiy the patient To ensure that is the right patient
.6 Explain procedure to the patient To facilitate cooperation and relive
anxiety
.7 Keep patient privacy To minimize embarrassment
.8 Adjust bed hieght usually elbow hieght of the care To prevent back strain
giver.
.9 Position patient in comfortable position with head • Provides access to patient. •
slightly elevated.
.10 Put disposable pad under with venous access To reduce transmission of infection
.11 Apply mask and instruct patient to turn head away Reduces transfer of microorganisms;
from site during dressing change or provide mask prevents spread of airborne
for patient. microorganisms over CVAD
insertion site.
.12 Move the over bed table to convenient location To be eased to reach.
within easy reach.
.13 Setup of sterile field on the table according to your To setup of sterile field.
hand dominance. Open Dressing supplies and add To prevent ear from entering.
to sterile field. If IV solutions is infusing via CVC,
interrupt and place on hold during dressing
change. Apply slide clamp on each lumen of CVC.
.14 Wear clean gloves. To reduce transmission of infection
During procedure :
143 | P a g e
.15 Remove old TSM dressing by stabilizing catheter To replace a new dressing and
with non-dominant hand. prevent unintentional catheter
removal.
(Remove dressing by pulling up one corner and
gently pulling straight out toward the insertion
site.)
.16 Inspect catheter, insertion site, and surrounding To assess if any s signs of fluid
skin site for redness, swelling, and drainage, or infiltration, infection (redness,
blood around the site. swelling, tenderness), bleeding,
Measure external CVAD length and • thrombosis, interstitial placement, or
compare with measurement from insertion if catheter migration.
dislodgement is suspected. Measurement of external •
catheter length provides
comparison to determine
dislodgement.
.17 Discard old dressings and remove gloves To reduce transmission of infection
appropriately (as
per facility policy).
.18 Perform hand hygiene. To reduce transmission of infection.
.19 Put on sterile gloves To prevent the introduction of
microorganisms into insertion site
.20 Perform skin antisepsis with antiseptic agent To prevent the introduction of
(Povidone-iodine, 70% Alcohol) by using a gentle microorganisms into the bloodstream
friction in back-and-forth motion for 30 seconds or
moving from insertion site to outward with swab
in concentric circle.
Area to be cleaned should be same size as •
dressing.
Allow to dry completely. •
.21 Stabilize the catheter with your non dominant To prevent the introduction of
hand and wipe each catheter lumen with one microorganisms into the bloodstream
alcohol swab from inner to outer.
.22 Apply skin protectant if available allow to dry to protect skin damage when
completely so that skin is not tacky. dressing removed
.23 A. Apply sterile CVC dressing according to To minimize catheter movement and
hospital policy (TSM /gauze dressing). prevent dislodgement
B. Prepare dressing materials:
144 | P a g e
TSM dressing: change at least every 5 to 7 days.
Gauze dressing: change at least every 2 days.
Gauze under TSM: change at least every 2 days.
.24 Label the change dressing, date and time with your Provides information about next
signature. dressing change.
.25 Close Clamp the lumen and remove end cap. Disinfect the end of lumen
B. Flushing.
.26 Put on clean gloves. Reduces transmission of

microorganisms.
Prevents transfer of body fluids.
.27 Disinfect the end of the lumen with antiseptic To prevent the introduction of
agent. microorganisms into the bloodstream
.28 Connect the syringe filled with 0.9% Normal To flush the lumen
Saline (or heparinized solution) to the end of
lumen.
Always use 10-mL syringe to minimize •
pressure during injection.
.29 Unclamp the lumen. To flush the lumen
.30 Aspirate for positive blood return To confirm catheter patency
.31 Flush with 0.9% NS (or heparinized solution). To flush the lumen
.32 If there is resistance never push To figure out what is wrong with the
Ask the patient to elevate his arm over the • catheter
head or cough.
Make sure that clamp is open. If not useful •
notify physician
.33 Near completion of injection, continue pressure on To prevent air embolism
plunger then clamp lumen before withdrawing
syringe.
.34 Clean the end of the catheter again with another To prevent the introduction of
alcohol swap. microorganisms into the bloodstream
.35 Apply a new end cap if available. To prevent the introduction of
microorganisms into the bloodstream
145 | P a g e
.36 Repeat for each lumen To prevent the introduction of
microorganisms into the bloodstream
.37 Turn the patient in comfortable position To maintain patient comfort
C. Removal.
Pre-Procedure
.38 Position the patient in bed in Trendelenburg • Position promotes venous filling and
position. If patient cannot tolerate Trendelenburg, prevents air embolus during catheter
put the patient in the supine position (they should removal.
not be
or sitting
upright).
.39 Place waterproof sheet under site. To minimize soiling of bed linen and
prevent transmission of infection.
.40 Wear clean gloves and mask. To prevent transmission of infection.
During procedure
.41 Remove old dressing and inspect the wound for To detect any abnormality.
signs of infection (redness, swelling, purulent
discharge).
.42 Discard old dressing and gloves appropriately in a To prevent transmission of infection.
red garbage container.
.43 Perform hand washing. To prevent transmission of infection.
.44 Remove gloves and perform hand hygiene; open To prevent transmission of infection.
CVAD dressing change kit and suture removal kit
(if CVAD is sutured in place). Add items to sterile
field.
.45 Put on sterile gloves. To prevent transmission of infection.
.46 Disinfect skin of insertion site with antiseptic To prevent the introduction of
solution. microorganisms into insertion site.
If CVAD is sutured in place, remove sutures.
Remove sutures:
.47 Hold scissors in dominant hand and forceps in To facilitate suture removal.
non-dominant hand.
146 | P a g e
.48 Grasp knot of suture with forceps. To facilitate suture removal.
.49 Pull up knot gently while slipping the tip of the To facilitate suture removal.
scissors under suture near the skin.
.50 Cut under the knot as close as possible to the skin There will be no way to remove the
at the distal end of the suture from below the surface.
knot. Never snip both
ends of the knot.
.51 Grasp knotted end with forceps, in one continuous

