Aseppsis and Adevanced Procedures 3

INFECTION PREVENTION
prepared by:
Getenet.d
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The Chain of Infection
 Infectious agent or pathogen
 Reservoir
 Portal of exit
 Mode of transmission
 Portal of entry
 Susceptible host
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ASEPSIS
• The term asepsis means the absence of disease-
producing microorganisms.
• Infection:- is the invasion of the body by micro
organism
• Infection can be symptomatic or asymptomatic
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Concept of Asepsis
• The nurse’s efforts to minimize the onset & spread of

infection are based on the principles of aseptic technique.
• Aseptic technique:- is an effort to keep the client as free

from exposure to infection-causing pathogens as possible.
• This can be achieved by ensuring that only sterile

equipment & fluids are used during invasive medical &
nursing procedures.
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Types of Asepsis Technique
• There are two types of asepsis:
Medical asepsis & Surgical asepsis.
• Medical or Clean Asepsis reduces the number of

organisms & prevents their spread.
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Surgical or Sterile Asepsis or Sterile
Technique
• includes procedures used to eliminate micro-
organisms from an area & is practiced by nurses in
ORTs, labour & delivery area, major diagnostic
areas & Rx areas.
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Medical Asepsis
• During daily routine care, the nurse uses basic
medical aseptic techniques to break the infection
chain.
• E .g of medical asepsis are changing client’s bed
linen daily, handwashing, barrier techniques, &
routine environmental cleaning.
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1. Hand Hygiene
 Proper hand hygiene and the use of protective glove is
a key component in minimizing the transmission of
disease causing microorganisms and maintaining an
infection-free environment.
 Appropriate hand hygiene must be carried out:
•Before coming in direct contact with patients
•Before putting on sterile surgical gloves or

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Appropriate hand…cont
•After any situation in which hands may be
contaminated, such as (handling contaminated

objects, including used instruments; touching
mucous membranes , blood, body fluids, secretions
or excretions except sweats)
• After removing gloves
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cont….d
• The purpose of hand washing is to mechanically remove

soil and debris from skin and reduce the number of
transient microorganisms.
• appropriate hand washing has three essential

components:
oSoap or chemical
oWater
o07/10/2022
friction getenet d 10
Hand washing procedure
• Lather with soap and scrub between fingers,

on the backs of your hands, and under nails
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Hand washing procedure
• Wash for 20 seconds, or as long as it
takes to sing “Happy Birthday”
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Handwashing procedure
Dry hands using a paper towel or
electric hand dryer
Use paper towels to turn off the tap
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Hand Hygiene: Frequently Missed Areas
Courtesy of SDS Kerr

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cont…..d
• hand antisepsis is performed to remove soil and debris

and reduce both transient and resident flora on the
hands.
• Hand antiseptic should be done before:
o Examining or caring for highly susceptible patients
o Performing an invasive procedure
o Leaving the room of patients

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Transient skin flora
• Transient or temporary skin flora refers to the
microorganisms that transiently colonize the skin.
This includes bacteria, fungi and viruses, which
reach the hands, for example, by direct skin-to-skin
contact or indirectly via objects.
• Hygienic hand disinfection primarily aims at
deactivating the microorganisms of the transient
flora.
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Antiseptic Hand rub:
• The purpose of antiseptic hand rub is to inhibit or kill

transient and resident flora.
• Use of a waterless, alcohol-based hand rub product is

more effective in killing transient and resident flora
than antimicrobial hand washing agents or plain soap
and water.
• Antiseptic hand rub is quicker and easier to perform, and

gives
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a greater initial reduction
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in hand flora. 17
Cont…
• A nonirritating, antiseptic hand rub can be made by
adding glycerin to alcohol (2 ml glycerin in 100 ml
of 60% to 90% ethyl or isopropyl alcohol solution)
• Use 5 ml (about one teaspoonful) for each
application and continue rubbing the solution over
the hands until it is dry (15 to 30 seconds).
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 For appropriate hand rub:
o Apply enough alcohol-based antiseptic to cover
the entire surface of hands and fingers.
o Rub the solutions vigorously into hands,
especially between the fingers and under the
nails until dry.
o Do not rinse hands after applying hand rub
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Efficacy of Hand Hygiene Preparations in Killing
Bacteria in Health Care Settings
GOOD BETTER BEST
PLAIN
SOAP & ANTIMICROBIAL ALCOHOL-
WATER SOAP & WATER BASED HAND
RUB*
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Soap and water vs. hand sanitizers
Soap and water Hand sanitizer(alcohol
based hand rub)
Does not kill anything, but Kills all germs- the good, the
washes it away bad and the harmless
Soap does not need to be Does not remove dirt

antibacterial for it to be effective
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Cont….d
• It is important to note that gloves are not a substitute

for effective hand-washing.
• During hand-wash jeweler should be removed.
• Skin care is important because healthy, unbroken
Skin provides a valuable, natural barrier to
infection. Skin breaks should be covered with a
water-resistant occlusive dressing.
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Cont…..d
2. Use Personal protective equipment (PPE)

• Definition: specialized clothing or equipment worn
by an employee for protection against infectious
materials.
• Types of PPE Used in Healthcare
• Gloves – protect hands
• Gowns/aprons – protect skin and/or clothing

Cont…….d
• Masks and respirators– protect mouth/nose
– Respirators – protect respiratory tract from

airborne infectious agents
• Goggles – protect eyes
• Face shields – protect face, mouth, nose, and eyes
Cont……d
Gloves
• Gloves are a form of personal protective equipment.
• Clinicians and other health care workers should wear

gloves whenever there is a risk of exposure to blood or
body substances.
• should change their gloves and wash their hands after
contact with each patient and during procedures with the
same patient if there is a chance of cross contamination.
Gloving
Types of gloves available in Ethiopia
1. Sterile or high-level disinfected surgical gloves
2.Clean examination gloves, and
3.Utility gloves
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Cont…..d
Gloves must be used when:
• Handling blood and/or body substances,
• Touching mucous membranes,
• Touching non-intact skin,
• Handling contaminated sharps, Performing invasive
procedures, Cleaning body substances spills or any
equipment (instruments) or materials (linen) or surface that
may have been contaminated by body substances

Cont……..d
• Do’s and Don’ts of Glove Use
• Limit opportunities for “touch contamination” -

protect yourself, others, and the environment
– Don’t touch your face or adjust PPE with
contaminated gloves
– Don’t touch environmental surfaces except as
necessary during patient care
Cont…….d
• Change gloves
– During use if torn and when heavily soiled (even

during use on the same patient)
– After use on each patient
• Discard in appropriate receptacle
– Never wash or reuse disposable gloves

Cont……..d
Sequence* for Donning PPE:

 Gown first
 Mask or respirator
 Goggles or face shield

 Gloves
Cont……..d
Sequence for Removing PPE:

• Gloves
• Face shield or goggles
• Gown
• Mask or respirator
Gowning
• The purpose of wearing sterile gown is in order to
prevent your self from infectious and non infectious
fluids
• There are two methods gowning:-
 Gowning self and
Gowning another
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Surgical Asepsis
• Sterilization destroys all microorganisms &

their spores.
• Surgical asepsis demands the highest level of
aseptic technique & requires that all areas be kept
as free as possible of infectious micro-
organisms.
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Cont…
• These techniques can be practiced by nurses in the
OR (surgical incision) or at the bedside (e.g.,
inserting IV or urinary catheter & reapplying
sterile dressings) where sterile instruments &
supplies are used.
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Cont…
• In surgical asepsis, an area or object may be
considered contaminated if touched by an object
that is not sterile (e.g., a tear in a surgical glove
during a procedure, a sterile instrument placed
on an unsterile surface).
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Cont…d
• The nurse working with a sterile field or with
sterile equipment must understand that the
slightest break in technique results in
contamination.
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• How to put on Sterile Gloves
Wearing sterile gloves is part of aseptic hand hygiene, since the hands
can never be sterile
 Preparation for putting on surgical gloves
• Gloves are cuffed to make it easier to put them on without
contaminating them. When putting on sterile gloves, remember that the
first glove should be picked up by the cuff only.
• The second glove should then be touched only by the other sterile glove.
Step 1:Prepare a large, clean, dry area for opening the package of gloves.
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Cont…….d
• Step 2
Open the inner glove wrapper, exposing the cuffed gloves with the palms up.
• Step 3
Pick up the first glove by the cuff, touching only the inside portion of the cuff
(the inside is the side that will be touching your skin when the glove is on).
• Step 4
While holding the cuff in one hand, slip your other hand into the glove.
(Pointing the fingers of the glove toward the floor will keep the fingers open)
.Be careful not to touch anything, and hold the gloves above your waist level.

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• NOTE: If the first glove is not fitted correctly, wait to make any
adjustment until the second glove is on. Then use the sterile
fingers of one glove to adjust the sterile portion of the other glove.
Step 5
Pick up the second glove by sliding the fingers of the gloved hand
under the cuff of the second glove. Be careful not to contaminate
the gloved hand with the ungloved hand as the second glove is
being put on.
• Step 6
Put the second glove on the ungloved hand by maintaining a

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Cont…….d
• Step 7
Adjust the glove fingers until the gloves fit
comfortably
• Gloves play a dual role in the healthcare
environment
• they act as a barrier to give personal protection
and help to prevent the transmission of infection.
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Key Point
• Only wear gloves when necessary.
• Sterile Latex Gloves should be worn when in direct contact with
blood, body fluids, non intact skin or mucous membranes.
• Sterile Glove usage is not a substitute for thorough hand hygiene.
• Sterile Latex Surgical Gloves should be changed after every task
intended or episode of patient care.
• Hands should be washed thoroughly before donning gloves and after
gloves have been removed.
• It 07/10/2022
is important to ensure that gloves fit correctly.
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• Gloves should not be washed, or decontaminated
using alcohol rubs/gels
• Powdered gloves must not be used within the health
care setting.
• Individuals who are sensitized to natural rubber
latex proteins and/or other chemicals in gloves need
to be tested for latex allergies.

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Disinfection and Sterilization of Patient-Care
Equipment
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Definition of terms
Sterilization
A physical or chemical process that completely destroys or removes
all microbial life, including spores.
Disinfection
It is killing or removing of harmful microorganisms
Disinfectant
Products used to kill microorganisms on inanimate objects or surfaces.
Disinfectants are not necessarily sporicidal, but may be sporostatic,
inhibiting germination or outgrowth
Antiseptic
A product that destroys or inhibits the growth of microorganisms in or
on living
The level of disinfection achieved depends on
several factors:
• contact time
• temperature
• type and concentration of the active ingredients of
the chemical germicide
• the nature of the microbial contamination.
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Types of disinfection
• High-level disinfection: can be expected to destroy all
microorganisms, with the exception of large numbers of
bacterial spores.
• Intermediate disinfection: inactivates Mycobacterium

tuberculosis, vegetative bacteria, most viruses, and most fungi;
does not necessarily kill bacterial spores.eg;heating with water.
• Low-level disinfection: can kill most bacteria, some viruses,

and some fungi; cannot be relied on to kill resistant
microorganisms
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getenet dbacilli or bacterial spores. 46
Medical devices, equipment, and surgical materials
are divided into three general categories based on the
potential risk of infection involved in their use:
critical items
 semicritical items
 noncritical items
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Critical items
 Critical items are instruments or objects that are introduced
directly into the bloodstream or into other normally sterile
areas of the body.
 Examples of critical items are surgical instruments,
cardiac catheters, implants, and the blood compartment of a
hemodialyzer.
 Sterility at the time of use is required for these items;.
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Semicritical items
• These items come in contact with intact mucous
membranes, but they do not ordinarily penetrate body
surfaces.
Examples are noninvasive flexible and rigid fiberoptic
endoscopes, endotracheal tubes, anesthesia breathing
circuits, and cystoscopes.
Sterilization is not absolutely essential; at a minimum, a
high-level disinfection is recommended.
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Noncritical items
• Noncritical items are those that either do not
ordinarily touch the patient or touch only intact skin.
• Such items include crutches, bedboards, blood
pressure cuffs, and a variety of other medical
accessories.
These items rarely, if ever, transmit disease.

