M1 : Lesson 1 : NGT insertion by L.

Sadorra

By inserting a nasogastric tube you are gaining access to the

stomach and its contents. There are many types of nasogastric tubes
that comes in different sizes. Among the most common are the Levin
catheter, which is single lumen, small bore tube more appropriate for
administration of medication or nutrition, invented by Abraham Louis
Levin, an American physician ( December 16, 1880- Sept 15, 1940.)
The Levin tube is also widely used for duodenal drainage after
surgery and management of trauma patients. The Salem Sump
catheter, is a large bore double lumen tube that can be used for
feeding or administering medication, but their primary function is
gastric suctioning and decompression.
Definition – A nasogastric tube is a flexible plastic tube inserted through
the nostrils, down the nasopharynx, and into the stomach or the upper
portion of the small intestine. Placement of NG tube is always confirmed by
with an X ray prior to to use. ( Perry, Potter & Ostendorf, 2014.)
PURPOSES:
● To administer tube feedings and medications to clients unable to
eat by mouth or swallow a sufficient diet without aspirating food or
fluids into the lungs
● To establish a means for suctioning stomach contents to prevent
gastric distention, nausea, and vomiting
● To remove stomach contents for laboratory analysis
● To lavage (wash) the stomach in case of poisoning or overdose of
medications

ASSESSMENT
● Check for history of nasal surgery or deviated septum
● Assess patency of nares
● Determine presence of gag reflex
● Assess mental status or ability to participate in the procedure

PLANNING
Before inserting a nasogastric tube, determine the size of the tube to be
inserted and whether the
tube is to be attached to a suction

Equipment
● Large – or small-bore tube (nonlatex preferred )
● Non allergenic adhesive tape, 2.5 cm (1 in.) wide
● Clean gloves
● Water - soluble lubricant
● Facial tissues
● Glass of water and drinking straw
● 20 – 50 -ml syringe with an adapter
● Basin
● Ph test strip or meter
 ● Bilirubin dipstick
● Stethoscope
● Disposable pad or towel
● Suction apparatus
● Safety pin and elastic band
● C02 detector (optional)

IMPLEMENTATION

Preparation
● Assist the client to a high Identifying the patient ensures the
Fowler’s position if his or right patient receives the intervention
her health condition and helps prevents errors. (Lynn,
permits, and support the 20015)
head on a pillow. Explanation facilitates patient
● Place a towel or disposable
cooperation
pad across the chest.
(Lynn, 2015)
Performance
1. Prior to performing the insertion
introduce self and verify the client’s
identity using two patient's
identifiers,(i.g., name and date of
birth.) Explain to the client what you
are going to do, why it is necessary,
and how he or she can participate.
The passage of a gastric tube is
unpleasant because the gag reflex is
activated during insertion. Establish
a method for the client to indicate
distress and a desire for you to
pause the insertion. Raising a finger
or a hand is often used for this.
 Hand hygiene and PPE prevent the
2. Perform hand hygiene and
spread of microorganisms ( Lynn,
observe other appropriate infection
2015)
control procedures (e.g., clean
gloves).

Closing the door or pulling the

3. Provide for client privacy
curtain is the client's right to privacy (
Carter, 2012 )

4. Assess the client’s nares

· Apply clean gloves
· Ask the client to hyperextend
the head, and using a flashlight,
observe the intactness of the tissues
of the nostrils, including any
irritations or abrasions.
· Examine the nares for any
obstructions or deformities by asking
the client to breathe through one
nostril while occluding the other.
· Select the nostril that has the
greater airflow.
5. Prepare the tube
● If a small bore-tube is being -
used, ensure stylet or
guidewire is secured in
position. - An improperly positioned stylet or
guidewire can traumatize the
nasopharynx, esophagus and
stomach.
● If a large bore- tube (e.g
Salem sump tube) is being
used, place the tube in a
basin of warm water, while
preparing the client -This allows the tubing to become
more pliable and flexible. However, if
the softened tube becomes difficult
to control, it may be helpful to place
the distal end in a basin of ice water
to help it hold its shape.

-This length approximates the

6. Determine how far to insert the
distance from the nares to the
tube.
stomach. This distance varies
● Use the tube to mark off the among individuals.
distance from the tip of the
client’s nose to the tip of the
earlobe to the tip of the
xiphoid
● Mark this length with
adhesive tape if the tube
does not have markings
7. Insert the tube -A water-soluble lubricant dissolves
if the tube accidentally enters the
● Lubricate the tip of the tube
lungs. An oil-based lubricant, such
well with water soluble
as petroleum jelly, will not dissolve
lubricant or water to ease
and could cause respiratory
insertion. In some agencies,
complications if it enters the lungs.
topical lidocaine anesthetic
is used on the tube or in the
client’s nose to numb the -Hyperextension of the neck reduces
area. the curvature of the nasopharyngeal
junction.
● Insert the tube, with its
natural curve toward client, -Directing the tube along the floor
into the selected nostril. Ask avoids the projections (turbinate)
the client to hyperextend along the lateral wall.
the neck , and gently
advance the tube toward
the nasopharynx -Tears are a natural body response.
Provide the client with tissues as
needed.
● Direct the tube along the
floor of the nostril and
toward the ear on that side -The tube should never be forced
against resistance because of the
danger if injury
● Slight pressure and a
twisting motion are
sometimes required to pass -Tilting the head forward facilitates
the tube into the passage of the tube into the
nasopharynx and some posterior pharynx and esophagus
client’s eyes may water at rather than into the larynx;
this point. swallowing move the epiglottis over
the opening to the larynx.
● If the tube meets
resistance, withdraw it
relubricate it, and insert it in
the other nostril

● Once the tube reaches the

oropharynx (throat), the
client will feel the tube in
the throat and may gag and
retch. Ask the client to tilt
the head forward, and
encourage the client to tilt
the head forward, and
-The tube may be coiled in the
encourage the client to
throat, if so, withdraw it until it is
drink and swallow
straight, and try again to insert it.
● If the client gags, stop
passing the tube
momentarily. Have the
client rest, take a few
breaths, and take sips of
water to calm the gag
reflex.
● In cooperation with the
client pass the tube 5 to 10
cm (2 to 4 in.) with each
swallow, until the indicated
length is inserted.
● If the client continues to gag
and the tube does not
advance with each swallow,
withdraw it slightly and
inspect the throat by looking
through the mouth
● If a CO2 detector is used,
after the tube has been
advanced approximately 30
cm (12in), draw air through
the detector. Any change in
color of the color of the
detector indicates
placement of the tube in the
respiratory tract (Meyer et
al 2009), Immediately
withdraw the tube and
reinsert
8. Ascertain correct placement of the -Testing pH is a reliable way to
tube determine location of a feeding tube.
Gastric contents are commonly pH 1
● Aspirate stomach contents,
to 5; 6 or greater would indicate the
and check the pH, which
contents are from lower in the
should be acidic
intestinal tract or in the respiratory
● Aspirate can also be tested
tract. Some researches suggest that
for bilirubin. Bilirubin levels
a pH of greater than 4 should be
in the lungs should be
followed by further confirmation of
almost zero, while levels in
tube location (Stock, Gilbertson, &
the stomach will be
Babl, 2008
approximately 2.5mg/dl and
in the intestine more than -The stylet is sharp and could pierce
10mg/dl the tube and injure the client or cut
● Almost all nasogastric off the tube end.
tubes are radiopaque, and
position can be confirmed
by x-ray. Check agency
policy. If a small-bore tube
is used, leave the stylet or
guidewire in place until
correct position is verified
by x-ray. If the stylet has
been removed, never
reinsert it while the tube is
in place -This method does not guarantee
● Place a stethoscope over a tube position
client’s epigastrium and
inject 10-30 ml of air into
the tube while listening for a
whooshing sound. Although
still one of the methods
used, do not use this
method as the primary
 method for determining
placement of the feeding
tube.
● If the signs indicate
placement in the lung,
remove the tube and begin
again
● If the signs do not indicate
placement in the lungs or
stomach, advance the tube
5cm(2in), and repeat the
tests

9. Secure the tube by taping it to the

bridge of the client’s nose.
● If the client has oily skin,
wipe the nose first with
-Taping in this manner prevents the
alcohol to defat skin
tube from pressing against and
● Cut 7.5cm (3in) of tape,
irritating the edge of the nostril
and split it lengthwise at
one end, leaving 2.5-cm
(1in) tab in the end
● Place the tape over the
bridge of the client’s nose,
and bring the split ends
under the tubing and back
up over the nose. Ensure
that the tube is centrally
located prior to securing
with tape to maximize air
flow and prevent irritation to
the side of nares.
10. Once correct position has been
determined, attach the tube to a
suction source of feeding apparatus
as ordered , or clamp the end of the
tubing.

11. Secure the tube to the client’s

gown -The tube is attached to prevent it
● Loop an elastic band from dangling and pulling
around the end of the
tubing, and attach the
elastic band to the gown -This prevents gastric contents from
with a safety pin or flowing into the vent lumen
● Attach a piece of adhesive
tape to the tube, and pin the
tape to the gown.
If a Salem pump is used, attach the
anti-reflux valve to the vent port (if
used) and position the port above
the client’s waist
● Remove and discard
gloves. Perform hand
hygiene

12. Document relevant information;

The insertion of the tube the means
by which correct placement was
determined and client responses
(e.g. discomfort or abdominal
distention)
13. Establish a plan for providing
daily nasogastric tube care
● Inspect the nostril for
discharge and irritation
● Clean the nostril and tube
with moistened,
cotton-tipped applicators
● Apply a water-soluble
lubricant to the nostril if it
appears dry or encrusted
● Change the adhesive tape
as required
● Give frequent mouth care.
Due to the presence of the
tube, the client may breathe
through the mouth
14. If suction is applied ensure the
patency of both the nasogastric and
suction tubes is maintained
● Irrigations of the tube may
be required at regular
intervals. In some agencies,
irrigations must be ordered
by the primary care
provider. Prior to each
irrigation, recheck tube
placement
● If a Salem sump tube is
used, follow agency policies
for irrigating the vent lumen
with air to maintain patency
of the suctioning lumen.
Often, a sucking sound can
be heard from the vent port
if it is patent.
● Keep accurate records of
the client’s fluid intake and
output, and record the
amount and characteristics
of the drainage

15. Document the type of the tube

inserted, date and time of tube
insertion, type of suction used, color
and amount of gastric contents, and
the client’s tolerance of the
procedure

EVALUATION
 Conduct appropriate follow up, such as degree of client comfort,
client tolerance of the nasogastric tube, correct placement of nasogastric
tube in stomach, client understanding of restrictions, color and amount of
gastric contents if attached to suction , or stomach contents aspirated.

M1 : Lesson 2 : Gastric Gavage by: C.Salao

The state of being fed by a feeding tube is called "enteral feeding" or "tube
feeding." A feeding tube is a medical device used to provide nutrition to a
patient who cannot obtain nutrition by swallowing. Placement may be
temporary for the treatment of acute conditions or lifelong in the case of
chronic disabilities. a variety of feeding tubes are used in medical practice.
They are usually made of polyurethane or silicone. The diameter of
feeding tube is measured in "French units" (each French unit equals 0.33
mm). They are classified by site of insertion and intended use.
Enteral nutrition provides physiological, safe, and economical nutritional
support. Patients with enteral feedings receive formula via nasogastric
jejunal, or gastric tubes. Patients with a low risk of gastric reflux receive
gastric feedings: however, if there is a risk of gastric reflux, which leads to
aspiration, jejunal feeding is preferred. Enteral feeding can easily be given
in the home setting by either the nurse or a family caregiver. After an
enteral tube is inserted, verification of tube placement by x-ray film
examination needs to occur before the patient receives the first enteral
feeding. Feeding by enteral route reduces sepsis, minimizes the
hypermetabolic response to trauma, decreases hospital mortality, and
maintains intestinal structure and function (Khalid et al., 2010).
A serious complication associated with enteral feedings is aspiration of
formula into the tracheobronchial tree. Aspiration of the enteral formula
into the lungs irritates the bronchial mucosa, resulting in decreased blood
supply to affected pulmonary tissue 9McCance et al., 2010). This lead to
necrotizing infection, pneumonia, and potential abscess formation.