action pull suture out of the tissue by the forceps.
Removing central venous catheter:
.52 Using nondominant hand, apply sterile gauze to Valsalva maneuver reduces risk for
site. air embolus by decreasing negative
Instruct patient to take deep breath and perform pressure in respiratory system.
Valsalva maneuver (forced expiration with the
mouth closed Or remove at the end of inspiration
if mechanically ventilated) as catheter is
withdrawn.
.53 With dominant hand slowly remove catheter in Gentle removal of catheter prevents
smooth, continuous motion. Stop removal stretching and breaking it.
procedure if resistance is met while removing
catheter.
.54 Immediately apply pressure to site and continue Direct pressure reduces risk or
until bleeding stops. bleeding and hematoma formation.
.55 Apply petroleum-based ointment or gauze to exit To prevent risk of infection.
site. Apply sterile occlusive dressing such as TSM
dressing or sterile gauze to site. Change dressing
every 24 hours until healed.
147 | P a g e
.56 Label dressing with date, time, and your initials. Identifies date of catheter removal
and need for dressing change.
.57 Inspect catheter integrity for intactness, especially If catheter tip is broken or
along tip, and that length is appropriate for device. compromised, place in container and
Discard in appropriate biohazard container. label for possible follow-up and
notify health care provider.
.58 Position patient in a supine position for 30 minutes Reduces chance of air embolism.
after nontunneled CVAD removal
Post procedure:
.59 Dispose any used material To reduce transmission of infection

.60 Remove gloves To reduce transmission of infection
.61 Wash hands To reduce transmission of infection
.62 Document date, time, observation and the length To maintain continuity of care
of catheter that extended out from the insertion site
.63 Report any abnormalities To take future action if needed
References:
Hicks, M. A. & Lopez, P. P., 2018. Matthew A. Hicks; Peter P. Lopez.. [Online]
Available at: https://www.ncbi.nlm.nih.gov/books/NBK539811/
[Accessed 17 July 2023].
O'Grady, N. P. et al., 2017. Guidelines for the Prevention of Intravascular Catheter-
Related infections, 2011. [Online]
Available at:
https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsiguidelines-H.pdf
[Accessed July 13, 2023].
148 | P a g e
Defibrillation and Cardioversion
149 | P a g e
Defibrillation and Cardioversion
Defibrillation
Definition:
Defibrillation is the definitive treatment that uses an electrical current to help the heart
return to a normal rhythm immediately after life-threatening dysrhythmia in which the
patient does not have a pulse and is undertaken parallel with advanced cardiac life
support procedures.
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Indications:
Types of Defibrillators:
• Automated External Defibrillators

(AEDs): portable devices that are
designed to save lives when used on
victims of sudden cardiac arrest.
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• Semi-Automated Defibrillators:
These are like AEDs, but the
device prompts the user to press a
button to deliver a defibrillation
shock.
• Fully automated defibrillators:

analyze the heart's rhythm and
deliver a defibrillation shock if
commanded by the device
software without user intervention.
• Implantable Cardioversion-Defibrillator
(ICDs): Can give off a low-energy shock
that speeds up or slows down an abnormal
heart rate, or a high-energy shock to
correct a fast or irregular heartbeat. It is
like pacemakers, but pacemakers deliver
only low-energy electrical shocks.
152 | P a g e
• Manual External Defibrillator: It is used
mainly in emergency departments and
critical care units and gives the user the
capability to determine the problem with
the heart and treat it appropriately.
• Wearable Cardioverter Defibrillator: Worn by someone at risk of sudden cardiac

