OXYGENATION and HEMATOLOGY  If necessary a nurse or technologist will insert

an IV line, into a vein in your hand or arm.

CT SCAN
 The dose of radio tracer is then injected
Definition:
intravenously, swallowed or inhaled as a gas.
 An X-ray technique that produces images of your body
that visualize the internal structures in cross section rather
 Instruct client to rest quietly, avoiding
than the overlapping images typically produced by
movement and talking.
conventional x-ray exams.

 The client will be moved into the PET or CT

Indications:
 Used for biopsy scanner, and the imaging will begin.

 Detect osteoporosis ANGIOGRAPHY

 Diagnosis for tumors • Arteriography

 Diagnosis for liver cancer, spleenomegaly
 Diagnosis for vascular diseases.
Procedure:
 The patient will be placed and gently secured on the
scan table, by the technologist.
 He will be moved into the scanning chamber and the
images will be taken from several different angles.
 Instruct the patient to remain as still as possible.
MRI
Definition:
 A radio frequency electromagnetic field is then briefly
turned on, causing the protons to alter their alignment
relative to the field.
Contraindications:
 Cardiac pacemaker
 Implanted cardiac defibrillator
 Carotid artery vascular clamp
 Neuro-stimulator
 Insulin or infusion pump
 Bone growth or fusion stimulator
 Cochlear, otologic, or ear implant.
Procedure:
 Before your examination, an
Technologist will explain the procedure.
 Patient is not allowed to eat and drink an
hour before the examination
PET Scan( positron electron tomography)
• Is a radiographic technique that uses contrast agent to
assess blood vessels and the flow of blood through
them.
Indication
It is a technique used to visualize the inside, or lumen, of
blood vessels and organs of the body
 Coronary angiography – determines the degree of
obstruction in myocardial circulation
 Venography – outline veins
 Lymphography – outline lymphatic vessels
Contraindications
• Cardiac arrhythmias and renal failure.
• Prior contrast reactions are a relative contraindication;
such patients can frequently be pre-treated with the
use of a steroid and anti-histamine preparation one day
prior to the examination
Materials and Equipment
• Contrast agent (optional) – iodine-based
• Headphone or earplug
• Guide wires and catheters
• Hospital gown
• Angiogram or arteriogram
Preparation
• Check Diagnostic examination order
• Assemble equipment
Procedure
Preprocedure Care
• Explain to the client the purpose of CT scan, the sounds
and sensation the client will hear and feel as well as his
role in the success of the procedure.
• Obtain an informed consent
• Obtain a detailed baseline data; vital signs, quality and
symmetry of pulses in limbs, level of consciousness,
speech patterns and estimates of limb strengths.
Baseline data is crucial to accurate assessment of
MR- postprocedural changes.
• Prepare the client
o Note any allergy on iodine-based contrast agent.
o Instruct client to abstain from food for 6 to 8 hours.
Liquid can be taken. Liquid can reduce the risk
dehydration and clotting.
o The area of planned puncture should be shaved

Definition: During the procedure

Measures important body functions to help doctors
evaluate how well organs and tissues are functioning.
Preparation:
Assisting with CVP placement
Adhere to institutional Policy and Procedure.
Obtain history and assess the patient.
Explain the procedure to the patient, include:
 local anesthetic
 trendelenberg positioning
 draping
 limit movement
 need to maintain sterile field.
 post procedure chest X-ray
Procedure:
 Position on an examination table.
Depending on the type of angiogram, access to the
blood vessels is gained most commonly through the femoral
artery, to look at the left side of the heart and the arterial
system or the jugular or femoral vein, to look at the right
side of the heart and the venous system. Using a system of
guide wires and catheters, a type of contrast agent (which
shows up by absorbing the x-rays), is added to the blood to
make it visible on the x-ray images.
The X-ray images taken may either be still images,
displayed on a image intensifier or film, or motion images.
For all structures except the heart, the images are usually
taken using a technique called digital subtraction
angiography (DSA). Images in this case are usually taken at
2 - 3 frames per second, which allows the radiologist to
evaluate the flow of the blood through a vessel or vessels.
This technique "subtracts" the bones and other organs so
only the vessels filled with contrast agent can be seen. The
heart images are taken at 15-30 frames per second, not
using a subtraction technique. Because DSA requires the
patient to remain motionless, it cannot be used on the
heart. Both these techniques enable the radiologist or
cardiologist to see stenosis (blockages or narrowings) inside
the vessel which may be inhibiting the flow of blood and
causing pain.
Postprocedural care
• If the femoral approach was used keep the leg
immobile; tell the client not to flex the hip or the leg for
12 hours. If the brachial approach was use, release the
dressing and apply elastic bandage to client’s arm,; the
arm must remain straight. Limb movement can lodge
the clot at the puncture site and result in bleeding.
• Monitor vital signs every 15 minutes for 2 hours, then
hourly until stable.
• Keep a sandbag on a femoral puncture site to maintain
pressure on the site. Check puncture sites every 15
minutes for 2 hours, then hourly
• Monitor distal pulses every 14 minutes for 2 hours, then
hourly until stable, assess the quality of pulse and note
capillary filling time.
• Expect diuresis, provide ample fluid and keep a urinal
or bed pan nearby.
• Resume prescribed medications and usual diet.
Complications
• Decreased perfusion of the dial limb from hemorrhage
or hematoma at the puncture site.
• Allergic reaction in relation to contrast agent.
I. Stress Test
• It is a medical test that indirectly reflects arterial
blood flow to the heart during physical exercise.
When compared to blood flow during rest, the test
reflects imbalances of blood flow to the heart's left
ventricular muscle tissue – the part of the heart
that performs the greatest amount of work
pumping blood.
• It is used to evaluate the functional capacity of
clients with or without heart disease and can be
done serially to evaluate the effectiveness of
medical and surgical interventions.
• Two exercise
1. Bicycle ergometry – involves a device
equipped with a wheel operated by pedals
that can be adjusted to increase the
resistance to pedaling (multistage testing).
2. Treadmill testing – motorized device that has
an adjustable conveyor belt able to reach
speeds of 1 to 10 miles per hour.
Indications
• WPW Syndrome
• Left Ventricular Hypertrophy
• Especially with "strain" pattern
• Significant valvular disease
• Severe Hypertension
• Hypertrophic Cardiomyopathy
• Mitral Valve Prolapse
• Baseline ST-T Wave abnormality
Contraindications
Absolute Contraindications – stress should not
be performed until the condition is stabilized or adequately
treated.
• EKG change suggesting recent MI, severe
ischemia, or other significant cardiac events
• Unstable Angina
• Uncontrolled cardiac arrhythmias causing
symptoms
• Severe symptomatic aortic stenosis
• Symptomatic heart Failure
• Pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis
• Suspected or known dissecting aneurysm
• Acute systemic infection
Relative Contraindications – may be tested only
after careful evaluation of the risk/benefit ratio.
• Left main coronary stenosis
• Moderate Stenotic Vulvar Heart Disease
• Electrolyte abnormalities
• Hypertension, >200/110 at rest
• Tachyarrythmias or Bradyarrhythmias
• Hypertrophic cardiomyopathy
• High degree of a-v block
• Ventricular Aneurysm
• Uncontrolled metabolic disease (diabetes,
thyroid)
Materials and Equipment
• BP apparatus
• ECG
• Bicycle ergometry
• Treadmill
• Stethoscope
• Tape or belt
Preparation
• Check Diagnostic examination order
• Assemble equipment2.
• ECG preparation:
o The electrode sites should be rubbed with “Nu
Prep” and alcohol until the skin is erythematous to
remove skin oils and a superficial layer of skin.
o If hair is present the sites should be shaved.
o Electrodes are attached to the skin as per the
figure below. It is best, if possible to avoid placing
the electrode over large muscles masses.
o Obtain a 12 lead ECG to insure there is no baseline
artifact. If baseline artifact is present, repeat skin
prep described above and repeat the 12 lead ECG.
Procedure
Preprocedure Care
• Explain to the client the purpose of CT scan, the sounds
and sensation the client will hear and feel as well as his
role in the success of the procedure.
• Obtain an informed consent
• Prepare the client
• Instruct the client not to eat or smoke for 2 to 3
hours before the test and to dress appropriately for
exercise.
• No strenuous effort should be done for at least 12
hours.
• Brief history taking and physical examination
• Obtain baseline resting ECG and record standing ECG
and BP. To serve as basis in determining vasoregulatory
abnormalities.
• Prepare skin for electrode placement and secure
electrode to skin by tape or belt.
Procedure
• Provide patient with demonstration and explanation of
treadmill procedure.
• Start Quahog 2000 treadmill and have patient begin
walking as naturally as possible taking long steps and
keeping to the front of the treadmill.
• Press “Start Exercise” on the console
• The ECG and the presence of symptoms should be
monitored continuously during the test.
• An ECG and heart rate should be taken every minute
and a blood pressure should be obtained at the second
minute of every stage.
• Exercise termination should be symptom limited with
patients achieving at least 85% or greater of their age
predicted maximum heart rate (220 – age).
• The radiopharmaceutical should be injected close to the
peak of exercise. The patient should be encouraged to
continue to exercise for an additional 1-2 minutes after
the injection of the radiopharmaceutical.
• . Press “Stop Exercise”
During the procedure
• Obtain baseline BP, heart rate and rhythm strip
• Observe the ECG monitor constantly for changes
• Record the Client’s BP, heart rate, rhythm strip, and
activity level and time at specified intervals
• Monitor the client for chest pain, dysrhythmias, ST-
segment change, unexpected change in BP, etc.
Exercise Endpoints:
• Patient requests to stop
• Drop in systolic blood pressure of >20 mm Hg
from baseline blood pressure despite an
increase in workload, when accompanied by
other evidence of ischemia
• Moderate to severe angina
• Marked dyspnea or fatigue
• Increasing nervous system symptoms (e.g.,
ataxia, dizziness, or near-syncope
Postprocedure Care
 • Assist the client to chair, cart, or bed for recovery. Indication:
• Periodically monitor the client;s BP, heart rate and  Those with clotting disorders
rhythm strip for at least 15 minutes after completion or
until ECG returns to baseline
Material & Equipment:
Complication  Blood obtained by venipuncture
• Chest pain (angina)
• Irregular heart rhythm  Tube with sodium citrate
• Heart attack (rare)
 CaCl

Ultrasound Procedure:
 Client’s blood is obtained by venipuncture
Definition:
“Sonography”, involves exposing part of the body to high  The blood is mixed in a tube that contains sodium
frequency sound waves to produce pictures of the inside of citrate to prevent the clotting process from starting before
the body. the test.

Doppler Ultrasonography
 The blood cells are separated from plasma.
Special ultrasound technique that evaluates blood velocity
as it flows through a blood vessel, including the body’s
major arteries & veins in abdomen, arms, legs, & neck.  Patient’s blood plasma is added with a protein
thromboplastin that converts prothrombin to thrombin.
TYPES:
 Color Doppler  The mixture is kept in a warm water bath at 37C for
1-2 minutes.
 Power Doppler
 Calcium chloride is added to the mixture.
 Spectral Doppler
 The test is timed from the addition of calcium
Indication: chloride until the plasma clots.
Variety of conditions & to assess organ damage following
illness; limitations with bowel 0r organs obscured by the
bowel, large patients. Complications:
 Mild dizziness and a possibility of a bruise or swelling
Materials & Equipment:
in the area where the blood was drawn.
 Ultrasound scanner
Partial Thromboplastin Time
 Examination table
Definition:
 Clear water-based gel Partial thromboplastin time (PTT) is a blood test that
looks at how long it takes for blood to clot. It can help tell if
 Loose- fitting clothing for exam gown. you have bleeding or clotting problems.

Indications:
Complications:  The test may also be used to monitor patients who
No known complications. are taking heparin, a blood thinner.

Preparation:
 Wear comfortable, loose- fitting clothing for your Preparation:
ultrasound exam.  Medicines-If you are receiving heparin therapy, this
test may need to be repeated at regular intervals to
 May be asked to wear a gown during the procedure. evaluate your response to treatment. The health care
provider may tell you to stop taking certain drugs
 Other preparation depends on the type of examination before the test. Drugs that can affect the results of a PTT
the client will have. test include antihistamines, vitamin C (ascorbic acid),
aspirin, and chlorpromazine (Thorazine).

Procedure:  Activity-No changes necessary.