NASOGASTRIC TUBE FEEDING

Definition:
Gavage (gastric) feeding is an artificial method of giving fluids and
nutrients through a tube, that has passed into the esophagus and stomach
through the nose, mouth or through the opening made on the abdominal
wall, when oral intake is inadequate or impossible (Lynn, 2015).
Purposes: (Lynn, 2015)
1. When the client is unable to take food by mouth. For example,
unconscious, semiconscious and delirious clients.
2. For a client who refuses food. E.g. client with psychosis.
3. When condition of mouth or esophagus make the swallowing
difficult or impossible. For example, fracture of the jaw, repair of
the cleft palate and cleft lips, surgery of the mouth, throat and
esophagus, paralysis of face and throat, stricture of the
esophagus.
4. When the client is too weak to swallow food or when the
conditions make it difficult to take a large amount of food orally,
e.g., acute and chronic infections, severe burns, terminal
malignancy, malnutrition and prematurity.
5. When the client is unable to retain the food, e.g. anorexia nervosa
and vomiting
Equipment:
● Prescribed tube feeding formula at room temperature
● Feeding bag or prefilled tube feeding set
● Stethoscope
● Nonsterile gloves
● Disposable pad or towel
● Asepto or Toomey syringe
● Enteral feeding pump (if ordered)
● Clamp (Hoffman or butterfly)
● IV pole
● Water for irrigation and hydration, as needed
● pH paper
● Tape measure or other measuring device
● Osterized Food
Assessment: (Lynn, 2015)
1. Assess the abdomen by inspecting for presence of distention,
auscultate for bowel sounds, and palpate the abdomen for
 firmness or tenderness. If the abdomen is distended, consider
measuring the abdominal girth at the umbilicus.
2. If the patient reports any tenderness or nausea, exhibits any
rigidity or firmness of the abdomen, and if bowel sounds are
absent, confer with primary care provider before administering the
tube feeding. Assess for patient and/or family understanding, if
appropriate, for the rationale for the tube feeding and address any
questions or concerns expressed by the patient and family
members. Consult primary care provider, if needed, for further
explanation.
Planning: (Lynn, 2015)
1. Check feeding formula containers for expiry dates. Discard expired
formulas.
2. Powdered formulas should be used within 24 hours of mixing.
3. Shake the container well to mix the solution thoroughly.
4. The formula should be warmed to room temperature before
feeding. Administering cold formulas can increase the chance of
diarrhea. Do not warm the formula in direct heat or microwave as it
may cause the solution to curdle and the chemical composition.
Also, hot formula can injure the patient.

Implementation:
Criteria Rationale

1. Perform hand hygiene and Hand hygiene and PPE prevent the
put on PPE, if indicated. spread of microorganisms. PPE is
required based on transmission
precautions. (Lynn, 2015)

2. Identify the patient by using Identifying the patient ensures the

two identifiers (patient full name and right patient receives the intervention
date of birth) and greet him/her by and helps prevent errors. (Lynn,
name 2015)

3. Explain the procedure to the Explanation facilitates patient

patient and why this intervention is cooperation.
needed. Answer any questions as
(Lynn, 2015)
needed.

4. Close the patient’s bedside Closing curtains or door provides for

curtain or door. Raise the bed to a
comfortable working position, usually
elbow height of the caregiver.
Perform key abdominal assessments
as described above.
patient privacy. Having the bed at
the proper height prevents back and
muscle strain. Due to changes in the
patient’s condition, assessment is
vital before initiating the intervention.
(Lynn, 2015)

5. Gather equipment. Check This provides for an organized

amount, concentration, type, and approach to the task. Checking
frequency of tube feeding in the ensures that correct feeding will be
patient’s medical record. Check administered. Outdated formula
formula expiration date. may be contaminated. (Lynn, 2015)
6. Assemble equipment on Organization facilitates performance
overbed table within reach.
7. Position the patient with head
of bed (HOB) elevated at least 30 to
45 degrees or as near normal
position for eating as possible.
8. Put on gloves. Unpin the tube
from the patient’s gown. Verify the
position of the marking on the tube
at the nostril. Measure length of
exposed tube and compare with the
documented length.
of the task. (Lynn, 2015)
This position minimizes possibility of
aspiration into the trachea. Patients
who are considered at high risk for
aspiration should be assisted to at
least a 45-degree position. (Lynn,
2015)
Gloves prevent contact with blood
and body fluids. The tube should be
marked with an indelible marker at
the nostril. This marking should be
assessed each time the tube is used
to ensure the tube has not become
displaced. Tube length should be
checked and compared with this
initial measurement, in conjunction
with pH measurement and visual
assessment of aspirate. An increase
in the length of the exposed tube
may indicate dislodgement. (Lynn,
2015)
9. Attach syringe to end of tube The tube is in the stomach if its
and aspirate a small amount of contents can be aspirated: pH of
stomach contents. aspirate can then be tested to
determine gastric placement. If
unable to obtain a specimen,
reposition the patient and flush the
tube with 30 mL of air. This action
may be necessary several times.
Current literature recommends that
the nurse ensures proper placement
of the NG tube by relying on multiple
methods and not on one method
alone. (Lynn, 2015)

10. Check the pH Current research demonstrates that

the use of pH is predictive of correct
placement. The pH of gastric
contents is acidic (less than 5.5). If
the patient is taking an acid-inhibiting
agent, the range may be 4.0 to 6.0.
The pH of intestinal fluid is 7.0 or
higher. The pH of respiratory fluid is
6.0 or higher. This method will not
effectively differentiate between
intestinal fluid and pleural fluid.
Testing for pH before the next
feeding in intermittent feedings is
conducted since the stomach has
been emptied of the feeding formula.
However, if the patient is receiving
continuous feedings, the pH
measurement is not as useful, since
 the formula raises the pH. (Lynn,
2015)

11. Visualize aspirated contents, Gastric fluid can be green, with

checking for color and consistency. particles, off-white, or brown if old
blood is present. Intestinal aspirate
tends to look clear or straw-colored
to a deep golden yellow color. Also,
intestinal aspirate may be
greenish-brown if stained with bile.
Respiratory or tracheobronchial fluid
is usually off-white to tan and may
be tinged with mucus. A small
amount of blood-tinged fluid may be
seen immediately after NG insertion.
(Lynn, 2015)

12. If it is not possible to aspirate The x-ray is considered the most

contents; assessments to check reliable method for identifying the
placement are inconclusive; the position of the NG tube. (Lynn, 2015)
exposed tube length has changed;
or there are any other indications
that the tube is not in place, check
placement by x-ray.
13. After multiple steps have been
taken to ensure that the feeding tube
is located in the stomach or small
intestine, aspirate all gastric contents
with the syringe and measure to
check for gastric residual—the
amount of feeding remaining in the
stomach. Return the residual based
on facility policy. Proceed with
feeding if amount of residual does
not exceed agency policy or the limit
indicated in the medical record.
14. Flush tube with 30 mL of water
for irrigation. Disconnect syringe
from tubing and cap end of tubing
while preparing the formula feeding
equipment. Remove gloves.
Checking for residual before each
feeding or every 4 to 6 hours during
a continuous feeding according to
institutional policy is implemented to
identify delayed gastric emptying.
High gastric residual volumes (200
to 250 mL or greater) can be
associated with high risk for
aspiration and aspiration-related
pneumonia (Bourgault et al., 2007;
Metheny, 2008). Some experts now
recommend that the patient’s pattern
of residual is more important than
the amount (ASPEN, 2011;
Bourgault et al.; Metheny). Feedings
should be held if residual volumes
exceed 200 mL on two successive
assessments (ASPEN). Research
findings are inconclusive on the
benefit of returning gastric volumes
to the stomach or intestine to avoid
fluid or electrolyte imbalance, which
has been accepted practice. Consult
facility policy concerning this practice
(Lynn, 2015)
Flushing tube prevents occlusion
(ASPEN, 2011; Bourgault et al.,
2007; Metheny, 2008). Capping the
tube deters the entry of
microorganisms and prevents
leakage onto the bed linens. (Lynn,
2015)
15. Put on gloves before Gloves prevent contact with blood
preparing, assembling, and handling and body fluids and deter
any part of the feeding system. transmission of contaminants to
feeding equipment and/or formula.
(Lynn, 2015)

16. Administer feeding. (Lynn, 2015)

16.1 When Using a Feeding Bag
(Open System): Labeling date and time of first use
16.1.1 Label bag and/or tubing with allows for disposal within 24 hours,
date and time. Hang bag on IV pole to deter growth of microorganisms.
and adjust to about 12 inches above Proper feeding bag height reduces
the stomach. Clamp tubing. risk of formula being introduced too
quickly.

16.1.2 Check the expiration date of

the formula. Cleanse top of feeding
container with a disinfectant before
opening it. Pour formula into feeding
bag and allow solution to run through
tubing. Close clamp.
Cleansing container top with alcohol
minimizes risk for contaminants
entering feeding bag. Formula
displaces air in tubing.

16.1.3 Attach feeding setup to Introducing formula at a slow, regular

feeding tube, open clamp, and rate allows the stomach to
regulate drip according to the accommodate to the feeding and
medical order, or allow feeding to run decreases GI distress.
in over 30 minutes.

16.1.4 Add 30 to 60 mL (1 to 2 oz.)

Water rinses the feeding from the
of water for irrigation to feeding bag
tube and helps to keep it patent
when feeding is almost completed
and allow it to run through the tube.
16.1.5 Clamp tubing immediately
after water has been instilled.
Disconnect feeding setup from
feeding tube. Clamp tube and cover
end with cap.
Clamping the tube prevents air from
entering the stomach. Capping the
tube deters entry of microorganisms
and covering end of tube protects
patient and linens from fluid leakage
from tube.
16.2 When Using a Large Syringe
(Open System):

Introducing the formula at a slow,

16.2.1 Remove plunger from 30- or regular rate allows the stomach to
60-mL syringe. accommodate to the feeding and
decreases GI distress.

16.2.2 Attach syringe to feeding

tube, pour premeasured amount of The higher the syringe is held, the
tube feeding formula into syringe, faster the formula flows.
open clamp, and allow food to enter
tube. Regulate rate, fast or slow, by
height of the syringe. Do not push
formula with syringe plunger.

16.2.3 Add 30 to 60 mL (1 to 2 oz.) Water rinses the feeding from the

of water for irrigation to syringe when tube and helps to keep it patent.
feeding is almost completed, and
allow it to run through the tube.

By holding syringe high, the formula

will not backflow out of tube and onto
16.2.4 When syringe has emptied, patient. Clamping the tube prevents
hold syringe high and disconnect air from entering the stomach.
from tube. Clamp tube and cover Capping end of tube deters entry of
end with cap. microorganisms. Covering the end
protects patient and linens from fluid
leakage from tube.
16.3 When Using an Enteral
Feeding Pump:
16.3.1 Close flow-regulator clamp
on tubing and fill feeding bag with
prescribed formula. Amount used
depends on agency policy. Place
label on container with patient’s
name, date, and time the feeding
was hung.
This prevents air from being forced
16.3.2 Hang feeding container on IV
into the stomach or intestines.
pole. Allow solution to flow through
tubing.
16.3.3 Connect to feeding pump
following manufacturer’s directions.
Set rate. Maintain the patient in the
upright position throughout the
feeding. If the patient needs to lie flat
temporarily, pause the feeding.
Resume the feeding after the
patient’s position has been changed
back to at least 30 to 45 degrees.
Closing clamp prevents formula from
moving through tubing until nurse is
ready. Labeling date and time of first
use allows for disposal within 24
hours, to deter growth of
microorganisms.
Feeding pumps vary. Some of the
newer pumps have built-in
safeguards that protect the patient
from complications. Safety features
include cassettes that prevent
free-flow of formula, automatic tube
flush, safety tips that prevent
accidental attachment to an IV
setup, and various audible and
visible alarms. Feedings are started
at full strength rather than diluted,
which was recommended previously.
A smaller volume, 10 to 40 mL, of
feeding infused per hour and
gradually increased has been shown
to be more easily tolerated by
patients.
17. Observe the patient’s response
during and after tube feeding and
assess the abdomen at least once a
shift.
Pain or nausea may indicate
stomach distention, which may lead
to vomiting. Physical signs, such as
abdominal distention and firmness or
regurgitation of tube feeding, may
indicate intolerance. (Lynn, 2015)

18. Have patient remain in upright This position minimizes risk for
position for at least 1 hour after backflow and discourages aspiration,
feeding. if any reflux or vomiting should
occur. (Lynn, 2015)

19. Remove equipment and return
patient to a position of comfort.
Remove gloves. Raise side rail and
lower bed.
Promotes patient comfort and safety.
Removing gloves properly reduces
the risk for infection transmission
and contamination of other items.
(Lynn, 2015)

20. Put on gloves. Wash and clean This prevents contamination and
equipment or replace according to deters spread of microorganisms.
agency policy. Remove gloves. Reusable systems are cleansed with
soap and water with each use and
replaced every 24 hours. Refer to
agency’s policy and manufacturer’s
guidelines for specifics on equipment
care. (Lynn, 2015)

21. Remove additional PPE, if Removing PPE properly reduces the

used. Perform hand hygiene. risk for infection transmission and
contamination of other items. Hand
hygiene prevents transmission of
microorganisms. (Lynn, 2015)
Evaluation: (Lynn, 2015)
1. Observe the patient’s response during and after tube feeding and
assess the abdomen at least once a shift.
2. Have patient remain in upright position for at least 1 hour after
feeding.
3. Remove equipment and return patient to a position of comfort.
Remove gloves. Raise side rail and lower bed.
4. Put on gloves. Wash and clean equipment or replace according to
agency policy. Remove gloves.
5. Remove additional PPE, if used. Perform hand hygiene.