death. It automatically detects certain irregular and life-threatening heartbeats,
then can automatically deliver a treatment shock to correct the arrhythmia and
restore a normal rhythm to the heart.
Complication:
If performed for patients who don’t have ventricular tachycardia (with no pulse) or
ventricular fibrillation, may cause Ventricular fibrillation and Cardiac arrest.
153 | P a g e
154 | P a g e
Manual External Defibrillator Procedure
Equipment:
• Crush cart
• Defibrillator with monitor
• CPR-board.
• k y jells.
• Cotton.
155 | P a g e
Manual External Defibrillator Procedure
No Steps Rational
1. Assess the cardiac status for PVT or VF To avoid any mistakes.
and confirm the absence of a pulse.
3. Prepare the equipment. To save time and effort.
4. Wear gloves. To maintain infection control.
5. Keep patient privacy. To decrease patient embarrassment
(Patient right).
6. Remove any metallic objects from the To prevent the current interference.
patient and dentures.
7. Place a backboard under the patient. To provide a hard surface for CPR.
8. Start CPR until the defibrillator is ready. To preserve heart and brain function.
9. Bring a crash cart to the patient’s bed. To save time and effort.
10. Prepare paddles with a proper To enhance electrical conduction and
conductive agent. minimize patient burn.
11. Place one paddle at the heart’s apex just
to the left of the nipple in the
midaxillary line.
Place the other paddle just below the
right clavicle to the right of the sternum.
156 | P a g e
12. Prepare the defibrillator by placing the To ensure proper functioning.
synchronizer button switched off and
charging the defibrillator paddle as
prescribed.
13. Modify the joules button according to To ensure proper functioning.
the ACLS protocol.
14. Apply suitable pressure to each paddle To ensure proper functioning.
against the chest wall.
15. State “All clear'' loudly and usually To avoid accidental shocking for
verify that all personnel are clear of personnel.
contact with the patient's bed and
equipment and disconnect the oxygen
supply if attached.
16. Look for cardiac rhythm on the monitor.
17. Depress both buttons on the paddles
simultaneously and hold until the
defibrillator fires.
18. If VF persists, resume CPR following
ACLS protocol and immediately start
with chest compressions according to
(algorithm).
19. Verify rhythm after approximately 2
minutes of CPR. If the rhythm was
unchanged, charge the defibrillator
again and shock as above.
157 | P a g e
20. Continue CPR and give shock according
to the rhythm and follow ACLS
protocol.
21. Assess the patient’s pulse.
22. Assess the patient’s ECG rhythm on the
cardiac monitor.
23. Assess the skin from the burn.
24. Return the equipment.
25. Clean and dry defibrillator.
26. Discard supplies. To reduce the risk of transmission of
microorganisms.
27. Connect the defibrillator to the electrical To ensure proper functioning.
charge.
28. Remove gloves. To maintain infection control.
30. Record in the patient's chart: Maintaining patient safety and keep-
• Date and time of defibrillation. documented source helps in following
• Joules used. the patient’s status.
• Times of shocks.
• Patient’s response.
• ECG interpretation.
31. Report any abnormalities to physician. To detect any abnormality.
158 | P a g e
Cardioversion
Definition:
Cardioversion is the use of low-energy electrical shocks to resume the heart’s normal
electrical rhythm in patients with certain types of dysrhythmias. Cardioversion is
different from defibrillation, an emergency procedure that's done when the heart stops
or quivers uselessly. Defibrillation delivers more powerful shocks to the heart to
correct its rhythm.
159 | P a g e
Indications:
160 | P a g e
161 | P a g e
Types of Cardioversions:
• Electric Cardioversion: uses a machine and sensors (electrodes) to deliver

quick, low-energy shocks to the chest. Electric cardioversion allows a
healthcare provider to instantly see if the procedure has restored a typical
heartbeat.
• Chemical (pharmacological) Cardioversion: cardioversion uses medicine to

