GEL MARIE C.
LOBATON BSN1-B
I have performed hand hygiene to reduce
transmission of microorganisms. I have also gathered
all necessary equipment and arrange them according
to use to promote efficiency. Good morning Ma’am, I
am Gel Marie Lobaton, 1st year student nurse from
WVSU. If you ever need help, I will be here to assist
your needs. Can I see your armband please? Can you
recite your full name? How do you want me to
address you?
*assess client appropriately*
Ma’am, I will position you in a semi-fowler’s position.
This help in relaxing the abdominal muscles (knees
flexed, one pillow on head and on knees, drape)
Ma’am I will auscultate to check your lung fields.
Inhale exhale inhale exhale. So maam, I will
demonstrate the different deep breathing and
coughing exercises. These are the abdominal, apical
expansion and basal expansion exercises. The reason
why I am teaching you this exercise is to increase the
volume of air exchanged during inspiration and
expiration.
First, I will teach you the abdominal breathing. This is
the type of breathing exercise that uses the
diaphragm rather than the upper chest muscles. To
start with, you need to place your hand on your
abdomen and other hand on your chest this is to
allow you feel the movement of your chest and
abdomen as you inhale and exhale, concentrate on
feeling the abdomen rise and fall. Inhale for 3 secs
thru the nose with mouth close to humidify, warm
and filter the air breathe. If you have any trouble
breathing, do a forceful inhalation through the nose.
Then exhale thru your mouth with pursing your lips
like you are going to whistle and gently make a
whooshing sound. Also prevent puffing out cheeks,
focus on feeling the abdomen fall, tighten your
abdominal muscles while breathing out, do not arch
your back and count to 7 during exhalation.
Okay so ma’am, I will demonstrate to you on how to
do the abdominal breathing (demo) again ma’am
(demo). Do you have any questions ma’am? Can you
please perform it for me ma’am? Inhale exhale. Again
inhale exhale. Very good ma’am.
Next is the apical expansion exercise, it is the type of
exercise required for clients who restrict their upper
chest movement because of pain from a disease or
operation.
To perform this, you need to place your fingers below
your collarbones with moderate pressure. Inhale thru
the nose and concentrate on pushing the upper chest
upward and forward against the fingers this is to
aerate the apical areas of the upper lung lobes. Hold
for 3-4 secs to promote aeration of the alveoli. Exhale
through the mouth or nose slowly, quietly, and
passively while concentrating on moving the upper
chest inward and downward.
Okay so ma’am I will demo to you on how to do the
apical expansion exercise. Inhale hold exhale, Again
inhale hold exhale. Do you have any questions
ma’am? Can you perform it? Inhale, hold for few
secs, exhale. Inhale, hold for few secs, exhale.
Then perform this exercise for at least 5 respirations,
4 times a day. To help re-expand your lung tissue and
eliminate secretions.
Moving on to our next exercise, the basal expansion.
It is required for client with restricted bilateral chest
movements due to pain from a respiratory disorder,
chest surgery or upper abdominal surgery.
Provide a pillow splint for postop clients to support
incision and help minimize the pain. To perform this
exercise, place your palms on the lower ribs. This
enables you to evaluate the depth of basal
inspiration. Make sure that the focus is on this area
only, not on the abdomen and chest. Inhale thru the
nose and hold it for a few secs. Exhale thru the nose
or mouth slowly, quietly and passively.
I will demo to you on how to do the basal expansion
exercise. Inhale hold exhale. Again inhale hold exhale.
Do you have any questions ma’am? Can you perform
it? Inhale, hold for few secs, exhale. Inhale, hold for
few secs, exhale. Then perform this exercise for at
least 5 respirations, 4 times a day.
Sputum
Next, Im going to teach you the sputum specimen
collection and double cough technique. First, im
GEL MARIE C. LOBATON BSN1-B
going to take your sputum specimen. (Assist to Sitting
position and give a tissue and 3 folded towels. Put a
towel on the chest, give a cup of water,) So maam
you can gargle using this water then spit it on the
kidney basin. It is ideally to get sputum specimen in
the morning because secretions accumulate
overnight. Ma’am this is a specimen cup where your
sputum will be stored, kindly do not touch the inside
of the cup, spit or expectorate sputum directly in the
cup but if there are any spoilage I assure you that I
will clean it with disinfectant or water with soap and
if possible the outside of the cup should be free from
sputum. Im going to collect 1-2 tsp of sputum
because it is the adequate amount for the test. If you
are unable to do it, Im going the specimen cup for
you with gloves on.
Next, I will teach you the double cough technique.