Nursing Considerations: (Lynn, 2015)

1. Feeding can be provided on an intermittent or continuous basis.
Intermittent feedings are delivered at regular intervals, using
gravity for instillation or a feeding pump to administer the formula
over a set period of time.
2. Intermittent feedings might also be given as bolus, using a syringe
to instill the formula quickly in one large amount. Intermittent
feedings are the preferred method, introducing the formula over a
set period of time via gravity or pump.
3. If order calls for continuous feeding, an external feeding pump is
needed to regulate the flow of formula. Continuous feedings
permit gradual introduction of the formula into the GI tract,
promoting maximal absorption. However, there is a risk of both
reflux and aspiration with this method.
4. Feeding intolerance is likely to occur with smaller volumes.
hanging smaller amounts of feeding also reduces the risk for
bacteria growth and contamination of feeding at room temperature
(when using open system).
M1 : Lesson 3 : Gastric Lavage by: Dr.J.Delen

Gastric lavage is the aspiration of the stomach contents and washing out of the stomach
by means of a gastric tube. (Lynn, 2015).
It is contraindicated in patients with an unprotected airway, with ingestions of
substances that carry a high risk of aspiration (e.g., hydrocarbons) or that are corrosive,
with ingestion of sharp objects, with an underlying pathologic condition that increases
the risk of hemorrhage or gastric perforation, and in patients that are post-surgical or
have medical conditions that may be compromised by the lavage procedure.

The Current Role of Gastric Lavage in Treating Acute Poisonings?

Gastric lavage Links to an external site. must be performed soon after ingestion Links to
an external site. to be at all effective in removing drugs from the stomach. For this
reason, many clinicians do not lavage patients who have overdosed if more than 1 hour
has elapsed since ingestion. Gastric lavage may result in major morbidity (e.g.,
esophageal perforation). Gastric lavage can be accomplished without prior tracheal
intubation Links to an external site. in most patients, but it is advised that airway
equipment Links to an external site. including suction be immediately available at the
bedside. Whenever gastric lavage is performed, a large-bore (36 or 40 French tube in
adults) should be placed through the mouth, and proper location of the tube in the
stomach should be verified clinically or radiographically.

PURPOSES: (Lynn, 2015)

1. To remove unabsorbed poison after poison ingestion
2. To diagnose gastric hemorrhage and for the arrest of
hemorrhage
3. To cleanse the stomach before endoscopic procedures
4. To remove liquid or small particles of material from the
stomach
EQUIPMENT:
■ NGT connected to continuous or intermittent suction
■ Stethoscope
■ Water or normal saline solution for irrigation (based on
facility policy)
■ Non-sterile gloves
■ Additional PPE, as indicated
■ Irrigation set (or a 60-mL catheter-tip syringe and cup for
irrigating solution)
■ Clamp
 ■ Disposable waterproof pad or bath towel
■ Emesis basin
■ Tape measure (as needed for measurement of abdominal
girth)
■ pH paper and measurement scale ( optional)

ASSESSMENT: (Lynn, 2015)

1. Assess abdomen by inspecting for presence of
distention, auscultating for bowel sounds, and palpating
the abdomen for firmness or tenderness. If the abdomen
is distended, consider measuring the abdominal girth at
the umbilicus. If the patient reports any tenderness or
nausea, or exhibits any rigidity or firmness of the
abdomen, confer with the primary care provider.
2. If the NGT is attached to suction, assess suction to
ensure that it is running at the prescribed pressure.
3. Inspect drainage from NGT, including color, consistency,
and amount.
IMPLEMENTATION:

Criteria Rationale

1. Perform hand hygiene and Hand hygiene and PPE prevent the
put on PPE, if indicated. spread of microorganisms. PPE is
required based on transmission
precautions. (Lynn, 2015)

2. Identify the patient using Identifying the patient ensures the right
two identifiers. patient receives the intervention and
helps prevent errors. (Lynn, 2015)
3. Explain the procedure to the Explanation facilitates patient
patient and why this intervention cooperation. (Lynn, 2015)
is needed. Answer any questions,
as needed.

4. Pull the patient’s bedside Provide for privacy. Appropriate

curtain. Raise bed to a working height facilitates comfort and
comfortable working position, proper body mechanics for the nurse.
usually elbow height of the This position minimizes risk for
caregiver. Assist patient to 30- to aspiration. Preparing the irrigation
45-degree position, unless this is provides for an organized approach to
contraindicated. Pour the the task. (Lynn, 2015)
irrigating solution into container.

5. Gather equipment. Verify Assembling equipment provides for an

the medical order or facility policy organized approach to the task.
and procedure regarding Verification ensures the patient
frequency of irrigation, solution receives the correct intervention.
type, and amount of irrigant. Facility policy dictates safe interval for
Check expiration dates on reuse of equipment. (Lynn, 2015)
irrigating solution and irrigation
set.

6. Assemble equipment on Organization facilitates performance of

overbed table within reach. the task. (Lynn, 2015)

7. Put on gloves. Place Gloves prevent contact with body

waterproof pad on the patient’s fluids. Waterproof pad protects patient’s
chest, under the nasogastric tube clothing and bed linens from accidental
and suction tubing. leakage of gastric fluid. (Lynn, 2015)
8. Check placement of NG Checking placement before the
tube. Auscultation of air instillation of fluid is necessary to
insufflated through the feeding prevent accidental instillation into the
tube ('whoosh' test). respiratory tract if the tube has become
dislodged. (Lynn, 2015)

8.1 Attach syringe to end of tube The tube is in the stomach if its
and aspirate a small amount of contents can be aspirated: pH of
stomach contents. aspirate can then be tested to
determine gastric placement. If unable
to obtain a specimen, reposition the
patient and flush the tube with 30 mL of
air. This action may be necessary
several times. Current literature
recommends that the nurse ensures
proper placement of the NG tube by
relying on multiple methods and not on
one method alone. (Lynn, 2015)
8.2 Check the pH Current research demonstrates that the
use of pH is predictive of correct
placement. The pH of gastric contents
is acidic (less than 5.5). If the patient is
taking an acid-inhibiting agent, the
range may be 4.0 to 6.0. The pH of
intestinal fluid is 7.0 or higher. The pH
of respiratory fluid is 6.0 or higher. This
method will not effectively differentiate
between intestinal fluid and pleural
fluid. Testing for pH before the next
feeding in intermittent feedings is
conducted since the stomach has been
emptied of the feeding formula.
However, if the patient is receiving
continuous feedings, the pH
measurement is not as useful, since
the formula raises the pH. (Lynn, 2015)
8.3 Visualize aspirated contents, Gastric fluid can be green, with
checking for color and particles, off-white, or brown if old
consistency. blood is present. Intestinal aspirate
tends to look clear or straw-colored to a
deep golden yellow color. Also,
intestinal aspirate may be
greenish-brown if stained with bile.
Respiratory or tracheobronchial fluid is
usually off-white to tan and may be
tinged with mucus. A small amount of
blood-tinged fluid may be seen
immediately after NG insertion. (Lynn,
2015)

8.4 If it is not possible to aspirate The x-ray is considered the most

contents; assessments to check reliable method for identifying the
placement are inconclusive; the position of the NG tube. (Lynn, 2015)
exposed tube length has
changed; or there are any other
indications that the tube is not in
place, check placement by x-ray.

9. Draw up 30 mL of irrigation This delivers measured amount of

solution (or amount indicated in irrigant through the tube. Saline
the order or policy) into syringe. solution (isotonic) may be used to
compensate for electrolytes lost
through nasogastric drainage. (Lynn,
2015)
10. Place tip of syringe in tube. Gentle insertion of saline solution (or
Hold syringe upright and gently gravity insertion) is less traumatic to
insert the irrigant (or allow gastric mucosa. (Lynn, 2015)
solution to flow in by gravity if
facility policy or medical order
indicates). Do not force solution
into tube.

11. If unable to irrigate tube, Tube may be positioned against gastric

reposition patient and attempt
irrigation again. Inject 10 to 20 mL
of air and aspirate again. If
repeated attempts to irrigate tube
fail, consult with physician .
mucosa, making it difficult to irrigate.
Injection of air may reposition end of
tube. (Lynn, 2015)

12. After irrigant has been Return flow may be collected in an

instilled, hold end of NGT over
irrigation tray or emesis basin.
Observe for return flow of NG
drainage into available container.
irrigating tray or other available
container and measured. This amount
will need to be subtracted from the
irrigant to record the true NG drainage.
A second method involves subtracting
the total irrigant from the shift from the
total NG drainage emptied over the
entire shift, to find the true NG
drainage. Check agency policy for
guidelines. (Lynn, 2015)

13. Remove gloves. Lower the Lowering bed and assisting the patient
bed and raise side rails, as to a comfortable position promote
necessary. Assist the patient to a safety and comfort. (Lynn, 2015)
position of comfort. Perform hand
hygiene.
14. Put on gloves. Measure
returned solution, if collected
outside of suction apparatus.
Rinse equipment if it will be
reused. Label with the date,
patient’s name, room number, and
purpose (for NGT/ irrigation).
Gloves prevent contact with blood and
body fluids. Irrigant placed in tube is
considered intake; solution returned is
recorded as output. Record on the
intake and output record. Rinsing
promotes cleanliness, infection control,
and prepares equipment for next
irrigation. (Lynn, 2015)

15. Remove gloves and Removing PPE properly reduces the

additional PPE, if used. Perform risk for infection transmission and
hand hygiene. contamination of other items. Hand
hygiene prevents transmission of
microorganisms. (Lynn, 2015)

EVALUATION: (Lynn, 2015)

1. Patient demonstrates a patent and functioning NGT.
2. Patient reports no distress with the irrigation.
3. Patient remains free of any signs and symptoms of injury or
trauma.
NURSING CONSIDERATION:
1. Document assessment of the patient’s abdomen. Record if the
patient’s NGT is clamped or connected to suction, including the
type of suction.
2. Document the color and consistency of the NG drainage.
3. Record the solution type and amount used to irrigate the NGT, as
well as ease of irrigation or any difficulty related to the procedure.
4. Record the amount of returned irrigant, if collected outside suction
apparatus. Alternately, record irrigant amount so it can be
subtracted from total NG drainage amount at the end of the shift.
Record the patient’s response to the procedure and any pertinent
teaching points that were reviewed, such as instructions for the
patient to contact the nurse for any feelings of nausea, bloating, or
abdominal pain.
 M1 : Lesson 4 : Blood Transfusion

blood transfusion is a safe, common procedure in which blood is

given to you through an intravenous (IV) line in one of your blood vessels.
Blood transfusions are done to replace blood lost during surgery or due to a
serious injury. A transfusion also may be done if your body can't make
blood properly because of an illness. During a blood transfusion, a small
needle is used to insert an IV line into one of your blood vessels. Through
this line, you receive healthy blood. The procedure usually takes 1 to 4
hours, depending on how much blood you need.

Definition:
A blood transfusion is the infusion of whole blood or a blood component
such as plasma, red blood cells, cryoprecipitate, or platelets into the
patient’s venous circulation.

Purposes:
A blood product transfusion is given when a patient’s red blood cells,
platelets, or coagulation factors decrease to levels that compromise a
patient’s health.

Equipment:
● Blood product
● Blood administration set (tubing with in-line filter, or add-on filter,
and Y for saline administration)
● 9% normal saline for IV infusion
● IV pole
● Venous access; if peripheral site, preferably initiated with a
20-gauge catheter or larger
● Alcohol or other disinfectant wipes
● Clean gloves
● Additional PPE, as indicated
● Tape (hypoallergenic)
 ● Second registered nurse (or other licensed practitioner; e.g., a
physician) to verify blood product and patient information

Assessment:
1. Obtain a baseline assessment of the patient, including vital signs,
heart and lung sounds, and urinary output.
2. Review the most recent laboratory values, in particular, the
complete blood count (CBC).
3. Ask the patient about any previous transfusions, including the
number he or she has had and any reactions experienced during a
transfusion.
4. Inspect the IV insertion site, noting the gauge of the IV catheter.
Blood or blood components may be transfused via a 14- to
24-gauge peripheral venous access device. Transfusion for
neonate or pediatric patients is usually given using a 22- to
24-gauge peripheral venous access device (INS, 2011).