restore the heart's rhythm. It takes longer to work than electric cardioversion. If
the healthcare provider recommends cardioversion with medications to restore
the heart's rhythm, the patient won't receive electric shocks to the heart.
162 | P a g e
Electric Cardioversion Procedure
Equipment:
• Crush cart
• Cardioversion machine.
• CPR-board.
163 | P a g e
Cardioversion Procedure
No Steps Rational
1. Assess the cardiac status for SVT, AF or To avoid any mistakes.
atrial flutter, VT with a pulse.
3. Prepare the equipment. To save time and effort.
5. Identify the patient by 2 Nurses. To increase patient trust and prevent
errors.
6. Explain the procedure to the patient. To increase patient cooperation.
7. Obtain informed written consent from
the patient.
8. Instruct the patient to be fast prior to the
procedure for at least 6 hours.
9. Instruct the patient to stop Digitalis at
least 48 hours before the procedure.
10. Check the recent blood investigation
such as K, Ca, urea, ABG, and INR.
11. Keep patient privacy. To decrease patient embarrassment
(Patient right).
12. Wear gloves. To maintain infection control.
13. Remove any metallic objects from the To prevent the current interference.
patient and dentures.
14. Place a backboard under the patient. To provide a hard surface for CPR.
15. Check the patient's vital signs.
164 | P a g e
16. Give the patient the prescribed
medication prior to the implementation
of the procedure (sedatives).
17. Bring the cardioversion to bed.
18. Prepare paddles with a proper
conductive agent.
19. Place one paddle at the heart’s apex just
to the left of the nipple in the
midaxillary line.
Place the other paddle just below the
right clavicle to the right of the sternum.
20. Prepare the cardioversion by placing the To ensure proper functioning.

synchronizer button switched on.
21. Charge the paddles with joules To ensure proper functioning.
according to the type of dysrhythmia
and doctor’s prescription.
22. Apply suitable pressure to each paddle To ensure proper functioning.
against the chest wall.
23. State “All clear'' loudly and usually To avoid accidental shocking for
verify that all personnel are clear of personnel.
contact with the patient's bed and
165 | P a g e
equipment and disconnect the oxygen
supply if attached.
24. Look for cardiac rhythm on the monitor.
25. Depress both buttons on the paddles
simultaneously and hold until the
cardioversion fires.
26. Assess the patient’s pulse.
27. Assess the patient’s ECG rhythm on the
cardiac monitor.
28. Assess the skin from the burn.
29. Return the equipment.
30. Clean and dry cardioversion.
31. Discard supplies. To reduce the risk of transmission of
microorganisms.
32. Connect the cardioversion to the To ensure proper functioning.
electrical charge.
33. Remove gloves. To maintain infection control.
35. Record in the patient's chart: Maintaining patient safety and keep-
• Date and time of cardioversion. documented source helps in following
• Joules used. the patient’s status.
• Patient’s response.
• ECG interpretation.
36. Report any abnormalities to physician. To detect any abnormality.
166 | P a g e
References:
• Tintinalli, J. and Ma, J. (2020) Tintinalli’s emergency medicine: A

comprehensive study guide. New York etc.: McGraw-Hill Education.
• Lynn, P. (2019) Taylor’s clinical nursing skills: A nursing process approach.
Philadelphia, PA: Wolters Kluwer Health.
167 | P a g e
Nasogastric Tube
168 | P a g e
Nasogastric Tube Feeding
Definition NGT Feeding
Nasogastric tube feeding is administering of nutrients or medication from the nasal

route into the stomach via a feeding tube.
Indications of NGT Feeding
➢ Unconscious patient.
➢ Patient can’t swallow.
➢ Patient who has oral surgery.
Purpose:
• To administer of liquid food, liquid medication and fluids to the patient.
Equipment for (NGT feeding):
▪ Toomey syringe, 50ml

▪ Clean gloves
▪ Towel
▪ Kidney basin
▪ Cup of water
▪ Feeding (formula).
▪ Tape measure.
169 | P a g e
Nasogastric Tube Feeding (NGT) Procedure
Steps Rational
Pre procedure :
1. Verify physician prescription for appropriate To ensure safety
formula; (check amount, concentration, type,
frequency) and check formula expiration date.
2. Wash hands. To prevent transmission of infection
3. Prepare all needed equipment. To save time and effort.
4. Introduce yourself to patient. To build trust
5. Identify the patient. To ensure that, right patient receives the
intervention.
6. Explain procedure to the patient. To facilitate cooperation.
7. Keep patient privacy. To minimize embarrassment.
8. Raise bed to a comfortable working position, To prevent back and muscle strain.
usually elbow height.
9. Put the patient in high fowler position. If there is To avoid aspiration.
contraindication for high fowler position, place the
patient in reverse Trendelenburg position after
physician verification (such as patient with spinal
precautions).
Reverse Trendelenburg
11. Wear clean gloves. To prevent transmission of infection.
During procedure :
12. Put towel over patient's chest. To keep patient clothes clean and dry.
13. Pinch end of tube and remove cap. Prevents excessive air from entering
patient’s stomach and leakage of gastric
contents.
170 | P a g e
14. Check placement of feeding tube by:
a. Attach the syringe to the end of the tube and Gastric fluid can be green with particles.
aspirate a small amount of stomach contents.
Check for color and consistency.
b. Measure the length of the exposed tube at the
The tube should be marked with an
nostril. indelible marker at the nostril at the time
of insertion. This marking should be
assessed each time the tube is used.
15. Check gastric residual volume before each GRV determines if gastric emptying is
feeding through aspirate the gastric content by ryle delayed.
syringe.
16. Return aspirated contents to stomach slowly if it Returning aspirated contents to stomach
is 50 ml or less and continue feeding and if it is prevents loss of nutrients and
greater than 50 ml hold feeding and report to electrolytes in aspirated fluid.
physician.
17. Administer feeding:
a. Remove plunger from 60mL syringe
b. Attach syringe to feeding tube.