Consequently, washing with a detergent may be
sufficient.
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• Items must be thoroughly cleaned before
processing, because organic material (e.g., blood
and proteins) may contain high concentrations of
microorganisms.
• Also, such organic material may inactivate chemical
germicides and protect microorganisms from the
disinfection or sterilization process.
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For noncritical items
cleaning can consist only of
1) washing with a detergent or a disinfectant-

detergent,
2) rinsing,
3) thorough drying.
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Processes for sterilization
• Decontamination with disinfectant solution
• Clean with brush ,clean water and soap
• Dray
• Enter into autoclave
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Methods of Sterilization
1. Physical methods
Heat
Dry
Moist
Radiation
U.V. light
Ionizing radiation
Filtration
2. Chemical Methods
Radiation:
– U.V. light- Has limited sterilizing power because of poor
penetration into most materials. Generally used in
irradiation of air in certain areas e.g.. Operating Rooms
and T.B. laboratories.
– Ionizing radiation- e.g. Gamma radiation: Source
Cobalt60 has greater energy than U.V. light, therefore
more effective. Used mainly in industrial facilities e.g.
sterilization of disposable plastic syringes, gloves,
specimens containers.
 Filtration
Best known example is the membrane filter
made from cellulose acetate. Generally
removes most bacteria but viruses and some
small bacteria e.g. Chlamydia & Mycoplasmas
may pass through. Thus filtration does not
technically sterilize items
Main use: for heat labile substances e.g.
antibiotics.
The recommended size filter that will
exclude the smallest bacterial cells is 0.22
micron
Sterilization by Heat: Most common
method
Dry Heat
Simplest method is exposing the item to be
sterilized to the naked flame.
Hot air oven expose items to 160°C for 1
hour.
It has electric element in the chamber as
source of heat plus a fan to circulate air for
even distribution of heat in chamber.
Used for Metals, Glassware
Moist Heat: Uses hot water. Moist heat kills
microorganisms by denaturing proteins.
Boiling – quite common especially in domestic

circumstances.
The process involves boiling for a period (typically 20

minutes) at atmospheric pressure, cooling, incubating
for a day; boiling, cooling, incubating for a day; boiling,
cooling, incubating for a day, and finally boiling again.
 The three incubation periods are to allow heat-resistant spores
surviving the previous boiling period to germinate to form the
heat-sensitive vegetative (growing) stage, which can be killed by
the next boiling step.
 The procedure only works for media that can support bacterial
growth - it will not sterilize plain water.
Autoclaving
 Standard sterilization method in hospitals.
• The Autoclave works under the same principle as the

pressure cooker where water boils at increased
atmospheric pressure i.e. because of increased pressure
the boiling point of water is >100°C.
• The autoclave is a tough double walled chamber in
which air is replaced by pure saturated steam under
pressure.
Methods of Sterilization
The air in the chamber is
evacuated and filled with saturated
steam. The chamber is closed
tightly the steam keeps on filling
into it and the pressure gradually
increases.
The usual temperature achieved is
121 °C at a pressure of 15 pps.i. at
exposure time of only 15-20 mins.
By increasing the temperature, the
time for sterilizing is further
reduced.
Advantages of Autoclave
• Temperature is > 100°C therefore spores are
killed.
• Condensation of steam generates extra heat
• The condensation also allows the steam to
penetrate rapidly into porous materials.
Monitoring of autoclaves
Physical- use of thermocouple to measure
accurately the temperature.
Chemical- it consists of heat sensitive
chemical that changes color at the right
temperature and exposure time.
Autoclave tape
Biological – where a spore-bearing

organism is added during the sterilization
process and then cultured later to ensure
that it has been killed.
Sterilization by Chemical Methods
Useful for heat sensitive materials e.g. plastics and lensed instruments
endoscopes).
Ethylene Oxide Chamber:
Ethylene oxide alkylates DNA molecules and thereby inactivates microorganisms.
Ethylene oxide may cause explosion if used pure so it is mixed with an inert gas e.g.
Neon, Freon at a ratio of 10:90
It requires high humidity and is used at relative humidity 50-60% Temperature :
55-60°C and exposure period 4-6 hours.
Activated alkaline Glutaraldehyde 2%:

Immerse item in solution for about 20 minutes if organism is TB. In case of spores,
the immersion period is extended to 2-3 hours.
 Factors influencing activity of Disinfectants
Directly proportional to temperature.
Directly proportional to concentration up to a point – optimum concentration.
Time: Disinfectants need time to work.
Range of Action : Disinfectants are not equally effective against the whole
spectrum of microbes. e.g. Chlorhexidine is less active against GNB than Gram
Positive Cocci.
May be inactivated by ;Dirt, organic matter,Proteins, Pus, Blood,
Mucus, Faces ,Cork and some plastics.
Hypochlorite and Glutaraldehyde are more active against hepatitis
viruses than most other disinfectants.

Common disinfectants

Iodine is effective against all kinds of bacteria, many endospores, fungi, and some
viruses. Its mechanism of activity may be its combination with the amino acid
tyrosine in enzyme and cellular proteins.
Chlorine is used as a gas or in combination with other chemicals. Chlorine gas is
used for disinfecting municipal water supplies, swimming pools, and sewage.
Sodium hypochlorite – ordinary household bleach- is good disinfectant.
Chloramines consist of chlorine and ammonia. They are more stable than most
chlorine. It used in military as a tablets for field disinfection of water.
Chlorine dioxide in gaseous form is used for area disinfection, most notably to
kill endospores of anthrax bacteria.

Alcohols
• Both ethanol and isopropanol (rubbing alcohol) are
widely used, normally at a concentration of about 70%.
• Concentrations of 60% to 95% are effective.
• They are bactericidal and fungicidal but are not
effective against endospores or non-enveloped viruses.
• Alcohols enhance the effectiveness of other chemical
agents.
Therapeutic and diagnostic
advanced procedure
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PARACENTHESIS
• Objectives
– At the end of this lesson the students will be able
to:-
• Define the term abdominal paracenthesis.
• Describe the term ascites.
• List the common indications of abdominal
paracenthesis.
• Discuss the procedure of abdominal
paracenthesis.
• List and describe the contraindications and
complications of the procedure.
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Anatomy of Abdominal cavity …revision
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Anatomy of Abdominal cavity …revision
The peritoneal cavity is the fluid-filled gap

between the wall of the abdomen and the organs
contained within the abdomen
• The peritoneal cavity consists of the visceral and
the parietal peritoneum.
– Parietal peritoneum
– Visceral peritoneum
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PARACENTESIS
• Definition
– Abdominal Paracentesis is a procedure in which a needle or

catheter is inserted into the peritoneal cavity to obtain ascetic
fluid for diagnostic or therapeutic purposes.
– Diagnostic paracentesis refers to the removal of a small

quantity of fluid for testing.
– Therapeutic paracentesis refers to the removal of fluid to

reduce intra-abdominal pressure and relieve the associated
dyspnea, abdominal pain, and
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PARACENTESIS
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PARACENTESIS
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Cont……d
• Indications
– To relieve abdominal pressure from ascites
– To diagnose spontaneous bacterial peritonitis and
other infections (e.g. Abdominal TB)
– To diagnose metastatic cancer
– To diagnose blood in peritoneal space in trauma
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PARACENTESIS
• Ascites:Ascites is a medical term simply means
the accumulation of fluid with in the abdomen.
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PARACENTESIS
• Ascites
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PARACENTESIS
• Causes of ascites
– Cancer cells
– Liver cancer
– Liver cirrhosis.
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pathophysiology
• Mechanical – obstruction of lymphatic drainage
by tumor cells
Cytokines – implicated in the increased vascular
permeability leading to excess fluid accumulation as

in cirrhosis
• Hormonal – decrease removal of fluid (lymphatic
obstruction) – reduced blood volume
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PARACENTESIS
• Symptoms of ascites
– Swelling of the abdomen, with associated
pain or discomfort
– Difficulty in moving or sitting comfortably
– SOB
– Tiredness
– Nausea and vomiting
– Indigestion
– Reduced appetite
– Altered bowel habit
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PARACENTESIS
Assisting and performing

Abdominal Paracenthesis
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PARACENTESIS
• Equipments
– Sterile equipments
• Antiseptic solution
• Towel with hole that is drape
• Hand towel
• Glove
• Guaze
• Swab in a galipot
• 5ml syringe
• 50ml syringe
• Specimen tube
• Drainage tubing
• Evacuated container andgetenet
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Dressing
d
set 86
PARACENTESIS
• Equipments…
– Clean equipments
• Lidocain
• Rubber sheet
• Scissor and plaster
• Screen
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PARACENTESIS
• Equipments
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cont……d
• Procedure
– Wash hand
– Bring equipments to the bed side
– Explain the procedure to the patient
– Screen the bed
– Position the patient
• Supine position or,
• Sitting up position or,
• High fowler’s position
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PARACENTESIS
• Supine position
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PARACENTESIS
• Sitting position
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PARACENTESIS
• High fowler’s position
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PARACENTESIS
• Procedure…
– Wash hand and put glove then clean and

anesthetize the area
– Insert the needle
• The site of needle insertion is midway between
the umbilicus and the symphysis pubis along
the midline or 3 cm superior and medial to the
anterior superior iliac spine.
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PARACENTESIS
• Site of needle insertion
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PARACENTESIS
• Site of needle insertion
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PARACENTESIS
– For drainage
• Insert the trochar and cannula, the trochar will then removed
and the cannula will be connected with tubing for drainage
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• Procedure…
– The specimen put in the bottle and labeled then sent
to the laboratory
– At the end dress the punctured site
– Check leakage of fluid
– Remove gloves, dispose of equipment, and wash
hands.
– Help client adjust position to promotes client
comfort.
– Assess and document the time of aspiration , amount
and color of fluid removed.
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PARACENTESIS
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• After the procedure, ask the patient to lie in his bed for 4
hours and the nurse to check vital signs q 1 hr for 4 hours to
avoid hypotension.
• Occurs after ≥ 5L of fluid taken off, Give 8 gm of
Albumin per L of fluid taken off

• It is generally recommended to give 25 cc of albumin (25%
solution) for every 2 liters of ascetic fluid removed. For
example, if the patient had a 4-liter paracentesis, he should

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• Contraindications
Disseminated intravascular coagulation disorder
Relative contraindications are:
• Pregnancy
• Distended urinary bladder

– Make the patient urinate before the procedure
• Abdominal wall cellulitis
• Distended bowel
• Intra-abdominal adhesions.
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– Bowel may be adhered to thegetenet d
peritoneum
100
• Risks of the procedure
– Post paracentesis circulatory dysfunction
– Persistent leakage of ascetic fluid
– Localized infection
– Abdominal wall hemorrhage

– Intra-abdominal wall hemorrhage (0.2%)
– Intra-abdominal organ injury
– Inferior epigastric artery puncture
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Key Points
• Definition of paracentesis
• Indications for abdominal paracentesis
• What ascites is
• Abdominal paracentesis procedure
• Contraindication and complications of
abdominal paracentesis
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Thoracentesis
• Thoracentesis also known as pleural tap,
– Is an invasive procedure to remove fluid or

air from the pleural space for diagnostic or
therapeutic purposes.
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Cont……………d
• A cannula, or hollow needle, is carefully
introduced into the thorax, generally after
administration of local anesthesia.
• The recommended location varies depending
upon the source.
• Some sources recommend the midaxillary line, in
the sixth, seventh, or eighth intercostal space
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Thoracentesis
• Indications
– The most common causes of pleural
effusions
• Congestive heart failure
• Cancer
• Pneumonia
• Recent surgery
– Pneumothorax
– Hemothorax
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Thoracentesis
• Left-sided Pleural Effusion
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• Thoracenthesis usually takes 10-15 min but if
there is a lot of fluid, it may take up to 45
minute.
• After thoracentesis, the client may need a
chest x-ray to check for any lung problems.
07/10/2022 getenet d 107

Thoracentesis
• Complications
– Pneumothorax (3-30%),
– Hemopneumothorax,
– Hemorrhage,
– Pulmonary edema.
– infection
07/10/2022 getenet d 108

Performing Thoracentesis
• Equipments
– Sterile set containing
• Galipots
• Pair of artery forceps
• Swabs and gauze an a receiver
• Towel with a hole fun striated towel
• Hand towel
• Gloves
• Syringe and needle for local anesthesia
• Glass tube for specimen
• Receiver to collect fluid

07/10/2022 getenet d 110
• Equipments…
– Clean
• Rubber sheet and towel
• Receiver for used instrument

• Local anesthesia
• Plaster and scissor
07/10/2022 getenet d 111

• Procedure
– Bring the equipment to the bedside and screen
– Position the patient
• Sitting up position with the arm on the
affected side above the head in order to extend
the inter costal space is preferred.
• He may also leaning forward on a pillow on
over-bed table, or can lie on unaffected side
with the arm above the head if the patient can
not sit up, in the sitting up position.
07/10/2022 getenet d 112
• Procedure
– Place rubber sheet and towel behind and
expose the back of the patient
– Open the sterile set and pour the cleansing
solution into the galipot
– Scrub your hand , put glove and clean the
area
– Anesthetize the area
07/10/2022 getenet d 113
• Procedure…
– At the end punctured area will be
covered with a dry sterile dressing
– Record the color, amount and viscosity
of the aspirated fluid
– Leave the patient in comfortable
position
07/10/2022 getenet d 114