Implementation:

Criteria Rationale

1. Verify the medical order for Verification of order ensures the

transfusion of a blood product. right patient receives the correct
Verify the completion of informed intervention. Premedication is
consent documentation in the sometimes administered to
medical record. Verify any decrease the risk for allergic and
medical order for pre-transfusion febrile reactions for patients who
medication. If ordered, administer have received multiple previous
medication at least 30 minutes transfusions.
before initiating transfusion.
2. Gather all equipment. Preparation promotes efficient time
management and an organized
approach to the task.

3. Perform hand hygiene and Hand hygiene and PPE prevent the
put on PPE, if indicated. spread of microorganisms. PPE is
required based on transmission
precautions.

4. Verify patient using 2 Identifying the patient ensures the

identifiers —such as a patient's right patient receives the
full name, date of birth and/or intervention and helps prevent
medical identification (ID) errors.
number—be used for every
patient encounter.

5. Close the curtains around This ensures the patient’s privacy.

the bed and close the door to the Explanation relieves anxiety and
room, if possible. Explain what facilitates cooperation. Previous
you are going to do and why you reactions may increase the risk for
are going to do it to the patient. reaction to this transfusion. Any
Ask the patient about previous reaction to the transfusion
experience with a transfusion and necessitates stopping the
any reactions. Advise the patient transfusion immediately and
to report any chills, itching, rash, evaluating the situation.
or unusual symptoms.
6. Prime blood administration Normal saline is the solution of
set with the normal saline IV fluid. choice for blood product
administration. Solutions with
dextrose may lead to clumping of
red blood cells and hemolysis.

7. Put on gloves. If patient Gloves prevent contact with blood

does not have a venous access
in place, initiate peripheral
venous access. Connect the
administration set to the venous
access device via the extension
tubing. Infuse the normal saline
per facility policy.
and body fluids. Infusion of fluid via
venous access maintains patency
until the blood product is
administered. Start an IV before
obtaining the blood product in case
the initiation takes longer than 30
minutes. Blood must be stored at a
carefully controlled temperature
(4°C) and transfusion must begin
within 30 minutes of release from
the blood bank.
8. Obtain blood product from
blood bank according to agency
policy. Scan for bar codes on
blood products if required.
Bar codes on blood products are
currently being implemented in
some agencies to identify, track, and
assign data to transfusions as an
additional safety measure.
9. Two nurses compare and Most states/agencies require two
validate the following information registered nurses to verify the
with the medical record, patient following information: unit numbers
identification band, and the label match; ABO group and Rh type are
of the blood product: the same; expiration date (after 35
days, red blood cells begin to
9.1 Medical order for transfusion
deteriorate). Blood is never
of blood product
administered to a patient without an
9.2 Informed consent identification band. If clots or signs
of contamination (clumping, gas
9.3 Patient identification
bubbles) are present, return blood to
number
the blood bank.
9.4 Patient name
9.5 Blood group and type
9.6 Expiration date
9.7 Inspection of blood product
for clots, clumping, gas bubbles

10. Obtain baseline set of vital Any change in vital signs during the
signs before beginning the transfusion may indicate a reaction.
transfusion.
11. Put on gloves. If using an
electronic infusion device, put the
device on “hold.” Close the roller
clamp closest to the drip chamber
on the saline side of the
administration set. Close the
roller clamp on the administration
set below the infusion device.
Alternately, if infusing via gravity,
close the roller clamp on the
administration set.
Gloves prevent contact with blood
and body fluids. Stopping the
infusion prevents blood from
infusing to the patient before
completion of preparations. Closing
the clamp to saline allows blood
product to be infused via electronic
infusion device.

12. Close the roller clamp Filling the drip chamber prevents air
closest to the drip chamber on from entering the administration set.
the blood product side of the The filter in the blood administration
administration set. Remove the set removes particulate material
protective cap from the access formed during storage of blood. If
port on the blood container. the administration set becomes
Remove the cap from the access contaminated, the entire set would
spike on the administration set. have to be discarded and replaced.
Using a pushing and twisting
motion, insert the spike into the
access port on the blood
container, taking care not to
contaminate the spike. Hang the
blood container on the IV pole.
Open the roller clamp on the
blood side of the administration
set. Squeeze drip chamber until
the in-line filter is saturated.
Remove gloves.
13. Start administration slowly Transfusion reactions typically occur
(no more than 25 to 50 mL for the during this period, and a slow rate
first 15 minutes). Stay with the will minimize the volume of red
patient for the first 5 to 15 blood cells infused.
minutes of transfusion. Open the
Verifying the rate and device
roller clamp on the administration
settings ensures the patient
set below the infusion device. Set
receives the correct volume of
the flow rate and begin the
solution. If the catheter or needle
transfusion. Alternately, start the
slips out of the vein, the blood will
flow of solution by releasing the
accumulate (infiltrate) into the
clamp on the tubing and counting
surrounding tissue.
the drops. Adjust until the correct
drop rate is achieved. Assess the
flow of the blood and function of
the infusion device. Inspect the
insertion site for signs of
infiltration.

14. Observe the patient for These signs and symptoms may be
flushing, dyspnea, itching, hives an early indication of a transfusion
or rash, or any unusual reaction.
comments.
15. After the observation period
(5 to 15 minutes) increase the
infusion rate to the calculated rate
to complete the infusion within
the prescribed time frame, no
more than 4 hours.
If no adverse effects occurred
during this time, the infusion rate is
increased. If complications occur,
they can be observed and the
transfusion can be stopped
immediately. Verifying the rate and
device settings ensures the patient
receives the correct volume of
solution. Transfusion must be
completed within 4 hours due to
potential for bacterial growth in
blood product at room temperature.

16. Reassess vital signs after Vital signs must be assessed as

15 minutes. Obtain vital signs part of monitoring for possible
thereafter according to facility adverse reaction. Facility policy and
policy and nursing assessment. nursing judgment will dictate
frequency.

17. Maintain the prescribed flow Rate must be carefully controlled,

rate as ordered or as deemed and the patient’s reaction must be
appropriate based on the monitored frequently.
patient’s overall condition,
keeping in mind the outer limits
for safe administration. Ongoing
monitoring is crucial throughout
the entire duration of the blood
transfusion for early identification
of any adverse reactions.
18. During transfusion, assess If a transfusion reaction is
frequently for transfusion suspected, the blood must be
reaction. Stop blood transfusion stopped. Do not infuse the normal
if you suspect a reaction. saline through the blood tubing
Quickly replace the blood tubing because you would be allowing
with a new administration set more of the blood into the patient’s
primed with normal saline for IV body, which could complicate a
infusion. Initiate an infusion of reaction. Besides a serious
normal saline for IV at an open life-threatening blood transfusion
rate, usually 40 mL/hour. Obtain reaction, the potential for
vital signs. Notify primary care fluid–volume overload exists in older
provider and blood bank. patients and patients with
decreased cardiac function.

19. When transfusion is Saline prevents hemolysis of red

complete, close roller clamp on blood cells and clears remainder of
blood side of the administration blood in IV line.
set and open the roller clamp on
Proper disposal of equipment
the normal saline side of the
reduces transmission of
administration set. Initiate
microorganisms and potential
infusion of normal saline. When
contact with blood and body fluids.
all of blood has infused into the
patient, clamp the administration
set. Obtain vital signs. Put on
gloves. Cap access site or
resume previous IV infusion.
Dispose of blood- transfusion
equipment or return to blood
bank, according to facility policy.
20. Remove equipment. Ensure
patient’s comfort. Remove gloves.
Lower bed, if not in lowest
position.
Promotes patient comfort and
safety. Removing gloves properly
reduces the risk for infection
transmission and contamination of
other items.

21. Remove additional PPE, if Removing PPE properly reduces the

used. Perform hand hygiene. risk for infection transmission and
contamination of other items. Hand
hygiene prevents transmission of
microorganisms.

22. Monitor and assess the Ensures early detection and prompt
patient for one hour after the intervention. Delayed transfusion
transfusion for signs and reactions can occur one to several
symptoms of delayed transfusion days after transfusion.
reaction. Provide patient
education about signs and
symptoms of delayed transfusion
reactions.

23. Complete all documentation Documentation may include:

as required by agency.
● Transfusion record form
● All vital signs and reactions
● Any significant findings,
initiation and termination of
transfusion
● Record of transfusion on
the in-and-out sheet
Evaluation
1. Patient receives the blood transfusion without any evidence of a
transfusion reaction or complication.
2. Patient exhibits signs and symptoms of fluid balance, improved
cardiac output, and enhanced peripheral tissue perfusion.
3. The venous access device remains patent.

Documentation:
Document that the patient received the blood transfusion; include the type
of blood product. Record the patient’s condition throughout the transfusion,
including pertinent data, such as vital signs, lung sounds, and the
subjective response of the patient to the transfusion. Document any
complications or reactions and whether the patient had received the
transfusion without any complications or reactions. Document the A As
Assessment of the IV site, and any other fluids infused during the
procedure. Document transfusion volume and other IV fluid intake on the
patient’s intake and output record.
M1 : Lesson 6 : Inserting a Straight Catheter or Indwelling Catheter to a Male and
Female Patient

INTRODUCTION:
An indwelling catheter may be inserted for an acute episode of urinary
retention or when other strategies to manage retention are ineffective. A
catheter is chosen that minimizes urethral irritation and maximizes drainage
from the bladder.
Definition: Catheterization of the bladder involves introduction of a
rubber or silicone tube through the urethra and into the bladder. It is used
for the following purposes: immediate relief of bladder distention,
management of an incompetent bladder, obtaining a sterile urine specimen,
and assessment of residual urine after voiding.

Figure A: Placement of Urinary Catheter to a Male and Female

Patient
PLANNING:
● Prepare the materials needed.
• Sterile gloves
• Sterile drapes
• Lubricant KY jelly
• Antiseptic cleansing solution
• Cotton balls
• Forceps
● Pre filled 10 cc syringe with normal saline to inflate balloon of
indwelling catheter
• Catheter of correct size and type of procedure (i.e., intermittent or
indwelling)
• Flashlight or gooseneck lamp
• Waterproof absorbent pad
• Trash receptacle
• Hospicare bag or urinary bag
 • Micropore tape 2-3inches wide
• Specimen container (as needed)

Figure B: Different types of Urinary Catheters and Parts

Folye's is classified according to:

-The number of lumens:
● 1 way - for aspiration and drain.
● 2 way > one for the balloon inflation and the other for drain or
aspiration.
● 3 way - one for irrigation (infusion), one for the balloon inflation, and
the third for drain. >> see the pic.

The material it was made of:

○ Rubber made
○ irritative and immunogenic
○ not used for longer periods of time, may induce fibrotic
changes. (not more than a week!], (remember, foley's induced
strictures]
 ○ Silicone coated rubber
○ less immunogenic, used for longer time than the rubber alone
○ Silicone made
○ used for longer periods reaching up to one month!.

ASSESSMENT:
Assess status of patient:
1. When patient last voided
2. Level of awareness or developmental stage
3. Mobility and physical limitations of patient
4. Patient’s sex and age
5. Distended bladder
6. Any pathological conditions and allergies

IMPLEMENTATION:

CRITERIA RATIONALE

Washing your hands and taking

1.Wash your hands. Wear gloves and follow
standard precautions prevent the
standard precautions if contact with blood or
spread of infections. (Carter, 2012)
body fluids cannot be avoided.