 The client is positioned lying face-up on an examination
table that can be tilted or moved.
 A clear water-based gel is applied to the area of the body
being studied.
 The sonographer then presses the transducer firmly
against the skin.
Prothrombin test
Definition:
Prothrombin time test belongs to a group of blood tests that
asess the clotting ability of blood.
Normal Results:
 Time 11-15 seconds
 Normal control value along with patient results
 Normal counts of clotting factor VII & X
Do not stop taking any medicine without first talking to
your doctor.
 Disrobing-None required. Roll up sleeve only.
 Diet--No changes necessary.
Procedure:
 Technician, doctor or nurse applies a tourniquet or
blood-pressure cuff to the upper arm if blood is collected
from a vein.
 Skin over the vein to be stuck is cleaned with alcohol
or other antiseptic on a piece of cotton.
 When blood is drawn from a vein, the operator feels
the vein to be used then punctures both the skin and vein in
one quick stroke. The needle used is a sterile, disposable
needle attached to a sterile, disposable syringe.
 Operator withdraws the needle and transfers
sample from the collecting syringe into sterile tubes
(identified with your name) before sending samples to the
laboratory for analysis. Tubes are treated with an anti-
coagulant chemical to prevent clotting.
 If blood is collected from a finger, heel or ear lobe,
skin over the selected site is cleaned with an antiseptic. The
operator quickly pierces the skin to a shallow depth, using a
sterile, disposable metal lancet. The drop or two of blood
produced is collected into a capillary pipette.
Complications:
Risks of any blood test may include:
 Excessive bleeding
 Fainting or feeling light-headed
 Hematoma (blood accumulating under the skin)
 Infection (a slight risk any time the skin is broken)
 Multiple punctures to locate veins
PLATELET DETERMINATION
Definition:
A platelet count is a test to measure how many platelets
you have in your blood. Platelets help the blood clot. They
are smaller than red or white blood cells.
Complications:
 Excessive bleeding
 Fainting or feeling light-headed
 Hematoma (blood accumulating under the skin)
 Infection (a slight risk any time the skin is broken)
 Multiple punctures to locate veins
Materials and Equipment:
 Microscope
 Improved Neubauer counting chamber
 RBC Pipette
 Platelet diluting fluid. It is prepared as follows
 a) Procaine hydrochloride : 3.0 g
 b) Sodium chloride : 10 g
 c) Distilled water to : 100 ml
 Filter it through Whatman No. 44 filter paper and
store in a clean and dry plastic container. It is stable at 2-
8°C.
Preparations and Procedure:
 Mix the blood specimen carefully.
 By using RBC pipette draw blood up to 0 5 mark.
 Wipe excess blood on the outside of the pipette.
 The diluting fluid is drawn up to mark 101 (blood is
diluted 1:200)
 Mix the contents in the bulb thoroughly.
 After 5 minutes, discard the first drop, then transfer
a small drop on one side of the counting chamber
 Place the filled mounted counting chamber under a
petri dish with a moist filter paper. Let it stay undisturbed
for 15 minutes. (This permits the platelets to settle and also
pre vents evaporation of diluting fluid in the chamber).
 Place the counting chamber carefully on the stage of
the microscope. Under low power magnification focus red
cell counting area. Move to view the corner square of the
red cell area and change to high power objective.
 Keep the condenser down and reduce the light by
adjusting the diaphragm. The plate lets will appear like
highly refractile particles.
 Count platelets in all 25 small squares. The area
covered by 25 squares is equivalent to 1 sq. mm.
COMPLETE BLOOD COUNT (CBC)
The complete blood count (CBC) is a common blood
test that evaluates the three major types of cells in the
blood: red blood cells, white blood cells, and platelets.
Why It's Done
A CBC may be ordered as part of a routine checkup, or if
your child is feeling more tired than usual, seems to have
an infection, or has unexplained bruising or bleeding.
• Red blood cells: The CBC's measurements of red
blood cell (RBC) count, hemoglobin (the oxygen-
carrying protein in RBCs), and mean (red) cell volume
(MCV) provides information about the RBCs, which carry
oxygen from the lungs to the rest of the body. These
measurements are usually done to test for anemia, a
common condition that occurs when the body has
insufficient red blood cells.
• White blood cells: The white blood cell (WBC) count
measures the number of WBCs (also called leukocytes)
in the blood. The WBC differential test measures the
relative numbers of the different kinds of WBCs in the
blood. WBCs, which help the body fight infection, are
bigger than red blood cells and there are far fewer of
them in the bloodstream. An abnormal WBC count may
indicate an infection, inflammation, or other stress in
the body. For example, a bacterial infection can cause
the WBC count to increase, or decrease, dramatically.
• Platelets: The smallest blood cells, platelets play an
important role in blood clotting and the prevention of
bleeding. When a blood vessel is damaged or cut,
platelets clump together and plug the hole until the
blood clots. If the platelet count is too low, a person can
be in danger of bleeding in any part of the body.
The CBC can also test for loss of blood, abnormalities in the
production or destruction of blood cells, acute and chronic
infections, allergies, and problems with blood clotting.
Preparation
No special preparations are needed. Having your
child wear a short-sleeve shirt on the day of the test can
make things easier for the technician who will be drawing
blood.
The Procedure
Not much blood is drawn in a CBC. A health
professional will usually draw the blood from a vein. For an
infant, the blood may be obtained by puncturing the heel
with a small needle (lancet). If the blood is being drawn
from a vein, the skin surface is cleaned with antiseptic, and
an elastic band (tourniquet) is placed around the upper arm
to apply pressure and cause the veins to swell with blood. A
needle is inserted into a vein (usually in the arm inside of
the elbow or on the back of the hand) and blood is
withdrawn and collected in a vial or syringe.
After the procedure, the elastic band is removed.
Once the blood has been collected, the needle is removed
and the area is covered with cotton or a bandage to stop
the bleeding. Collecting blood for this test will only take a
few minutes.
What to Expect
Either method (heel sticking or vein withdrawal) of
collecting a sample of blood is only temporarily
uncomfortable and can feel like a quick pinprick. Afterward,
there may be some mild bruising, which should go away in
a few days.
Getting the Results
The blood sample will be processed by a machine.
Parts of the CBC results can be available in minutes in an
emergency, but more commonly the full test results come
after a few hours or the next day.
If a CBC test points to anemia, infection, or other concerns,
your child's doctor may repeat the test just to be sure. If the
second set of test results come back the same, your doctor
will likely order further lab tests for your child to determine
what's causing the problem and how to treat it.
Risks
The CBC test is considered a safe procedure. However,
as with many medical tests, there are some problems that
can occur with having blood drawn:
• fainting or feeling lightheaded
• hematoma (blood accumulating under the skin
causing a lump or a bruise)
• pain associated with multiple punctures to locate a
vein
Helping Your Child
Having a blood test is relatively painless. Still,
many children are afraid of needles. Explaining the test in
terms your child can understand might help ease some of
the fear.
Allow your child to ask the technician any questions he or
she might have. Tell your child to try to relax and stay still
during the procedure, as tensing muscles and moving can
make it harder and more painful to draw blood. It also may
help if your child looks away when the needle is being
inserted into the skin.
BLEEDING TIME
Bleeding time is a blood test that looks at how fast
small blood vessels close to stop you from bleeding.
How the Test is Perform
A blood pressure cuff inflates around your upper
arm. While on the cuff is on your arm, the health care
provider makes two small cuts on the lower arm. They are
just deep enough to cause a tiny amount of bleeding.
The blood pressure cuff is immediately deflated.
Blotting paper is touched to the cuts every 30 seconds until
the bleeding stops. The health care provider records the
time it takes for the cuts to stop bleeding.
How to Prepare for the Test
Certain medications may change the test results.
Always tell your doctor what medications you are taking,
even over-the-counter drugs. Drugs that may increase
bleeding times include dextran, nonsteroidal anti-
inflammatory drugs (NSAIDs), and salicylates (including
aspirin).
Your doctor may tell you to stop taking certain
medicines a few days before the test. Never stop taking
medicine without first talking to your doctor.
How the Test Will Feel
The tiny cuts are very shallow. Most people say it
feels like a skin scratch.
Why the Test is Perform
This test helps diagnose bleeding problems.
Normal Results
Bleeding normally stops within 1 to 9 minutes.
However, values may vary from lab to lab.
What Abnormal Results Mean
Longer-than-normal bleeding time may be due to:
• Blood vessel defect
• Platelet aggregation defect
• Thrombocytopenia (low platelet count)
Additional conditions under which the test may be
performed:
• Acquired platelet function defect
• Congenital platelet function defects
• Primary thrombocythemia
• Von Willebrand's disease
Risks
There is a very slight risk of infection where the skin is
broken. Excessive bleeding is rare.
ACTIVATED CLOTTING TIME (ACT)
• The activated whole blood clotting time is a rapid
bedside test for monitoring heparin anticoagulation.
• factors that may affect the ACT include hemodilution,
hypothermia, cardioplegic solutions, platelet
dysfunction, hypofibrinogenemia, other coagulopathies
and certain drugs. ACT is prolonged in patients with
antiphospholipid antibodies and may not demonstrate a
linear response to heparin. If unexpected test results
are obtained, more specific coagulation tests should be
performed for further investigation.
• The APTT is preferred to the ACT for monitoring
standard heparin therapy (for treatment of venous
thromboembolism, unstable angina, myocardial
infarction etc.), because it shows significantly better
precision and is less subject to technical variability. On
the other hand, the ACT is the recommended test for
monitoring heparin in interventional cardiology
procedures.
• The ACT is a test of whole blood that uses a strong
contact activator of the intrinsic coagulation pathway,
either celite or kaolin. As a result, it is linearly
responsive to the high concentrations of heparin used
during bypass (1-5 U/mL). The usual monitoring
protocol consists of a baseline ACT followed by a bolus
of heparin. The baseline ACT should be shorter than
200 seconds and the postheparinization ACT should be
longer than 450 seconds prior to the onset of bypass.
• During bypass, the ACT is repeated every 15 to 20
minutes; if the result is less than 450 seconds,
additional heparin is administered. The ACT is designed
to be prolonged about 100 seconds above baseline for
each unit per milliliter of heparin concentration in a
typical patient. At the completion of CPB, heparin is
neutralized with protamine and the ACT is performed
again to ensure that it has returned to baseline levels.
Whole blood clotting time
1. 5ml of blood is placed in a glass container, kept at
body temperature and observed
• A clot should occur in 5 to 15 minutes
Prolonged = Severe deficiency of any of the
coagulation proteins
• The clot should retract in 30 to 60 minutes
Weak friable clot = hypofibrinogenaemia
Early dissolution = enhanced fibrinolysis
TERMINOLOGIES RELATED TO HEMATOLOGY
 Clot Retraction: The rate and degree of contraction of the
blood clot.
 Coagulation Time: The time required for venous blood, in
the absence of all tissue factors, to clot in glass tubes
under controlled conditions.
 Color Index: The ratio between the amount of hemoglobin
and the number of red blood cells.
 Complete Blood Count: A hematology study which
consists of a red cell count, white cell count, hematocrit,
hemoglobin, and blood smear study including differential
white cell count.
 Color Index: The ratio between the amount of hemoglobin
and the number of red blood cells.
 Complete Blood Count: A hematology study which
consists of a red cell count, white cell count, hematocrit,
hemoglobin, and blood smear study including differential
white cell count.
 Differential Count: An en1.meration of the types of white
blood cells seen on a stained blood smear.
 Ecchymosis: Subcutaneous extravastion of blood covering
a large area.
 Erythrocyte: Red blood cell.
 Erythrocytosis: An increase in the total number of
erythrocytes.
 Erythrogenic: Producing erythrocytes.

 Fibrinogen: The precursor of fibrin that is present
normally in the plasma and produced by the liver.
 Hematocrit: The packed cell volume (PVC) of red blood
cells obtained by globin and forms hemoglobin.
Definition:
Blood transfusion is the process of transferring blood or
blood-based products from one person into the circulatory
system of another. Blood transfusions can be life-saving in
some situations, such as massive blood loss due to trauma,
or can be used to replace blood lost during surgery.
 Blood components used in transfusion.

 Hematology: The branch of medicine that deals with the - RBC

study of blood cells, blood producing organs and the - PLASMA
manner in which these cells and organs are affected in -PLATELETS
disease. - IMMUNOGLOBULINS
- WBC
INDICATION:
 Hematoma: Subcutaneous effusion of blood with resulting  Anemia
swelling, pain, and discoloration, forming a tumorlike
mass.  Major Surgical Operation

 Hematopoietic (Hemopoietic): Blood forming.  Accidents resulting in considerable blood loss

 Cancer patients requiring therapy

 Hemoglobin: The coloring matter of the red blood cells. A
complex iron-bearing pigment that carries oxygen and  Women in childbirth and newborn babies in
carbon dioxide. certain cases

 Hemolysis: The dissolution or dissolving of the  Patients of hereditary disorders like

erythrocytes. Haemophilia and Thalassaemia

 Hemostasis: The checking of the flow of blood, especially  Severe burn victims.
from a vessel. In Vitro: Within a test tube (glass, etc.).

CONTRAINDICATION
 In Vitro: Within a test tube (glass, etc.).  previous malaria or hepatitis

 In Vivo: Within the living organism, as in life.  a history of intravenous drug abuse

 Leukocyte: White blood cell.  donors who have received human-derived

pituitary hormones

 Normocyte (Erythrocyte): A red blood cell of normal size.  donors with high-risk sexual behaviour
(variably defined)
 Plasma: The fluid portion of the blood composed of serum
and fibrinogen, obtained when an anticoagulant is used.  donors who have previously been transfused
(12-month min. deferral)
 Plasma Cell: A lymphocyte-like cell with an eccentrically
placed deep-staining nucleus. The nuclear chromatin is MATERIALS AND EQUIPMENTS
distributed in a "wheel-spoke" fashion. The cytoplasm is  blood pack with SF 518
deep blue with a lighter halo about the nucleus.
 thermometer
 Platelet: Thrombocyte.
 blood pressure cuff

 Prothrombin: The inactive precursor of thrombin that is

 stethoscope
formed in the liver and present normally in the plasma. Its
formation depends upon adequate vitamin K.
 blood transfusion recipient set ("Y" type)

 Thrombin: This is an enzyme formed from prothrombin  IV stand

that converts fibrinogen to fibrin. This is not present in
circulating blood.  tourniquet

 Thrombocyte: A blood platelet.  needle and syringe

 IV cathetertape
 Thrombocytopenia: A decrease in blood platelets; also
thrombopenia.  alcohol and betadine prep pads

 Thrombocytosis: An increase in blood platelets.  gloves

 A container of 0.9% normal saline for injection

 Thromboplastin: The substance that initiates the process
of blood clotting. It is released from injured tissue and/or
 patient's clinical record
formed by the disintegration of platelets in combination
with several plasma factors.
PREPARATION AND PROCEDURE
 Venipuncture: The act of puncturing a vein in order to Standards: Administered the blood IAW the physician's
remove a sample of blood. orders and without causing injury to the patient.
Performance Steps
1. Verify and inspect the blood pack received from the
BLOOD TRANSFUSION laboratory.