Thoracentesis
• Thoracentesis
07/10/2022 getenet d 115

Nursing Actions
• Apply a dressing over the puncture site and position the client on the
unaffected side for 1 hr.
• Monitor the client’s vital signs and respiratory status (respiratory rate
and rhythm, breath sounds, oxygenation status) hourly for the first
several hours after the thoracentesis.
• Encourage the client to deep breathe to assist with lung expansion.
• The client can usually resume normal activity after 1 hr if no signs of

complications are present.
• Obtain a post procedure chest x-ray (check resolution of effusions, rule

out pneumothorax).
07/10/2022 getenet d 116
Water seal drainage system
• Underwater-seal chest drainage is a closed

(airtight) system for drainage of air and fluid from
the chest cavity.
07/10/2022 getenet d 117

• A chest tube
– Is a flexible plastic tube that is inserted through

the chest wall and into the pleural space or
mediastinum.
– It is used to remove air or fluid, or pus from the
intrathoracic space.
– The site of insertion is 5th intercostals space
slightly anterior to mid axilary line
07/10/2022 getenet d 118
• Chest tube
07/10/2022 getenet d 119

Cont…….d
• The underwater-seal system is established by

connecting a catheter (chest tube) that has been
placed in the patient's pleural cavity to drainage
tubing that leads to a sealed drainage bottle.
• Air and fluid drain into the bottle, but water acts as a
seal to keep the air from being drawn back into the
pleural space.
07/10/2022 getenet d 120
Cont……….d
• By keeping the drainage bottle at floor level, fluid

will be prevented from being siphoned back.
• As air and fluid are drained, pressure on the lungs
is relieved and re-expansion of the lung is
facilitated.
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• Indication
– Pneumothorax-accumulation of air in
the pleural space
– Pleural effusion-accumulation of fluid
in the pleural space
– Empyma-a pyogenic infection of the
pleural space
– Hemothorax- accumulation of blood
in the pleural space
07/10/2022 getenet d 122
• Chest tube
07/10/2022 getenet d 123

• Types of water seal drainage system
– The Single-Bottle Water-Seal System.
– The Two-Bottle Water-Seal System.
– The Three-Bottle Water-Seal System.
07/10/2022 getenet d 124

Cont…….d
• The Single-Bottle Water-Seal System.
– Connecting or drainage tubing joins the patient's chest tube with a
drainage tube (glass rod) that enters the drainage bottle.
– The end of the glass rod is submerged in water, extending about
2.5 cm (1 inch) below the water level.
– The water seal permits drainage of air and fluid from the pleural
space but does not allow air to reenter the chest.
– Drainage depends upon gravity, the mechanics of respiration, and,
if07/10/2022
ordered, the addition of controlled
getenet d suction. 125
Cont…..d
– The second tube in the drainage bottle is a vent

for the escape of any air drained from the lung. If
suction is ordered, it is attached here.
• Bubbling at the end of the drainage tube may or
may not be visible. Bubbling may mean persistent
air leaking from the lung or a leak in the system.
07/10/2022 getenet d 126

The Single-Bottle Water-Seal System.
• The water level in the bottle fluctuates as the

patient breathes. It rises when the patient
inhales and lowers when the patient exhales.
• Since fluid drains into this bottle, be certain to
mark the water level prior to opening the
system to the patient. This will allow correct
measurement of patient drainage.
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• The Two-Bottle Water-Seal System.
– The two-bottle system consists of the same water-seal bottle

plus a fluid collection bottle.
– Pleural fluid accumulates in the collection bottle, and not in the

water-seal bottle (as in the single-bottle system).
– Drainage depends upon gravity or the amount of suction added

to the system.
– When suction is added, it is connected at the vent tube in the

water-seal bottle.
07/10/2022 getenet d 129
• The Two-Bottle Water-Seal System.
07/10/2022 getenet d 130

Cont……..d
The Three-Bottle Water-Seal System.
– This system consists of the water-seal bottle, the
fluid collection bottle, and a third bottle which
controls the amount of suction applied.
– The third bottle, called the manometer bottle, has
three tubes.
– One short tube above the water level comes from
the water-seal bottle.
07/10/2022 getenet d 131
Cont…..d
• The Three-Bottle Water-Seal System.
– A second short tube leads to the suction.
– The third tube extends below the water level and

opens to the atmosphere outside the bottle.
– It is this tube that regulates the suction, depending
upon the depth the tube is submerged.
– It is normally submerged 20 cm (7.6 inches).
07/10/2022 getenet d 132
Cont………d

– The suction pressure causes outside air to be
sucked into the system through the tube, creating
a constant pressure.
– Bubbling in the manometer bottle indicates the
system is functioning properly.
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07/10/2022 getenet d 134

07/10/2022 getenet d 135

• Types
07/10/2022 getenet d 136

• Water seal
07/10/2022 getenet d 137

• It is important to check the chest tube connections for
• signs of air leaks, such as “hissing” sounds
• Also check the chest tube dressings and
condition of the tube itself, such as position or clotting in
the tube.
• If a tube accidentally pulls out, the insertion site
should be quickly sealed with a petroleum gauze dressing
to prevent air from entering the pleural cavity.

07/10/2022 getenet d 138
Cont…….d
• In order to confirm that your patient’s chest

catheter(s) are patent, temporarily turn suction off
and check for oscillation of the patient pressure float
ball in the water seal column coinciding with patient
respiration.
07/10/2022 getenet d 139

• Complications
• Hemorrhage
• Infection
07/10/2022 getenet d 140

Postural Drainage
• Is an airway clearance technique that helps patients with

respiratory illnesses like COPD clear mucus from their
lungs
• Postural drainage refers to positioning the patient so that
his thorax is lower than the rest of the body.
• In this way the force of gravity and ciliary activity of the
small bronchial airway will move secretions to the main
bronchi and trachea. Then removed by coughing.
07/10/2022 getenet d 141

Indications and Contraindication
• Indications
• Chest infection
• Cystic Fibrosis
• Contraindication
• Bruises on skin
• Never percuss over the kidneys, spine or female
breasts
Postural Drainage
• Positions
07/10/2022 getenet d 143

Cont…….d
• The patient's body is positioned so that the trachea is
inclined downward and below the affected chest area.
• Postural drainage is essential in treating
bronchiectasis
• The treatment is often used in conjunction with a
techniques for loosening secretions in the chest
cavity called chest percussion and vibration.
• Chest percussion is performed by clapping the back
or chest with a cupped hand.
• Alternatively, a mechanical vibrator may be used in
some cases to facilitate loosening of secretions.
07/10/2022 getenet d 144
Cont….d
• Purpose
– To facilitate the flow of secretions from various

parts of the lung into the bronchi, trachea and
throat so it can be cleaned and expelled from the
lungs more easily.
– The matching of ventilation and perfusion.
07/10/2022 getenet d 145

Cont………d
• When should you NOT use postural drainage?
– Gastro-oesophageal reflux
– Nausea
– Current haemoptysis (fresh blood in your sputum)
– Recent rib, spine or muscle injury
– Tracheal spasm (wheezing sound)
07/10/2022 getenet d 146

Cont……………d
• You have to know the part of the lung affected before performing
postural drainage.
• The patient should remain in each position 3-15 minutes sit up
and cough properly before changing to a new drainage position.
• To minimize the possibility of vomiting, drainage is best done
before meals or at least one hour after eating.
• Early in the morning and at the bed time are recommended for
postural drainage.
• Do not percuss over bare skin. Use a thin towel to cover the area
to07/10/2022
be percussed. getenet d 147
• If you have a tracheostomy tube with a cuff, recheck it when you are
finished with PD&P. Your cuff should be:
•  Inflated after PD&P
•  Deflated after PD&P
• Problems rarely occur during PD&P, however, watch for symptoms

of dizziness and more difficulty in breathing. If these symptoms
occur, stop the treatment. When you are feeling better, you may
try PD&P again. Position yourself with your head higher if
needed.
• Percuss only to the top of the breasts

getenet d
in females. 148
• Endothracheal Intubation
07/10/2022 getenet d 149

Objectives
• At the end of this lesson the students will be
able to:-
– Define what an Endothracheal intubation,
cricothyrotomy and tracheotomy mean.
– Identify the indications for Endothracheal
intubation
– List the common complications of ETI
– Identify the equipments for ETI
– Discuss ETI procedure
– Discuss the general rules of Intubation
07/10/2022 getenet d 150

Anatomy of Respiratory System
• The airways can be divided in to parts namely:
The upper airway.
The lower airway.
07/10/2022 getenet d 151

• Epiglottis
07/10/2022 getenet d 152

07/10/2022 getenet d 153

Endotracheal intubation
• It is insertion of a tube into the trachea to
maintain the airway.
• It is a rapid, simple, safe and non surgical
technique that achieves all the goals of airway
management, namely:-
– Maintains airway patency
– Protects the lungs from aspiration
– Permits leak free ventilation during mechanical
ventilation
• The gold standard procedure for airway
management.
07/10/2022 getenet d 154
• ETI
07/10/2022 getenet d 155

• Indications for Intubation
– Inadequate oxygenation(decreased arterial
PO2) that is not corrected by supplemental
oxygen via mask/nasal.
– Inadequate ventilation (increased arterial
PCO2).
– Any patient in cardiac arrest.
– Any patient in deep coma who cannot protect
his airway.
07/10/2022 getenet d 156

• Indications for Intubation…
– Severe head and facial injuries with compromised
airway.
– Sometimes for patient in general anesthesia
during surgical procedure
– Any patient in respiratory arrest
– Respiratory failure
• Hypoventilation/Hypercarbia
– Paco2 > 55mmhg
• Arterial hypoxemia refractory to O2
– Pao2 < 70 on 100% O2
getenet d 157
• Equipments
– Laryngoscope handle and blade
– Properly sized endotracheal (ET) tube
– Stylet…Flexible introducer.
– 10-mL syringe
– Water-soluble lubricant for the ET tube
– Bag-valve-mask with oxygen connected.
– Tape or adhesive plaster.
– Magill forceps
– Stethoscope
– Surgical glove
– ECG monitoring if possible
– 07/10/2022
Suction unit getenet d 158
• Equipments
07/10/2022 getenet d 159

Endotracheal intubation.. Equipments
• Laryngoscope
– Used to sweep the tongue out of the way and
align the airway so the vocal cords can be
visualized.
07/10/2022 getenet d 160

• Laryngoscope
– Macintosh (curved) and Miller (straight) blade
• Adult : Macintosh blade
• Small children : Miller blade
Miller blade Macintosh blade

07/10/2022 getenet d 161
• Endotracheal tubes:-Proper-sized tube for

adults ranges from 7.0 to 8.5 mm
07/10/2022 getenet d 162

• Endotracheal tubes:-
 Z-79
 Disposible (Do not reuse)
 Oral/ Nasal
 Radiopaque marker
07/10/2022 getenet d 163
– Tube sizes.. Internal diameter (ID)
Newborn – to 4 kg - 2.5 mm (uncuffed).
1-6 months 4-6 kg – 3.5 mm (uncuffed).
7-12 months 6-9 kg – 4.0 mm (uncuffed).
1 year 9 kg – 4.5 mm (uncuffed).
2 years 11 kg – 5.0 mm (uncuffed).
3-4 years 14–16 kg - 5.5 mm (uncuffed).
5-6 years 18–21 kg – 6.0 mm (uncuffed).
7-8 years 22-27 kg – 6.5 mm ( uncuffed).
07/10/2022 getenet d 164
– Tube sizes.. Internal diameter (ID)
• 9-11 years 28-36 kg – 7.0 mm(cuffed).
• 14 to adults 46+ kg –7.0–80 mm (cuffed).
• Adult female 7.0 – 8.0mm (cuffed).
• Adult male 7.5 – 8.5 mm (cuffed).
– N.B.
• The size of the tube may also be determined by the size of the
patients little finger.
• patients below the age of 8 require uncuffed ETT due to
damage caused by the cuff in younger patients.
• Always monitor the ECG activity during intubation
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– Depth of endotracheal tube :
– Midtrachea or below vocal cord 2cms
• Adult
 Male = 23 cms
 Female = 21 cms
• Children
Oral endotracheal tube = (age/2) +
12 (cm)
Nasal endotracheal tube = (Age/2) + 15 (cm)
Or 6+wt (kg)
07/10/2022 getenet d 166
• ECG monitoring machine
07/10/2022 getenet d 167

• Stylet
– Inserted into the ET tube to add rigidity and shape during
intubation
– Bend the tip to form a gentle curve.
– Do not insert past Murphy’s eye.
07/10/2022 getenet d 168

• Syringe
– Use a 10-mL syringe to test for air leaks in the

ET tube before intubation.
• Other equipment
– A suction unit may be needed to clear

secretions or blood.
07/10/2022 getenet d 169

• Prerequisites for Intubation

– Pre oxygenate before intubation with 100%
oxygen
– Deliver Free Flow oxygen during intubation
– Not more than 20 sec per attempt : Not more than
3 attempts
– Ventilate with Bag and mask with 100% oxygen
in between attempts
07/10/2022 getenet d 170
Endotracheal intubation..Procedure
• Position of the patient:

– Unless contraindicated – i.e. Trauma.
• Elevating the patient’s head about 10cm with pads
under the occiput and extension of the head into the
sniffing position serve to align the oral, pharyngeal
and laryngeal axis, so that the passage from the lips to
the glottic opening is almost a straight line.
07/10/2022 getenet d 171

• Position of the patient…

• Open mouth by separating the lips and pulling on
upper jaw with the index finger.
• This position permits better visualization of the
glottis and vocal cords and allows easier passage of
the endotracheal tube.
07/10/2022 getenet d 172

• Snuffing position for better visualization
07/10/2022 getenet d 173

• Hyper-oxygenate the patient with 100% oxygen for 2

minutes.
• Hold laryngoscope in left hand, insert scope into
mouth with blade directed to right tonsil.
• Pass the blade to the right of the tongue, and advance
the blade into the hypo pharynx, pushing the tongue to
the left.
• Suctioning if needed
07/10/2022 getenet d 174
• Suctioning
07/10/2022 getenet d 175

• Lift the laryngoscope upward and forward, without

changing the angle of the blade, to expose the vocal cords.
• An assistant should apply gentle downward pressure on the
Cricoid cartilage, start off slowly and then gradually
increase the downward force.
• Pass the tube through the vocal cords and withdraw the
stylet.
• Connect the bag-valve mask and begin ventilation with
100% oxygen.
07/10/2022 getenet d 176
• Verify tube placement.