2. Identify the person using two identifiers Identifying the person ensures that the
(age and date of birth), and greet him or her procedure is being done on the correct
by name. patient or resident. Greeting the person
by name is being courteous. (Carter,
2012)
3. Explain the procedure and encourage the Helps the person know what to expect
person to participate as appropriate. and helps him understand how he can
help. (Carter, 2012)
4. Provide privacy by showing any visitor Asking visitors to leave the room, and
where they should wait, if necessary, until you closing the door and curtain protect the
have completed the procedure. Close the person’s right to privacy. (Carter, 2012)
door and the curtain.
5. Facing patient, stand on left side of bed if
right handed. Clear bedside table and arrange
equipment.
6. Place side rail on opposite side of the bed. Successful catheter insertion requires
nurse to assume comfortable position
with all equipment easily accessible.
(Perry, 2013)
7. Place waterproof pad under patient.
8. Position client. Assist to supine position
with thighs slightly abducted

9. Drape patient. Drape upper trunk with bath This promotes client’s safety. (Perry,
blanket and cover lower extremities with bed 2013)
sheets exposing only genitalia.
10. When inserting indwelling catheter, open Prevents soiling of bed linen. (Perry,
package containing drainage system. Place 2013)
drainage bag over edge of bottom bed frame.
Bring drainage tube up between side rail and
mattress.
11. Open catheterization kit according to This position relaxes abdominal and
directions, using aseptic technique. Place perineal muscles. (Smith, 2011)
waste receptacle in accessible place.
12. Don sterile gloves. This avoids unnecessary exposure of
body parts and maintains client’s
comfort. (Perry, 2013)

13. Organize supplies on sterile field: This facilitates connection of the

catheter to the drainage system and
13.1 Open sterile package containing
provided for easy access. (Taylor, 2014)
catheter; pour sterile package of antiseptic
solution in correct compartment containing
sterile cotton balls

13.2 Lubricate tip of catheter, remove

specimen container and pre-filled syringe
from collection compartment of tray and set
them aside of sterile field.
14. Nurses may want to ensure that inflatable Placement of equipment near the work
balloon of indwelling catheter is intact by site increases efficiency. Sterile
inserting syringe tip through valve of intake technique protects the patient and
lumen and injecting sterile fluid until balloon prevents the spread of microorganisms.
inflates. Then aspirate all fluid out of inflated (Taylor, 2014)
lumen.
15. Apply sterile drape. Apply drape over This allows nurse to handle sterile
thighs just below penis. Pick up fenestrated supplies without contamination. (Perry,
sterile drape, allow it to unfold, and drape it 2013)
over penis with fenestrated slit resting over
penis.
16.Place sterile tray and contents on sterile
drape between thighs.

17.Determine that catheter tip is properly It is necessary to open all supplies and
lubricated. Male 12.5-17.5 cm prepare for the procedure while both
(5-7 inches). hands are sterile. (Taylor, 2014)

Cleanse urethral meatus. This eases insertion of catheter through

urethral canal. (Perry, 2013)
18.1 If patient is not circumcised, retract
foreskin with nondominant hand. Grasp penis
at shaft just below glans. Retract urethral
meatus between thumb and forefinger.
Maintain nondominant hand in this position
throughout procedure.

18.2 With dominant hand, pick up cotton ball

with forceps and clean penis. Move it in
circular motion from meatus down to base of
glans. Repeat cleansing two more time using
clean cotton balls each time.

19. Pickup catheter with gloved dominant
hand 7.5-10 cm (3-4 inches) from catheter tip.
Hold end of catheter loosely coiled in palm of
dominant hand. Place distal end of catheter in
urine tray specimen.
This checks integrity of balloon. Do not
use the catheter if the balloon does not
inflate or leaks. Checking the balloon in
this way may stretch the balloon and
cause increased trauma on insertion.
(Perry, 2013)
 20. Insert catheter The drape expands the sterile field and
protects against contamination. Use of
20.1 Lift penis to position perpendicular to
fenestrated drape may limit
client’s body and apply slight traction.
visualization and is considered optional
by some practitioners. (Taylor, 2014)
20.2 Ask patient to bear down as if to void This provides easy access to supplies
and slowly insert catheter through meatus. during catheter insertion. (Perry, 2013)

20.3 Advance catheter 17.5-22.5 cm (7-9 This eases insertion of catheter through
inches) in adult and 5- 7.5 cm (2-3 inches) in urethral canal. (Perry, 2013)
young child or until urine flows out catheter’s
end. If resistance is felt, withdraw catheter
and do not force it through urethra. When
urine appears, advance catheter another 5 cm
(2 inches).
20.4 Lower penis and hold catheter securely The hand touching the penis becomes
in nondominant hand. Place end of catheter in contaminated. Cleansing the area
urine tray receptacle. around the meatus and under the
foreskin in the uncircumcised male
patient helps prevent infection. (Taylor,
2014)

For Female Patient Moving from the meatus toward the

base of the penis prevents bringing
21. Cleanse urethral meatus
organisms to meatus. (Taylor, 2014)
21.1 With nondominant hand, carefully retract
the labia to fully exposed urethra meatus.
Maintain position of nondominant hand
throughout the procedure

21.2 With dominant hand, pick up cotton ball

with forceps and clean perineal by wiping
from front to back or from clitoris towards
anus. Use new cotton ball for each wipe along
near labial fold, directly over meatus and
along labial fold.
22. Pick up catheter with gloved dominant Hold catheter near tip because it allows
hand 7.5-10 cm (3-4 inches) from catheter tip. easier manipulation during insertion into
Hold the end of catheter loosely coiled in the urethral meatus and prevents distal end
palm of the dominant hand. Place distal end from striking contaminated surface.
of catheter in urine tray specimen.
23. Insert catheter
This movement straightens the urethra
23.1 Ask patient to bear down as if
for easier insertion of catheter. (Smith,
to void and slowly insert catheter
2011) Bearing down eases the passage
through meatus.
of the catheter through the urethra.
(Taylor, 2014)

23.2 Advance catheter 5-7.5 cm (2-3 inches)
in adult and 2.5 cm (1 inch) in young child or
until urine flows out catheter’s end. When
urine appears, advance catheter up to
another 5cm (2 inches). Do not force against
resistance.
Deep breaths or slight twisting of the
catheter bay ease the catheter past
resistance at sphincters. Advancing an
indwelling catheter facilitates inflation of
the balloon without damaging the
urethra. (Taylor, 2014)

23.3 Release labia and hold catheter securely This allows sterile specimen to be
with nondominant hand. obtained for culture analysis. (Perry,
2013)
24. Collect urine specimen as needed: fill This allows sterile specimen to be
specimen cup to desired level (20-30 mL) by obtained for culture analysis. (Perry,
holding the end of catheter with the dominant 2013)
hand over the cup. With dominant hand, pinch
catheter to stop urine flow temporarily.
Release catheter to allow remaining urine in
bladder to drain in the collection tray. Cover
the specimen cup and set aside for labeling.
25. Allow bladder to empty full (750-1000 mL) Retained urine may serve as reservoir
unless institution policy restricts maximal for growth of microorganisms. (Perry,
volume of urine to drain with each 2013)
catheterization.
25.1 For straight, single use catheter, pinch This causes less discomfort to the
catheter and remove slowly but smoothly patient. (Taylor, 2014)
when urine ceases to flow.
25.2 For indwelling catheter, inflate balloon of The balloon anchors the catheter in
the indwelling catheter. place in the bladder. Sterile water is
used to inflate the balloon as a
precaution in case the balloon ruptures.
(Taylor, 2014)
25.3 While holding catheter with your thumb
and little finger of the nondominant hand at
meatus, take end of catheter and place it
between first two fingers of nondominant
hand.
25.4 With free dominant hand, attach syringe
to injection port at the end of catheter.

25.5 Slowly inject total amount of solution. If

client complains of sudden pain, aspirate back
solution and advance catheter further.
25.6 After inflating the balloon fully, release Improper inflation can cause patient’s
catheter with the nondominant hand and pull it discomfort and malpositioning of
gently if there is resistance. catheter. (Taylor, 2014)
26. Attach end of catheter to the collecting To facilitate drainage of urine by gravity.
tube of drainage system. Drainage bag must Raising bag on side rail will cause
be below level of bladder. backflow of urine into bladder. (Perry,
2013)
27. Tape catheter tubing on top of thigh or Closed drainage system minimizes the
lower abdomen. Allow slack in catheter so risk of organisms being introduced into
movement does not create tension on the bladder. (Taylor, 2014)
catheter.
28. Be sure that there are no obstructions or Anchoring catheter to lower abdomen
kinks in tubing. Inspect all that may lead to reduces pressure on urethra at junction
obstruction in the flow of the urine from the of penis and scrotum, thus reducing the
catheter to the drainage bag. possibility of tissue injury at this area.
(Perry, 2013)
29. Remove gloves and dispose of
equipment, drapes and urine in proper
receptacle.
30.Assist client to comfortable position. Wash
dry perineal area as needed.
31.Instruct patient on ways to lie in bed with This facilitates drainage of urine and
catheter. Side lying facing drainage system prevents the backflow of urine. (Taylor,
with catheter and tubing draped over thigh 2014)
and side lying facing away from the system,
catheter and tubing extended between legs.
32. Caution patient against pulling the It maintains comfort and security.
catheter. (Perry, 2013)
33. Wash hands thoroughly. It reduces transmission of
microorganisms. (Perry, 2013)

EVALUATION:
1. Palpate bladder and ask if patient remains uncomfortable.
2. Determine if there is no urine leaking from catheter or tubing connections.
3. Record time of procedure, characteristics and amount of urine in drainage
system.
4. Observe for signs of obstruction (e.g., decreased urine in collection bag,
voiding around the catheter, abdominal discomfort and bladder distention).

Nursing Considerations:
1. Maintain catheter patency. Place drainage tubing properly to avoid
kinking or pinching.
2. Irrigate catheter as necessary.
3. Ensure comfort and safety. Relieve bladder spasms by administering
belladonna suppositories (if ordered). Ensure adequate fluid intake and
provide perineal care.
4. Prevent infection by maintaining a closed drainage system and prevent
backflow of urine by keeping drainage system below level of bladder.
5. Empty collection bag at least 8 hours.
6. Promote acidification of the urine with acid ash diet and ascorbic acid.
7. Change catheter or drainage system only when necessary.
8. For children or adolescents: they may be tempted to pull or tug on the
catheter. Children and adolescents may be more active in and out of
bed, so the catheter must be taped securely to the thigh to prevent it
from being pulled out.
 M1: Lesson 7 : Collecting a sterile specimen from an Indwelling Catheter

Urine specimens are collected by a variety of methods based on the age and medical
condition of the client. In all types of urine collection, it is the prime responsibility of the
nurse to maintain strict aseptic technique so as not to contaminate the urine specimen.
Non invasive methods for specimen collection include the clean-catch methods for
adults and a bagged collection from an infant or child. These methods have a greater
probability of specimen contamination. If the client has an indwelling transurethral
catheter (foley catheter), a specimen can be collected from the sampling port but not
from the urine collection bag because contamination is very possible to occur.

Definition: A urine specimen is collected from an indwelling catheter when

a urinary tract infection is suspected and a sterile urine specimen is needed
for a urine culture and sensitivity test. The specimen must be obtained
aseptically, so as not contaminate the closed drainage system or
contaminate specimen. A registered nurse (RN) or licensed practical nurse
(LPN) may collect the specimen from the indwelling catheter
Assessment:
1. Determine how long catheter has been in place.
2. Observe any discharge or encrustation around urethral meatus.
Assess for complaints of pain or discomfort.
Planning:
Prepare the materials needed.
1. 3 mL syringe with 1inch needle (21-25 gauge) for culture or 20 mL
syringe with 1inch needle (21-25 gauge) for routine urinalysis
2. Metal clamp or rubber band
3. Alcohol, povidone-iodine, or other disinfectant swab
4. Specimen container: non-sterile for routine urinalysis, sterile for
culture
5. Specimen label
6. Completed laboratory requisition with patient’s name, date and
time of collection
7. Clean, disposable gloves
Implementation:
Criteria Rationale

1. Wash your hands. Wear gloves and Washing your hands and taking standard
follow standard precautions if contact precautions prevent the spread of infections.
with blood or body fluids cannot be (Carter, 2012)
avoided.

2. Identify the person, and greet him or Identifying the person ensures that the
her by name. procedure is being done on the correct
patient or resident. Greeting the person by
name is being courteous. (Carter, 2012)

3. Explain the procedure and encourage Helps the person know what to expect and
the person to participate as appropriate. helps him understand how he can help.
(Carter, 2012)

4. Provide privacy by showing any visitor Asking visitors to leave the room, and
where they should wait, if necessary, until closing the door and curtain protects the
you have completed the procedure. person’s right to privacy. (Carter, 2012)
Close the door and the curtain.

5. Clamp the drainage tubing with clamp This ensures that the urine specimen is
or rubber band for 30 minutes. adequate. (Smith, 2011)

6. Return to room and inform patient that This promotes cooperation. (Perry, 2013)
the procedure to collect specimen from
the catheter will begin.

7. Wash hands again or an alcohol and Handwashing deters the spread of

don gloves. microorganisms. Gloves protects the nurse
from exposure to microorganisms in the
urine. (Taylor, 2014)

8. Cleanse entry port for needle with This prevents the transmission of
disinfectant swab. microorganisms. (Taylor, 2014)
9. Insert the needle at 30-degree angle This facilitates sealing of the rubber in the
just above where the catheter is attached port following removal of the needle. This
to drainage tube or built-in sampling port. allows urine to accumulate in the tubing.
(Smith, 2011)

10. Draw urine into 30 mL syringe for

culture or draw urine into 20 mL syringe
for urine urinalysis.

11. Transfer urine from syringe into

specimen container.