2. Establish baseline data.

 3. Prepare the blood and the blood recipient set.
4. Perform the venipuncture
5. Begin the infusion of blood.
6.Monitor and evaluate the patient throughout the
procedure.
7. Discontinue the infusion of blood.
8. Dispose of the used blood pack IAW local SOP.
9. Document the procedure and significant nursing
observations on the appropriate forms IAW local SOP.
COMPLICATIONS
 Fluid overload
 Allergic reaction
 Haemolytic reaction
 Graft versus host disease
ELECTROCARDIOGRAPHY
Electrocardiography is a procedure by which a
physician obtains a tracing of the electrical activity of the
heart. The rhythmic beating of the heart is maintained by
an orderly series of discharges originating in the sinus node
of the right atrium and proceeding through the
atrioventricular node and the bundle of neuromuscular
fibers (the bundle of His) to the ventricles. By attaching
electrodes to various parts of the body, a record of this
current can be obtained. This record is called an
electrocardiogram, or ECG or EKG for short.
The impulse waves, recorded by the ECG machine on graph
paper, are designated by the letters P, QRS, and T. The P
wave represents depolarization of the atria. The QRS
complex represents depolarization of the ventricles. The T
wave represents the polarization of the ventricles. An ECG
tracing also shows the voltage of waves and the duration of
both the waves and the intervals.
Normal time durations for waves and intervals are as
follows:
• P wave: less than 0.11 second
• PR interval: 0.12 to 0.20 second
• QRS complex: 0.04 to 0.11 second
• QT interval: in women, up to 0.43 second; in men, up to
0.42 second
Indications and Contraindications
• The ECG is often helpful in showing the cause of an
abnormal heart rhythm or an evolving heart attack.
• The ECG can also detect damage from a previous heart
attack.
• In an exercise stress test, an ECG is recorded while a
patient is performing physical activity such as walking
on a treadmill or riding a stationary bicycle. As the
intensity of exercise increases, the doctor looks for
specific changes in the ECG that indicate the heart is
not getting enough oxygen.
• When a patient complains of chest pain, for instance,
emergency medical professionals will likely hook the
patient up to an electronic monitor to measure heart
and respiratory function, take a chest X ray, and
determine electrical activity of the heart using
electrocardiography.
• Doctors diagnose pericarditis by using a chest X ray, an
electrocardiogram (ECG) and echocardiogram (to rule
out a heart attack), and a blood test.
• Most often, arrhythmias can be diagnosed with the use
of an ECG.
Materials/ Equipment
• ECG machine
o This instrument consists of a recording device
attached to electrodes that are placed at various
points on a person’s skin. The recording device
measures different phases of the heartbeat and
traces these patterns as peaks and valleys in a
graphic image
• Graph paper
Preparation
• ECG graph paper is divided into horizontal lines and
vertical lines
• Voltage is represented on the vertical axis of the ECG
paper.
• Time is measured on the horizontal axis.
• By studying the duration of the waves and intervals, the
examiner can diagnose abnormal impulse formation
and conduction.
• The electrode sites should be rubbed with alcohol to
remove skin oils and a superficial layer of skin.
• If hair is present, the sites should be shaved.
• Electrodes are then attached to the skin and secure
electrode to skin by tape or belt. It is best if possible to
avoid placing the electrode over large muscle masses.
Procedure
The standard ECG has a 12- lead system, offering 12 points
of reference for recording the electrical activity of the heart,
looking in both horizontal and vertical planes.
• RA electrode, below the right clavicle at MCL;
• LA electrode, below the left clavicle at MCL;
• RL electrode, right abdomen at MCL;
• LL electrode, left abdomen at MCL.
V1 TO V6 are the precordial or chest leads:
• v1, fourth ICS at right sternal border;
• v2, fourth ICS at left sternal border;
• v3, fourth ICS, midway between left sternal border and
MCL;
• v4, fifth ICS at left MCL;
• v5, fifth ICS, midway between left MCL and AAL;
• v6, fifth ICS at left AAL.
[AAL, anterior axillary line; ICS, intercostals space; LA, left
arm; LL, left leg; MAL, midaxillary line; MCL, midclavicular
line; RA, right arm; RL, right leg.]
The standard 12-lead ECG has 6 limb leads (used to view
the heart in a frontal or vertical plane and 6 precordial leads
(used to view the heart in a horizontal plane). Together, the
12-leads permit multidirectional examination of the electric
events in the heart. The location of pathologic change
within the heart, which alters electrical activity, can be pin-
pointed.
Electrocardiograph
An electrocardiograph (ECG or EKG) records the electrical
activity of the heart. Preceding each contraction of the
heart muscle is an electrical impulse generated in the
sinoatrial node; the waves displayed in an ECG trace the
path of that impulse as it spreads through the heart.
Irregularities in an ECG reflect disorders in the muscle,
blood supply, or neural control of the heart.
Complications
Since it is a non-invasive procedure, no severe
complications have been manifested. In pregnant women, it
is rarely used unless a specific heart anomaly is suspected.
But, ECG with stress tests, chest angina, irregular heart
rhythm, heart attack is most common.
ARTERIOGRAPHY
Definition
Arteriography also called coronary angiography, is a
common procedure done by injecting a dye visible by X-ray
into the bloodstream. Then X-ray pictures are taken and
studied to see if the arteries are damaged.
Arteriography is a key part in evaluating many people at
high risk of stroke.
Electrocardiography
Definition:
A procedure by which a physician obtains a tracing of the
electrical activity of the heart. By attaching various
electrodes to various parts of the body, a record of this
current can be obtained.
Impulse waves:
- P, QRS, T
Normal time durations:
- P wave: less than 0.11 second
- Pr interval: 0.12 to 0.20 second
- Qrs complex: 0.04 to 0.11 second
- Qt interval: in women, up to 0.43 second; in men, up to
0.42 second
Materials/ Equipment:
 ECG machine
 Graph paper
Procedure
 The Standard ECG has a 12- lead system,
offering 12 points of reference for recording the electrical
activity of the heart.
 Together the 12-lead is placed on its
respective sites, in the right and left clavicle, right and left
abdomen, chest leads, right and left sternal border, midway
the left sternal border, midway between left MCL and AAL,
left AAL.
Complications:
 No severe implications indicated.
Thalium 201
Definition:
A soft, malleable, highly toxic metallic element, used in
photocells, infrared detectors, low-melting glass, and
formerly in rodent and ant potions.
Indications:
 Identify clients with a decreased ejection
fraction.
 Clients with diastolic dysfunction.
 Clients with peripheral vascular disease.
Procedure:
 The heart is scanned after administration of radio
active thalium.
 Dipyridamole is then given as a vasodilator.
Complications:
 Identification of ischemia in aged population is
important because they have more severe disease
than the younger population and a higher surgery
risk for cardiac and non-cardiac procedure.
 A number of initial Thalium 201, defects
induced by exercise are independent predictors of
multi-vessel disease.
PHONOCARDIOGRAPHY
the graphic recording of heart sounds and
murmurs; by extension, the term includes pulse tracings
(carotid, apex and venous pulse).
Phonocardiography involves picking up, through a
highly sensitive microphone, sonic vibrations from the heart
which are then converted into electrical energy and fed into
a galvanometer, where they are recorded on paper. The
procedure is most useful when there is evidence of heart
murmurs or unusual heart sounds, such as gallops, that are
difficult to discern by the human ear. Most recordings are
made through an externally applied microphone but
intracardiac recordings, made through a phonocatheter, are
possible.
ECHOCARDIOGRAPHY
Echocardiography (EK-o-kar-de-OG-ra-fee), or echo,
is a painless test that uses sound waves to create pictures
of your heart.
The test gives your doctor information about the
size and shape of your heart and how well your heart's
chambers and valves are working. Echo also can be done to
detect heart problems in infants and children.
The test also can identify areas of heart muscle
that aren't contracting normally due to poor blood flow or
injury from a previous heart attack. In addition, a type of
echo called Doppler ultrasound shows how well blood flows
through the chambers and valves of your heart.
Echo can detect possible blood clots inside the
heart, fluid buildup in the pericardium (the sac around the
heart), and problems with the aorta. The aorta is the main
artery that carries oxygen-rich blood from your heart to
your body.
Who needs echocardiography?
Your doctor may recommend echocardiography
(echo) if you have signs and symptoms of heart problems.
For example, shortness of breath and swelling in the legs
can be due to weakness of the heart (heart failure), which
can be seen on an echocardiogram.
Your doctor also may use echo to learn about:
• The size of your heart. An enlarged heart can be
the result of high blood pressure, leaky heart
valves, or heart failure.
• Heart muscles that are weak and aren't moving
(pumping) properly. Weakened areas of heart
muscle can be due to damage from a heart attack.
Weakening also can mean that the area isn't
getting enough blood supply, which may be due
to coronary heart disease (also called coronary
artery disease).
• Problems with your heart valves. Echo can show
whether any of your heart valves don't open
normally or don't form a complete seal when
closed.
• Problems with your heart's structure. Echo can
detect many structural problems, such as a hole in
the septum and other congenital heart defects. The
septum is the wall that separates the two chambers
on the left side of the heart from the two chambers
on the right side. Congenital heart defects are
structural problems present at birth. Infants and
children may have echo to detect these heart
defects.
• Blood clots or tumors. If you've had a stroke, echo
might be done to check for blood clots or tumors
that may have caused it.
Your doctor also may use echo to see how well your
heart responds to certain heart treatments, such as
those used for heart failure.
Types:
There are several types of echocardiography (echo)—all use
sound waves to create pictures of your heart. This is the
same technology that allows doctors to see an unborn baby
inside a pregnant woman.
Unlike x rays and some other tests, echo doesn't involve
radiation.
Transthoracic Echocardiography
Transthoracic (tranz-thor-AS-ik) echo is the most
common type of echocardiogram test. It's painless and
noninvasive. "Noninvasive" means that no surgery is
done and no instruments are inserted into your body.
This type of echo involves placing a device called a
transducer on your chest. The device sends special
sound waves, called ultrasound, through your chest wall
to your heart. The human ear can't hear ultrasound
waves.
As the ultrasound waves bounce off the structures of your
heart, a computer in the echo machine converts them
into pictures on a screen.
Stress Echocardiography
Stress echo is done as part of a stress test. During
a stress test, you exercise or take medicine (given by
your doctor) to make your heart work hard and beat
fast. A technician will take pictures of your heart using
echo before you exercise and as soon as you finish.
 Some heart problems, such as coronary heart
disease, are easier to diagnose when the heart is
working hard and beating fast.
Transesophageal Echocardiography
With standard transthoracic echo, it can be hard to
see the aorta and other parts of your heart. If your
doctor needs a better look at these areas, he or she
may recommend transesophageal (tranz-ih-sof-uh-JEE-
ul) echo (TEE).
During this test, the transducer is attached to the
end of a flexible tube. The tube is guided down your
throat and into your esophagus (the passage leading
from your mouth to your stomach). This allows your
doctor to get more detailed pictures of your heart.
Fetal Echocardiography
Fetal echo is used to look at an unborn baby's
heart. A doctor may recommend this test to check a
baby for heart problems. Fetal echo is commonly done
during pregnancy at about 18 to 22 weeks. For this test,
the transducer is moved over the pregnant woman's
belly.
Three-Dimensional Echocardiography
A three-dimensional (3D) echo creates 3D images
of your heart. These images provide more information
about how your heart looks and works.
During transthoracic echo or TEE, 3D images can
be taken as part of the process used to do these types
of echo. (See above for more information on how
transthoracic echo and TEE are done.)
3D echo may be used to diagnose heart problems
in children. This method also may be used for planning
and monitoring heart valve surgery.
Researchers continue to study new ways to use 3D echo.
What to expect before echocardiography?
Echocardiography (echo) is done in a doctor's office
or a hospital. No special preparations are needed for most
types of echo. Usually you can eat, drink, and take any
medicines as you normally would.
The exception is if you're having a transesophageal
echo. This test usually requires that you don't eat or drink
for 8 hours prior to the test.
If you're having a stress echo, there may be special
preparations. Your doctor will let you know how to prepare
for your echo test.
What to expect during echocardiography?
Echocardiography (echo) is painless and usually
takes less than an hour to do. For some types of echo, your
doctor will need to inject saline or a special dye into one of
your veins to make your heart show up more clearly on the
test images. This special dye is different from the dye used
during angiography (a test used to examine the body's
blood vessels).
For most types of echo, you'll be asked to remove
your clothing from the waist up. Women will be given a
gown to wear during the test. You'll lay on your back or left
side on an exam table or stretcher.
Soft, sticky patches called electrodes will be
attached to your chest to allow an EKG(electrocardiogram)
to be done. An EKG is a test that records the heart's
electrical activity.
A doctor or sonographer (a person specially trained
to do ultrasounds) will apply gel to your chest. The gel helps
the sound waves reach your heart. A wand-like device
called a transducer will then be moved around on your
chest.
The transducer transmits ultrasound waves into
your chest. Echoes from the sound waves will be converted
into pictures of your heart on a computer screen. During the
test, the lights in the room will be dimmed so the computer
screen is easier to see.
The sonographer will make several recordings of
the pictures to show various locations in your heart. The
recordings will be put on a computer disc or videotape for
the cardiologist (heart specialist) to review.
During the test, you may be asked to change
positions or hold your breath for a short time so that the
sonographer can get good pictures of your heart.
At times, the sonographer may apply a bit of
pressure to your chest with the transducer. This pressure
can be a little uncomfortable, but it helps get the best
picture of your heart. You should let the sonographer know
if you feel too uncomfortable.
This process is similar for fetal echo. However, in
that test the transducer is placed over the pregnant
woman's belly at the location of the baby's heart.
Transesophageal Echocardiography
Transesophageal echo (TEE) is used when your
doctor needs a more detailed view of your heart. For
example, TEE may be used to look for blood clots in
your heart. A doctor, not a sonographer, performs this
type of echo.
The test uses the same technology as
transthoracic echo, but the transducer is attached to
the end of a flexible tube. The tube will be guided down
your throat and into your esophagus (the passage
leading from your mouth to your stomach). From this
angle, your doctor can get a more detailed image of the
heart and major blood vessels leading to and from the
heart.
For TEE, you'll likely be given medicine to help
you relax during the test. The medicine will be injected
into one of your veins. Your blood pressure, the oxygen
content of your blood, and other vital signs will be
checked during the test. You'll be given oxygen through
a tube in your nose. If you wear dentures or partials,
you'll have to remove them.
The back of your mouth will be numbed with a
gel or a spray so that you don't gag when the
transducer is put down your throat. The tube with the
transducer on the end will be gently placed in your
throat and guided down until it's in place behind the
heart.
The pictures of your heart are then recorded as
your doctor moves the transducer around in your
esophagus and stomach. You shouldn't feel any
discomfort as this happens.
Although the imaging usually takes less than
an hour, you may be watched for a few hours at the
doctor's office or hospital after the test.
Stress Echocardiography
Stress echo is a transthoracic echo combined
with either an exercise or pharmacological (FAR-ma-ko-
LOJ-i-kal) stress test.
For an exercise stress test, you'll walk or run on
a treadmill or pedal a stationary bike to make your
heart work hard and beat fast. For a pharmacological
stress test, you'll be given medicine to make your heart
work hard and beat fast.
A technician will take pictures of your heart
using echo before you exercise and as soon as you
finish. The Diseases and Conditions Index Stress
Testing article provides more information about what to
expect during a stress test.
What you may see and hear during
echocardiography?
As the doctor or sonographer moves the transducer
around, different views of your heart can be seen on the
screen of the echo machine. The structures of the heart will
appear as white objects, while any fluid or blood will appear
black on the screen.
Doppler ultrasound techniques often are used
during echo tests. Doppler ultrasound is a special
ultrasound that shows how blood is flowing through the
blood vessels.
This test allows the sonographer to see blood
flowing at different speeds and in different directions. The
speeds and directions appear as different colors moving
within the black and white images.
The human ear is unable to hear the sound waves
used in echo. If Doppler ultrasound is used, you may be
able to hear "whooshing" sounds. Your doctor can use these
sounds to learn about blood flow through your heart.
What to expect after echocardiography?
You usually can go back to your normal activities
right after having echocardiography (echo).
If you have a transesophageal echo (TEE), you may
be watched for a few hours at the doctor's office or hospital
after the test. Your throat might be sore for a few hours
after the test.
You also may not be able to drive right after a TEE.
Your doctor will let you know whether you need to arrange
for someone to take you home.
What does it shows?
Echocardiography (echo) shows the size, structure,
and movement of the various parts of your heart. This
includes the valves, the septum (the wall separating the
right and left heart chambers), and the walls of the heart
chambers. Doppler ultrasound shows the movement of
blood through the heart.
Echo can be used to:
• Diagnose heart problems
• Guide or determine next steps for treatment
• Monitor changes and improvement
• Determine the need for more tests
 Echo can detect many heart problems. Some may
be minor and pose no risk to you. Others can be signs of
serious heart disease or other heart conditions. Your doctor
may use echo to learn about:
• The size of your heart. An enlarged heart can
be the result of high blood pressure, leaky
heart valves, or heart failure.
• Heart muscles that are weak and aren't moving
(pumping) properly. Weakened areas of heart
muscle can be due to damage from a heart
attack. Weakening also could mean that the
area isn't getting enough blood supply, which
may be due to coronary heart disease.
• Problems with your heart's valves. Echo can
show whether any of the valves of your heart
don't open normally or don't form a complete
seal when closed.
• Problems with your heart's structure. Echo can
detect many structural problems, such as
a hole in the septum and other congenital
heart defects. Congenital heart defects are
structural problems present at birth.
• Blood clots or tumors. If you've had a stroke,
echo might be done to check for blood clots or
tumors that may have caused it.
Risks
Transthoracic and fetal echocardiography (echo)
have no risks. These tests are safe in adults, children, and
infants.
If you have a transesophageal echo (TEE), some
risks are associated with the medicine given to help you
relax. These include a bad reaction to the medicine,
problems breathing, or nausea (feeling sick to your
stomach).
Your throat also might be sore for a few hours after
the test. Rarely, the tube used during TEE can cause minor
throat injuries.
Stress echo has some risks, but they're related to
the exercise or medicine used to raise your heart rate, not
to the echo. Serious complications from stress tests are
very uncommon. Go to the Diseases and Conditions
Index Stress Testing article for more information about the
risks of that test.
Key Points
• Echocardiography (echo) is a painless test that
uses sound waves to create pictures of your heart.
• This test gives your doctor information about the
size and shape of your heart and how well your heart's
chambers and valves are working. In addition, a type of
echo called Doppler ultrasound shows how well blood flows
through the chambers and valves of your heart.
• Your doctor may recommend echo if you have signs
and symptoms of heart problems. The test can be used to
confirm a diagnosis, determine the status of an existing
problem, or help guide treatment.
• There are several types of echo. Transthoracic and
stress echo are standard types of the test. Transesophageal
echo (TEE) is used if the standard tests don't produce clear
results. A fetal echo is used to look at an unborn baby's
heart. A three-dimensional (3D) echo may be used to help
diagnose heart problems in children or plan and
monitor heart valve surgery.
• Echo is done in a doctor's office or hospital. The
test usually takes up to an hour to do. A standard echo
doesn't require any special preparations or followup. If
you're having a TEE, you usually shouldn't eat or drink for 8
hours prior to the test.
• During a standard echo, your doctor or
sonographer will move a wand-like device called a
transducer around on your chest to get pictures of your
heart. During a TEE, the transducer will be put down your
throat to get a better view of your heart.
• A cardiologist (heart specialist) will review the
results from your echo.
• You usually can go back to your normal activities
right after having echo. If you have TEE, you may be
watched for a few hours at the doctor's office or hospital
after the test.
• Transthoracic and fetal echo have no risks. If you
have TEE, some risks are associated with the medicine
given to help you relax. Rarely, the tube used in TEE can
cause minor throat injuries. The risks for stress echo are
related to the exercise or medicine used to raise your heart
rate. Serious complications from stress echo are rare.
CARDIAC CATHETERIZATION
Cardiac catheterization (heart cath) is the
insertion of a catheter into a chamber or vessel of the heart.
This is done for both investigational and interventional
purposes. Coronary catheterization is a subset of this
technique, involving the catheterization of the coronary
arteries.
Your doctor may perform cardiac catheterization to:
• Diagnose or evaluate coronary artery disease
• Diagnose or evaluate congenital heart defects
• Diagnose or evaluate problems with the heart valves
• Diagnose causes of heart failure or cardiomyopathy
Right Heart Catheterization
Right heart catheterization (also known as
pulmonary artery catheterization or Swan-Ganz
catheterization) is a common procedure in critically ill
patients. The catheter is a long thin hollow tube that is
placed through a central venous catheter and is then
guided through the chambers of the heart and into the large
blood vessels of the lungs. The catheter is left in place in a
pulmonary (lung) artery. This catheter measures pressures
in the heart and large blood vessels and checks how well
the heart is working.
Some common situations in which doctors recommend right
heart catheterization include:
• Low blood pressure (hypotension or shock) -
When the blood pressure remains very low despite
giving fluids and medications to the patient.
• Kidney abnormalities - When urine flow is too low
to get rid of the wastes of the body and giving fluids
and/or diuretics (medicines intended to stimulate
urine output) does not increase urine output.
• Lung water (pulmonary edema) - In patients with
a lot of water in their lungs due to heart failure or
inflammation of the lungs, the catheter can help
monitor treatments to prevent more water from
accumulating in the lungs.
• Specific heart abnormalities - There are some
abnormalities of the heart - such as when fluid
collects around the heart or a heart valve doesn't
close properly - in which measurements with the
catheter help to make the diagnosis and guide
treatments.
Left heart catheterization
A test that permits your doctor to inspect the inside
of your heart's left chambers, where blood is pumped out to
the rest of the body. The procedure is also called coronary
arteriography (ar-TEER-ee-og-ruh-fee) or a "left heart cath."
Retrograde Approach
Catheter maybe introduced percutaneously by
puncture of the femoral artery or by direct brachial
approach and advanced under fluoroscopic control into the