– Visualize tube passing through the cords.
– Movement of the chest with respirations.
– Auscultation of the chest (You should hear
breath sounds on both sides of the chest).
– Auscultation of the stomach (You shouldn’t
hear gurgles here).
– Rising or stable O2 saturation.
• Secure the tube in place with tape or a
commercial device.
07/10/2022 getenet d 177
• Signs of ET Tube in Esophagus
– Poor response to intubation (cyanosis,

bradycardia etc
– No audible breath sounds
– Air heard entering stomach
– Gastric distension may be seen
– Poor chest movements

07/10/2022 getenet d 178
• Rules of Intubation
– Always have a suction unit available.
– An intubation attempt should never exceed
30 seconds.
– Oxygenate the patient pre and post
intubation with a bag-valve-mask.(100%
O2).
– Have sedative medication available if
needed.
– Always recheck tube placement manually
guided by oxygen saturation readings.
(Spo2).
07/10/2022 getenet d 179
• Complications
– Trauma of the teeth, larynx and related structures.
– Hypertension and tachycardia can occur.
– Transient cardiac arrhythmias related to vagal
stimulation or sympathetic nerve traffic may
occur
– Damage to the endotracheal tube cuff, resulting in
a cuff leak and poor seal.
– Intubation of the esophagus
07/10/2022 getenet d 180

Extubation (Removal of Endotracheal Tube)
1. Explain procedure.
2. Have self-inflating bag and mask ready in case
ventilatory assistance is required immediately
after extubation.
3. Suction the tracheobronchial tree and
oropharynx, remove tape, and then deflate the
cuff.
4. Give 100% oxygen for a few breaths, then insert a
new, sterile suction catheter inside tube.
5. Have the patient inhale. At peak inspiration
remove the tube, suctioning the airway through
the tube as it is pulled out.
getenet d 181
• Care of Patient Following Extubation
1. Give heated humidity and oxygen by face mask and
maintain the patient in a sitting or high Fowler’s
position.
2. Monitor respiratory rate and quality of chest
excursions.
Note stridor, color change, and change in mental
alertness or behavior.
3. Monitor the patient’s oxygen level using a pulse
oximeter.
4. Keep NPO or give only ice chips for next few hours.
5. Provide mouth care.
6. Teach patient how to perform coughing and deep
breathing
07/10/2022
exercises. getenet d 182
• Key points
– Endotracheal intubation,
– Indications for ETI
– Complications of ETI
– The equipments for ETI
• Laryngoscope
• endotracheal (ET) tube
• Stylet…Flexible introducer.
• 10-mL syringe
• Bag-valve-mask with oxygen connected.
• Stethoscope……
– Rules of intubation
07/10/2022 getenet d 183

Tracheostomy
07/10/2022 getenet d 184

Tracheoostomy
• Objectives
– After the end of this lesson the students will be
able to:
• Describe artificial air way and types of
artificial air ways
• Define the terms tracheostomy and
tracheotomy
• List the indication of tracheostomy
• Discuss how to perform tracheostomy care
07/10/2022 getenet d 185

Tracheoostomy
07/10/2022 getenet d 186

Tracheostomy
• Artificial airways
– A tube or tube-like device that is inserted through

the nose, mouth, or into the trachea to provide an
opening for ventilation
• Artificial airways may be used for clients with
significant airway obstruction that cannot be
relieved by more conservative means or who require
mechanical ventilator support.
07/10/2022 getenet d 187
Cont…….d
Types of artificial airways

– Nasal airways
– The oral airway
– Endo tracheal tube
– Tracheoostomy tube
07/10/2022 getenet d 188

Tracheostomy
• Oral airway and endotracheal tube
Nasal airways
• Tracheostomy
– Is an artificial airway consisting of a plastic
tube surgically implanted just below the
larynx into the trachea.
07/10/2022 getenet d 189
• A tracheostomy
– Is a surgical procedure done to provide long-term
airway support or as an emergency procedure
when an endotracheal tube cannot be passed
successfully.
• An opening (stoma) is made in the trachea below
the larynx and the cricoids cartilage, and a semi
rigid plastic tube (tracheostomy tube) is passed
through the opening and into trachea.
07/10/2022 getenet d 190
Tracheostomy
07/10/2022 getenet d 191

Tracheostomy
• Many tracheostomy tubes consist of two tubes or
cannulae:
– An outer cannula that stays in place and an
inner cannula that can be removed to be
cleaned or replaced.
• The outer cannula is connected to a flange that
permits the tubes to be secured around the neck
with twill tape or a cloth strap.
07/10/2022 getenet d 192
Tracheostomy
• Tracheostomy cannulae
07/10/2022 getenet d 193

Tracheostomy
• Indication
– Sever or recurrent upper airway
obstruction
– Patient who regularly aspirate food or
stomach content
– Patients who requires long term
mechanical ventilation
07/10/2022 getenet d 194

Post tracheotomy care
• Your patient is adjusting to the trauma of surgery,

the pain of a fresh incision, the presence of a foreign
object in the trachea, and the inability to
communicate through speech.
• Patients commonly report choking sensations and
generally take one to three days to adapt to
breathing through a tracheostomy tube
07/10/2022 getenet d 195

Post tracheotomy care
• check vital signs every fifteen minutes for one hour,

every half an hour for the next hour, then hourly for
four hours
• Follow your organization's guidelines for the care of
patients returning from the operating room.
07/10/2022 getenet d 196

Anticipated Side Effects of Tracheostomies
• Respiratory secretions will often temporarily
increase in your patient after a tracheostomy.
Observe for signs and symptoms of impaired gas
exchange that can be created by mucus plugs.
Encourage your patient to breathe deep and cough.
Ensure adequate humidification and fluid intake to
keep secretions thinned.
07/10/2022 getenet d 197
• A small amount of bleeding from the stoma is
expected for a few days after a tracheostomy but
constant oozing is abnormal and requires intervention.
• A blood vessel may need surgical litigation or the
patient’s physician may direct you to pack the wound
around the tube to stop the bleeding.
• Slight inflammation commonly occurs at the surgical
site too. There may also be redness, pain, and a small
amount of drainage.
07/10/2022 getenet d 198
• Lower respiratory infection requires more frequent
assessment and most likely antibiotic intervention.
• Air sometimes escapes into the tracheostomy incision
creating subcutaneous emphysema around the stoma.
• Excessive manipulation of the trach tube during coughing
and suctioning can break improperly secured ties and
dislodge the tube. Within the first 48 hours the freshly
created stoma has a potential to close shut, constituting a
medical emergency.
getenet d 199
• To minimize this risk, trach ties are not usually
changed for 24 hours. The first tube change is
generally done by a physician after approximately
one week
• Each organization will have emergency policies and
procedures to follow in the case of a dislodged fresh
tracheostomy tube.
getenet d 200
• Dried secretions can completely occlude the
tube so that tracheostomy clients must be well
hydrated.
• Because it prevent the movement of air
through the vocal cords, which produce
speech, the client will not be able to talk while
these tubes are in place
07/10/2022 getenet d 201
• In addition, many patients have acute and/or chronic
diseases that predispose to stagnation of
secretions. Frequent repositioning, deep breathing and
coughing, chest physiotherapy, postural drainage, oral
and parenteral hydration, and supplemental
humidification all help to thin and mobilize secretions.
Acute care patients need to be assessed every

__2__hours for the need for suctioning
07/10/2022 getenet d 202
Indications for suctioning include:
• Dyspnea: Flared nostrils, chest retractions and / or
prolonged wheezing
• Noisy breathing
• Cyanosis and clammy skin
• Restlessness and agitation
• Copious secretions; moist cough
• Low oxygen saturation

• Increased peak inspiratory pressure on mechanical ventilator
07/10/2022 getenet d 203
Performing Tracheostomy Care
• Equipment
– Tracheostomy care kit
• Two sterile containers(one for H2O2 and one for N/S)
• Sterile cotton-tip applicators
• Sterile pipe cleaner
• Sterile nylon brush
• Sterile 4 × 4 gauze pad
• Sterile drapes
• Tracheostomy ties
07/10/2022 getenet d 204
Equipment…
– Two pairs of sterile gloves
– Plastic bag for disposal
– Sterile 0.9% sodium chloride solution

– Hydrogen peroxide solution
– Suction kit and suction equipment
– Sterile precut 4 × 4 drain sponges

– Artery and tissue forceps
– Scissor and tape,Personal protective devices: gown,

07/10/2022 getenet d 205
• Assemble equipment, explain the

procedure to the patient, screen , hand
wash
• Position (semi-Fowler’s) the patient.
07/10/2022 getenet d 206

• Position (semi-Fowler’s) the patient.
07/10/2022 getenet d 207

• Suction the client’s tracheostomy tube then
remove the soiled tracheostomy dressing.
• Remove the gloves by pulling them over the
discarded dressing, and discard the gloves and
dressing.
– Suctioning clears the airway of loose
secretions.
07/10/2022 getenet d 208
• Open the tracheostomy care kit, taking care to
avoid touching the inside of the kit.
• Using sterile gloving technique put on the
gloves supplied in the tracheostomy care kit (if
included) or a separate pair of sterile gloves
– Maintains sterility of the supplies in the kit.
07/10/2022 getenet d 209

• Open the inner wrapper of the tracheostomy
care kit to form a sterile field.
• Separate the two sterile containers and place
them on the field.
• Lay the cotton applicators, pipe cleaners, nylon
brush, and sterile 4 × 4’s pads on the field.
07/10/2022 getenet d 210

• Place the sterile drape on the patient’s chest,
with its upper edge as near to the tracheostomy
tube as possible.
• Fold a tuck of the drape over your fingers as
you position the drape.
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• Designate one hand as sterile (able to touch only
sterile items) and the other as clean (able to touch
only non sterile items).
– Usually, the dominant hand is the sterile hand,
while the non dominant hand is clean.
– This system prevents contamination of sterile
supplies while allowing you to handle unsterile
items.
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• Using your clean hand, open the bottles
of sterile saline and peroxide, laying the
caps outside of the sterile field.
• Pour about 100 ml of saline into one
sterile container and about 100 ml of
hydrogen peroxide into the other
container.
• Set the bottles down outside of the sterile
field.
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• Using your sterile hand, pick up a sterile cotton
swab(by forceps) and saturate the tip with hydrogen
peroxide.
• Swab the peristomal skin, including the area under
the tracheostomy tube’s faceplate.
• If you must touch the tracheostomy tube or the
client, do so with your clean hand
07/10/2022 getenet d 214
• Cleaning
07/10/2022 getenet d 215

• Using your clean hand, gently loosen the inner
cannula of the tracheostomy tube by twisting the
outer ring counterclockwise; then withdraw the
inner cannula in a smooth motion. Place the inner
cannula into the basin of peroxide.
– Minimizes trauma to the client’s tracheal tissues
and reduces reflexive coughing. The hydrogen
peroxide serves to dissolve crusted secretions.
– Note: Some tracheostomy tubes use disposable
inner cannulae that would be replaced at this
point in the procedure.
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• Using your sterile hand, pick up the cannula.
• Using your clean hand, pick up the nylon
brush and scrub to remove any visible crusts
or secretions from inside and outside the
cannula
– Any secretions retained on the inner cannula
may be aspirated into the client’s lungs,
causing infection and possible airway
obstruction.
– In some cases, the pipe cleaners may be
needed to gain access to the inner surface of
the cannula.
07/10/2022 getenet d 217
• Place the cannula into the container of sterile
saline. Agitate so that all surfaces are bathed in
saline.
– Rinses the peroxide off of the cannula
before it is returned to the client.
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07/10/2022 getenet d 219