12. Place lid tightly on container.

13. Unclamp catheter and allow urine to This facilitates drainage of urine and
flow into drainage bag. prevents the backflow of urine. (Taylor,
2014)

14. Secure attached properly completed

identification label and laboratory
requisition specimen.

15. Send specimen to laboratory

immediately or place in specimen
refrigerator.

16. Dispose of soiled supplies and wash This reduces transmission of

hands. microorganisms. (Perry, 2013)

Evaluation:

1. Check laboratory report for results.

2. Record collection of specimen on nurse’s notes; note time and date,
appearance and odor.
 M2 : Introduction

Oxygen is a colorless, odorless, tasteless gas that is utilized by the body for
respiration. Oxygen has played a major role in respiratory care. Oxygen therapy
is useful in treating hypoxemia but is often thought of as a benign therapy. After
many years of study, we have learned a great deal of the benefits and potential
risk of this powerful drug.

The administration of oxygen to children requires the selection of an oxygen

delivery system that suits the child’s age, size, needs, clinical condition, and
therapeutic goals. Oxygen delivery systems are categorized as low-flow (variable
performance) systems or high-flow (fixed performance) systems. With low-flow
systems, 100% oxygen mixes with room air during inspiration, and room air is
entrained, making the percentage of delivered oxygen variable. Highflow devices
provide such a high flow of premixed gas that the child is not required to inhale
room air. Supplemental oxygen therapy is often recommended for children when
peripheral oxygen saturation is consistently below 94%.

Every year, over 5.9 million children die, mostly from preventable or easily
treatable diseases, and more than 95% of those deaths occur in developing
countries. Pneumonia is the leading cause of death in children under 5 years of
age, being responsible for at least 18% of all deaths in this age category (1). In
2010, there were an estimated 120 million episodes of pneumonia in children
under 5 years, of which 14 million progressed to severe disease and 1.3 million
led to death (2). Hypoxaemia (insufficient oxygen in the blood) is the major fatal
complication of pneumonia, increasing the risk for death many times. It is
estimated that at least 13.3% of children with pneumonia have hypoxaemia (3),
corresponding to 1.86 million cases of hypoxaemic pneumonia each year.

Inhaled medications are the mainstay of therapy for many pediatric pulmonary
diseases. These therapies are given to patients who receive different types of
respiratory support. Improvements in survival and development of new
technologies have also changed the prognosis of many pediatric pulmonary
conditions. This heterogeneous population includes pediatric patients with
asthma (maintenance therapy and rescue therapy during exacerbations),
patients with respiratory distress requiring invasive mechanical ventilation or
noninvasive ventilation (NIV) support, pediatric patients requiring transnasal
support in the form of high-flow nasal cannula (HFNC), and spontaneously
breathing tracheostomized pediatric patients.
Many aerosol delivery devices are available to deliver inhaled aerosols to
children. Nebulizers, pressurized metered-dose inhalers (pMDIs), soft mist
inhalers, and dry powder inhalers for different drugs are available on the market.
Many inhaled drugs are used off label in pediatric patients because they are used
for either a different indication or a younger age group, or because they are
delivered through artificial airways and different respiratory support devices.

Nurses must be familiar with respiratory conditions affecting children in order to

provide guidance and support to families. Since respiratory illness accounts for
the majority of pediatric admissions to general hospitals, nurses caring for
children require expert assessment and intervention skills in this area. The child
and the family need the nurse’s support throughout the course of a respiratory
illness. Nurses are also in the unique position of being able to have a significant
impact upon the burden of respiratory illness in children by the appropriate
identification of, education about, and encouragement of prevention of respiratory
illnesses. All of these you will learn in this Module and will equip you with
knowledge and skills that of a world-class future nurse.
 M2 : Lesson 1 : Nebulization

In the healthcare setting a nebulizer is a small device that can convert a

drug from a solution into an aerosol form by means of a
compressor/compressed gas source.
Nebulization creates a mist of drug particles that can be inhaled via a face
mask or mouthpiece. Bronchodilators are the most common nebulized
drugs but many others can be nebulized, including steroids and antibiotics.
A nebulizer is a device that turns liquid medication into a fine mist
containing particles small enough to reach deep into the bronchial tree.
Nebulizers use compressed gas to change a liquid drug into a vapour, so
delivering drugs into the lungs in a mist of particles small enough to reach
the bronchioles and sometimes the alveoli.
● Nebulizers are used in preference to inhalers for adults:
○ when large drug doses are needed
○ when it is not possible for patients to control and coordinate
their breathing to make the use of inhalers possible (e.g. in
acute severe asthma or an exacerbation of COPD)
○ when inhalers have been found to be ineffective in managing
the patient’s chronic lung disease
○ when preparations such as antibiotics and lignocaine are
required since such preparations are unavailable as inhalers.
● Bronchodilators, steroids, antibiotics, rhDNase, pentamadine,
lignocaine and 0.9% sodium chloride are available for nebulization.
Water should not be nebulized since it may cause
bronchoconstriction.
● Nebulizers with masks are better for acutely ill patients who may find
holding the nebulizer tiring.
● Nebulizers with mouthpieces should be used:
○ if patients find masks claustrophobic
○ if steroids are being used, to prevent deposition on the face
○ for nebulized antibiotics, so that a filter can be used to prevent
exhalation of antibiotic into the air
 ○ with certain anticholinergic drugs, since they may exacerbate
glaucoma.
The mouth should be rinsed out after nebulizing steroids and antibiotics to
prevent the development of oral thrush.
Assessment:
1. Assess respiratory rate, pulse and breath sounds before and after
treatment. It will be used to establish a baseline and determine the
effectiveness of the medication.
2. Assess the client’s medical history, allergies, and medication history.
3. If ordered, assess the patient’s oxygen saturation level before
medication administration.
4. Assess the patient’s knowledge and understanding of the
medication’s purpose and action.
Planning:
Prepare the materials needed and assembles the following
equipment according to the manufacturer’s directions.
● Stethoscope
● Medication
● Nebulizer tubing and chamber
● Nebulizer
● sterile saline and PPE, as indicated
Implementation:

CRITERIA RATIONALE

Washing your hands and taking

1. Perform hand hygiene and put
standard precautions prevent the
on PPE, if indicated.
spread of infections. (Carter, 2012)

2. Introduce self to the client. Effective communication skills are

essential to foster therapeutic
nurse-patient relationships based on
mutual trust and respect.

Identifying patients accurately and

3. Verify the client using at least
matching the patient’s identity with the
two identifiers (i.e. name and birth
correct treatment or service is a critical
date or name and identification
factor of patient safety.
number). Compare identifiers with
information on the client’s medical
record/client’s identification band.

Helps the person know what to expect

4. Explain the procedure to the
and helps him understand how he can
client and encourage them to
help. (Carter, 2012)
participate as appropriate.
5. Close the room door and/or Closing the door and curtain protects
curtains around the bed if possible. the person’s right to privacy. (Carter,
2012)

6. Complete necessary
Clinicians should check a person’s
assessments before administering
drug allergy status and confirm it with
medications. Check the patient’s
them, or their family members or
allergy bracelet or ask the patient
carers as appropriate, before
about allergies
prescribing, dispensing, or
administering any drug.
(Improve recording of drug allergy to
reduce risk of reactions. (2014,
September 3).

An upright position can help to expand

7. Position patient semi-fowlers or
the chest.
upright position if possible in the
bed or in the chair.
8. Remove the nebulizer cup from To ensure that you give the correct
the device and open it. Place amount of
premeasured unit-dose medication medication
in the bottom section of the cup or
use a dropper to place a
concentrated dose of medication in
the cup. Add prescribed diluent, if
required

9. Screw the top portion of the

nebulizer cup back in place and
attach the cup to the nebulizer.
Attach one end of the tubing to the
stem on the bottom of the
nebulizer cup.

10. Turn on the nebulizer. Check

that a fine medication mist is
produced by opening the valve.
Place the mouthpiece into the
mouth and grasp securely with
teeth and lips.
11. Instruct the patient to inhale
If the client is using a mask, he/she
slowly and deeply through the
may breathe
mouth. A nose clip may be
normally.
necessary if the patient is also
breathing through the nose. Hold
each breath for a slight pause,
before exhaling.

12. Continue this inhalation To ensure that the client inhales the
technique until all medication in the entire dose
nebulizer cup has been
aerosolized (usually about 15
minutes). Once the fine mist
decreases in amount, gently flick
the sides of the nebulizer cup.

13. Have the patient gargle and Gargling cleanses the mouth. When
rinse with tap water after using the steroid
nebulizer, as necessary. remains inside the mouth, infection of
fungus
may occur.

14. Clean the nebulizer according To avoid contamination.

to the manufacturer’s directions.
 This reduces the transmission of
15. Remove gloves and additional
microorganisms. (Perry, 2013)
PPE, if used. Perform hand
hygiene.

Evaluation:
1. Evaluate the patient’s response to the medication within an
appropriate time frame. Re-assess for improved lung sounds and
respiratory effort.
2. Document the administration of the medication immediately after
administration, including date, time, dose, and route of administration
or record using the required format.
Nursing Considerations:
● Teach the client how to use personnel devices.
○Rationale: To ensure appropriate self-care after discharge
● Avoid treatment immediately before and after meals.
○ Rationale: To decrease the chance of vomiting or appetite
suppression, especially with medication that causes the client to
cough or expectorate or those that are done in conjunction with
percussion/ bronchial drainage
 Oxygen Therapy via Nasal Cannula and Oxygen Mask

Nasal cannulas and face masks are used to deliver oxygen to people who
don’t otherwise get enough of it. They are commonly used to provide relief
to people with respiratory disorders. A nasal cannula consists of a flexible
tube that is placed under the nose. The tube includes two prongs that go
inside the nostrils. A face mask covers the nose and mouth.
Both methods of delivery attach to oxygen sources, which come in
a variety of sizes. Nasal cannulas and simple face masks are typically used
to deliver low levels of oxygen. Another type of mask, the Venturi mask,
delivers oxygen at higher levels. Sometimes nasal cannulas are also used
to deliver high levels of oxygen.

DEFINITION:
Oxygen may be administered by the use of a nasal cannula, mask, mist
tents or holds when the oxygen level is below normal or the demand is
increased. The need for oxygen, the type of delivery system, and the
amount of oxygen administered are determined by the physician.
A nasal cannula is a simple, comfortable device for delivering oxygen to a
client. The two tips of the cannula, about 1.5 cm (1/2 inch) long, protrude
from the center of a disposable tube and are inserted into the nostrils

An oxygen mask is shaped to fit snugly over the client’s mouth and nose
and is secured in place with a strap. Most masks are made of clear, pliable
plastic or rubber that can be molded to fit the face.
 PURPOSES:
Nasal Cannula
1. To prevent or reduce hypoxia. A nasal cannula is an effective
mechanisms for oxygen delivery. It allows the client to breathe
through the mouth or nose; it is available for all age groups, and is
adequate for short term or long-term use. Cannulas are
inexpensive, disposable, generally comfortable and are easily
accepted by most clients.
2. To deliver low-concentration and medium-concentration oxygen
concentrations (O’Discoll et al. 2017)
3. To allow uninterrupted delivery of oxygen while the client ingests
food or fluids.
Oxygen Mask
1. To provide moderate 02 support and a higher concentration of
oxygen and/ or humidity than is provided by cannula. The mask
may deliver a high concentration of oxygen (>50%) and is
therefore not recommended for patients who require low
concentration oxygen therapy because of the risk of carbon
dioxide retention (O’Discoll et al. 2017).
2. The mask is suitable for patients with respiratory failure without
hypercapnia (type 1 respiratory failure) but is not suitable for
patients with hypercapnic (type 2) respiratory failure.