aorta and into the left ventricle.
Transseptal approach
Catheter is passed from the right femoral vein into
the right atrium. A long needle is passed up through the
catheter and is used to puncture the septum of the right
and left atria
Indications & Contraindications:
Some of the indications for cardiac catheterization
procedure are -
• Unstable angina or Chest pain [uncontrolled
with medications or after a heart attack]
• Heart attack
• Before a bypass surgery
• Abnormal treadmill test results
• Determine the extent of coronary artery
disease
• Disease of the heart valve causing symtpoms
(syncope, shortness of breath)
• To monitor rejection in heart transplant
patients
• Syncope or loss of consiousness in patients
with aortic valve disease
Some of the relative contraindiciations for
cardiac catheterization are
 • Allergy to contrast (dye) medium
• Uncontrolled Blood Pressure (Hypertension)
• Problems with blood coagulation
(Coagulopathy)
• Kidney failure or dysfunction
• Severe anemia
• Electrolyte imbalance
• Fever
• Active systemic infection
• Uncontrolled rhythm disturbances
(arrhythmias)
• Uncompensated heart failure
• Transient Ischemic attack
Preparations:
• Patients may be required to be admitted to the hospital
the night before the procedure. For some patients,
overnight stay is not required.
• Nilper oral [NPO] or nothing to eat or drink by mouth
6-8 hours before the test.
• The cardiologist will explain the procedure and risks
associated with it.
• Consent form should be signed before the procedure.
• Any questions or doubts should be asked and clarified
with the doctor before surgery.
• The doctor should be informed of allergies to
medications, iodine or food. It should also be
documented legibly in the patient’s chart.
• Previous allergic reactions to contrast dyes must be
mentioned.
• Catheterization
procedure requires X-ray fluoroscopy.
Women patients in childbearing age can undergo
pregnancy test to rule out pregnancy.
• Medications that are taken on the day of cardiac
catheterization should be discussed with the doctor.
Some medicines taken for blood thinning (e.g.,
Aspirin), erectile dysfunction (Sildenafil or Tadalafil) or
diabetic medication (metformin) needs to be stopped
on the day or few days before the procedure.
• Kidney disease should be assessed before, as
contrast materials or dyes may not be used in patients
with abnormal kidney function.
• Some blood tests and electrocardiogram (ECG) will be
performed before the procedure.
• A mild sedative will be given orally or intravenously to
comfort the patient and relieve anxiety.
• Allpersonal belongings and jewellery will be removed
and patient will be dressed in a hospital gown before
being transported to the catheterization laboratory.
Nursing patient Care considerations:
Preprocedure:
• Client should have X-ray, CBC with differential,
urinalysis, and 12 lead ECG.
• Know which approach which to be used in order to
anticipate possible complications.
• Withhold food and fluid 6 hours before procedure.
• Ascertain history of previous allergies.
• Mark distal pulses for easy reference after
catheterization.
• Explain to patient that he would lying on examination
table for a prolong period that he may experience
certain sensations.
o Occasional thudding sensation in the chest.
o Strong desire to cough may occur during contrast
medium injection.
o Transient feeling of hot flushes or nausea as the
contrast medium is injected.
• Evaluate client’s emotional status before
catheterization.
o Is this patient’s first catheterization?
o Is patient apprehensive about procedure?
o Ask whether has heard stories about having
catheterization.
• Dentures, glasses or hearing aids should be sent with
patient for procedure.
• Have patient void before procedure.
Procedure
• In the catheterization laboratory, the insertion area
(usually the groin, neck, or forearm) is cleansed with a
sterilizing solution, shaved, and covered with sterile
drapes. A small-needle injection of a local anesthetic is
used to numb the area.
• A small incision is made and a pencil-sized plastic tube,
called a sheath, is inserted into the artery (e.g., femoral
artery, carotid artery) or vein. A catheter, which is
usually 2 to 3 mm in diameter, is passed via the sheath
through the artery to the heart, and into a coronary
artery.
• A contrast agent (dye) is injected into the catheter to
show areas of blockage and angiograms of the artery
are taken. The dye often causes a "hot-flash" sensation
throughout the body that lasts for 10 to 15 seconds.
• In some cases, a catheter is passed through the sheath
to the heart's left ventricle and dye injected to show
how the left ventricle is functioning.
Postprocedure
1. record blood pressure measurement and apical
pulse every 15 minutes (or more frequently) until vital
signs are stable to discern dysrrhytmias
2. Check peripheral pulses in affected extremity;
evaluate extremity temperature, color, and complaints
of pains, numbness or tingling sensation to determine
signs of arterial insufficiency.
3. Watch cutdown sites for hematoma formation.
Question patient about increase in pain or tenderness
at site.
4. Assess for complaints of chest pain and report
immediately. MI (Myocardial Infarction) may occur and
is serious complications of cardiac catheterization.
5. Enforce activity restrictions which are based on
coagulation status and whether avascular closure
method was employed. (2-24 hours)
6. Evaluate complaints of back, thigh, or groin pain
(may indicate) retroperitoneal bleeding.
7. Be alert of signs and symptoms of vagal reaction
(nausea, diaphoresis, hypotension, bradycardia); treat
as directed with atropine and fluids.
Complications:
The overall risk for complications from cardiac
catheterization is about 1 in 1000. Contrast dyes cause
adverse effects in almost 1 out of 10 patients. The
common side effect is nausea or vomiting. Some of the
complications due to dye allergy are
• Fast heartbeat
• Slow heartbeat
• Nausea
• Vomiting
• Shock
• Kidney failure
• Epilepsy
• Itching
• Rashes
Few other complications are
• Bleeding at the insertion site
• Damage to the blood vessels used for catheter entry
• Infection
• Ventricular arrhythmias
• Pneumothorax [air collection between the chest wall
and the lungs]
• Cardiac tamponade [fluid collection around the heart]
• Heart attack
• Stroke [0.1%]
• Air embolism
• Death [0.1- 0.2%]
CENRAL VENOUS PRESSURE
Indications
• Inability to achieve adequate peripheral venous
access
• Delivery of substances not safely given via
a peripheral IV (TPN, vasopressors, etc.)
• Hemodialysis, CVVH, plasmapheresis
• Measurement of cardiac filling pressures
• Placement of pulmonary artery catheter
• Placement of transvenous pacer
• Access for frequent blood sampling H. Hemothorax
• Remember that triple lumen catheters are less • Seen most commonly with arterial puncture
useful than large bore IV’s for rapid volume administration – • Suspect with development of post procedure
unless introducer catheter placed. effusion/drop in hematocrit
I. Hydrothorax
Contraindications J. Hemomediastinum
• Absolute: K. Hydromediastinum
o Operator inexperience L. Infection (insertion site, thrombophlebitis, bacteremia,
sepsis, cellulitis, osteomyelitis)
o Uncooperative/combative patients
o Uncorrected coagulopathy in a stable • Minimize risk with wide sterile barrier precautions –
drape should cover head, and extend past waist
patient
• Relative:
• Hand washing
o Uncorrected coagulopathy in an unstable • Physician should not have artificial/long nails
patient • Chlorhexidine instead of iodine – good scrub (friction
o Cellulitis over anticipated insertion site for at least 30 seconds), at least 10cm in diameter
o Injury or previous surgery to SVC (prior spanning from ear to clavicle to trachea. Allow to dry
XRT, prior long term venous cannulation at site. completely.
o Inability to tolerate pneumothorax (femoral • Chlorhexidine disc: Use of a chlorhexidine-impregnated
vein should be considered) disc (e.g. Biopatch) around the catheter insertion site
o Ability to provide adequate care via has been shown to reduce the rate of catheter-related-
BSI. When placing these discs, make sure that the
peripheral access
catheter is fed through the hole in the disc and that the
o Morbid obesity. Consider placement of line
chlorhexidine side of the disc faces the skin (white side
in cephalic vein on upper outer chest using ultrasound facing skin, light blue side facing up).
guidance beyond the rib edges.
o Vasculitis • Risk of infection increases with each needle stick. If you
are having trouble, seek help!
o COPD/bullous lung disease (subclavian
lines) • If your patient requires removal of hair prior to the
procedure, remember that razors can cause significant
o Congenital heart disease (Glenn or Fontan
skin abrasions – clipping is recommended.
anastamoses). These patients have increased risk of
clotting with upper body central lines. Consider a femoral • Appropriately anchor/sew catheter in place to prevent it
approach. from moving in and out of the skin.
o Presence of a pacemaker or ICD – • Minimal number of ports and minimal accessing is
especially relevant for subclavian lines, pulmonary artery associated with decreased infection rate.
catheters, and right IJ lines. The more recently placed the • Catheter related bacteremia rates:
device, the more likely lead dislodgement becomes. o 8.6% with IJ vs. 3.9% for subclavian in
Consider having devices interrogated following study by Ruesche et al, 2002 but this was not
placement/removal of CVC’s. statistically significant.
M. Injury to adjacent nerves
Risks and Complications • Brachial plexus injury has been reported with IJ catheter
Complication Internal Subclavian Femoral insertions
Jugular • Femoral nerve injury has been reported with femoral
Arterial 6.3-9.4% 3.1-4.9% 9.0-15.0% catheter placements
puncture N. Malposition of catheter tip:
Hematoma <0.1-2.2% 1.2-2.1% 3.8-4.4% • Reported in 1.8 – 14% of IJ placements (Ruesch et al
Hemothorax N/A 0.4-0.6% N/A 2002, Gladwin et al 1999, Iovino et al 2001)
Pneumothorax <0.1-0.2% 1.5-3.1% N/A • Reported in 1.8-9.3% of Subclavian placements
Total 6.3-11.8% 6.2-10.7% 12.8-19.4% (Ruesch, Mansfield, Iovino)
O. Pneumothorax:
(McGee and Gould, NEJM 2003 – without U/S guidance):
• Increased rate of pneumothorax with multiple passes of
needle. If having trouble, ask for help from experienced
A. Air embolization
person.
• Venous (pulmonary) > arterial (via septal defect or
AVM)
• Patient may cough, develop pleuritic pain, develop
cardiopulmonary compromise, or be asymptomatic
• 50-100 mL of entrained air can be fatal via “air lock” or
obstruction of the pulmonary outflow tracts.
• Remember to check a chest x-ray whether or not a line
was successfully placed after attempting IJ or
• Higher risk in patients spontaneously breathing with subclavian line placement
large negative intrathoracic pressures, low CVP.
• If air aspirated, make sure to check a delayed chest x-
• Minimize risk by placing patients in Trendelenberg, ray as sometimes pneumothoraces are not immediately
quick insertion of guidewire through needle, asking visible
patient to valsalva, clamping all but proximal (brown) P. Subcutaneous fluid infiltration
ports during insertion, hum/exhalation with removal of
central lines.
• Important to confirm that all ports draw back blood and
flush easily.
B. Arrhythmia
• Usually associated with malpositioned catheter tip • Important to confirm location of line with post
procedure chest x-ray.
within right atrium or ventricle and resolves with pulling
Q. Tamponade (Cardiac)
back of guidewire or catheter.
• If unstable arrhythmia, proceed with ACLS algorithm • Ensure appropriate placement of catheter tip via chest
x-ray following procedure.
C. Arteriovenous fistula formation
R. Tracheal perforation/Endotracheal cuff perforation
• Most commonly seen when vein is reached through S. Vein thrombosis
punctured artery creating track.
D. Central Vein perforation
• Femoral veins: ~ 20% with thrombotic complications
(Mian et al 1997 & Merrer et al 2001)
• Ensure appropriate placement of catheter tip via chest
x-ray following procedure
• Internal Jugular: wide range of published thrombosis
rates (0-66%), but thought generally to be of lower risk
E. Clot embolization
for thrombosis than femoral lines.
F. Chylothorax
• Due to injury of thoracic duct • Subclavian: 1-2% risk of thrombosis; keep in mind that
there is about a 50% risk of subclavian stenosis
• Right IJ preferred side to avoid such injury development in patients undergoing subclavian line
G. Guidewire embolization placement for dialysis so don’t put dialysis catheters
• Keep your eye on the wire! there.
• Make sure that the guidewire is exiting the proximal • Thrombosis is most often due to poor tip placement.
(brown) port BEFORE threading the catheter through Ideally, the catheter tip should be in the lower 1/3 of
the skin. the SVC or at the caval-atrial junction, at which time the
• When possible, keep a hold on the guidewire.
 tip is parallel to the vena cava walls. Tips that impinge
against the vessel wall initiate venous thrombosis.
• Mural/catheter related thromboses are associated with
increased risk of catheter-related infections.
Management of Complications
Air Embolus:
• Suspect this if a patient decompensates during your
procedure.
• Occlude any open lumen.
• Place patient in left lateral decubitus position &
Trendelenberg to position the RV outflow tract inferior
to the RV, thus floating air away from the outflow tract
(Duran’ts position).
• Provide high FiO2 to encourage nitrogen resorption
• Attempt to aspirate air through your catheter.
• CXR in left lat decubitus may show air in heart & heart
exam may reveal mill wheel murmur
Arrhythmia:
• Usually results from deep placement of the guidewire or
line and resolves upon repositioning.
• If unstable, initiate ACLS.
Arterial Puncture:
• With needle only: withdraw needle and apply 5-10
minutes of pressure. If patient develops bradycardia
(carotid massage), release pressure.
o CXR to r/o hemothorax
o Frequent vitals
o Hematocrit checks
• With dilator/catheter: Surgical emergency. Leave
line/dilator in place and call vascular surgery right
away.
Catheter Infection
• If catheter is no longer needed, remove catheter
• If blood cultures are positive, remove catheter
• See separate Duke CVC Curriculum Website
(DICON) for more detailed discussion
Catheter Knotting:
• Leave catheter in place and request help from IR or
vascular service.
Dysrhythmias:
• Usually occurs secondary to stimulation of myocardium
by catheter or guidewire
• Usually resolves after withdrawal of catheter or
guidewire
• If necessary, initiate ACLS protocols.
• Try to estimate distance from insertion site to SVC prior
to insertion.
Guidewire Embolization:
• Watch for arrhythmias and be prepared to manage
them.
• Obtain a CXR to check the location.
• Consult IR emergently for immediate removal.
Neck Hematoma:
• Monitor patient for airway compromise/carotid
occlusion
Pneumothorax:
• Monitor with serial chest x-rays if small and patient
spontaneously breathing without respiratory distress.
• If hemodynamic instability, place 14-16 gauge
angiocath in the 2nd intercostal space, midclavicular
line. Remove needle, leave open to air, call for
emergent chest tube placement.
• If hemodynamically stable, not on positive pressure
ventilation, and < 20%, then can observe with oxygen
administration and serial chest x-rays
• If patient on positive pressure ventilation, even small
pneumothorax may require chest tube placement.
Venous Thrombosis:
• If catheter is no longer needed, remove it
• Anticoagulation with heparin/warfarin is indicated
• Prevent this complication with appropriate tip
placement. Make sure the tip does not impinge agains
the vessel wall.
ARTERIAL BLOOD GAS (ABG)
Definition:
An arterial blood gas (ABG) is a blood test that is performed
using blood from an artery. It involves puncturing an artery
with a thin needle and syringe and drawing a small volume
of blood. The most common puncture site is the radial
artery at the wrist, but sometimes the femoral artery in the
groin or other sites are used. The blood can also be drawn
from an arterial catheter. An arterial blood gas (ABG) test
measures the acidity (pH) and the levels of oxygen and
carbon dioxide in the blood from an artery. This test is used
to check how well your lungs are able to move oxygen into
the blood and remove carbon dioxide from the blood.
Equipment:
• ABG kit
• Ice
Indications:
An ABG measures:
• Partial pressure of oxygen (PaO2).
• Partial pressure of carbon dioxide (PaCO2).
• pH.
• Bicarbonate (HCO3)
• Oxygen content (O2CT) and oxygen saturation (O2Sat)
values.
Contraindications:
• Cellulites or other infections over the radial artery.
• Absence of palpable radial artery pulse.
• Negative results of an Allen test (collateral circulation
test), indicating that only one artery supplies the hand
and suggest to select another extremity as the site for
arterial puncture.
• Coagulopathies or medium-to-high-dose anticoagulation
therapy (eg, heparin or coumadin, streptokinase, and
tissue plasminogen activator but not necessarily
aspirin) may be a relative contraindication for arterial
puncture.
• History of arterial spasms following previous punctures.
• Severe peripheral vascular disease.
• Abnormal or infectious skin processes at or near the
puncture sites.
• Arterial grafts.
• Arterial puncture should not be performed through a
lesion or through or distal to a surgical shunt (eg, as in
a dialysis patient). If there is evidence of infection or
peripheral vascular disease involving the selected limb,
an alternate site should be selected.
Preparation:
• Tell your doctor if you:
o Have had bleeding problems or take blood thinners,
such as aspirin or warfarin (Coumadin).
o Are taking any medicines.
o Are allergic to any medicines, such as those used to
numb the skin (anesthetics).
• If you are on oxygen therapy, the oxygen may be
turned off for 20 minutes before the blood test. This is
called a "room air" test. If you cannot breathe without
the oxygen, the oxygen will not be turned off.
• Talk to your doctor about any concerns you have
regarding the need for the test, its risks, how it will be
done, or what the results may mean.
Procedure:
• A sample of blood from an artery is usually taken from
the inside of the wrist (radial artery), but it can also be
collected from an artery in the groin (femoral artery) or
on the inside of the arm above the elbow crease
(brachial artery).
• You will be seated with your arm extended and your
wrist resting on a small pillow. The health professional
drawing the blood may rotate your hand back and forth
and feel for a pulse in your wrist.
• To prevent the possibility of damaging the artery of the
wrist when the blood sample is taken, a procedure
called the Allen test may be done to ensure that blood
flow to your hand is normal. An arterial blood gas (ABG)
test will not be done on an arm used for dialysis or if
there is an infection or inflammation in the area of the
puncture site.
• The health professional taking a sample of your blood
will:
o Clean the needle site with alcohol. You may be
given an injection of local anesthetic to numb that
area.
o Put the needle into the artery. More than one
needle stick may be needed.
 o Allow the blood to fill the syringe. Be sure to
breathe normally while your blood is being
collected.
o Put a gauze pad or cotton ball over the needle site
as the needle is removed.
o Put a bandage over the puncture site and apply
firm pressure for 5 to 10 minutes (possibly longer if
you take blood-thinning medicine or have bleeding
problems).
Complications
There is little chance of a problem from having blood
sample taken from an artery.
 You may get a small bruise at the site. You can lower
the chance of bruising by keeping pressure on the site
for at least 10 minutes after the needle is removed
(longer if you have bleeding problems or take blood
thinners).
• You may feel lightheaded, faint, dizzy, or nauseated
while the blood is being drawn from your artery.
• Ongoing bleeding can be a problem for people with
bleeding disorders. Aspirin, warfarin (Coumadin), and
other blood-thinning medicines can make bleeding
more likely. If you have bleeding or clotting problems,
or if you take blood-thinning medicine, tell your doctor
before your blood sample is taken.
• On rare occasions, the needle may damage a nerve or
the artery, causing the artery to become blocked.
• Though problems are rare, be careful with the arm or
leg that had the blood draw. Do not lift or carry objects
for about 24 hours after you have had blood drawn
from an artery.
HEART BYPASS SURGERY
Definition:
Coronary artery bypass graft surgery is a surgical procedure
in which one or more blocked coronary arteries are
bypassed by a blood vessel graft to restore normal blood
flow to the heart. These grafts usually come from the
patient's own arteries and veins located in the leg, arm, or
chest.
Indications:
Bypass surgery may be advised to the following patients:
• Has blockages in at least two to three major coronary
arteries, especially if the blockages are in arteries that
feed the heart's left ventricle or in the left anterior
descending artery
• Has angina so severe that even mild exertion causes
chest pain
• Has poor left ventricular function
• Cannot tolerate percutaneous transluminal coronary
angioplasty and do not respond well to drug therapy
Equipments/ Materials:
Heart stabilizer- allows the heart to beat while reducing
movement only in the area where your surgeon is
working.
Heart-lung bypass machine- used for beating heart
bypass surgery. It pumps blood through the body and
acts as the lungs.
Preparation:
• The individual should quit smoking or using tobacco
products before the surgery.
• Coronary artery bypass graft surgery should ideally
be postponed for three months after a heart attack.
Patients should be medically stable before the
surgery, if possible.
• Nurses should inform the patients on what to
expect during surgery and recovery.
• If the patient develops a cold, fever, or sore throat
within a few days before the surgery, he or she
should notify the surgeon's office.
• The evening before the surgery, the patient
showers with antiseptic soap provided by the
surgeon's office.
• After midnight, the patient should not eat or drink
anything.
• The patient is usually admitted to the hospital the
same day the surgery is scheduled. The patient
should bring a list of current medications, allergies,
and appropriate medical records upon admission to
the hospital. Before the surgery, the patient is
given a blood-thinning drug usually heparin that
helps to prevent blood clots. A sedative is given the
morning of surgery. The chest and the area from
where the graft will be taken are shaved.
• Coronary angiography will have been previously
performed to show the surgeon where the arteries
are blocked and where the grafts might best be
positioned. Heart monitoring is initiated. The
patient is given general anesthesia before the
procedure.
Procedure
• The patient is brought to the operating room and
moved on to the operating table.
• An anesthetist places a variety of intravenous lines and
injects an induction agent to render the patient
unconscious.
• An endotracheal tube is inserted and secured by the
anesthetist or assistant.
• The chest is opened via a median sternotomy and the
heart is examined by the surgeon.
• The bypass grafts are harvested - frequent conduits
are the internal thoracic arteries, radial arteries and
saphenous veins. When harvesting is done, the patient
is given heparin to prevent the blood from clotting.
• In the case of "off-pump" surgery, the surgeon places
devices to stabilize the heart.
• If the case is "on-pump", the surgeon sutures cannulae
into the heart and instructs the perfusionist to start
cardiopulmonary bypass (CPB). Once CPB is
established, the surgeon places the aortic cross-clamp
across the aorta and instructs the perfusionist to deliver
cardioplegia to stop the heart.
• One end of each graft is sewn on to the coronary
arteries beyond the blockages and the other end is
attached to the aorta.
• The heart is restarted; or in "off-pump" surgery, the
stabilizing devices are removed. In some cases, the
Aorta is partially occluded by a C-shaped clamp, the
heart is restarted and suturing of the grafts to the
aorta is done in this partially occluded section of the
aorta while the heart is beatinProtamine is given to
reverse the effects of heparin.
• The sternum is wired together and the incisions are
sutured closed.
• The patient is moved to the intensive care unit (ICU) to
recover. After awakening and stabilizing in the ICU
(approximately 1 day), the person is transferred to the
cardiac surgery ward until ready to go home
(approximately 4 days).
Complications
• graft closure or blockage
• development of blockages in other arteries
• damage to the aorta
• long-term development of atherosclerotic disease of
saphenous vein grafts
• abnormal heart rhythms
• high or low blood pressure
• recurrence of angina
• blood clots that can lead to a stroke or heart attack
• kidney failure
• depression or severe mood swings
• possible short-term memory loss, difficulty thinking
clearly, and problems concentrating for long periods
(These effects generally subside within six months after
surgery.)
ANGIOPLASTY
Definition:
Angioplasty is the technique of mechanically widening a
narrowed or obstructed blood vessel; typically as a result of
atherosclerosis. Tightly folded balloons are passed into the
narrowed locations and then inflated to a fixed size using
water pressures some 75 to 500 times normal blood
pressure (6 to 20 atmospheres).
Indications:
• Improve symptoms of CAD, such as angina and
shortness of breath.
• Reduce damage to the heart muscle from a heart
attack.
• Reduce the risk of death in some patients.