(Handkerchief on back pocket). Coughing exercises
facilitate in expelling thick secretions. These are
performed to clear the tracheobronchial tree from
secretions. So maam in doing double cough, inhale
cough cough. Again inhale cough cough. You can
repeat this for 1 full minute and rest for at least 2
mins. Also if, you feel short in breath, repeat it for 5-
10 mins for 4 times a day. (Don gloves) Specimen cup
has name, date, time collected, type of specimen.
Open cup. Okay ma’am, do the double cough exercise
and expectorate or spit on the cup. Again ma’am.
(Check for consistency, color odor). Close the cup. (If
there are spoilage, clean the cup and remove gloves).
Assuming that there is a requisition form with the
label on the cup attached. Ma’am how are you
feeling? Do you feel comfortable now? Ensure client’s
comfort. (Remove gloves) Ma’am you’re going to
gargle with mouthwash. What do you want, pure
mouthwash or you want it with water? (Pour
mouthwash on the cup) Ma’am do not swallow the
mouthwash just gargle it and spit on the basin. (All
used items outside of tray) (Arrange items to be sent
to the laboratory, label the cup) So your specimen
ma’am will be sent to the laboratory for testing.
(perform H.H)
The purposes of the sputum specimen collection are:
Specimen for culture & sensitivity - To identify a
specific microorganism and its drug sensitivities
Specimen cytology – to identify the cancer in the lung
and its specific cell type; this requires serial collection
of three early morning specimens
Specimen for acid-fast bacillus – To identify the
presence of TB; this requires serial collection for
three consecutive days
To assess the effectiveness of therapy
CHEST PHYSIOTHERAPY
Assuming that I have performed HH, Introduce self,
Verify the client, ang provided client privacy.
Today ma’am I will perform a chest physiotherapy so
this includes percussion, vibration, postural drainage,
deep breathing and coughing exercises.
First, is the percussion, so it is forceful striking on the
skin with cupped hand to drain secretions. Next is the
vibration, it is a series of vigorous quivering produced
by hands that are placed on a flat against the client’s
chest wall during exhalation. Can I start ma’am?
(Libot) Raise side rails. Check the bed mechanism to
operate the bed properly during procedures. So,
ma’am for now, we will only use the diaphragmatic or
the abdominal breathing like this.
I will auscultate first, okay so ma’am there are
secretions in the______ position. So we need to
remove it by percussing and vibrating. POSITION THE
CLIENT. DRAPE. Ma’am I will put a towel here on your
chest to reduce discomfort. (Cup your hands) So
ma’am I will now percuss your ___________ using my
cupped hands. Alternate hands to listen to hollow
sounds. Do not percuss on bony prominences and
body organs. Inhale exhale inhale exhale. Okay good.
Can you feel any pain? Percuss the area 1-2mins.
Ma’am can you do the double cough? Okay
expectorate. (give another towel)
Im going to do the vibration next. Ma’am again I have
placed the towel here to reduce discomfort. Do the
abdominal breathing ma’am, breath on your nose
and do the purse lip when exhaling. Also do the
double coughing after 3-4 vibration and expectorate
the secretions (hands kidney basin to client) (Place
my hands on top of each other) Inhale exhale
(vibrate) Inhale exhale (vibrate). Relieve pressure on
GEL MARIE C. LOBATON BSN1-B
the thorax as the client exhales. Okay very good
ma’am. Assuming that I have vibrated for 2-5 mins
depending on the viscosity of secretions and patient
tolerance.
Assist the patient to the normal sitting position. Allow
a rest period for several minutes. Do you want to
gargle mouthwash? Yes? Okay. Just gargle it, do not
swallow. Ma’am I will now auscultate again to check
the effectiveness of the therapy. So there are no
secretion heard on the _______ segment.
Discard container or send specimen to the
laboratory. Aftercare. H.H
Document: procedure, time performed, duration,
position used, client response, lung/breath sounds
heard before and after the therapy, breathing
patterns and sign of dyspnea. Then report abnormal
findings.
I have performed H.H before entering the room to
reduce the transmission of microorganisms.
I have already verified the doctor’s order.
Good afternoon ma’am, I am Gel Marie Lobaton Level
1 student of CON of WVSU. Can I check your armband
please? Could you please state your full name
ma’am? How do you want me to address you? Today,
I will be assisting you in the following procedures:
oxygen therapy and suctioning. I have already
checked your doctor’s order and at the same time I
will assess you further on your condition as you need
for oxygen therapy. Im going to check your
respiratory system by auscultation, inhale exhale
inhale exhale. There are presence of secretions on
your lungs therefore we’re going to suction that later
on. Because we are the using the prongs, im going to
check for your nares if there are any obstructions.