• Inspect the inner cannula again to be sure it is
clean; then remove excess saline from the
lumen by tapping the cannula against a sterile
surface.
– Fluid trapped in the lumen of the cannula
can be aspirated by the client.
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• Gently replace the inner cannula, following the
curve of the tube.
• When fully inserted, lock the inner cannula in
place by rotating the external ring clockwise
until it clicks into place.
• Place a new sterile gauze dressing around the
stoma, between the faceplate and the skin
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• Inspect the ties or strap securing the faceplate. If
damp or soiled, carefully cut the ties (or loosen
the Velcro to remove a strap). Remove the ties or
strap and inspect the underlying skin for redness
or breakdown.
– Ties or straps that are wet contribute to skin
breakdown and infection. Note: Tracheostomy
ties should not be removed or changed for the
first 24 hours after tracheostomy tube insertion
to prevent dislodgement of the tube and
bleeding from the stoma.
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• To replace ties, cut a length of twill tape about
as long as the circumference of the client’s
neck. Fold over one end to 1 inch and cut a
small (1/2 inch) slit into the folded end.
07/10/2022 getenet d 223

• Thread the slit end of the tape through the eye of one side of
the tracheostomy faceplate from the underside of the
faceplate. Thread the end of the tie through the cut slit and
secure it with a knot.
– Creates a secure knot that can be easily cut when the tape
needs to be removed and changed.
• Slip the tape under the client’s neck, keeping it smooth and
flat against the skin.
– Prevents excessive looseness
07/10/2022 getenet d or bunching of the tape 224
• Bring the loose end of the tape around to the
other side of the faceplate. Ask the client to flex
his or her neck and slip one of your fingers
under the tape as you measure the desired
tightness of the tie.
– Flexion of the neck simulates the increase in
neck circumference that occurs with
coughing. The tape should be secure but not
tight.
– Caution: clients who have had neck surgery
or injury should be monitored frequently for
tightening of the tape due to neck swelling.
07/10/2022 getenet d 225
Tracheostomy
• Fold the end of the tape and cut a slit then tie the
end. Trim off excess tape from the end and knot
the cut ends of the tape.
• Reconnect the patient to oxygen and reposition
for comfort.
• Discard soiled items in the appropriate
container.
• Remove and discard soiled gloves. Wash hands.
• Document the procedure, noting the
appearance of the stomal site and any exudate.
07/10/2022 getenet d 226

Steam inhalation
• Steam inhalation
– Is a method of introducing warm, moist
air into the lungs via the nose and throat
for therapeutic benefit.
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Steam inhalation
07/10/2022 getenet d 228

Steam inhalation
• Respiratory benefits
– Inhaling steam is a great treatment for
respiratory complications and is
recommended for dealing with common
cold, flu, bronchitis, sinusitis, asthma, and
allergies.
– Dry air passages are moistened, and mucus
is loosened/eliminated easier by coughing or
blowing the nose.
– The moist air also alleviates difficulty
breathing, throat irritation and
inflammation.
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Steam inhalation
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Steam inhalation
• Natural expectorant
– An expectorant increases the amount of
secretions, resulting in clearer secretions and as a
result, lubricates the irritated respiratory tract.
– The inhalation of steam benefits the lungs and
throat by acting like an effective natural
expectorant. This helps to relax muscles, thereby
relieving coughing.
– Inhaling steam is necessary for preventing
excessive drying of the mucous membranes.
07/10/2022 getenet d 231

Steam inhalation
07/10/2022 getenet d 232

Steam inhalation
• Improved circulation
– When the body's temperature rises, blood
vessels begin to dilate. This encourages
blood flow and overall circulation in the
body.
– The increase in circulation can provide
relief from headaches and migraines.
– The rise in temperature can also strengthen
the immune system by stimulating the
circulation of germ fighting white blood
cells.
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Steam inhalation
07/10/2022 getenet d 234

Steam inhalation
• Reduce Stress
– Stress causes the inner layer of the blood
vessels to constrict.
– Steam inhalation triggers the vasodilation of
blood vessels.
– When blood vessels dilate, blood flow is
increased, promoting relaxation.
– Further stress reduction can be achieved by
using specific essential oils.
07/10/2022 getenet d 235

Steam inhalation
• Procedure
– A common method of inhaling steam is to boil a
few cups of water and then pour the steaming
water into a large bowl.
– Next, a towel can be placed over the sufferer's
head, as he leans over the bowl of water.
– The steam will soon relieve any congestion. But
continue to inhale steam into the nasal passages
for as long as you can without discomfort.
– Inhaling steam for 10 to 15 minutes or so each
morning and evening can provide wonderful
07/10/2022
relief getenet d 236
Steam inhalation
07/10/2022 getenet d 237

• Instructions to do steam inhalation
• Pour hot water into a bowl and 3 drops of the essential
oil that you have selected, place your head about 12
inches (30 cm) above the bowl and cover your head
with a towel in such a way that the sides are totally
closed and you in actual fact form a tent over the bowl.
• Keep your eyes shut and breathe deeply through your
nose for 1 to 2 minutes.
• If you feel that the treatment is getting too much for
you, raise the towel so that fresh air is brought into the
area and breathe through your mouth a couple of
times and then resume the treatment. Should you at
any time feel uncomfortable discontinue the
treatment.
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Oils for steam inhalation
• Eucalypts
• Peppermint
• rosemary
07/10/2022 getenet d 239

Contra indication
• CHF patient
• Pregnancy
• Asthmatic patient with oil inhalation

• Peoples with epilepsy
07/10/2022 getenet d 240

Lumbar puncture
• Objectives
– At the end of this lesson the students will be
able to:-
• Define what lumbar puncture means
• Know the site of lumbar puncture
• List the purpose of lumbar puncture
• Discuss lumbar puncture procedure
• List and describe the contraindications and
complications of lumbar puncture
07/10/2022 getenet d 241
Anatomy revision of CNS
• Classification of CNS
– Brain
• Cerebral hemispheres
• Diencephalon
–Thalamus
–Hypothalamus
• Brain stem
–Midbrain
–Pons
–Medulla
• Cerebellum
– Spinal cord
07/10/2022 getenet d 242
Anatomy of HUMAN BRAIN
• Brain
07/10/2022 getenet d 243

Anatomy of spinal cord
07/10/2022 getenet d 244

Protection of CNS
– Skull
– Meningens
• Dura mater (outer)
• Arachnoid mater (middle)
• Pia mater (inner)
– 3 Potential spaces
• Epidural: outside dura
• Subdural: between dura & arachnoid
• Subarachnoid: deep to arachnoid
– CSF
– Blood brain barrier
07/10/2022 getenet d 245
Cranial Meningeal Spaces
 Epidural space
Potential space superior to dura.
 Subdural space
Potential space between dura and arachnoid
mater.
 Subarachnoid space
Filled with CSF
Contains the blood vessels supplying brain.
07/10/2022 getenet d 246
Protection of the brain
07/10/2022 getenet d 247

Spinal cord
07/10/2022 getenet d 248

Cerebrospinal fluid
• Cerebrospinal fluid (CSF) is a clear

colorless bodily fluid found in the brain and
spine.
• The CSF occupies the subarachnoid space
07/10/2022 getenet d 249

CSF circulation
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Cerebrospinal Fluid (CSF)
Roles of CSF:
1. Cushions and insulates delicate nervous tissue.
2. Gives Buoyancy to the brain (“floats” in CSF).
3. Exchange of gases (O2 and CO2), nutrients and

wastes.
07/10/2022 getenet d 252

CSF…
• CSF PRESSURE
– Normal CSF pressure ranges from
• 70 to 180 mmH2O in adults and
• 50 to 80 mmH2O in infants and children .
07/10/2022 getenet d 253

CSF…
• NORMAL CSF VALUES
Adult
White blood cell 0–5
count(WBC/mm3)
Glucose (mg/dL) 50–80
CSF/blood glucose ratio
Normal ratio 60–70%
Abnormal ratio 0.4–0.5
Protein (mg/dL) 15–45
07/10/2022 getenet d 254
Brainstorming!!!
• What is lumbar puncture ?
07/10/2022 getenet d 255

Lumbar puncture
Definition
– A lumbar puncture or a spinal tap is a
diagnostic and at times therapeutic procedure
that is performed to collect a sample of
cerebrospinal fluid (CSF) for biochemical,
microbiological, and cytological analysis.
07/10/2022 getenet d 256

Lumbar puncture
• LP
Site of
puncture
Between L-3
and L-4
07/10/2022 getenet d 257

• Purpose
– To remove CSF in increased CSF pressure
– Suspicion for a central nervous system infection,

such as meningitis, or for a subarachnoid
hemorrhage.
– To measure the pressure of CSF
– To inject spinal anesthesia
07/10/2022 getenet d 258

Lumbar puncture
• Site of lumbar puncture
07/10/2022 getenet d 259

LP (lumbar puncure) = spinal tap
Epidural space is external to dura

Anesthestics are often injected into epidural space
Injection into correct space is vital; mistakes can be lethal
07/10/2022 getenet d 260
Lumbar puncture..Procedure
• Equipments
– Sterile set
• Galipot
• Towel with hole and hand towel
• Sterile glove
• Drape
• Dressing set
• Syringe with needle for local anesthesia
• Test tube for specimen
• Lumbar puncture needle
07/10/2022 getenet d 261
Lumbar puncture
07/10/2022 getenet d 262

Lumbar puncture
• Equipments…
– Clean set
• Skin cleansing(iodin)
• Rubber sheet
• Plaster and scissors
07/10/2022 getenet d 263

Lumbar puncture
• Procedure
– Position the patient in the lateral
recumbent position lying on the edge of
the bed and facing away from operator.
07/10/2022 getenet d 264

Lumbar puncture
• Procedure
– Position
07/10/2022 getenet d 265

Lumbar puncture
• Procedure…
– Put the rubber sheet under the patient and
instruct the patient during the procedure
– Open the sterile set and pour cleansing
solution in to the galipot
– Scrub your hand with the sterile towel and
put on glove then clean the area.
– Anesthetize the area and insert the needle in
to the spine.
07/10/2022 getenet d 266

Lumbar puncture
• Procedure…
– The specimen will be collected, the
needle remove and the site will be
dressed.
– At the end watch the patient for
complications of lumbar
puncture(headache).
– Record time of procedure, amount and
color of the spacemen
07/10/2022 getenet d 267
Lumbar puncture
• CONTRAINDICATIONS
– Increased intracranial pressure
– Brain abscess
– Coagulation defects
– Localized cellulites
– Bacteremia
07/10/2022 getenet d 268

• COMPLICATIONS
– Post puncture headache - the most common
complication
– Cerebral herniation- is the most immediately
life threatening.
– Localized cellulitis
– Dural abscesses
– Localized bleeding- Hemorrhage
07/10/2022 getenet d 269

Key points
• Definition of Lumbar puncture

• Purpose of LP
• Site of LP
• Lumbar puncture procedure
• Contraindication
• complication
07/10/2022 getenet d 270

Bone marrow aspiration
07/10/2022 getenet d 271

Bone marrow puncture
• Objectives
– At the end of this lesson the students will
be able to:-
• Define the term bone marrow aspiration
• know the common indication for bone
marrow aspiration
• List the sites for bone marrow aspiration
• Discuss bone marrow aspiration technique
07/10/2022 getenet d 272

• Bone marrow aspiration

– Is the removal of a small amount of liquid
organic material in the modularly canals of
selected bone.
07/10/2022 getenet d 273

• BMA
07/10/2022 getenet d 274

• Purpose
– For diagnosis of blood disease
especially aplastic anemia and
leukemia.
07/10/2022 getenet d 275

• Site of puncture
– The sternum
– Iliac crest
07/10/2022 getenet d 276

• Equipment
– Sterile set containing
• Sterile towel with hole
• Hand towel
• Gloves
• Swabs and guaze
• Dressing forceps
• Syringe and needle
• Sternal puncture needle staylet
• 10ml syringe
• Slides
07/10/2022 getenet d 277
• Needles
07/10/2022 getenet d 278

• Equipment…
– Clean equipments
• Sodium oxalate solution(anticougulant)
• Antiseptic lotion
07/10/2022 getenet d 279