Contraindications:
Absolute contraindications include
• Lack of cardiac surgical support
• Significant obstruction of the left main coronary artery
without a nonobstructed bypass graft to the left
anterior descending or left circumflex arteries
Relative contraindications include
• Coagulopathy
• Hypercoagulable states
• Diffusely diseased vessels without focal stenoses
• A single diseased vessel providing all perfusion to the
myocardium
• Total occlusion of a coronary artery
• Stenosis < 50%
Materials
• balloon-tipped catheter
• stent - tiny mesh tube that looks like a small spring.
The stent is inserted in the area where the artery is
narrowed to keep it open
• plaque remover - used to cut away plaque that narrows
in the inside of the arteries
• laser - used to dissolve or vaporize plaque
Preparation
• Tell your doctor what drugs you are taking, even drugs
or herbs you bought without a prescription.
• You will usually be asked not to drink or eat anything
for 6 to 8 hours before the test.
• Take the drugs your doctor told you to take with a small
sip of water.
• Tell your doctor if you are allergic to seafood, if you
have had a bad reaction to contrast material or iodine
in the past, if you are taking Viagra, or if you might be
pregnant.
• The nurse may check your heart rate and blood
pressure, and test your urine.
• A nurse will clean (and may shave) your groin, arm or
wrist where a catheter (a thin flexible tube) will be
inserted during the procedure.
• May have tests prior to the procedure (blood tests, ECG,
and angiogram)
• You may be asked to wear compression stockings to
help prevent blood clots forming in the veins in your
legs.
• You may need to have an injection of an anti-clotting
medicine called heparin as well as, or instead of,
stockings.
Procedure
• Before the angioplasty procedure begins, you will be
given some pain medicine. You may also be given blood
thinning medicines to keep a blood clot from forming.
• You will lie down on a padded table. Your doctor will
make a small cut (incision) on your body, usually near
the groin. Then your doctor will insert a catheter
(flexible tube) through the incision into an artery.
Sometimes the catheter will be placed in your arm or
wrist. You will be awake during the procedure.
• The doctor uses live x-ray pictures to carefully guide
the catheter up into your heart and arteries. Dye will be
injected into your body to highlight blood flow through
the arteries. This helps the doctors see any blockages
in the blood vessels that lead to your heart.
• A guide wire is moved into and across the blockage. A
balloon catheter is pushed over the guide wire and into
the blockage. The balloon on the end is blown up
(inflated). This opens the blocked vessel and restores
proper blood flow to the heart.
•A stent (wire mesh tube) may then be placed in this
blocked area. The stent is inserted along with the
balloon catheter. It expands when the balloon is
inflated. The stent is then left there to help keep the
artery open.
Complications
The main complications of balloon angioplasty and stenting
are
• Thrombosis
• Restenosis
• The treated arteries gradually re-narrowing. If this
happens the angioplasty may need to be repeated.
Stents may help to slow down the narrowing.
• Some people can have an allergic reaction to the dye
used in the angiogram. The coronary artery may
become completely blocked during or soon after the
procedure. The angioplasty may need to be repeated
straight away or emergency coronary artery bypass
graft surgery may be needed to bypass the affected
veins.
• The tip of the catheter can dislodge a clot of blood or
fatty plaque from the wall of a blood vessel. It's possible
for these to block an artery leading to the heart or
brain, causing a heart attack or stroke.
• There is a risk of death but this is very rare.
PULMONARY FUNCTION TEST
Definition:
Pulmonary function tests are a group of tests that measure
how well the lungs take in and release air and how well they
move oxygen into the blood. It can also diagnose problems
with the lungs, and/or determine how well treatment for a
lung condition is working.
• Spirometry measures airflow. By measuring how much
air you exhale, and how quickly, spirometry can
evaluate a broad range of lung diseases.
• Lung volume measures the amount of air in the lungs
without forcibly blowing out. Some lung diseases (such
as emphysema and chronic bronchitis) can make the
lungs contain too much air. Other lung diseases (such
as fibrosis of the lungs and asbestosis) make the lungs
scarred and smaller so that they contain too little air.
• Testing the diffusion capacity allows the doctor to
estimate how well the lungs move oxygen from the air
into the bloodstream
Indications:
Pulmonary function tests are done to:
• Diagnose certain types of lung disease (especially
asthma, bronchitis, and emphysema)
• Find the cause of shortness of breath
• Measure whether exposure to contaminants at work
affects lung function
It also can be done to:
• Assess the effect of medication
• Measure progress in disease treatment
Contraindications:
These tests should not be done to patients who have:
• An unstable heart or lung disease
• Recently suffered a heart attack
• Active tuberculosis
• An acute asthma attack
• Respiratory distress
• Active bleeding from the lower respiratory tract
Equipments:
• Spirometer
• Body plethysmograph
• Nose clip
Preparation:
• Do not eat a heavy meal before the test.
• Do not smoke for 4 - 6 hours before the test.
• Wear loose-fitting clothing.
• Review your medications with your doctor; there may
be some that you should stop taking before testing.
• You'll get specific instructions if you need to stop using
bronchodilators or inhaler medications.
• You may have to breathe in medication before the test.
Procedure:
Immediately before each PFT, the technician will explain
how each test is performed and how the PFT device being
used works. You may be asked to sit in an atmosphere-
controlled booth and/or put on a nose clip. In some cases,
one or more of these tests may be done during or
immediately following exercise (on a treadmill or stationary
bike). If you have breathing problems, pain, or dizziness
during testing, tell the technician right away.
The pulmonary function tests consist of:
• Spirometry—the main measurements include: forced
expiratory volume in one second (FEV1) and forced vital
capacity (FVC)
In a spirometry test, you breathe into a mouthpiece
that is connected to an instrument called a spirometer.
The spirometer records the amount and the rate of air
that you breathe in and out over a period of time.
 • Lung volumes—include total lung capacity (TLC),
functional residual capacity (FRC), and residual volume
(RV)
Lung volume measurement can be done in two
ways:
The most accurate way is to sit in a sealed,
clear box that looks like a telephone booth (body
plethysmograph) while breathing in and out into a
mouthpiece. Changes in pressure inside the box
help determine the lung volume.
Lung volume can also be measured when you
breathe nitrogen or helium gas through a tube for a
certain period of time. The concentration of the gas
in a chamber attached to the tube is measured to
estimate the lung volume.
• Quantification of diffusing capacity—measures gas
exchange
o To measure diffusion capacity, you breathe a
harmless gas for a very short time, often one
breath. The concentration of the gas in the air you
breathe out then is measured. The difference in the
amount of gas inhaled and exhaled can help
estimate how quickly gas can travel from the lungs
into the blood.
• Additional pulmonary function tests that are used in
certain situations include:
• Oxygen saturation test—A small probe is
painlessly strapped or clipped to one of your fingers
or toes to measure the amount of oxygen being
carried in the blood.
• Allergen challenge tests—You are exposed to
specific allergens during pulmonary function
testing. This is only done in limited situations,
under close and careful supervision.
• Bronchoprovocation testing:
• Methacholine provocation test—People with asthma
will experience a mild constriction of the airways
when the drug methacholine is inhaled. This test
may be done in situations where asthma is
suspected but other pulmonary function tests have
not shown a clear diagnosis of asthma.
Possible Complications
• Slight risk of collapsed lung in some patients with lung
disease.
• Allergen challenge tests can pose dangers
• Since the test involves some forced breathing and rapid
breathing, you may have some temporary shortness of
breath or light-headedness.
PULSE OXIMETRY
• Be cautious interpreting figures where there has been
an instantaneous change in saturation - for example
99% falling suddenly to 85%. This is physiologically not
possible.
• If in doubt, rely on your clinical judgement, rather than
the value the machine gives.
COMPLICATIONS
• Pulse oximetry is considered a safe procedure, but
because of device limitations, false-negative results for
hypoxemia and/or false-positive results for normoxemia
or hyperoxemia may lead to inappropriate treatment of
the patient.
• Tissue injury may occur at the measuring site as a
result of probe misuse.
SPIROMETRY
• Spirometry is a quick, painless test in which measures
how much air a person's lungs can hold (air
• volume) and the speed of inhalations and exhalations
during breathing (flow rate).
• This test is used in children older than 5 years.
Spirometric values
• FVC - Forced vital capacity; the total volume of air that
can be exhaled during a maximal force expiration.
effort.
• FEV1- Forced expiratory volume in one second; the
volume of air exhaled in the first second under force
after a maximal inhalation.
• FEV1/FVC ratio -The percentage of the FVC expired in
one second.
Lung volumes
• ERV-Expiratory reserve volume; the maximal volume of
air exhaled from end-expiration.
• IRV-Inspiratory reserve volume; the maximal volume of
air inhaled from end-inspiration.
• RV-Residual volume; the volume of air remaining in the
lungs after a maximal exhalation.
• VT-Tidal volume; the volume of air inhaled or exhaled
during each respiratory cycle.
Lung capacities
• FRC-Functional residual capacity; the volume of air in
the lungs at resting end-expiration.
• TLC-Total lung capacity; the volume of air in the lungs
at maximal inflation.
• VC-Vital capacity; the largest volume measured on
complete exhalation after full inspiration.