c. Pour premeasured amount of formula into To feed prescribed amount of formula.
syringe, open clamp, and allow food to enter tube
d. Elevate of syringe with tube no more than 45 cm. To help flow of formula by gravity.
e. Allow syringe to empty gradually until prescribed Introducing the formula at a slow,
ordered amount has been administered. regular rate decreases GI distress.
f. Control rate, fast or slow, by elevate or lower of
the syringe.
(DO NOT push the liquid forcefully in the
NGT).
g. Flush tube with amount of water (30 ml) after Provides patient with source of water to
finishing feeding. help maintain fluid and electrolyte
balance. It also Clears tubing of formula.
171 | P a g e
18. Disconnect syringe from tubing and cap end of Capping the tube deters the entry of
tubing. microorganisms and prevents leakage
onto the bed linens.
19. Keep the patient at high fowler position for 1 hour To avoid aspiration.
after feeding.
Post procedure:
20. Dispose any used supplies. To prevent transmission of infection
21. Remove gloves and discard in proper bag. To prevent transmission of infection
22. Wash hand. To reduce transmission of infection
23. Record amount, concentration, type of food and To ensure continuity of care
time of feeding.
24. Report any abnormalities as vomiting and reports To ensure patient safety.
from the patient such as abdominal pain.
Complications of NGT Feeding
Aspiration: it is a serious complication that happen due to inhalation of gastric

contents into the larynx and lower respiratory tract.
Skin irritation and breakdown especially around nares may because of fixation by
adhesive tape due to consistent pressure.
References
• Perry, AG, Potter, PA &Ostendorf ,WR (2018). Clinical Nursing Skills and
Techniques (9th edition) China, pp. 852-857.
• Taylor, C., Lynn, P. & Bartlett, J (2019). Fundamentals of Nursing: The Art and
Science of Person-Centered Care (9th edition) Philadelphia, Wolters Kluwer,
pp1459- 1460.
• Stein, L.N.M. and Hollen, C.J., 2020. Concept-Based Clinical Nursing Skills:
Fundamental to Advanced. Elsevier Health Sciences.
• Sigmon, D.F. and An, J., 2021. Nasogastric Tube. In StatPearls [Internet].
StatPearls Publishing.
• Judd, M., 2020. Confirming nasogastric tube placement in adults.
Nursing2022, 50(4), pp.43-46.
• Yasuda, H., Kondo, N., Yamamoto, R., Asami, S., Abe, T., Tsujimoto, H.,
Tsujimoto, Y. and Kataoka, Y., 2021. Monitoring of gastric residual volume
during enteral nutrition. Cochrane Database of Systematic Reviews, (9).
172 | P a g e
Total Parenteral Nutrition
173 | P a g e
Total Parenteral Nutrition
Definition
Total parenteral nutrition (TPN) is a method of supplying nutrients to the body by
infusing a specially formulated solution into the central circulation through a central
catheter.
Purposes
1. To provide essential nutrients with an intravenous solution

of carbohydrates, fats, amino acids, electrolytes, minerals
vitamins and water.
2. To maintain a positive fluid and electrolyte balance.
3. To maintain muscle mass and provide calories for metabolic demands.
Indications
1. Non functional GIT because of interruption in continuity of GIT or impaired

absorptive capacity.
2. When >7 days of nothing-by-mouth (NPO) status anticipated, as in the case
of inflammatory bowel disease, patients with an acute exacerbation paralytic
ileus or bowel obstruction
3. Specific disorders such as tracheoesophageal fistula, diaphragmatic hernia.
4. Infants with congenital or acquired disorders
5. When the patient is suffering from chronic diarrhea and vomiting or is
extremely undernourished
174 | P a g e
Equipment.
• TPN solution (Remove
TPN bag from the
refrigeration 1 hour
prior to initiation of
infusion).
• Prescribed lipid
emulsion bottle (for
separate infusion).
• Filtered IV
administration set.
• Four povidin-iodine
pads or swab sticks.
• Two 5 ml syringe.
• 10 ml vial of 0.9 %
sodium chloride.
• 10 ml vial of heparin
(10 to 100 U/ml).
• Tape and IV stand.
175 | P a g e
Total Parenteral Nutrition Procedure
Steps Rational
Pre procedure :
1. Check physician order for patient name, date, To ensure safety
formula component, duration of infusion time.
2.Wash hands. To prevent transmission of infection