EQUIPMENT:
● Oxygen-delivery device as ordered by patient’s health care
provider
● Oxygen tubing (consider extension tubing)
● Humidifier (if indicated) with sterile distilled water
● Oxygen source
 ● Oxygen flowmeter connected to oxygen supply
● Stethoscope, pulse oximeter
● Gauze to pad elastic band (optional)
● Personal Protective Equipment (PPE) as indicated
● Appropriate room signs (e.g., no smoking, flammable, oxygen in

use)

Figure 1. Oxygen tank with humidifier Figure 2. Wall mounted oxygen with humidifier
Figure 3. Oxygen tank

ASSESSMENT:
1. Assess the patient’s oxygen saturation level before starting
oxygen therapy to provide a baseline for determining the
effectiveness of therapy (Lynn, 2015).
2. Assess the patient’s respiratory status, including respiratory rate,
rhythm, effort, and lung sounds. Note any signs of respiratory
distress, such as tachypnea, nasal flaring, use of accessory
muscles, or dyspnea (Lynn, 2015).
3. Review the patient’s medical record on order for oxygen. Note method
of delivery, flow rate and duration of oxygen therapy
Delivery Flow Fractio Advantages Disadvantages
Device Rate n of
Inspire
d
Oxygen

1-5 24-40% It is convenient as Easily dislodged, not

1. Nasal
liters patient can talk and as effective is a
cannula
per eat while receiving patient is a mouth
minute oxygen. May be breather or has
drying to nares if level blocked nostrils or a
is above 4 L/min. deviated septum or
Easy to use, low cost, polyps.
and disposable
2. Simple 6-10 40-60% Used to provide Difficult to eat with
Face liters moderate oxygen mask on. Mask may
Mask per concentrations. be confining for some
minute Efficiency depends on patients, who may
how well mask fits feel claustrophobic
and the patient’s with the mask on.
respiratory demands.
Readily available on
most hospital units.
Provides higher
oxygen for patients.
3. 10-15 60-80% With a good fit, the These masks have a
Non-rebre liters mask can deliver risk of suffocation if
ather per between 60% and the gas flow is
mask minute 80% FiO2 (fraction of interrupted. The bag
(High-flow inspired oxygen). should never totally
system) The flow meter should deflate. The patient
be set to deliver O2 at should never be left
10 to 15 L/min. Flow alone unless the
rate must be high one-way valves on
enough to ensure that the exhalation ports
the reservoir bag are removed. They
remains partially are not available on
inflated during general wards due to:
inspiration. 1. the risk of
suffocation, 2. the
chance of
hyper-oxygenation,
and 3. their possible
lack of humidity. The
mask also requires a
tight seal and may be
hot and confining for
the patient. The mask
will interfere with
talking and eating.
4. Partial 10-12 80-90% Used short term for The partial
rebreather liters patients who require re-breather bag has
mask per high levels of oxygen. no one-way valves,
(High-flow minute so the expired air
system) mixes with the
inhaled air. The mask
may be hot and
confining for the
patient and will
 interfere with eating
and talking.
5. Face 15 liters 30-50% Face tents are used to It is difficult to
tent per provide a controlled achieve high levels of
(Low-flow minute concentration of oxygenation with this
system) oxygen and increase mask.
moisture for patients
who have facial burn
or a broken nose, or
who are are
claustrophobic.
6. Venturi 4-12 24-60% Delivers a more The mask may be hot
mask liters precise level of and confining for
(High-flow per oxygen by controlling some patients, and it
system) minute the specific amounts interferes with talking
of oxygen delivered. and eating. Need a
The port on the properly fitting mask.
corrugated tubing Nurses may be asked
(base of the mask) to set up a high-flow
sets the oxygen system
concentration.
Delivers humidified
oxygen for patient
comfort. It does not
dry mucous
membranes.

PLANNING:
1. Bring necessary equipment to the bedside stand or overbed table.

Rationale: Bringing everything to the bedside conserves time and

energy. Arranging items nearby is convenient, saves time, and avoids
unnecessary stretching and twisting of muscles on the part of the nurse
(Lynn, 2015).

IMPLEMENTATION:

RATIONALE
CRITERIA

1. Perform hand hygiene and Hand hygiene and PPE prevent the
put on PPE, if indicated spread of microorganisms. PPE is
required based on transmission
precautions (Lynn,2015).

2. Identify the person by using Identifying the person ensures that

two identifiers (patient full name, and the procedure is being done on the
date of birth), and greet him or her correct patient or resident. Greeting
by name. the person by name is being
courteous. (Carter, 2012)

3. Explain the procedure and Helps the person know what to

encourage the person to participate expect and helps him understand
as appropriate. how he can help. (Carter, 2012)
4. Provide privacy by showing Asking visitors to leave the room,
any visitor where they should wait, if and closing the door and curtain
necessary, until you have completed protect the person’s right to privacy.
the procedure. Close the door and (Carter, 2012)
the curtain.
5. Attach face mask to oxygen Oxygen forced through a water
source (with humidification, if reservoir is humidified before it is
appropriate, for the specific mask). delivered to the patient, thus
Start the flow of oxygen at the preventing dehydration of the
specified rate. For a mask with a mucous membranes. A reservoir bag
reservoir, be sure to allow oxygen to must be inflated with oxygen
fill the bag before proceeding to the because the bag is the oxygen
next step. supply source for the patient (Lynn,
2015).
6. Position tips of nasal cannula Directs flow of oxygen into a
properly in a patient’s nares and patient’s upper respiratory tract.
adjust elastic headband or plastic Patient is more likely to keep
slide on cannula so it is snug and cannula or face mask in place if it fits
comfortable. Figure 2. Position face comfortably. (Potter, 2012)
mask so it is snug and comfortable.
If using an oxygen mask, adjust
elastic headband until mask fits
comfortably over a patient’s face and
mouth.
7. Maintain sufficient slack on Allows patient to turn head without
oxygen tubing and secure to removing oxygen mask or dislodging
patient’s clothes cannula and reduces pressure on
tips of nares. (Potter, 2012)
8. Observe for proper
Ensures patency of delivery device
functioning of
and proper oxygen flow. (Potter,
oxygen-delivery device:
2012)
8.1 Nasal cannula: Cannula is Oxygen therapy causes drying or
positioned properly in nares with nasal mucosa. Oxygen delivered at
humidification function. flow rates greater than 4 L/min must
be humidified. (AARC, 2002)

8.2 Reservoir nasal cannula Delivers higher flow of oxygen than

oxymizer: fit as for nasal cannula.
Reservoir is positioned under a
patient’s nose or worn as a pendant.
cannula without changing to a mask,
which is claustrophobic for some
patients. Delivers a 2:1 ratio (e.g., 6
L/min nasal cannula is approximately
equivalent to 3.5 L/min with oxymizer
device). (Potter, 2012)
8.3 Non-rebreathing mask: Apply
mask over a patient’s mouth and
nose to form tight seal. Valves on
mask close so exhaled air does not
enter reservoir bag.
Does not allow exhaled air to be
rebreathed. Valves on mask side
ports permit exhalation but close
during inhalation to prevent inhaling
room air. (Potter, 2012)
8.4 Partial rebreathing mask:
Apply mask over a patient’s mouth
and nose to form tight seal. Ensure
that bag remains partially inflated.
Allow exhaled air to mix with inhaled
air. Port on side of mask permits
most of expired air to escape;
however, the bog remains partially
inflated. (Potter, 2012)
8.5 Venturi mask: Apply mask over Reduces carbon dioxide build up.
a patient’s mouth and nose to form a (Potter, 2012)
tight seal. Select appropriate flow
rate

8.6 Face tent: Apply tent under a Excellent source of humidification;

patient’s chin and over mouth and however, you cannot control oxygen
nose. It will be loose, and a mist is concentrations. (Potter, 2012)
always present
9. Verify setting on flow meter Ensures delivery of prescribed
and oxygen source for proper setup oxygen therapy in conjunction with
and prescribed flow rate. the specific cannula or mask. (Potter,
2012)

10. Check cannula or mask every Ensures patency of cannula and

8 hours. Keep humidification oxygen flow. Oxygen is a dry gas:
container filled at all times. when it is administered via any
route, you must add humidification
so the patient inhales humidified
oxygen. (Woodrow, 2007)
11. Remove PPE if used, Perform Removing PPE properly reduces the
hand hygiene risk for infection transmission and
contamination of other items. Hand
hygiene prevents the spread of
microorganisms (Lynn,2015).
EVALUATION:
1. Monitor patient’s response to changes in oxygen flow rate with
pulse oximetry.
2. Reassess the patient’s respiratory status, including respiratory
rate, effort, and lung sounds. Note any signs of respiratory
distress, such as tachypnea, nasal flaring, use of accessory
muscles, or dyspnea. Check adequacy of oxygen flow each shift.
3. Observe patient’s external ears, bridge of nose, nares, and nasal
mucous membranes for evidence of skin breakdown.
4. Remove the mask and dry the skin every 2 to 3 hours if the
oxygen is running continuously. Do not use powder around the
mask (Lynn, 2015).
 Oxygen Therapy via Croupette

Oxygen hoods are generally used to deliver oxygen to infants. They can
supply an oxygen concentration up to 80% to 90% (Kyle & Carman, 2013).
The oxygen hood, a clear plastic cover, is placed over the infant’s head and
neck; it allows easy access to the chest and lower body. Continuous pulse
oximetry allows for monitoring oxygenation and making adjustments
according to the infant’s condition (Perry et al., 2010).

DEFINITION:
Oxygen croupette are often used for children who will not leave a face
mask or nasal cannula in place. The oxygen croupette gives the patient
freedom to move in the bed or crib while cool, highly humidified oxygen is
being delivered (Lynn, 2015).

PURPOSE:
1. To prevent or reduce hypoxia

EQUIPMENT:
● Croupette
● Croupette
● Humidifier
● Sterile water
● Oxygen source
● Flowmeter
● Ice or refrigeration unit
● Infant oxygen hood
● Oxygen hood
● Humidifier
● Oxygen source
● Flowmeter
● Tent
● Oxygen tubing
● Oxygen analyzer
● Sterile distilled water
● Temperature regulator to warm humidified oxygen
● Appropriate room signs

ASSESSMENT:
1. Assess the patient’s lung sounds. Secretions may cause the
patient’s oxygen demand to increase (Lynn, 2015).
2. Assess the oxygen saturation level. There will usually be an order
for a baseline or goal for the oxygen saturation level (i.e., deliver
oxygen to keep SpO2 ≥ 95%) (Lynn, 2015).
3. Assess skin color. A pale or cyanotic patient may not be receiving
sufficient oxygen (Lynn, 2015).
4. Assess the patient’s respiratory status, including respiratory rate,
rhythm, and effort (Lynn, 2015).
5. Assess the patient for any signs of respiratory distress, such as
nasal flaring, grunting, or retractions; oxygen-depleted patients
often exhibit these signs (Lynn, 2015).

PLANNING:
1. Prepare the materials needed.

INTERVENTION:
CRITERIA RATIONALE

1. Perform hand hygiene and Hand hygiene is the most effective

put on PPE, if indicated. way to help prevent the spread of
organisms. PPE is required based
on transmission precautions.
(Berman, 2016; Lynn 2015)
The term hand hygiene applies to
either the use of antiseptic hand
rubs, including alcohol-based
products; handwashing with soap
and water; or surgical hand
antisepsis (Lynn, 2015).
This is essential to foster therapeutic
2. Introduce self to client.
nurse-patient relationships based on
mutual trust and respect (Guest,
2016).
Identifying the patient ensures the
3. Verify the client using at
right patient receives the right
least two identifiers (i.e. name and
intervention/procedure and helps
birth date or name and identification
prevent errors (Lynn, 2015).
number). Compare identifiers with
information on the client’s medical
record/client’s identification band

4. Explain the procedure to the Discussion and explanation

client and encourage to participate encourage client’s understanding,
as appropriate participation and reduces
apprehension (Lynn, 2015).
5. Close the room door and/or This ensures the patient’s privacy
curtains around the bed if possible (Lynn, 2015).
6. Review safety precautions Oxygen supports combustion; a
necessary when oxygen is in use. small spark could cause a fire (Lynn,
2015).
7. Calibrate the oxygen analyzer Ensures accurate readings and
according to manufacturer’s appropriate adjustments to therapy
directions. (Lynn, 2015).

8. Administer oxygen therapy

8.1 Via Croupette

8.1.1 Position cooling This prepares equipment and allows

nebulizer unit on bed or crib and
attach canopy to unit and position
over bed.
8.1.2 Fill ice chamber or start
refrigeration unit.
8.1.3 Fill the nebulizer
reservoir with sterile distilled water
and set flow meter to at least 10
L/min.
8.1.4 Place child in tent and if
toy or blanket is present, be sure it
does not produce friction or static
electricity.
for smooth, organized completion of
the procedure. (Potter, 2013)
This provides for moisture in the
system. Humidified air is less drying
to the nares and to the lungs.
(Craven, 2009)
Use of sterile water decreases
incidence of bacterial growth and
mineral build up within the system. It
ensures that the child is actually
receiving the amount of oxygen the
physician deemed necessary.
(Craven, 2009)
Sparks or static electricity will ignite
the oxygen. (Craven, 2009)
 8.1.5 Tuck sides of canopy or Leaks will decrease fraction of
tent under mattress and fold sheet inspired oxygen levels. Secured
over front portion of tent. Check tent bedding decreases chance that the
frequently to be sure its sides and child will become tangled in the
front are secured. blankets. (Craven, 2009)
8.1.6 Check ice reservoir It ensures that the order oxygen
frequently. Do not allow chamber to concentration level is available.
be empty (Craven, 2009)
8.1.7 Organize nursing care so Limiting the time the unit is opened
that the tent is not opened as will maximize the quality of oxygen
frequently as possible, but maintain therapy. Each time the unit is
continuous assessment of child’s opened, the oxygen level decreases.
respiratory status. (Craven, 2009)
8.1.8 After tent has remained This ensures that the ordered
open, flush with oxygen by oxygen concentration level is
increasing flow meter setting. Reset available. (Craven, 2009)
flowmeter to prescribed setting.