There are none. Next, im going to check for your skin
condition especially your capillary refill, there is
decrease in your capillary refill, it is more than 3 secs.
Therefore, you have the need for more oxygen. Your
doctor have ordered O2 at a rate of ____ LPM. We
need to position you appropriately to a semi-fowler’s
position, this will provide lung expansion and have
your knees flex to relax your abdominal muscles,
therefore having more space for the diaphragm to
expand to have more oxygen taken in.
This is the :
Oxygen cylinder – holds dry oxygen
Hand wheel – allows the O2 to flow out of the
cylinder
Pressure gauge – determines the amount of oxygen
inside the tank
Flow meter – determines the amount of liters per
minute that will be administered to the client. Unit is
LPM or liters per minute. The ball usually floats to the
appropriate level wherein the doctor have ordered.
Flow meter knob – used to adjust the flow meter
Humidifier – should always be half-full with sterile or
distilled water to allow area for bubbling, which
indicates the presence of oxygen.
Check the surroundings for any potential source of
fire or sparks. Observe safety precautions like placing
No smoking sign: Oxygen in use”
This is the nasal prong which delivers oxygen in a rate
of 2-6 liters per minute. Low flow device. This is the
face mask which delivers 5-10 liters of O2 per minute.
The doctor have ordered _____ LPM. We are going to
use the prong/face mask.
There are nasal prongs, avoid touching the prongs
because it is sterile. Remove from the pack, attach to
the humidifier, make sure it fits. Open the tank adjust
to ____ LPM, the ball is currently at ____ LPM as per
doctor’s order. Verify the presence of bubbling w/c
indicates the presence of O2. Make sure there are no
kinks, check if there is air moving out of the tube with
the back of your hand. Place lubricant above the
kidney basin, adjust the knob down, inhale thru your
nose. Tuck on the ears, place knob not to tight. Place
gauze pads on bony prominences, the cheeks to
prevent irritation of the tubing on the skin. Tape the
gauze not on the tubing. Ma’am always remember to
breathe thru your nose and not your mouth because
breathing in mouth will cause O2 loss. I’ll be checking
the cannula every 8hours. Also, I will assess your
nares and external nose for skin breakdown every 6-8
GEL MARIE C. LOBATON BSN1-B
hours. To prevent dislodgement of the tubing, we’ll
secure it at the back of your pillow with the use of
tape and pin. Provide oronasal care to patient as
needed. DONE!
Your doctor have ordered to increase your O2 in ___
LPM, so we’ll be using the face mask. I have already
checked the size of the face mask appropriate for
you. Don’t worry, there are air vents on the face
mask. You can hold it to familiarize yourself while im
removing the prongs. Avoid touching the prongs itself
and discard.
Attach the distal end of the mask on the humidifier
making sure it is fitted. Adjust the knob to ___ LPM
according to doctor’s order, the ball is at ____ LPM.
And there is a presence of bubbles which indicates
presence of O2. No kinks at the tubing. check if there
is air moving out of the tube with back of your hand.
Breathe normally thru your nose. Now, fit it that it
covers both the nose and the mouth. Making sure
there are no escape of O2 at the sides and tighten.
Secure the elastic band so that the mask is
comfortable but snug. Attach tubings to pillows and
linen. I will stay with you until the flow rate is
maintained and you are calmed down. I will also be
assessing you for 15-30 mins depending on your
condition regularly, if there are any presence of
dyspnea or hypoxia. Then provide oronasal care if
needed. DONE!
As I have auscultated your lungs, there is a presence
of secretions thus there is a need to suction it. So
first, if the client if conscious place in a semi-fowler’s
position with the head turned to one side, if
unconscious lateral position facing the nurse. Place
the towel and basin at the side of the face to prevent
soiling of your linen. Since I will be doing the
oropharyngeal suctioning, a catheter will be inserted
in your mouth and sometimes you feel like gagging or
vomiting, there is a basin here at the side. So I will be
setting the pressure on the suction gauge and turn on
the suction. I will also be hyperoxygenate you for 10-
15secs to provide sufficient amount of O2 before I
insert the catheter and suctioning. Check if the
machine is working and the water for rinsing, make
sure that the equipment are ready. Pour sterile water
on the container with your nondominant hand. Open
the sterile suction pack, exposing only the tip. Avoid
touching the inside portion. Open also the gauze pad.
And don gloves. Ma’am I will be inserting a catheter
to your mouth for 5 secs by the side of your mouth to
prevent gag reflex. I’ll be withdrawing the catheter
and I’ll instruct you to inhale. When I instruct you to
exhale I’ll be rotating and suctioning for 5 mins then
stop suctioning. During the interval, please perform
deep breathing and coughing exercises.