3.Prepare all needed equipment. To save time and effort.
4.Introduce yourself to patient. To build trust
5.Identify the patient. To ensure that, right patient receives the
intervention.
6.Explain procedure to the patient. To facilitate cooperation.
7.Keep patient privacy. To minimize embarrassment.
8.Raise bed to a comfortable working position, To prevent back and muscle strain.
usually elbow height.
Assessment
9.Assess the nutritional status of the patient as:
• Laboratory examination (as serum electrolytes,
BUN levels, Hemoglobin)
• Radiological examination.
To assess bone density.
• Physical examination and anthropometric
measurements (Patient weight, height, skin fold
thickness & arm circumference).
• Patient history (dietery history, medical and
surgical history).
10.Disinfect your hands. To prevent transmission of infection.
11.Wear clean gloves. To prevent transmission of infection.
12.Check solution for cloudiness and turbidity. To prevent transmission of infection.
During procedure :
-To prevent air embolism and blood
13.Clamp central venous catheter.
back up.
176 | P a g e
-To reduce risk of infection.
14.Clean the connector with an alcohol swab

vigorously for 30 seconds and allow to dry
15.Place IV administration set into infusion pump and -To identifying time frame for changing
label it with date and time. IV set.
16.Connect IV administration set to TPN bag. To accurate, consistent delivery of TPN.
17.Tape the connection and open catheter clamp. -To prevent accidental disconnection.
18.Set prescribed rate of infusion on pump and start -To consistent delivery of TPN to
pump. prevent metabolic complications.
19.For cycled TPN
-Infuse TPN for 1st hour at rate 50–85 ml/h then -To improve patient tolerance to
gradually increased over 24 hours. glucose load.
-One to two hours prior to end of TPN cycle, decrease -To decrease pancreatic secretion of
rate of TPN infusion to half. insulin to prevent hypoglycemia.
-At the end of TPN infusion turn off infusion pump,
clamp IV tube.
- Saline flushes catheter lumen of TPN
-Fill syringe with 3-5 cc 0.9% saline and fill a second solution and prevents drug– nutrient
syringe with 1-5 cc heparin (10-100 U/ ml). interactions with heparin.
To prevent blood clotting in catheter
-Flush catheter with saline then heparin. lumens.
20.Heparinize other lumens of multi lumen catheter if
not being used for infusions every 24 hours.
21.If the TPN administration is interrupted for any
reason, notify physician for appropriate orders.
177 | P a g e
22.During the TPN infusion monitor the patient for
signs and symptoms of metabolic-related
complications
Post procedure:
23.Dispose any used supplies. To prevent transmission of infection
24.Remove gloves and discard in proper bag. To prevent transmission of infection
25. Wash hand. To reduce transmission of infection
26.Record Date and time, Infusion rate ,The type of To ensure continuity of care
nutrition ,Patient maintained desired weight.
27.Reporting patient's reactions as: Changes in vital To ensure patient safety.
signs, Dyspnea , Dizziness ,Chest and eye pain
,Nausea and vomiting.
Complications of Parenteral nutrition
1. Inflammation and sepsis of the catheter insertion site.
2. Hyperglycemia caused by rapid metabolism of dextrose that leading to
dehydration and decreasing level of consciousness.