• Procedure
– Bring equipment to the bed side
– Screen the bed
– Position on procedure table and expose iliac
crest:
• Prone for the posterior superior iliac crest
(if patient is awake)
• Supine for the anterior site
• Side lying may also be used
07/10/2022 getenet d 280
• Procedure…
– Palpate the posterior or anterior iliac crest
and locate the site for aspiration:
– The posterior superior iliac crest is located
as visible and palpable bony prominence
superior and lateral to the inter gluteal cleft.
– Place bone marrow aspiration tray on a
stand and open using sterile technique
– Place all needed syringes and needles on the
sterile field
07/10/2022 getenet d 281
• Procedure…
– Wash hands (using antimicrobial scrub), put
on gown, mask with eye shield
– Apply sterile gloves and prepare the marrow
puncture site with three chlorhexadine
swabs (or alternative antiseptic solution)
using a circular motion and working from
inner to outer aspect
– Apply sterile drape on the patient
07/10/2022 getenet d 282

• Procedure…
– Anesthetize the marrow site with 1-2 cc
of 2% Lidocaine.
• Initial injection should be done
intradermally, with the needle
parallel to the skin, bevel up to
produce a wheal.
• Slowly inject more deeply,
infiltrating the area including the
periosteum
07/10/2022 getenet d 283
• Procedure…
• While waiting for anesthesia to take
effect, assemble BMA needle.
• The stylet must remain locked in place
when the needle is advanced into the
marrow cavity.
07/10/2022 getenet d 284

• Procedure…
– Puncture the skin with BMA needle
and advance to the periosteum.
– Using a firm, slightly twisting motion,
push the needle through cortex and into
the marrow cavity until a “give” is felt
and the needle is firmly anchored in the
bone
07/10/2022 getenet d 285

• BMA
07/10/2022 getenet d 286

• Procedure…
– Remove the stylet and attach a 10 cc
syringe to the needle hub (patient may
experience discomfort when stylet is
removed and when suction is applied)
07/10/2022 getenet d 287

• Iliac aspiration needle has been placed into the

marrow cavity. The obturator is being removed.
07/10/2022 getenet d 288

• Procedure…
– Apply strong suction to obtain no more
than 0.5 cc of bone marrow
07/10/2022 getenet d 289

• Suction is being applied to the syringe, with
successful aspiration of marrow
07/10/2022 getenet d 290

• Procedure…
– Carefully disconnect syringe from needle
hub and immediately replace stylet into
aspiration needle.
07/10/2022 getenet d 291

• Procedure…
– Make smears from bone marrow aspirate
immediately (or have a lab technician,
another physician or an assistant do it)
07/10/2022 getenet d 292

• Procedure…
– Completed blood smear
07/10/2022 getenet d 293

• Procedure…
– Using a new syringe, relocate the needle and
obtain additional samples if needed.
– Depending on the tests required, use 10 cc
syringes prepared with 0.2 cc heparin.
– Withdraw the aspiration needle, and apply
manual pressure to the puncture site with
gauze pads
– Record patient condition
07/10/2022 getenet d 294

• LIVER BIOPSY
• FOR 2nd YEAR NURSING STUDENTS

07/10/2022 getenet d 295
Liver Biopsy
Objectives
– At the end of this session the students will be
able to :-
– Define the terms biopsy and liver biopsy
– List the purpose and types of liver
biopsy
– Discuss liver biopsy procedure
– Describe the contraindications and
complications of liver biopsy
07/10/2022 getenet d 296

Liver Biopsy
• The liver
07/10/2022 getenet d 297

Liver Biopsy
07/10/2022 getenet d 298

Liver Biopsy
• Functions of the liver:

– Production of bile
– Production of certain proteins for blood plasma
– Conversion of excess glucose into glycogen for storage
– Regulation of blood levels of amino acids
– Processing of hemoglobin for use of its iron
– Conversion of poisonous ammonia to urea
– Clearing the blood of drugs and other poisonous
substances
– Resisting infections by producing immune factors
07/10/2022 getenet d 299

Liver Biopsy
• Definition
• Is an excision of a small amount of body tissue

for microscopic examination.
– Liver biopsy
• Is a procedure to remove a small piece of liver
tissue, so it can be examined with microscope for
a sign of damage or disease.
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Liver Biopsy
• Purpose
– To diagnose a tumor
– To identify abnormalities in liver tissue
– For assessment of prognosis (disease
staging)
– To assist in making therapeutic
management decisions.
07/10/2022 getenet d 301

• Types of liver biopsy
– Percutaneous Liver Biopsy
– Transvenous Liver Biopsy

– Laparoscopic Liver Biopsy
– Plugged Biopsy
07/10/2022 getenet d 302

Liver Biopsy
• Percutaneous Liver Biopsy
– The most commonly used technique
– A hollow needle is inserted through the abdomen
into the liver to remove a small piece of tissue.
– During the procedure, patients lie on their back on
a table with their right hand resting above their
head.
– A local anesthetic is applied to the area where the
biopsy needle will be inserted
07/10/2022 getenet d 303

Liver Biopsy
• Procedure
07/10/2022 getenet d 304

• Transvenous Liver Biopsy
– Transvenous liver biopsy is used when a person’s
blood clots slowly or when excess fluid is present in
the abdomen, a condition called ascites.
– A small incision is made in the neck and a specially
designed hollow tube called a sheath is inserted into
the jugular vein.
– The doctor threads the sheath down the jugular vein,
along the side of the heart, and into one of the hepatic
veins, which are located getenet
07/10/2022
in the d
liver. 305
Liver Biopsy
Transvenous biopsy
07/10/2022 getenet d 306

• Laparoscopic Liver Biopsy
– Laparoscopic liver biopsy used to obtain a tissue sample

from a specific area or from multiple areas of the liver or
when the risk of spreading cancer or infection exists.
– We may take a liver sample during laparoscopic surgery
performed for other reasons, liver surgery.
– During laparoscopy, patients lie on their back on an
operating table.
07/10/2022 getenet d 307

Plugged Biopsy
• The plugged biopsy is a modification of the percutaneous
method in which the biopsy needle track is plugged with
collagen or thrombin.
The plugged biopsy has been proposed as being potentially
safer than standard percutaneous biopsy among certain
patients (i.e., those believed to be at high risk for bleeding
such as those with coagulopathy and/or thrombocytopenia or a
small cirrhotic liver).
07/10/2022 getenet d 308

Liver Biopsy
• Early preparation of the patient before liver
biopsy date
– Obtain patient consent is signed and NPO
for the procedure
– Complete blood count, including platelet
count, prothrombin time
– Grouping and cross match
– Vit K injection may be given for some day
before the biopsy
– Sedative may be given about one hour
before the biopsy it to be taken
07/10/2022 getenet d 309
Liver Biopsy
• Equipments
– Sterile container
• Towel with hole and hand towel
• Swabs and gauze
• Gali pot
• Gloves
• Dressing forceps
• Syringe with needle for local anesthesia
• Liver biopsy needle
07/10/2022 getenet d 310
Liver Biopsy
07/10/2022 getenet d 311

Liver Biopsy
• Equipments…
– Clean
• Cleansing solution
• Small bottle for the specimen
07/10/2022 getenet d 312

Liver Biopsy
• Procedure
– Position the patient on his back over the
right side of the bed
– Expose the right side of the patient
abdomen
– And open the sterile set then scrub your
hand wear glove and clean the area.
– Anesthetize the area and insert biopsy
needle
07/10/2022 getenet d 313
Liver Biopsy
• Procedure
07/10/2022 getenet d 314

Liver Biopsy
• Procedure
07/10/2022 getenet d 315

Liver Biopsy
• Procedure…
– The specimen is then put in bottle and
labeled and sent to the laboratory
07/10/2022 getenet d 316

Liver Biopsy
• Procedure…
– The wound is covered with dry dressing
– Immediately after the biopsy, vital signs are
typically obtained at least every 15 minutes for
the first hour, and every 30 minutes during the
second hour.
07/10/2022 getenet d 317

Liver Biopsy
• Fig. 1. Specimens of liver biopsies obtained with various sized needles and
differing techniques.
07/10/2022 getenet d 318

Liver Biopsy
• Procedure…
– The patient is often placed in the right
lateral recumbent position
– The patient should be observed carefully
over the first three hours after biopsy for the
risk of bleeding.
07/10/2022 getenet d 319

Liver Biopsy
• How soon do results come back from a liver
biopsy?
– Results from a liver biopsy take a few days to
come back.
– The liver sample goes to a pathology laboratory
where the tissue is stained.
– Staining highlights important details within the
liver tissue and helps to identify signs of liver
disease.
– The pathologist looks at the tissue with a
microscope and sends a report to the patient’s
doctor.
07/10/2022 getenet d 320
Liver Biopsy
• How long does it take to recover from a liver
biopsy?
– Most patients fully recover from a liver biopsy in 1
to 2 days.
– Patients should avoid intense activity, exercise, or
heavy lifting during this time.
– Soreness around the incision site may persist for
about a week.
– Acetaminophen or other pain medications that do
not interfere with blood clotting may help.
07/10/2022 getenet d 321

Liver Biopsy
• Contraindications
– Uncooperative patient
– Severe coagulopathy
– Infection of the hepatic bed
– Ascites
– Morbid obesity
– Possible vascular lesions
07/10/2022 getenet d 322

Liver Biopsy
• Complications
– Pain
– Bleeding
– Death?????????
07/10/2022 getenet d 323

Key points
• Definition of biopsy and liver biopsy

• Purpose of liver biopsy
• Types of liver biopsy
• Contraindication and complications of liver
biopsy
• Early preparation of the patient before liver
biopsy date
• Liver biopsy procedure
07/10/2022 getenet d 324
• CAST
• FOR 2ND YEAR NURSING STUDENTS
07/10/2022 getenet d 325

Cast
• Objectives
– At the end of this lesson the students will be
able to
• Define the term cast
• Describe the indications and contraindications
for cast application.
• Identify the materials used in cast application
and cast removal.
• List and explain the steps to applying a plaster
cast and removing cast.
• List the complications of cast
• Discuss nursing cares for patient with cast
07/10/2022 getenet d 326
A cast is a rigid external immobilizing device that is molded
to the contours of the body.
• A cast is used specifically to immobilize a reduced
fracture, to correct a deformity, to apply uniform
pressure to underlying soft tissue, or to support and
stabilize weakened joints.
• Casts permit mobilization of the patient while restricting
movement of a body part.The purposes of a cast are to
immobilize a body part in a specific position and to apply
uniform
07/10/2022
pressure on encased soft tissue.
getenet d 327
Types of Cast
– Short arm cast
– Thumb spica cast
– Long arm cast
– Short leg cast
– Long leg cast
– Hip spica cast
– Shoulder spica cast
– Cylinder/stovepipe cast
– Walking cast
07/10/2022 getenet d 328

Types of Cast
• Short arm cast
– Extends from below the elbow to the palmar
crease, secured around the base of the thumb.
– If the thumb is included, it is known as a thumb
spica or gauntlet cast.
– The short arm cast may be used for:
• Distal forearm fractures
• Wrist sprains and carpal injuries
• Some metacarpal fractures
07/10/2022 getenet d 329

Types of Cast
• Short arm cast…
07/10/2022 getenet d 330

Types of Cast
• Thumb spica cast
– The thumb spica cast may be used for:
• Scaphoid fractures
• Some thumb fractures
07/10/2022 getenet d 331

Types of Cast
• Long arm cast
– Extends from the upper level of the axillary
fold to the proximal palmar crease.
– The elbow usually is immobilized at a right
angle.
– The long arm cast may be used for:
• Mid to proximal forearm fractures
• Elbow fractures and dislocations
• Distal humeral fractures
07/10/2022 getenet d 332

Types of Cast
• Long arm cast…
07/10/2022 getenet d 333

Types of Cast
• Short leg cast:
– Extends from below the knee to the base of the
toes.
07/10/2022 getenet d 334

Types of Cast
• Long leg cast
– Extends from the junction of the upper and
middle third of the thigh to the base of the
toes.
– The long leg cast may be used for:
• Tibial fractures
07/10/2022 getenet d 335

Types of Cast
• Long leg cast…
07/10/2022 getenet d 336

Types of Cast
• Cylinder/stovepipe cast
– The cylinder/stovepipe cast may be used
for:
• Patellar fractures or dislocations
• Distal femoral fractures (some)
07/10/2022 getenet d 337

Types of Cast
• Cylinder/stovepipe cast
07/10/2022 getenet d 338

Types of Cast
• Shoulder spica cast:
– A body jacket that encloses the trunk and the
shoulder and elbow.
07/10/2022 getenet d 339

Types of Cast
• Hip spica cast:
– Encloses the trunk and a lower extremity.
07/10/2022 getenet d 340

Types of Cast
• Walking cast:
– A short or long leg cast reinforced for strength.
07/10/2022 getenet d 341

Types of Cast
• Walking cast:
– A short or long leg cast reinforced for strength.
07/10/2022 getenet d 342