Grab the pack of suction package with left hand, get
the catheter with right hand. Attach the tip to the
suction machine, the colored part is considered
unsterile once attached. Check if the machine is
working and test for the pressure of the suction and
the patency of the catheter by applying suction.
Moisten the tip with sterile water. Remove the face
mask because hyperoxygenation is good only for
2minutes. Measure from the tip of the nose to the tip
of the earlobe. Mark the position on the tube with
fingers on the sterile gloved hand. Pull the tongue
forward with gauze if necessary. So ma’am I will be
inserting the catheter up to the marked area, inhale.
Thumb up to not apply suction while inserting. Gently
insert the catheter 4-6 inches on one side of the
mouth. Suction intermittently exhale. Rotate and
apply suction for 5-10 secs. 123 up. 123 up. Remove
the catheter. Perform deep breathing and coughing
exercises. Submerge the tip of the catheter that was
inserted to the mouth. Rinse it appropriately and
apply suction. Wipes the catheter with sterile gauze if
there are thick secretions. Flush the catheter with
sterile water. Relubricate the catheter and repeat
suctioning until air passage is clear. Repeat
suctioning. Allow 20-30 secs interval between each
suction. Perform deep breathing and coughing
exercises between suctions. Limit suction to 5 mins in
total. Add water if necessary using the nondominant
hand. Sterile hand always with catheter. Turn off the
machine. Dispose the catheter from the tip detach,
gloves, water and waste container. Wrap the catheter
around the sterile gloves and roll it inside the glove.
Remove kidney basin, wipe the mouth of client then
remove towel. Provide oronasal care. Place back the
face mask. Making sure that the rate is as per
doctor’s order. DONE!
GEL MARIE C. LOBATON BSN1-B
NASOPHARYNGEAL effective. Provide oronasal care as needed. Would
there be anymore that I could assist you ma’am?
You doctor has ordered for nasopharyngeal
None? Thank you for your cooperation and have a
suctioning. I will position you to a semi-fowler with
good day! Perform aftercare of equipment to get for
neck hyperextended for full visualization of nares.
the next use. Place everything back to the tray.
Place towel on chest just below the chin and kidney
Removing the suction machine bottle. Open the
basin. Open the lubricant for ease of insertion of the
suction machine bottle, next pour left over fluid. Do
catheter. Use the nasopharyngeal bottle. Use forceps
not pour unused water. Take note of the fluid at the
to get the catheter. Attach the tip to the suction
start of the procedure. At the start, there is _____ml,
machine, the colored part is considered unsterile
and now there is only ____ ml left. And here, based
once attached. Check if the machine is working and
on the calibration, there is already _____ ml.
test for the pressure of the suction and the patency
Therefore, I have suctioned ______ml from the client
of the catheter by applying suction. Moisten the tip
and document it, also document the color, odor,
with sterile water. Remove the face mask because
consistency of the secretions. Then this will be
hyperoxygenation is good only for 2minutes.
discarded to the toilet, rinse, wash then return it back
Measure from the tip of the nose to the tip of the
for further usage. Perform H.H and document the
earlobe. Mark the position on the tube with fingers
procedure done and report abnormal findings for
on the sterile gloved hand. Lubricate the catheter tip
proper referral. DONE!
with water-soluble gel 1-2 inches from the tip to ease
insertion. Ma’am I’ll insert the catheter, inhale and
exhale slowly. Never force insertion if there is an
obstruction, try the other naris. Rotate and apply
suction for 5-10 secs. Suction intermittently 123 up.
123 up. Remove the catheter. Perform deep
breathing and coughing exercises. Submerge the tip
of the catheter that was inserted to the mouth. Rinse
it appropriately and apply suction. Wipes the
catheter with sterile gauze if there are thick
secretions. Flush the catheter with sterile water.
Relubricate the catheter and repeat suctioning until
air passage is clear. Insert on another naris to prevent
trauma from suctioning. Inhale and slowly exhale.
Repeat suctioning. Allow 20-30 secs interval between
each suction. Perform deep breathing and coughing
exercises between suctions. Return catheter
maintaining sterility. Limit suction to 5 mins in total.
Add water if necessary using the nondominant hand.
Sterile hand always with catheter. Turn off the
machine. Do not dispose the catheter for further use.
Secure forceps, detach. Remove kidney basin, wipe
the nose of client then remove towel. Place back the
face mask. Make sure that there are no leaks at the
side, adjust. Making sure that the rate is as per
doctor’s order. Auscultate the client and check for
condition if there is improvement on the suctioning
done. Inhale exhale inhale exhale. There is a decrease
in the secretions heard therefore the therapy is