3. Fluid and electrolyte imbalances during the early phase of TPN.
4. Anemia and bleeding tendencies.
References
• Taylor, C., Lynn, P. & Bartlett, J (2019). Fundamentals of Nursing: The Art
and Science of Person-Centered Care (9th edition) Philadelphia, Wolters
Kluwer, pp1459- 1460.
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Gastric Lavage
179 | P a g e
Gastric Lavage
Definition
Gastric lavage s a technique of cleaning out the contents of the stomach. This is carried
out through insertion of re orogastric or nasogastric tube followed by repetitive
instillation and aspiration of small amounts of fluid.
Indications
• Upper gastrointestinal hemorrhage.
• Ingestion of large amounts of drugs or toxins.
Purposes
• Remove or aspirate the unabsorbed fractions of toxins and drug. It is most
effective if done within 60 minutes of ingestion.
• Diagnose and control gastric bleeding.
• As a cooling technique in hypothermia.
• Cleanse stomach before diagnostic endoscopic procedures.
Contraindications
Absolute Contraindications
• Patients with depressed level of consciousness and unsecured airway.
• Ingestion of sharp metals.
• Ingestion of corrosive agent (alkali or acidic).
• Ingestion of a foreign body (e.g., drug packet).
• Patients who have sustained head injury.
Relative Contraindications
• Patients with upper airway or GIT anatomical deformity.
• Patients with esophageal varices.
180 | P a g e
• If there is a delay in the time of ingestion of toxin
and arrival at health care facility.
• Patients who have ingested poison with effective antidote.
Methods of Gastric Lavage
1- Closed System Irrigation
• Connect the bag or bottle of lavage fluid to orogastric/ nasogastric tube with a
Y- connector.
• Connect the other end of the Y- connector to the suction tube. Aspiration of the
stomach content followed by clamping of the suction tube and then allowing
50-200 ml of the lavage fluid to run into stomach by gravity.
• When the required amount of solution has been instilled. It is drained by gravity
or removed by suctioning (Figure 1).
• Repeat this procedure till the desired results are obtained.
• Estimation of gastric output is important to assess the fluid balance and it can
be measured by subtracting the irrigant fluid from the total amount of drained
fluid.
• The closed system helps in minimizing the contact risk with body fluid for
healthcare professional.
Figure 1: Closed System Irrigation
181 | P a g e
2- Intermittent Open System Irrigation
• Taking complete personal protective measures as necessary (e.g. gown and
face protection).
• Empty the gastric content by suctioning or 50 ml catheter tip syringe.
• Draw up approximately 50 ml of irrigation solution through the syringe and
instill it using gentle pressure after aspiration of irrigation fluid.
• Discard solution into measuring container.
• Continue this procedure until the clear irrigant has been obtained (Figure 2).
Figure 2: Intermittent Open System Irrigation
Equipment
− Irrigation syringe (Tommy syringe).

− Lavage fluid: normal saline or tape water.
− Drainage bag.
− Specimen container for aspirate (for overdose).
− Tissue paper.
182 | P a g e
− Emesis basin.
− Clean gloves.
− Clamp.
-Suction source and connecting tube.
Procedure of Gastric Lavage
No. Steps Rational

Pre-Procedure
1 Verify physician prescription. To avoid any mistakes
2 Wash Hands. To maintain infection control
3 Prepare needed Equipment. To save time and effort
4 Introduce yourself. To avoid mistakes
5 Verify the patient by 2 Nurses. To increase patient trust and help prevent error
6 Explain procedure to the patient. To increase patient’s cooperation
7 Keep patient privacy. Patient right (to decrease patient
embarrassment)
8 Assess the patient’s need for lavage.
9 Disinfect your hands. To prevent transmission of infection.
10 Wear clean gloves. To prevent transmission of infection.
During Procedure
11 Stand on the right side of the bed. To prevent unnecessary body strain.
Aspirate gastric contents using To remove gastric content

12
irrigating syringe. (Blood, toxic agent).
In case of toxic agents or drug To identify the type of toxin and determine the
13
overdose, send a specimen for analysis. antidote.
183 | P a g e
Perform intermittent lavage (with To prevent hypothermia
normal saline slightly warmed or at
14
room temperature or by using tape
water).
Instill from 200 to 300 ml of warm To break up clots and rinse out the stomach of
normal saline or water into the tube using blood (in case of hemorrhage).
15
Irrigating syringe. To dilute toxic agents and wash it out of the
stomach before absorption (in case of toxins).
Aspirate gastric contents through To evacuate gastric contents from the
irrigating syringe or connect lavage tube stomach.
to intermittent suction (Figure3).
16
Irrigating Syringe
Continue lavage until returns are clean To ensure that the stomach is completely free
and free of clots (in case of hemorrhage) from its contents.
17
or free of toxic agents (in case of drug
overdose or toxins).
Post procedure:
Dispose any used supplies and Remove − - To promote comfort.

18
the NGT if not needed as follows:
184 | P a g e
-Clamp the tube
-Remove the tape around the tube gently.
-Instruct patient to take a deep breath and
hold it.
-Quickly and carefully remove tube while
patient holds breath.
-The patient is offered a glass of water
to rinse their mouth.
Put the patient in a comfortable

19 position.
Assess the patient's vital signs, cardiac

20 rhythm, and oxygen saturation level,
LOC during and after procedure.
Assess the amount and color of gastric
21
wash.
Reassess the position of the tube each To decrease the risk of aspiration.
22 time before instillation of medications,
feeding or irrigation.
Frequent assessment of the amount of
23 the drainage.
Remove gloves and discard in proper To prevent transmission of infection

24
bag.
25 Wash hand. To reduce transmission of infection
185 | P a g e
Record The date and time of lavage. To ensure continuity of care
-History of ingestion of drugs, toxin or
upper GIT bleeding.
-Type and amount of lavage fluid.
-Purpose of gastric lavage.
26
-The amount and characteristics of
aspirate.
-The amount of gastric drainage after
lavage.
Reporting patient's for any To ensure patient safety.