Types of Cast
• Walking cast:
07/10/2022 getenet d 343

Types of Cast
• Walking cast:
07/10/2022 getenet d 344

Cast Application
• Indications:
• Fractures
• Severe sprains
• Dislocations
• Protection of post-operative repairs
• Gradual correction of a deformity
07/10/2022 getenet d 345

Cast Application
• Contraindications:
– Open fractures
– Severe swelling
– Ulcers or draining wounds
– Compartment syndrome
– Insensate limbs
07/10/2022 getenet d 346

Cast Application
• Equipments
– Stockinette
– Cotton
– Plaster of paris
– Bucket
07/10/2022 getenet d 347

Cast Application
• Equipments
– Stockinette
• Stockinette is usually the first layer applied
over the area to be cast.
• Its ends can be folded over the cast edges to
soften them.
07/10/2022 getenet d 348

Cast Application
• Equipments …Stockinette
07/10/2022 getenet d 349

Cast Application
• Equipments
– Cotton
• Cotton comes in a range of widths from
5-15 cm; the smallest ones are easiest to
work with.
• 5-10 cm cotton should be used for the
upper extremity and 10-15 cm for the
lower extremity.
07/10/2022 getenet d 350

Cast Application
• Equipments …Cotton
07/10/2022 getenet d 351

Cast Application
• Equipments
– Plaster of Paris
• Plaster is the most commonly used
casting material.
• Immersion in water initiates an
exothermic reaction in the plaster causing
it to harden.
• Once applied, it will feel hard within 4
minutes, however, it takes 2-3 days to dry
completely.
07/10/2022 getenet d 352

Cast Application
• Equipments…Plaster of Paris
07/10/2022 getenet d 353

Cast Application
• Equipments
– Bucket
• The bucket should be filled with water at
or below room temperature.
• Cooler water decreases the risk of
burning the patient’s skin as the plaster
sets and also allows for more working
time with the casting material.
07/10/2022 getenet d 354

Cast Application
• Equipments-Bucket
07/10/2022 getenet d 355

Cast Application
• Equipments…Plaster of Paris
07/10/2022 getenet d 356

o n
c a ti
pl i
A p
st
C a
u re
c e d
Pro
07/10/2022 getenet d 357
Cast Application
• Step 1: Evaluation
– Before cast application, certain
examinations must be performed:
• Complete neurovascular exam of the affected
region
• Note the quality of the skin in the region to be
cast
• Radiographs as necessary
07/10/2022 getenet d 358

Cast Application
• Step 2: Prepare equipment
– Choose appropriate width stockinette:
• 5 cm for arm
• 7.5 cm for leg
– Prepare rolls of the appropriate width of
plaster of paris
• 7.5 cm for arm
• 10-15 cm for lower leg
• 20 cm for thigh
– Fill plaster bucket with room temperature
water.
07/10/2022 getenet d 359
Cast Application
• Step 3: Prepare patient
– The patient should be positioned such
that both they, and the person applying the
cast, will be comfortable for the procedure.
– For upper extremity casting, this
may sometimes involve propping the patients
arm up on a table or similar support.
– For lower leg casts, the patient may sit with
their leg over the side of the bed or raised up
from the bed on a prop.
–
07/10/2022 getenet d 360
• Step 4: Stockinette
– Measure the length of stockinette needed.
– It should extend 3-4 cm beyond the area to be

cast at each end.
– Using your own palm length as a guide,
determine where the thumb hole is to be cut.
07/10/2022 getenet d 361

Cont……d
• Step 4: Stockinette
– At this location, cut a slit in the stockinette large

enough to give the base of the thumb lots of
space.
– Roll the stockinette over the area to be casted and
smooth it out.
– Never apply plaster to skin or stockinette
alone!
07/10/2022 getenet d 362
Cont……d
• Step 5: Cotton
– Begin wrapping the cotton about 2 cm above

where the cast edges will be.
– Beginning proximally, wrap the cotton distally,
overlapping the layers by 50%.
– When you reach the hand, the cotton may need to
be torn to better contour the base of the thumb.
07/10/2022 getenet d 363
Cont……d
• Step 5: Cotton …
– Once the hand is wrapped, continue back up

the forearm
– Extra pieces of cotton folded to half their
width can be applied at either end of the cast
for smoother cast edges.
07/10/2022 getenet d 364

Cont…..d
• Step 6: Prepare plaster

– Hold the plaster roll in one hand and the free end
of the plaster in the other
– Holding the roll obliquely, immerse the entire roll
of plaster in water.
07/10/2022 getenet d 365

Cont…….d
• Step 6: Prepare plaster
– When the bubbles stop, remove the roll

and gently squeeze to remove some of the excess
water.
• Do not squeeze too much water out or you will
have less working time and much of the plaster
will be squeezed back into the bucket.
07/10/2022 getenet d 366
Cast Application
• Step 7: Apply plaster
– As the plaster is being applied, it can be
smoothed out with the flat palmar surface of
the hand.
– The entire cast should use about 3 rolls of
plaster.
– Start proximally and wrap towards the hand
– When applying plaster to the palm and
between thumb and index finer, pinch the
plaster to decrease its width.
07/10/2022 getenet d 367

Cont…..d
• Step 7: Apply plaster…

– Fold the plaster back on itself to create a thicker
pad of plaster to reinforce the palm, where much
cast wear occurs.
– Fold the stockinette and cotton over the first layer
of plaster to create a smooth cast edge.
– Continue to apply the final layer of plaster and
smooth
07/10/2022 out getenet d the surface.
368
• Step 8: Mould plaster
– The cast should be moulded, depending on the

type of cast, to maximize its fit on the limb.
– Rub the cast to help the plaster layers adhere to
each other and give it a smooth surface
– To mould, apply pressure with the flat palmar
surface of your hands.
07/10/2022 getenet d 369

Cast Application
• Step 9: “Finish” cast:

– Smooth edges.
– Trim and reshape with cast knife or cutter.
– Remove particles of casting materials from

skin.
07/10/2022 getenet d 370

Cast Application
• Step 10: Support cast during hardening.
– Handle hardening casts with palms of
hands.
– Support cast on firm smooth surface.
– Do not rest cast on hard surfaces or on sharp

edges.
– Avoid pressure on cast.

07/10/2022 getenet d 371
Cast Application
• Step 11: Promote drying of cast.

– Leave cast uncovered and exposed to air.
– Turn patient every 2 hours supporting major

joints.
– Fans may be used to increase air flow and

speed drying.
07/10/2022 getenet d 372

Cast Application
• Step 12: Patient instructions
– Keep the cast dry!
– Plaster casts take 2-3 days to dry completely
– To reduce and minimize swelling, the limb

should be elevated above the heart for at least
2 days.
– Fingers and toes should be wiggled often

07/10/2022 getenet d 373
Cast Application
• Step 12: Patient instructions…
– DO NOT:
• Put anything down the cast
• Trim or cut the cast
• Remove any padding from the cast
• Drive while in a cast.
07/10/2022 getenet d 374

Cast removal
• It is important to remember that removing a

cast can be a frightening experience for
patients.
• A clear explanation of how the cast saw works
will help improve the patient’s comfort.
07/10/2022 getenet d 375

Cast removal
• Equipments
– Cast saw
– Cast spreaders
– Bandage scissors
07/10/2022 getenet d 376

Cast removal
• Removing the cast (equipment)
– Cast saw
07/10/2022 getenet d 377

Cast removal
– Cast spreaders
07/10/2022 getenet d 378

Cast removal
– Bandage scissors
07/10/2022 getenet d 379

v a l
o
R em
st
C a
u re
c e d
Pro
07/10/2022 getenet d 380
Cast removal
• Step 1: Cast saw
– Inform and explain the patient about the

procedure.
– Cut two straight lines down either side of the cast
moving the saw in and out with brisk movements
07/10/2022 getenet d 381

Cast removal
• Step 1: Cast saw…
– When making a cut, apply pressure until you

feel the release of the saw cutting through to
the other side.
– If the patient complains of pain, stop the saw
and assess the area.
07/10/2022 getenet d 382

Cast removal
• Step 1: Cast saw…
07/10/2022 getenet d 383

Cast removal
• Step 2: Cast spreader
– Use the cast spreaders to widen the opening

made by the cast saw.
• Step 3: Cut through padding
– Use the blunt ended bandage scissors to cut the
cotton and stockinette.
07/10/2022 getenet d 384

Cast removal
• Step 4: Skin treatment
– Assess the skin that was under the cast for

any damage, and to ensure any incisions
have healed.
– The skin can be washed with a mild soap.

– Apply emollient lotion.
07/10/2022 getenet d 385

Cast removal
• Step 4: Patient teaching
– Teach patient to avoid rubbing and
scratching skin.
– Teach patient to control swelling by

elevating the extremity or using elastic
bandage if prescribed.
07/10/2022 getenet d 386

Cast
• Complications
– Compartment syndrome
– Pressure points/skin breakdown
– Skin irritation
– Loss of reduction(healing)
07/10/2022 getenet d 387

Cast Care
• The following information provides general
guidelines
– Keep cast dry.
– Walking casts.
– Avoid dirt.
07/10/2022 getenet d 388

Cast Care
• The following information provides general
guidelines…
– Padding.
– Itching.
– Trimming.
07/10/2022 getenet d 389

Cast Care
• Swelling due to the injury may cause pressure in the

cast for the first 48 to 72 hours.
• This may cause the injured arm or leg to feel snug
or tight in the cast.
• It is very important to keep the swelling down.
• This will lessen pain and help the injury heal.
07/10/2022 getenet d 390

Cast Care
• To help reduce swelling:-
– Elevate.
• It is very important to elevate your
injured arm or leg for the first 24 to 72
hours.
• Elevation allows clear fluid and blood to
drain "downhill" to your heart.
– Exercise.
• Move uninjured, but swollen fingers or
toes gently and often.
07/10/2022
• Moving them often will prevent stiffness
getenet d 391
Cast Care
• To help reduce swelling…
– Ice.
• Apply ice to the cast.
–Place the ice in a dry plastic bag or ice
pack and loosely wrap it around the
cast at the level of the injury.
07/10/2022 getenet d 392

Cast Care
• Warning Signs
– Increased pain and the feeling that the cast
is to tight.
– Numbness and tingling in the hand or foot.
– Burning and stinging.
– Excessive swelling below the cast.
– Loss of active movement of toes or fingers.
07/10/2022 getenet d 393

Cast…..Nursing care
• Check color, temp, capillary refill, movement

& sensation of exposed part every 2 hrs for 24
hrs then every 4 hrs.
• Change patient's position every 2 hrs.

while awake.
• Use proper positioning to keep pressure off

prominences in cast (i.e. heels).
07/10/2022 getenet d 394

Cast…Nursing care
• Check skin around cast edge every 4 hrs
• Monitor if there is any broken skin, foul odor

or drainage noted under cast edges.

• Provide daily nursing care.
• Teach family care of cast while in hospital.
07/10/2022 getenet d 395

Cast
• Key points
– Definition of cast
– Types of cast
– Cast application
• Equipment
• Procedure
– Cast removal
• Equipment
• Procedure
– Nursing care for pts with cast
07/10/2022 getenet d 396
Fixation
• Objectives
– At the end of this lesson the student will be
able to:-
• Define what fracture fixation mean
• Describe the difference between internal and
external fixation of fracture
• Identify internal and external fixation materials
• Discuss how to assist during fixation
application
• Discuss nursing care for patient with fracture
fixation
07/10/2022 getenet d 397
Soft tissue injuries…Revision
• Soft tissue injuries
– Contusion
• Is a soft tissue injury produced by blunt
force, such as a blow, kick, or fall.
– Strain
• Is a “muscle pull” caused by overuse,
overstretching, or excessive stress.
– Sprain
• is an injury to the ligaments surrounding a
joint that is caused by a wrenching or
twisting motion.
07/10/2022 getenet d 398
Joint Dislocations…Revision
• A dislocation of a joint is a condition in which the articular

surfaces of the bones forming the joint are no longer in
anatomic contact.
• Common site for dislocation
– Shoulder
– Knee
– Wrist
– Hip
– Elbow
07/10/2022 getenet d 399
Fractures…Types…
07/10/2022 getenet d 400

Fixation
• Fixation is the process of holding or fastening in

a fixed position
• Fracture Fixation is the immobilization of the
parts of a fractured bone especially by the use of
various metal attachments.
07/10/2022 getenet d 401

Fixation
• The basic goal of fracture fixation is

– To stabilize the fractured bone.
– To enable fast healing of the injured bone.
– To return early mobility and full function of

the injured extremity.
07/10/2022 getenet d 402

Fixation
• Internal Fixation for Fractures
– Internal fixation is an operation in
orthopedics that involves the surgical
implementation of implants for purpose of
repairing a bone.
07/10/2022 getenet d 403

Internal Fixation
• Indications for Internal Fixation
– Displaced intra-articular fracture
– Axial, angular, or rotational instability
that cannot be controlled by closed
methods
– Open fracture
– Polytrauma
07/10/2022 getenet d 404