DEFINITION FVC
Pulse oximetry is a non-invasive method allowing the
monitoring of the oxygenation of a patient's hemoglobin.

INDICATION
• Whenever a patient's oxygenation is unstable, including
intensive care, critical care, and emergency department
areas of a hospital. 80% to 120%
• The need to monitor the adequacy of arterial
oxyhemoglobin saturation Absolute FEV1/FVC ratio

CONTRAINDICATION
• The presence of an ongoing need for measurement of
pH, PaCO2, total hemoglobin, and abnormal
hemoglobins may be a relative contraindication to pulse Within 5% of the predicted ratio
oximetry.
TLC
EQUIPMENTS
• Pulse oximeter

PROCEDURE
• Plug the pulse oximeter in to an electrical socket, if
available, to recharge the batteries.
80% to 120%
• Turn the pulse oximeter on and wait for it to go through
Pulmonary function test Normal value (95
its calibration and check tests.
percent confidence
• Select the probe you require with particular attention to
interval)
correct sizing and where it is going to go. The digit
FEV1 80% to 120%
should be clean (remove nail varnish).
FVC 80% to 120%
• Position the probe on the chosen digit, avoiding excess Absolute FEV1/FVC ratio Within 5% of the
force. predicted ratio
• Allow several seconds for the pulse oximeter to detect TLC 80% to 120%
the pulse and calculate the oxygen saturation. FRC 75% to 120%
• Read off the displayed oxygen saturation and pulse RV 75% to 120%
rate.