27
abnormalities.
Complications
• Vomiting.
• Esophageal tears or perforation after orogastric tube insertion.
• Inadvertent tracheal intubation and/or airway trauma.
• Aspiration pneumonia.
• Cardiac arrhythmias or ECG changes.
186 | P a g e
References
• Taylor, C., Lynn, P. & Bartlett, J (2019). Fundamentals of Nursing: The Art and
Science of Person-Centered Care (9th edition) Philadelphia, Wolters Kluwer,
pp1459- 1460.
• Stein, L.N.M. and Hollen, C.J., 2020. Concept-Based Clinical Nursing Skills:
Fundamental to Advanced. Elsevier Health Sciences.
• Sigmon, D.F. and An, J., 2021. Nasogastric Tube. In StatPearls [Internet].
StatPearls Publishing.
• Judd, M., 2020. Confirming nasogastric tube placement in adults.
Nursing2022, 50(4), pp.43-46.
• Yasuda, H., Kondo, N., Yamamoto, R., Asami, S., Abe, T., Tsujimoto, H.,
Tsujimoto, Y. and Kataoka, Y., 2021. Monitoring of gastric residual volume
during enteral nutrition. Cochrane Database of Systematic Reviews, (9).
187 | P a g e

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Faculty of Nursing

Critical Care and Emergency Nursing

- Prof. Manal Ismail.

- Associate. Prof. Marwa Fathallah.

• 50% Dextrose 50ml • Dobutamine 250mg in 5ml or

• Syringes: 3/5/10/20/50 cm - Ryle Extension line- Arterial line - 3 way –

Laryngoscope - Endotracheal tubes sizes – Oxygen mask – Nasal cannula –

• 1,000 ml dextrose 5% in water • 1,000 ml lactate solution,

Procedure of Performing Endotracheal Intubation

- An endotracheal tube is a flexible tube that is placed in the

Components of endotracheal tube:

Purposes of performing endotracheal intubation :

Indications of performing endotracheal intubation:

• Inadequate oxygenation and ventilation.

Procedure of Performing Endotracheal Intubation

position with in-line spinal

and torn tape edges around

43. Dispose of equipment appropriately. To reduce risk of transmission of

The LEMON mnemonic can be used to determine whether a difficult

• L = Look Externally: look for features associated with a difficult

Complications from endotracheal intubation:

• Intubation of esophagus or right main-stem bronchus

Goodrich, C. (2019) Endotracheal Intubation (Perform). Available from:

Oropharyngeal Airway Insertion and Care

An oropharyngeal airway (also known as an oral airway, or Guedel

• To maintain or open a patient's airway.

• Oropharyngeal airway of appropriate size.

Procedure of Oropharyngeal Airway Insertion and Care

No. Steps Rational

During Procedure (oropharyngeal airway insertion)

Suctioning is defined as a sterile invasive procedure which is used for

• Maintain patent airway by removing the accumulation of secretion.

• Auscultation of adventitious lung sounds (rhonchi) or crackles over the

• to obtain a sputum specimen/ETA (Endo Tracheal Aspiration) for

• Encourage the patient to do breathing and coughing exercises if

• Portable suction machine (if wall suction is not available).

1. Verify physician prescription. To ensure safety.

2. Wash hands. To prevent transmission of

3. Prepare equipment. To save time and effort.

4. Introduce yourself to the patient. To build trust.

6. Explain procedure to the patient. To facilitate cooperation and decrease

7. Keep patient’s privacy. To minimize embarrassment.

8. Adjust the height of bed. To maintain comfort during

10. Disinfect your hands. To prevent transmission of

11. Apply clean gloves. To prevent transmission of

13. Positioning of the patient:

o If conscious, place patient in semi- o Semi-fowler’s position helps

18. Adjust suction to appropriate pressure: Higher pressures cause mucosal

19. Remove gloves and discard it. To prevent transmission of infection.

20. Disinfect your hands. To prevent transmission of infection.

21. Open the suction kit without To prevent transmission of infection.

24. Disinfect your hands. To prevent transmission of infection.

25. Wear sterile gloves. To maintain sterility during

27. Connect suction catheter to the suction To maintain sterility of suction

Nasopharyngeal and Nasotracheal suctioning:

30. Lubricate 6–8 cm of suction catheter with

31. Remove oxygen-delivery device, if

33. Nasotracheal: During patient inhalation,

Endotracheal/ Tracheostomy suctioning:

38. Reapply oxygen-delivery device and To prevent risk of hypoxemia.

40. Assess effectiveness of suctioning and repeat, To determine patient need to

42. Provide 10 minutes between suctioning To prevent elevations in

44. Roll catheter around fingers of dominant To prevent transmission of