Internal Fixation
• Benefits of Internal Fixation
– Earlier functional recovery
– More predictable fracture alignment
– Potentially faster time to healing
07/10/2022 getenet d 405

Internal Fixation
• Internal Fixation materials for Fractures
– The most common types of internal fixation
materials are :-
• Wires
• Plates
• Pins
• Nails or Rods
• Screws
07/10/2022 getenet d 406

Internal Fixation
• Internal Fixation materials…
– Wires
• Wires are often used as sutures or threads
to "sew" the bones back together.
07/10/2022 getenet d 407

Internal Fixation
– Wires
07/10/2022 getenet d 408

Internal Fixation
– Pins
• Pins hold pieces of bone together.
• They are usually used in pieces of bone

that are too small to be fixed with screws.
07/10/2022 getenet d 409

Internal Fixation
– Pins
07/10/2022 getenet d 410

Internal Fixation
• Internal Fixation materials
– Plates
• Plates are like internal splints that hold the
fractured ends of bone together.
• Extend along the bone and are screwed in

place.
07/10/2022 getenet d 411

Internal Fixation
– Plates
07/10/2022 getenet d 412

Internal Fixation
– Nails or Rods
• inserting a rod or nail through the hollow
center of the bone that normally contains
some marrow.
• Held in place by screws until the fracture

has healed.
07/10/2022 getenet d 413

Internal Fixation
– Nails or Rods
07/10/2022 getenet d 414

Internal Fixation
– Screws
• Bone screws are used for internal fixation
more often than any other type of implant.
• Can be used alone to hold a fracture, as well

as with plates, rods, or nails.
• May be left in place, or removed after the

bone heals.
07/10/2022 getenet d 415

Internal Fixation
– Screws
07/10/2022 getenet d 416

External Fixation
• External fixation is a surgical treatment used

to stabilize bone and soft tissues at a distance
from the operative or injury focus.
07/10/2022 getenet d 417

External Fixation
• External fixators are used to manage open
fractures with soft tissue damage.
• Complicated fractures of the humerus,

forearm, femur, tibia, and pelvis are managed
with external skeletal fixators.
• The fracture is reduced, aligned, and

immobilized by a series of pins inserted in the
bone.
07/10/2022 getenet d 418

External Fixation
• Indications
– Stabilization of severe fractures
– Initial stabilization of soft tissue and bony
disruption in poly trauma patients
– Closed fracture with associated severe soft
tissue injuries
– Transarticular stabilization of severe soft
tissue and ligamentous injuries
– Certain pediatric fractures
07/10/2022 getenet d 419

External Fixation
• External fixation materials
– The most common external fixation
materials
• Cast
• Splint
• Bandages
• Traction
07/10/2022 getenet d 420

External Fixation
• Splint
– A splint is a device used for support or
immobilization of limbs or of the spine.
07/10/2022 getenet d 421

External Fixation
• Bandage
– A bandage is a strip of material such as
gauze used to protect, immobilize,
compress, or support a wound or injured
body part.
07/10/2022 getenet d 422

External Fixation
• Bandage
07/10/2022 getenet d 423

External Fixation
• Traction
– A sustained pull applied mechanically especially to the
arm, leg, or neck so as to correct fractured or dislocated
bones, overcome muscle spasms, or relieve pressure.
07/10/2022 getenet d 424

External Fixation
• External Fixation Advantages
– Minimal damage to blood supply
– Minimal damage to soft tissues
– Fixation is away from site of injury
– Good option when significant infection risk
07/10/2022 getenet d 425

External Fixation
• External Fixation Disadvantages
– Restricted joint motion
– Pin tract infection
– Inadequate stability for certain fractures
07/10/2022 getenet d 426

Fixation
• Risks and complications of fixation materials
– Infection
– Stiffness
– Loss of range of motion,
– Non-union and mal-union
– Damage to the muscles and nerve
– Arthritis and tendonitis
– Chronic pain associated with plates, screws,
and pins
– Compartment syndrome and Deformity
07/10/2022 getenet d 427
External Fixation
• Nursing Interventions
– It is important to prepare the patient
psychologically for application of the external
fixator.
– After the external fixator is applied, the

extremity is elevated to reduce swelling.
– If there are sharp points on the fixator or pins,

they are covered to prevent device-induced
injuries.
07/10/2022 getenet d 428
External Fixation
• Nursing Interventions
– The nurse monitors the neurovascular status
of the extremity every 2 to 4 hours and
assesses each pin site for redness, drainage,
tenderness, pain, and loosening of the pin.
– Some serous drainage from the pin sites is
to be expected.
– The nurse must be alert for potential
problems caused by pressure from the
device on the skin, nerves, or blood vessels
and for the development of compartment
syndrome
07/10/2022 getenet d 429
• Nursing Interventions…
– This typically includes cleaning each pin site

separately three times a day with cotton-tipped
applicators soaked in sterile saline solution.
– Crusts should not form at the pin site.
– Sterile conditions and advances in surgical
techniques reduce, but do not remove, the risk of
infection when internal fixation is used.
– The severity of the fracture, its location, and the
07/10/2022 getenet d 430
Key points
• Definition of fixation
• Types of fixation
– Internal
– External
• Fixation materials
• Nursing intervention for patient with fixation
07/10/2022 getenet d 431

Cast
• Reference
– Burrell, gerlach, pless. Adult nursing - book
ix. 2nd ed., Appleton lang, 1997
– Smeltzer, s.C. & B.G. Bare. Brunner &
suddarth’s textbook of medical-surgical
nursing. 8 th ed., Lippincott, 1996.
– Sue C. DeLaune, and Patricia K. Ladne.
Fundamentals of nursing: Standards &
practice /— 2nd ed.2002.
– Www.Google.Com
– Www.Youtube.Com
07/10/2022 getenet d 432
Traction
• Traction
– Is the application of pulling force to body to
provide reduction, alignment and rest
• It is used to treat fractures, dislocations, and

long-duration muscle spasms, and to prevent
or correct deformities.
07/10/2022 getenet d 433

Traction
• Purpose
– To reduce and aligns the ends of a fracture
by pulling the limb into a straight position.
– To ends muscle spasm and relieves pain
– To promote healing
– To prevent deformity
07/10/2022 getenet d 434

Traction
• Types of traction
• Skin traction
• Skeletal traction
07/10/2022 getenet d 435

Traction
• Skin traction
– The pulling force is applied directly on the
skin and indirectly on the bone
– Skin traction is accomplished by weight that

pulls on a tape, sponge or rubber or plastic
materials attached to the skin
– The maximum wt that should be applied by

skin traction is 2.5 to 4.5.
07/10/2022 getenet d 436
Traction
• Skin traction
– Examples (Reading assignment)
• Bucks traction
• Russell’s traction
• Pelvic traction
07/10/2022 getenet d 437

Traction
• Skin traction
07/10/2022 getenet d 438

Traction
07/10/2022 getenet d 439

Traction
• Skeletal traction
– The force applied directly in the bone by
means of metal pin, wire or screw which is
inserted directly into the bone
– The wt usually ranges from 6.8 to 13.6kg
07/10/2022 getenet d 440

Traction
07/10/2022 getenet d 441

Traction
07/10/2022 getenet d 442

Traction Care
The nurse must assess and monitor the patient’s
psychological responses to traction.
It is important to evaluate the body part to be

placed in traction and its neurovascular status and
compare it to the unaffected extremity.
As long as the client is in traction, skin integrity

must be assessed and documented, examining
especially for redness, bruises, and lacerations.
07/10/2022 getenet d 443

Traction care
• Traction must be continuous to be
effective in reducing and immobilizing
fractures.
• Skeletal traction is never interrupted.
• Weights are not removed unless
intermittent traction is prescribed.
• Any factor that might reduce the
effective pull or alter its resultant line of
pull must be eliminated:
07/10/2022 getenet d 444
Traction Care
– The patient must be in good alignment in
the center of the bed when traction is
applied.
– Ropes must be unobstructed.
– Weights must hang free and not rest on

the bed or floor .
– Knots in the rope must not touch the
pulley or the foot of the bed.
07/10/2022 getenet d 445
Nursing Management:
 Alteration in Peripheral Tissue Perfusion:
 Tissue perfusion is enhanced by client

exercises within the limitations of the
traction.
 Exercises, regular deep breathing and

coughing, adequate fluids, and elastic
stocking work together to prevent deep
venous thrombosis.
07/10/2022 getenet d 446

Nursing Interventions:
 Peripheral sensation management :
 Evaluating the client’s pain, sensation, active
and passive ROM, color, temperature, capillary
refill time, and pulses.
 Providing pin site care:

 The wound at the pin insertion site requires
attention .
07/10/2022 getenet d 447

 Attaining maximum mobility with traction:
 During traction therapy:
 Encourage the patient to exercise
muscles and joints that are not in
traction.
 During the patient exercises :
 Ensures that traction forces are
maintained and that the patient is
properly positioned to prevent
complications resulting from poor
alignment.
07/10/2022 getenet d 448
 Maintaining the positioning :
 Maintain alignment of the patient’s body in

traction to promote an effective line of pull.
 The patient’s foot may be supported in a

neutral position by orthopedics devices.
07/10/2022 getenet d 449

• Monitoring and managing potential
complications:
– Pressure Ulcers
– Venous Stasis and Deep Vein Thrombosis
07/10/2022 getenet d 450

Traction
• Reference
– Redemann S, Modalities for immobilization. In
Maher A, Salmond S, Pellino T, (Ed.), Orthopaedic
Nursing, Chapter 12, 311-318, 2002. Philadelphia:
W B Saunders.
– Taylor I, Ward Manual of Traction, Chapter 2, 3, 5,
6. 1987, Churchill Livingstone.
– Traction Working Party, Traction update. Journal
of Orthopaedic Nursing, 6(4): 230-235, November
2002.
– 5National Association of Orthopaedic Nurses.
(NAON). Core Curriculum for Orthopaedic
07/10/2022
Nursing. 6th Edition.getenet
Chapterd
10. 2007. 451
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K Y
AN
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07/10/2022 getenet d 452

Aseppsis and Adevanced Procedures 3

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Aseppsis and Adevanced Procedures 3

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INFECTION PREVENTION

• The nurse’s efforts to minimize the onset & spread of

• Aseptic technique:- is an effort to keep the client as free

• This can be achieved by ensuring that only sterile

Medical asepsis & Surgical asepsis.

• Medical or Clean Asepsis reduces the number of

•Before coming in direct contact with patients

•Before putting on sterile surgical gloves or

•After any situation in which hands may be

contaminated, such as (handling contaminated

• After removing gloves

• The purpose of hand washing is to mechanically remove

• appropriate hand washing has three essential

• Lather with soap and scrub between fingers,

Courtesy of SDS Kerr

• hand antisepsis is performed to remove soil and debris

• Hand antiseptic should be done before:

o Examining or caring for highly susceptible patients

o Performing an invasive procedure

o Leaving the room of patients

• The purpose of antiseptic hand rub is to inhibit or kill

• Use of a waterless, alcohol-based hand rub product is

• Antiseptic hand rub is quicker and easier to perform, and

Soap does not need to be Does not remove dirt

• It is important to note that gloves are not a substitute

2. Use Personal protective equipment (PPE)

• Gloves – protect hands

• Gowns/aprons – protect skin and/or clothing

• Masks and respirators– protect mouth/nose

– Respirators – protect respiratory tract from

• Clinicians and other health care workers should wear

Types of gloves available in Ethiopia

1. Sterile or high-level disinfected surgical gloves

2.Clean examination gloves, and

Gloves must be used when:

• Handling blood and/or body substances,

• Touching mucous membranes,

• Touching non-intact skin,

• Handling contaminated sharps, Performing invasive

procedures, Cleaning body substances spills or any

equipment (instruments) or materials (linen) or surface that

may have been contaminated by body substances

• Do’s and Don’ts of Glove Use

• Limit opportunities for “touch contamination” -

– During use if torn and when heavily soiled (even

• Discard in appropriate receptacle

– Never wash or reuse disposable gloves

Sequence* for Donning PPE:

 Goggles or face shield

Sequence for Removing PPE:

• Face shield or goggles

• Sterilization destroys all microorganisms &

can never be sterile

 Preparation for putting on surgical gloves

• Gloves are cuffed to make it easier to put them on without

contaminating them. When putting on sterile gloves, remember that the

first glove should be picked up by the cuff only.

under the cuff of the second glove. Be careful not to contaminate

being put on.

Put the second glove on the ungloved hand by maintaining a

• Sterile Latex Gloves should be worn when in direct contact with

blood, body fluids, non intact skin or mucous membranes.

• Sterile Glove usage is not a substitute for thorough hand hygiene.

• Sterile Latex Surgical Gloves should be changed after every task