FRC
75% to 120%
RV
75% to 120%
INDICATION
spirometry tells health care professionals how well the
lungs are working. It's used to help diagnose and monitor
diseases that affect the lungs and make breathing
difficult, such as asthma and cystic fibrosis. It can also be
used to:
o find the cause of shortness of breath, coughing or
wheezing
o monitor treatment of respiratory problems
o evaluate lung functioning before surgery.
-find the cause of shortness of breath, coughing or wheezi
-monitor treatment of respiratory problems
-evaluate lung functioning CONTRAINDICATIONS
• hemoptysis of unknown origin (forced expiratory
maneuver may aggravate the underlying condition);
• unstable cardiovascular status (forced expiratory
maneuver may worsen angina or cause changes in
blood pressure) or recent myocardial infarction or
pulmonary embolus;
• thoracic, abdominal, or cerebral aneurysms (danger of
rupture due to increased thoracic pressure);
• presence of an acute disease process that might
interfere with test performance (eg, nausea,vomiting);
• recent surgery of thorax or abdomen.
EQUIPMENT
• Spirometer
PREPARATION
• The patient should avoid eating a big meal before the
test.
• If the patient is taking any medications, the doctor
might have the patient stop taking them for a certain
amount of time before the test.
• make sure that the patient doesn't wear tight clothing
that could interfere with the ability to breath in and out
deeply.
PROCEDURE
• Patient might have to wear soft nose clips during the
procedure to prevent air from escaping.
• Patient may be asked to stand during the test. If while
the test is performed, the patient should not lean
forward because this can affect breathing.
• Patient will be asked to take a very deep breath, place
the device in his or her mouth with the lips sealed
securely around the mouthpiece, and then exhale as
fast and hard as possible for as long as possible.
• The test may be repeated several times to confirm the
accuracy of the results.
• Spirometry is often performed before and after an
inhaled asthma medication called a bronchodilator is
administered. Use of this type of medication indicates
whether a lung problem can be treated with specific
medications.
• Spirometry usually takes 5-30 minutes, depending on
the number of times the test must be done.
• The results are expressed as percentages and are
generally considered abnormal if they're less than
80% of the normal value based on the patient’s age,
gender, height, and weight.
• Normal lungs can empty more than 80% of their
volume in 6 seconds or less.
CONTRAINDICATIONS
Spirometry is considered a safe procedure with little risk.
Because the test requires patients to breathe quickly and
deeply, some experience temporary shortness of breath or
lightheadedness. This test shouldn't be performed on
patients who have chest pain, a recent history of eye or
abdominal surgery, or serious heart disease.
CHEST X-RAY
Definition -A chest radiograph, commonly called a chest x-
ray (CXR), is a projection radiograph of the chest used to
diagnose conditions affecting the chest, its contents, and
nearby structures.
-Chest radiographs are among the most common films
taken, being diagnostic of many conditions.
-Like all methods of radiography, chest radiography
employs ionizing radiation in the form of x-rays to generate
images of the chest. The typical radiation dose to an adult
from a chest radiograph is around 0.06 mSv.
Indications and contraindications
A chest x-ray is typically the first imaging test used to help
diagnose symptoms such as:
• Shortness of breath.
• A bad or persistent cough.
• Chest pain or injury.
• Fever.
Physicians use the examination to help diagnose or monitor
treatment for conditions such as:
• Pneumonia.
• Heart failure and other heart problems.
• Emphysema.
• Lung cancer.
• Other medical conditions.
• Contraindicated for pregnant women
Equipment
• The equipment typically used for chest x-rays consists
of a wall-mounted, box-like apparatus containing the x-
ray film or a special plate that records the image
digitally and an x-ray producing tube, that is usually
positioned about six feet away.
• The equipment may also be arranged with the x-ray
tube suspended over a table on which the patient lies.
A drawer under the table holds the x-ray film or digital
recording plate.
• A portable x-ray machine is a compact apparatus that
can be taken to the patient in a hospital bed or the
emergency room.
• The x-ray tube is connected to a flexible arm that is
extended over the patient while an x-ray film holder or
image recording plate is placed beneath the patient.
Preparation
• A chest x-ray requires no special preparation.
• You may be asked to remove some or all of your clothes
and to wear a gown during the exam.
• You may also be asked to remove jewelry, eyeglasses
and any metal objects or clothing that might interfere
with the x-ray images.
• Women should always inform their physician or x-ray
technologist if there is any possibility that they are
pregnant. Many imaging tests are not performed during
pregnancy so as not to expose the fetus to radiation.
• If an x-ray is necessary, precautions will be taken to
minimize radiation exposure to the baby.
Procedure
• You will be asked to remove any clothing, jewelry, or
other objects that may interfere with the procedure.
• You will be given a gown to wear.
• The particular view that the physician orders will
determine how you are positioned for the x-ray such as
lying, sitting, or standing. You will be positioned
carefully so that the desired view of the chest is
obtained. The physician will also specify the number of
films to be made.
• For a standing or sitting film, you will stand or sit in
front of the x-ray plate.
• You will be asked to roll your shoulders forward, take in
a deep breath, and hold it until the x-ray exposure is
made. For patients who are unable to hold their breath,
the radiologic technologist will take the picture at the
appropriate time by watching the breathing pattern.
• It will be important for you to remain still during the
exposure, as any movement will blur the film.
 • For a side-angle view of the chest, you will be asked to
turn to your side and raise your arms above your head.
You will be instructed to take in a deep breath and hold
it as the x-ray exposure is made.
• The radiologic technologist will step behind a protective
window while the images are being made.
BRONCHOSCOPY
DEFINITION:
Bronchoscopy is a technique of visualizing the inside of the
airways for diagnostic and therapeutic purposes. An
instrument (bronchoscope) is inserted into the airways,
usually through the nose or mouth, or occasionally through
a tracheostomy
INDICATION
Diagnostic
• To view abnormalities of the airway
• To obtain tissue specimens of the lung in a variety of
disorders
•
To evaluate a person who has bleeding in the lungs,
possible lung cancer, a chronic cough, or a collapsed
lung
Therapeutic
• To remove secretions, blood, or foreign objects
lodged in the airway
• Laser resection of tumors or benign tracheal and
bronchial strictures
• Stent insertion to palliate extrinsic compression of the
tracheobronchial lumen from either malignant or
benign disease processes
• Bronchoscopy is also employed in percutaneous
tracheostomy
• Surgical procedures on the airways, such as tracheal
reconstruction, often require the use of bronchoscopy
CONTRAINDICATION
• Uncooperative Patient
• Acute Myocardial Infarction
• Tracheal Stenosis
• Asthma
PREPARATION:
• You will be asked to sign a consent form before a
bronchoscopy.
• Before you have a bronchoscopy, tell your doctor if you:
• Are taking any medicines.
• Are allergic to any medicines, including anesthetics.
• Have had bleeding problems or take blood-thinners,
such as aspirin, clopidogrel (Plavix), or warfarin
(Coumadin).
• Are or might be pregnant.
• Your doctor may order other tests before your
bronchoscopy, such as a complete blood count (CBC),
bleeding factors, arterial blood gas (ABG), or lung
function tests.
• Do not eat or drink for at least 8 to 10 hours before the
procedure.
• Arrange to have someone drive you home after the
procedure.
Procedure:
The patient will often be given antianxiety and antisecretory
medications (to prevent oral secretions from obstructing the
view), generally atropine, and sometimes an analgesic such
as morphine. The patient is monitored during the
procedure with periodic blood pressure checks, continuous
ECG monitoring of the heart, and pulse oximetry.
A flexible bronchoscope is inserted with the patient in a
sitting or supine position. Once the bronchoscope is
inserted into the upper airway, the vocal cords are
inspected. The instrument is advanced to the trachea and
further down into the bronchial system and each area is
inspected as the bronchoscope passes. If an abnormality is
discovered, it may be sampled, using a brush, a needle, or
forceps. Specimen of lung tissue (transbronchial biopsy)
may be sampled using a real-time x-ray (fluoroscopy).
Flexible bronchoscopy can also be performed on intubated
patients, such as patients in intensive care. In this case, the
instrument is inserted through an adapter connected to the
tracheal tube.
Complications and Risks:
• can scratch or tear airways or damage the vocal cords.
• Excessive bleeding following biopsy.
• laryngospasms is a rare complication but may
sometimes require intubation.
• Patients with tumors or significant bleeding may
experience increased difficulty breathing after a
bronchoscopic procedure, sometimes due to swelling of
the mucous membranes of the airways.
THORACOTOMY
DEFINITION:
Thoracotomy is an incision into the pleural space of the
chest.[1] It is performed by a surgeon, and, rarely, by
emergency physicians, to gain access to the thoracic
organs, most commonly the heart, the lungs, the esophagus
or thoracic aorta, or for access to the anterior spine such as
is necessary for access to tumors in the spine.
INDICATION:
A physician gains access to the chest cavity (called the
thorax) by cutting through the chest wall. Reasons for the
entry are varied. Thoracotomy allows for study of the
condition of the lungs; removal of a lung or part of a lung;
removal of a rib; and examination, treatment, or removal of
any organs in the chest cavity
Contraindications:
Contraindications are those general to surgery and include
coagulopathy that cannot be corrected, acute cardiac
ischemia, and instability or insufficiency of major organ
systems. vascular structures, a separate laparotomy is
recommended after the thoracotomy h as been completed.
Diagnosis/Preparation
Patients are told not to eat after midnight the night before
surgery. The advice is important because vomiting during
surgery can cause serious complications or death. For
surgery in which a general anesthetic is used, the gag reflex
is often lost for several hours or longer, making it much
more likely that food will enter the lungs if vomiting occurs.
Patients must tell their physicians about all known allergies
so that the safest anesthetics can be selected. Older
patients must be evaluated for heart ailments before
surgery because of the additional strain on that organ.
Procedure:
Three basic approaches are used.
• Limited anterior or lateral thoracotomy: A 6- to 8-cm
intercostal incision is made to approach the anterior
structures.
• Posterolateral thoracotomy: The posterolateral
approach gives access to pleurae, hilum,
mediastinum, and the entire lung.
• Sternal splitting incision (median sternotomy): When
access to both lungs is desired, as in lung volume
reduction surgery, a sternal splitting incision is used.
Patients undergoing limited thoracotomy require a chest
tube for 1 to 2 days and in many cases can leave the
hospital in 3 to 4 days. The principal indications for
thoracotomy are lobectomy and pneumonectomy (eg, lung
cancer surgery). Video-assisted thoracoscopic surgery has
replaced thoracotomy for open pleural and lung biopsies.
Complications:
In addition to pneumothorax, complications from
thoracotomy include air leaks, infection, bleeding and
respiratory failure. Postoperative pain is universal and
intense, generally requiring opioids, and does interfere with
the recovery of respiratory function.
Hemorrhage, infection, pneumothorax, bronchopleural
fistula, and reactions to anesthetics are the greatest
hazards.
SPUTUM COLLECTION
DEFINITION:
Sputum specimen collection is a procedure designed to
collect expectorated secretions from a patient respiratory
tract.
PREPARATION
If there is any difficulty in expectorating, the physician may
suggest the use of an inhalation, an expectorant, or
physiotherapy to aid in producing sputum for collection. The
sputum should be transferred to the laboratory within two
hours for analysis.
INDICATION:
Sputum induction is indicated on patients with suspect
tuberculosis who are unable to cough and produce an
adequate sputum sample.
CONTRAINDICATION:
Hypertonic saline will provoke cough in some patients. It is
“harsh” on the airways and may trigger severe
bronchospasm. It will not be used on patients with known
airway hypersensitivity such as asthma or on patients
actively wheezing at the time of the request. Patients who
experience severe bronchospasm after a sputum induction
may be candidates for bronchodilator or aerosol therapy to
relieve induced bronchospasm (0.5 ml albuterol in
treatment cup).
EQUIPMENTS NEEDED:
• Sterile specimen container with cover
• Clean disposable gloves
• Facial tissues
• Emesis basin (optional)
• Toothbrush (optional)
• Completed identification labels
• Completed laboratory requisition (date, time, name of
tests, source of culture)
• Small plastic bag for delivery of specimen to lab (or a
container as specified by agency)
PROCEDURE:
• Early morning sputum samples are preferable, but
samples collected at other times of the day are also
acceptable. Sputum is material brought up from as far
down in the lungs as possible after a deep cough. It is
not saliva.
• Use container provided by physician for collection
• Complete the information requested on the container
label. Make sure you include your full name, and the
date and time you collected the specimen. If you have a
requisition, note the date and time on the requisition
and your physician’s full name and address.
• If you wear dentures, remove them.
• Rinse your mouth well with water.
• Wash and dry your hands thoroughly.
• Remove the container cap.
• After a big cough, collect the sputum into the provided
empty container.
• Replace the cap and tighten firmly.
• Remember to wash your hands thoroughly after
collecting the specimen.
• Keep the sputum sample refrigerated until it is taken to
the laboratory. Take the specimen to the laboratory as
soon as possible.
THORACENTESIS
DEFINITION :
Also known as pleural fluid analysis, thoracentesis is a
procedure that removes an abnormal accumulation of fluid
or air from the chest through a needle or tube.
INDICATION:
Pleural effusion which needs diagnostic work-up:
Symptomatic treatment of a large pleural effusion.
CONTRAINDICATION
• Uncooperative patient.
• Uncorrected bleeding diathesis.
• Chest wall cellulitis at the site of puncture.
• Local skin infection over proposed site of thoracentesis.
• Uncontrolled bleeding and clotting abnormalities.
• Positive end-expiratory pressure (PEEP)
• mechanical ventilation.
• Only one functioning lung.
• Bullous disease, e.g. emphysema.
• Small volume of fluid (less than 1 cm
• thickness on a lateral decubitus film).
MATERIALS:
• 1.1% or 2% lidocaine with epinephrine for
• local anesthesia
• 3 ml syringe with 1 1/2” 25-gauge needle for
• anesthetic infiltration
• 3. 3. 1 1/2 “ 18-gauge needle
• Skin prep solution, sterile drapes
• 2- 1-litre evacuated bottles for fluid collection
• Thoracentesis or blood set tubing (these are short IV
tubings with a midpoint clamp fastened needle at one
end, and a port for a second needle at the other end)
o NOTE: A secondary IV tubing set may also be used
• Occlusive dressing
• Universal precautions materials
PREPARATION:
Patients should check with their doctor about continuing or
discontinuing the use of any medications (including over-
the-counter drugs and herbal remedies). Unless otherwise
instructed, patients should not eat or drink milk or alcohol
for at least four hours before the procedure, but may drink
clear fluids like water, pulp-free fruit juice, or tea until one
hour before. Patients should not smoke for at least 24 hours
prior to thoracentesis. To avoid injury to the lung, patients
should not cough, breathe deeply, or move during this
procedure.
PROCEDURE:
To change collection bottle:
• Close clamp on collection tubing. Leave intercostal
needle in place. Remove needle from the full collection
bottle, and replace it into the new empty collection
bottle. Then, re-open clamp.
When procedure is done:
• Leave tubing clamp OPEN. Remove intercostal needle
slowly and completely from patient. Dress puncture site
with an occlusive dressing. Leaving the collection
tubing clamp open maintains a negative pressure
throughout the system and in the pleural space,
minimizing the chance of an iatrogenic pneumothorax.
• Obtain a post-procedure radiograph to check for
iatrogenic pneumothorax.
COMPLICATIONS:
*Pneumothorax (3-30%)
*Hemopneumothorax
*Hemorrhage
*Hypotension due to a vasovagal response
*Pulmonary edema due to lung re expansion
*Spleen or liver puncture
*Air embolism
*Introduction of infection
TRACHEOSTOMY
DEFINITION
• A surgical incision into the trachea through overlying
skin and muscle for airway management (tracheotomy).
• The surgical creation of a stoma, or opening, into the
trachea through the overlying skin (tracheostomy).
INDICATION
• Acute respiratory failure, CNS depression,
neuromuscular disease, pulmonary disease, chest wall
injury
• Upper airway obstruction ( tumor, inflammation, foreign
body, laryngeal spasm)
• Anticipated upper airway obstruction from edema or
soft tissue swelling due to head and neck trauma, some
postoperative head and neck procedure involving the
airway, facial or airway burns, decreased level of
consciousness
• Aspiration prophylaxis
• Fracture of cervical vertebrae with spinal cord injury;
requiring ventilator assistance
CONTRAINDICATION
• No absolute contraindications exist to tracheostomy.
 • A strong relative contraindication to discrete surgical • iii.Point cannula downward and insert the tube maximally.
access to the airway is the anticipation that the • iv.Remove the obturator.
blockage is a laryngeal carcinoma. The definitive
procedure (usually a laryngectomy) is planned, and COMPLICATION
prior manipulation of the tumor is avoided because it a.Immediate Complication
may lead to increased incidence of stomal recurrence. • Apnea
Temporary tracheostomy may be performed just under • Bleeding
the first tracheal ring in anticipation of a laryngectomy • Injury to adjacent structure
at a later time. • Pneumothorax or pneumomediastinum
• Post-obstructive pulmonary edema
MATERIALS/EQUIPMENT
b.Early Complication
• Tracheostomy tube(sizes 6-9mm for adults)
• Early bleeding
• Sterile instruments: hemostat, scalpel, and blade,
• Plugging with mucus
forceps, sutures materials, scissors
• Tracheitis
• Sterile gown and drapes, gloves
• Cellulitis
• Cap and face shield
• Displacement
• Antiseptic prep solution
• Subcutaneous emphysema
• Gauze pads
• Atelectasis
• Shave prep kit
c. Late Complication
• Sedation
• Bleeding
• Local anesthetic and syringe
• Tracheomalacia
• Resuscitation bag and mask with oxygen source
• Stenosis
• Suction source and catheters
• Tracheoesophageal fistula
• Syringe for cuff inflation
• Tracheocutenous fistula
• Respiratory support available for post-
• Granulation
tracheostomy(mechanical ventilation, tracheal oxygen
mask, CPAP, T-piece). • Failure to decannulate
• Scarring
PREPARATION
• Assess for the patient’s heart rate, and respiratory ENDOTRACHEAL INTUBATION
status.
DEFINITION
• Provide a baseline to estimate the patient’s tolerance of
Intubation refers to the placement of a tube into an external
the procedure.
or internal orifice of the body.
a.Tracheal intubation
PROCEDURE
I.Nursing Action • Is the placement of a flexible plastic tube into the
a.Performance Phase trachea to protect the patient's airway and provide a
means of mechanical ventilation.
• Explain the procedure to the patient. Discuss a
b.Orotracheal intubation
communication system with the patient.
• Is the most common tracheal intubation is where,
• Obtain consent for operative procedure
with the assistance of a laryngoscope, an
• Shave neck region endotracheal tube is passed through the mouth,
• Assemble equipment. Using aseptic technique, inflate larynx, and vocal cords, into the trachea. A bulb is
tracheostomy cuff and evaluate for symmetry and then inflated near the distal tip of the tube to help
volume leakage. Deflate maximally. secure it in place and protect the airway from blood,
• Position the patient in a supine position with head vomit, and secretions.
extended and a support under the shoulder. c. Nasotracheal intubation
• Obtain an order for and apply soft wrist restraints if the • A tube is passed through the nose, larynx, vocal
patient is confused. cords, and trachea.
• Give medication if ordered. • Extubation is the removal of the tube.
• Position the light source.
• Assist with antiseptic prep. INDICATION
• Assist with gowning and gloving. • Acute respiratory failure, CNS depression,
• Assist with sterile draping. neuromuscular disease, pulmonary disease, chest wall
• Put on face shield. injury
• During procedure, monitor the patient’s vital signs, • Upper airway obstruction ( tumor, inflammation, foreign
suction as necessary, give medication as prescribed, body, laryngeal spasm)
and be prepared to administer emergency care. • Anticipated upper airway obstruction from edema or
• Immediately after the tube is inserted, inflate the cuff. soft tissue swelling due to head and neck trauma, some
The chest should be auscultated for the presence of postoperative head and neck procedure involving the
bilateral breath sounds, airway, facial or airway burns, decreased level of
• Secure the tracheostomy tube with twill tapes and consciousness
other securing device and apply dressing. • Aspiration prophylaxis
• Apply appropriate respiratory assistive device • Fracture of cervical vertebrae with spinal cord injury;
(mechanical ventilation, tracheostomy, oxygen mask, requiring ventilator assistance
CPAP, T-piece adapter).
• Check the tracheostomy tube cuff pressure. CONTRAINDICATION
• “tie suture” or “ stay suture” of silk may have been • Obstruction of the upper airway due to foreign objects
placed through either side of the tracheal cartilage at • Cervical fractures
the incision and brought out through the wound. Each is • The following conditions require caution before
to be taped to the skin at a 45-degree angle laterally to attempting to intubate:
the sternum. • Esophageal disease
b.Follow-up Phase • Ingestion of caustic substances
• Assess the vital signs and breath sounds; note tube size • Mandibular fractures
used, physician performing procedure, type, dose, and • Laryngeal edema
route of medication given. • Thermal or chemical burns
• Obtain chest x-ray.
• Assess and chart condition of stoma: MATERIALS/ EQUIPMENTS
• Bleeding • Laryngoscope with curved or straight blade and working
• Swelling light source
• iii.Subcutaneous air • Endotracheal tube with low-pressure cuff and adapter
• An extra tube, obturator, and hemostat should be kept to connect tube to ventilator or resuscitation bag
at the bedside. In the event of tube dislodgement, • Stylet to guide the Endotracheal tube
reinsertion of a new tube may be necessary. For • Oral airway (assorted sizes) or bite block to keep
emergency tube insertion: patient from bitting into and occluding the ET tube
• Spread the wound with a hemostat or stay sutures. • Adhesive tape or tube fixation system
• Insert replacement tube at an angle. • Sterile anesthetic lubricant jelly( water soluble)
 • 10ml syringe
• Suction source
• Suction catheter and tonsil suction
• Resuscitation bag and mask connected to oxygen
source
• Sterile towel
• Gloves
• Face shield
• End tidal CO2 detector
PREPARATION
• Assess the patient’s heart rate, level of consciousness,
and respiratory status.
• Provides a baseline to estimate the patient’s tolerance
of the procedure.
PROCEDURE
I. Nursing Action
a.Performance Phase
• Remove the patient’s dental bridgework and plates.
• Remove the headboard from the bed (optional).
• Prepare equipment.
1. Ensure function of resuscitation bag with mask and
suction.
2. Assemble the laryngoscope. Make sure the light bulb is
tightly attached and functional.
3. Select an ET tube of the appropriate size( 6-9mm for the
average adult).
4. Place the ET tube on a sterile towel.
5. Inflate the cuff to make sure it assumes a symmetrical
shape and hold volume without leakage. Then deflate
maximally.
6. Lubricate the distal end of the tube liberally with the
sterile anesthetic water-soluble jelly.
7. Insert the stylet into the tube (if oral intubation is
planned). Nasal intubation does not employ use of the
stylet.
o Aspirate the stomach contents if a nasogastric tube is
in place.
o If time allows, inform the patient of the impending
inability to talk and discuss alternative means of
communication.
o If the patient id confused, it may be necessary to apply
soft wrist restraints.
o Put on gloves and face shield.
o During oral intubation if cervical spine is not injured,
place patient’s head in a “sniffing” position (extended
at the junction of the spine and skull).
o Spray the back of the patient’s throat with anesthetic
spray.
o Ventilate and oxygenate the patient with the
resuscitation bag and mask before intubation.
o Hold the handle of the laryngoscope in the left hand
and hold the patient’s mouth open with the right hand
by placing crossed finger on the teeth.
o Insert the curved blade of the laryngoscope along the
right side of the tongue, push the tongue to the left,
and use right thumb and index finger to pull patient’s
lower lip away from lower teeth.
o Lift the laryngoscope forward (toward ceiling) to expose
the epiglottis.
o Lift the laryngoscope upward and forward at a 45-
degree angle to expose the glottis and visualize vocal
cords.
o As the epiglottis id lifted forward (toward ceiling), the
vertical opening of the larynx between the vocal cords
will come into view.
o Once the vocal cords are visualized, insert the tube into
the right corner of the mouth and pass the tube while
keeping vocal cords in constant view.
o Gently push the tube through the triangular space
formed by the vocal cord and back wall of trachea.
o Stop insertion just after the tube cuff has disappeared
from view beyond the cords.
o Withdraw laryngoscope while holding ET tube in place.
Disassemble mask from resuscitation bag, attach bag
to ET tube, and ventilate the patient.
o Inflate the cuff with the minimal amount of air required
to occlude the trachea.
o Insert a bite block if necessary.
o Ascertain expansion of both sides of the chest by
observation and auscultation of breath sounds.
o Record distance form proximal end to the point where
the tube reaches the teeth.
o Secure the tube to the patient’s face with adhesion
tape or apply a commercially available endotracheal
tube stabilization device.
o Obtain a chest X-ray to verify tube position.
o Documentation and monitor tube distance from lips to
end of ET tube.
b.Follow-up Phase
• Record tube type and size, cuff pressure, and patient
tolerance of the procedure. Auscultation breath sounds
every 2 hours or if signs and symptoms of respiratory
distress occur. Assess ABGs after intubation if
requested by the health care provider.
• Measure cuff pressure with manometer; adjust
pressure. Make adjustment in tube placement on the
basis of the chest X-ray result.
COMPLICATIONS
• Tracheal injury
o Sore throat, hoarse voice
o Glottis edema
o Ulceration or necrosis of tracheal mucosa
o Vocal cord ulceration, granuloma, or polyps
o Vocal cord paralysis
o Postextubation tracheal stenosis
o Tracheal dilation
o Formation of tracheal- esophageal fistula
o Formation of tracheal- arterial fistula
o Innominate artery erosion
• Pulmonary infection and sepsis
• Dependence on artificial airway
PERCUSSION
DEFINITION
Percussion or clapping, is the forceful striking of the skin
with cupped hands.
INDICATION
• presence of thick or excessive mucus
• inability to raise mucus with assisted cough
CONTRAINDICATION
• tenderness of involved parts
• Chest pain
• Fractured ribs
• Irregular pulse
MATERIALS / EQUIP0MENTS
• nurse’s hands, with the fingers and thumb are held
together and flexed slightly to form a cup
PREPARATION
For nurses, preparation includes:
• knowledge on the procedure
Others includes:
• preparation of materials, like mechanical percussion
cups, in cases involving the use of materials other that
the nurses bare hands
• preparing the client for the procedure by:
• explaining the procedure
• Clarifying why it is necessary; and
• telling him or her how he or she can cooperate
PROCEDURE
To percuss a client’s chest, the nurse follows these steps:
• Cover the area with a towel or gown to reduce
discomfort.
• ask the client to breath slowly and deedply to
promote relaxation.
• alternately flex and extend wrists rapidly to slap the
chest.
• percuss each affected lung segment for 1 – 2
minutes.
SIGNIFICANCE
Percussion, accomplished by by forcefully tapping
over the affected areas of the chest, dislodges and
mobilizes tenacious secretions from the air sacs into larger
airways so they can be coughed up or suctioned.
VIBRATION
DEFINITION
Vibration is a series of vigorous quiverings produced by
hands that are placed flat against the client’s chest wall.

INDICATION
• presence of thick or excessive mucus
• inability to raise mucus with assisted cough
CONTRAINDICATION
• Chest pain
• Fractured ribs
• Breathing difficulties
MATERIALS / EQUIP0MENTS
• nurse’s bare hands
PREPARATION
For nurses, preparation includes:
• knowledge on the procedure
Others includes:
• preparing the client for the procedure by:
• explaining the procedure
• clarifying why it is necessay; and
• telling him or her how he or she can cooperate
PROCEDURE
To vibrate the client’s chest, the nurse follows these steps:
• Place hands, palms down, on the chest area to be
drained, one hand over the other with the fingers
together and extended. Alternatively, the hands may be
placed side by side.
• Ask the client to inhale deeply and exhale slowly
through the nose or pursed lips.
• During the exhalation, tense all the hand and arm
muscles, and using mostly the heel of the hand, vibrate
(shake) the hands, moving them downward. Stop
vibrating when the client inhales.
• Vibrate during five exhalations over the affected lung
segment.
• After each vibration, encourage the client to cough and
expectorate secretions into the sputum container.
SIGNIFICANCE
Vibration is done, alongside with percussion, to
increase the turbulence of exhaled air, thus loosening thick
secretions and promoting better inhalation / breathing.
POSTURAL DRAINAGE
DEFINITION
Postural drainage is the drainage by gravity of the
secretions from various lung segments.
INDICATION
Postural drainage is frequently performed for:
• evidence or suggestion of difficulty with secretion
clearance
• presence of atelectasis caused by or suspected to be
caused by retained secretions
• Cavitating lung disease
• Foreign body in airway
CONTRAINDICATION
• Hemorrhage (severe hemoptysis)
• Untreated acute conditions
• Cardiovascular instability
• Recent neurosurgery
MATERIALS / EQUIP0MENTS
• those used in percussion and vibration
PREPARATION
For nurses, preparation includes:
• knowledge on the procedure
Others includes:
• preparing the client for the procedure by:
• explaining the procedure
• clarifying why it is necessay; and
• telling him or her how he or she can cooperate
PROCEDURE
The procedure of PVD is usually as follows:
• Positioning
• Percussion
• Vibration
• Removal of secretions by coughing or suction
SIGNIFICANCE
Postural drainage scheduled twice or three times daily,
primarily removes secretions in the lungs and/or respiratory
airways thus preventing the growth of bacteria and thus
infection, subsequently. These secretions also blocks
smaller airways hindering normal respirations. So, postural
drainage serves as a significant means to expectorate
secretions in the respiratory system thus promoting proper
ventilation and breathing.
TYPES OF OXYGEN THERAPY
• Compressed oxygen cylinders, or "green tanks"
• Oxygen concentrators
• Liquid oxygen systems
What is a compressed oxygen system?
Compressed oxygen comes in a tank that stores
oxygen as a gas. A flow meter and a regulator are attached
to the tank to adjust the oxygen flow. The tanks vary in
size, from very large stationary tanks to tanks that are
small enough to carry around.
The compressed oxygen system is generally
prescribed when oxygen is not needed all the time, such as
only when walking or performing physical activity.
Usage Procedures Safe use of compressed gases
involves the following activities:
• Properly handle leaking containers,
• Prevent abuse,
• Identify contents,
• Properly use container and valve caps and plugs, and
• Return empty containers.
• Remove any leaking containers to a well-ventilated
area and post a warning of the hazard.
• Make sure labels are legible before using containers;
otherwise, return the containers to the supplier.
• Do not misuse containers (i.e., using them for support);
only use them as they were intended.
• Keep containers away from fire, sparks, and electricity.
• Don't smoke or allow others to smoke in the vicinity of
flammable compressed gas containers.
• Do not subject containers to extreme heat or cold.
• Always keep removable caps and valve outlet
caps/plugs on containers except when connecting to
dispensing equipment.
• Do not use oxygen and compressed air
interchangeably. They are not the same.
• When empty, close and return cylinders. Empty
cylinders must be marked MT or Empty.
• Be sure valves are closed when not using the container
and before returning containers. Properly label
returning containers.
• Do not refill non-refillable containers once they are
empty.
Advantages
• Small, lightweight, portable tanks can be used
• for trips outside the home.
• Several tanks can be used to increase the time away
from home.
• Can deliver oxygen at a high flow rate.
• Contents of tank do not evaporate.
• No electricity needed.
Disadvantages
• Since the oxygen is stored under pressure, the tank can
be hazardous if dropped.
• Small portable oxygen tanks are limited in how long
they will last. Ask your oxygen supplier how long your
oxygen will last, depending on your prescribed flow rate
and type of tank.
OTHER EQUIPMENTS USED:
• VALVE a passageway allowing flow of oxygen from the
inlet to the outlet, controlling oxygen flow from a
compressed oxygen
• GAUGES commonly used on downside of regulator to
indicate regulated reduced pressure,
• REGULATORS measures the amount of oxygen in liters
per minute and in some cases fractions of a liter per
minute a person receives.
What is a liquid oxygen system?
At very cold temperatures, oxygen changes from a
gas to a liquid and becomes very cold. Oxygen becomes a
liquid when its temperature reaches about 300 degrees
Fahrenheit below zero and takes on a pale blue color
weighing 1.14 times the weight of water..
When liquid oxygen is warmed, it becomes a gas so
it can be delivered to you.
A liquid oxygen system includes a large stationary
unit that stays in the home. It also includes a small,
portable canister (weighing from 5 to 13 pounds) that can • Cannot deliver oxygen at high flow rates. (It has volume
be filled from the stationary unit for trips outside the home. limitations and can only deliver oxygen up to about 5
It can be hung over the shoulder (as shown, above left) or liters).
pulled on a roller cart. How long it lasts depends on the size • Motor produces noise and heat.
of the portable tank and the flow rate.
Even when not in use, evaporation will empty the portable EQUIPMENTS:
canister over time. Always check your portable canister • Nasal Cannula is a device used to deliver supplemental
before use. oxygen to a patient or person in need of extra oxygen.
This device consists of a plastic tube which fits behind
Advantages the ears, and a set of two prongs which are placed in
• Allows the user to be mobile, promoting an active the nostrils.
lifestyle. (User can fill own portable tank).
• Can deliver oxygen at a high flow rate. • HUMIDIFIER is a household appliance that increases
• Requires no electricity. humidity (moisture) in a single room or in the entire
• Doesn't make much noise; relatively silent. home.
• More oxygen can be stored in a liquid form than a
gaseous form. The following step-by-step instructions will help you
operate your oxygen concentrator.
Disadvantages
• Large tank needs to be refilled regularly by a service Step 1: Check the number of prongs on the plug of
technician. Depending on the flow rate and the size of your concentrator.
the tank, a liquid oxygen system may need to be Step 2: Attach nipple adaptor to the concentrator
refilled from once or twice a week to once a month. outlet and attach the oxygen tubing to the nipple
• Oxygen user must be home for scheduled tank fill-ups. outlet.
User must also return home to refill portable tank. Step 3: If a humidifier bottle is recommended,
• Contents of tanks evaporate, making it necessary to attach a bottle that is filled with distilled water.
have the tank refilled often. • Center the threaded cap on the humidifier
bottle under the threaded outlet tube on the
• A cylinder of oxygen is provided as a backup for the
concentrator.
electric system in case there is a system or power
• Turn the cap on the humidifier until it is tightly
failure. In addition, a small, lightweight portable tank is
screwed onto the outlet tube.
provided for trips outside the home (since the
Step 4: Turn machine ON. The alarm will sound for
concentrator system is not portable). This portable tank
a few seconds until the proper pressure is
can be hung over your shoulder or pulled on a roller
reached.
cart.
Step 5: Adjust the oxygen flow rate by turning the
• An oxygen concentrator may be recommended if you
flow selector until the flow is at the prescribed
need oxygen all the time or while sleeping.
number.
Handling and Storage
• Store and use liquid oxygen with adequate ventilation.
Do not store in a confined space.
• Cryogenic containers are equipped with pressure-relief
devices to control internal pressure. Under normal
conditions these containers will periodically vent
product. Do not plug, remove, or tamper with any
pressure-relief device.
• Where outside storage is used, provide for protection
against the extremes of weather.
• Oxygen must be separated from flammables and
combustibles by 20 feet or a half-hour fire wall. Post
"No Smoking" and "No Open Flames" signs.
• Customer storage sites having a capacity of more than
20,000 scf must be installed in accordance with the
National Fire Protection Association (NFPA) Standard 50.
• Use only oxygen compatible lubricants.

EQUIPMENTS
• Safety glasses
• Loose-fitting thermal insulated or leather gloves
• Long sleeve shirts and trousers without cuffs.
• In addition, safety shoes are recommended for people
involved in the handling of containers.

What is an oxygen concentrator system?

The oxygen concentrator is an electric oxygen
delivery system about the size of a large suitcase. The
concentrator extracts some of the air from the room and
separates the oxygen from other gases in the air. Oxygen is
then delivered to you through a nasal cannula. When in use,
the concentrator should be placed in an open area - never
place it in a closet or other closed space. Used to provide
oxygen therapy to a patient at substantially higher
concentrations than available in ambient air. They are used
as a safer, less expensive and more convenient alternative
to tanks of compressed oxygen.

Advantages
• Minimal maintenance needed.
• Does not need to be refilled.
• Provides an unlimited oxygen supply (as long as it is
plugged in and turned on).
• Can be moved easily from room to room.

Disadvantages
• Requires electricity and will increase your electric bill,
especially if used 24 hours a day.
• Is affected by power surges and outages, requiring
backup oxygen system.