8.2 Via Oxygen Hood

8.2.1 Place hood over crib or Oxygen forced through a water

bed. Connect the humidifier to the reservoir is humidified before it is
oxygen source in the wall and delivered to the patient, thus
connect the tent tubing to the preventing dehydration of the
humidifier. Adjust flow rate as mucous membranes (Lynn, 2015).
ordered by primary care provider.
Check that oxygen is flowing into the
hood
 The analyzer will give an accurate
8.2.2 Turn on analyzer. Place
reading of the concentration of
oxygen analyzer probe in hood, out
oxygen in the crib or bed (Lynn,
of patient’s reach
2015).

8.2.3 Adjust oxygen as Patient will receive oxygen once

necessary, based on sensor placed in the tent (Lynn, 2015).
readings. Once oxygen levels reach
the prescribed amount, place the
hood above the patient
8.2.4 Roll small blankets like a The blanket helps keep the edges of
jelly roll and tuck hood edges under the hood flap from coming up and
blanket rolls, as necessary letting oxygen out (Lynn, 2015).
8.2.5 Reassess the patient’s This assesses the effectiveness of
respiratory status, including oxygen therapy (Lynn, 2015).
respiratory rate, effort, and lung
sounds. Note any signs of
respiratory distress, such as
tachypnea, nasal flaring, use of
accessory muscles, grunting,
retractions, or dyspnea.
9. Remove PPE, if used. Removing PPE properly reduces the
Perform hand hygiene risk for infection transmission and
contamination of other items. Hand
hygiene prevents the spread of
microorganisms (Lynn, 2015).

EVALUATION:
1. Assess client’s response to administration of oxygen. Observe for
improved color, decreased respiratory effort (i.e., decreased
retractions, absence of stridor, absence of nasal flaring, decreased
restlessness).
2. Record the nurse’s notes at the beginning and end of shift
and include change-of-shift report on the following:
2.1 Oxygen therapy
2.2 Respiratory assessment and findings
2.3 Method of oxygen delivery
2.4 Flow rate
2.5 Patient’s response
2.6 Adverse reactions or side effects
2.7 Change in physician’s order

NURSING CONSIDERATIONS:
1. Supplemental oxygen relieves hypoxaemia but does not improve
ventilation or treat the underlying cause of hypoxaemia. Monitoring
of SpO2 indicates oxygenation not ventilation. Therefore, beware
of the use of high FiO2 in the presence of reduced minute
ventilation.
2. Many children in the recovery phase of acute respiratory illnesses
are characterized by ventilation/ perfusion mismatch (e.g. asthma,
bronchiolitis and pneumonia) and can be managed with SpO2 in
the low 90’s as long as they are clinically improving, feeding well
and don’t have obvious respiratory distress.
3. Normal SpO2 values may be found despite rising blood carbon
dioxide levels (hypercapnia). High oxygen concentrations have the
potential to mark signs and symptoms of hypercapnea.
4. Oxygen therapy should be closely monitored and assessed at
regular intervals. Therapeutic procedures and handling may
increase the child’s oxygen consumption and lead to worsening
hypoxaemia.
5. Children with cyanotic congenital heart disease normally have
SpO2 between 60%-90% in room air. Increasing SpO2 >90% with
supplemental oxygen is not recommended due to risk of over
circulation. However, in emergency situations with increasing
cyanosis supplemental oxygen should be administered to maintain
their normal level of SpO2
 Oropharyngeal and Nasopharyngeal Suctioning
Definition:
Suctioning is the removal of airway secretions using negative pressure.
Oropharyngeal and nasopharyngeal suctioning is used when the client is able
to cough effectively but is unable to clear secretions by expectorating or
swallowing. It is frequently used after the client coughs. Oropharyngeal and
nasopharyngeal suctioning may also be appropriate in less responsive or
comatose clients who require removal of oral secretions.

Purposes:
● To maintain a patent airway and prevent obstructions
● To remove secretions that obstruct the airway
● To promote respiratory functions (optimal exchange of oxygen and
carbon dioxide into and out of the lungs)
● To prevent pneumonia that may result from accumulated secretions

Equipment:
Suction catheter with intermittent control port of appropriate size for client:
● Infants: 5-8 Fr
● Children: 8-10 Fr
● Adults: 12-18 Fr
Suction Apparatus:
● Wall Unit:
○ Neonates: 60-80 mmHg
○ Infant: 80-125 mmHg
○ Children: 80-125 mmHg
○ Adolescent: 80-150 mmHg
○ Adults: 100-150 mmHg
○ Portable Unit:
○ Neonates 6-8 cmHg
○ Infant 8-10 cmHg
○ Children 8-10 cmHg
○ Adolescent 8-115 cmHg
 ○ Adult 10-15 cmHg
● Sterile disposable gloves, mask, googles, face shield
● Sterile water or normal saline approximately 100 mL in a glass container
or basin
● Connecting tubes (6 feet) and collecting bottle
● Clean towel/ Water proof pad
● If not using closed-suction catheter
● Water-soluble lubricant
● Small Y adapter if catheter does not have a suction port
● Sterile basin
● Sterile normal saline solution
● Collection Receptacle

Assessment:
● Assess signs and symptoms of upper and lower airway obstruction
including wheezes, crackles, or gurgling on inspiration or expiration,
restlessness, ineffective coughing, absent or diminished breath sounds,
tachypnea, cyanosis, decreased level of consciousness.
● Assess for signs of respiratory distress

Planning:
Prepare the necessary equipment and supplies

Implementation:

CRITERIA RATIONALE

Washing your hands and taking

1. Wash hand thoroughly. standard precautions prevent the
spread of infections. (Carter, 2012)
 Identifying the person ensures that the
procedure is being done on the correct
2. Identify the person, and greet him or
patient or resident. Greeting the
her by name.
person by name is being courteous.
(Carter, 2012)

3. Explain to patient how procedure will

help clear airway and relieve breathing Helps the person know what to expect
problems. Explain that coughing, and helps him understand how he can
sneezing or gagging is normal for oral help. (Carter, 2012)
suctioning.

4. Provide privacy by showing any visitor Asking visitors to leave the room, and
where they should wait, if necessary, closing the door and curtain protect
until you have completed the procedure. the person’s right to privacy. (Carter,
Close the door and the curtain. 2012)

5. Position the client:

5.1 Conscious Client: Semi fowler’s These positions facilitate the insertion
position with the head turned to one side of the catheter and help prevents
for oral suctioning and neck aspiration of secretions. (Kozier and
hyperextended for nasal suctioning Erbs, 2015)

This position allows the tongue to fall

5.2 Unconscious Client: lateral position forward, so that it will not obstruct the
facing the nurse catheter on insertion. (Kozier and
Erbs, 2015)
 Prevent contamination to the client
(Kozier and Erbs, 2015)
6. Place the towel or moisture resistant
Excessive negative pressure damages
pad over the pillow or under the chin
nasal, pharyngeal, and tracheal
mucosa and induces greater hypoxia.
(Potter, 2012)

7. Prepare the Suction Apparatus

7.1 Connect one end of connecting
tubing to suction machine and place Negative pressures should not exceed
other end in convenient location near 150 mm Hg because higher pressure
patient increases risk for airway trauma,
hypoxemia, and atelectasis. (AARC,
2004)
7.2 Turn suction device on and set
vacuum regulator to appropriate
negative pressure

Prepares catheter and prevents

8. Washes hands and opens suction
transmission of microorganisms.
catheter package. Do not allow suction
Provides sterile surface on which to
catheter to touch any surface other than
lay suction catheter between passes, if
inside of it's package.
needed. (Potter, 2012)

9. Fills container with 100ml sterile NSS/ Solution is used to flush catheter after
water each suction pass. (Potter, 2012)
 Taking standard precautions prevent
10. Wear mask.
the spread of infections. (Carter, 2012)

11. Apply sterile gloves to each hand Reduces transmission of

and designate the sterile which is the microorganisms and allows nurse to
dominant hand and non-sterile which is maintain sterility of suction catheter.
the non-dominant hand. (Potter, 2012)

12. Pick up suction catheter with

dominant hand without touching Reduces transmission of
non-sterile surfaces. Pick up connecting microorganisms and allows nurse to
tubing with non-dominant hand then maintain sterility of suction catheter.
connect suction catheter to the (Potter, 2012)
connecting tube.

13. Check the equipment if functioning Ensures suction is functioning.

properly by suctioning small amount of Lubricates internal catheter and
saline from the basin. tubing. (Potter, 2012)

14. Oropharyngeal Suctioning

14.1 Remove oxygen mask if present. Allows access to the patient’s mouth
Keep oxygen mask near the patient’s while having access to
face. If patient has a nasal cannula, it oxygen-delivery system. (Potter, 2012)
may remain in place.

14.2 Moisten the Yankauer Catheter/

This reduces friction and eases
Suction tip with saline water or water
insertion (Kozier and Erbs, 2015)
soluble lubricant
14.3 Advance the catheter about 10 to Directing the catheter along the side
15 cm (4 to 6 in.) along one side of the prevents gagging. (Kozier and Erbs,
mouth into the oropharynx. 2015)

14.4 It may be necessary during

oropharyngeal suctioning to apply
suction to secretions that collect in the
mouth and beneath the tongue.

If catheter does not have a suction

14.5 With suction applied intermittently,
control to apply intermittent suction,
move catheter around mouth, including
take care not to allow suction tip to
pharynx and gum line, until secretions
irritate oral mucosal surfaces with
are cleared.
continuous suction. (Potter, 2012)

Suctioning removes air from the

14.6 Replace the oxygen delivery device
patient’s airway and can cause
using your nondominant hand, if
hypoxemia. Hyperventilation can help
appropriate, and have the patient take
prevent suction-induced hypoxemia.
several breaths
(Taylor,2015)

14.7 Flush catheter with saline. Assess
effectiveness of suctioning and repeat,
as needed, and according to patient’s
tolerance. Wrap the suction catheter
around your dominant hand between
attempts.
Flushing clears the catheter and
lubricates it for next insertion.
Reassessment determines the need
for additional suctioning. Wrapping
prevents inadvertent contamination of
the catheter. (Taylor,2015)
15. Nasopharyngeal Suctioning
15.1 Lightly coat distal 6-8 cm (2-3 Lubricates catheter for easier
inches) of catheter tip with water-soluble insertion. (Potter, 2012)
lubricant.

Application of suction pressure while

15.2 Remove oxygen-delivery device, if
introducing catheter into
applicable, with nondominant hand.
nasopharyngeal tissues increases risk
Without applying suction and using
to damage to mucosa. When
dominant thumb and forefinger, gently
advanced intro trachea, suction could
insert catheter into naris during
damage mucosa and increases risk of
inhalation.
hypoxia. (Potter, 2012)

15.3 Have the patient take a deep

breath and insert catheter, following
natural course of naris; slightly slant
catheter downward and advance to the
back of pharynx. Do not force through
naris. In adults insert catheter about 16 Proper placement ensures removal of
cm (6 inches); in older children, 8 to 12 pharyngeal secretions. (Potter, 2012)
cm (3 to 5 inches); in infants and young
children. 4 to 8 cm (2 to 3 inches). Rule
of thumb is to insert catheter distance
from tip of nose (or mouth) to angle of
mandible.

16. Once correct position is ascertained,

apply suction for 5-10 sec. gently rotates
the catheter while pulling it slightly
upward.
17. Apply intermittent suction by placing
and releasing non-dominant hand thumb
over vent of catheter and slowly
withdraw catheter in twisting motion.
Encourage patient to cough.
Intermittent suction up to 15 seconds
safely removes pharyngeal secretions.
Suction time greater than 15 seconds
increases risk for suction-induced
hypoxemia. (AARC, 2004)

18. Replace oxygen delivery device.

Encourage patient to deep breath.

Removes secretions from catheter.

19. Rinse catheter and connecting Secretions that remain in suction
tubing with normal saline or water until catheter or connecting tubing
cleared. Use continuous suction. decrease suctioning efficiency. (Potter,
2012)

20. Repeat steps 13 or 14 as needed to

The interval allows for re-ventilation
clear secretions. Allow adequate time (at
and re-oxygenation of airways.
least 1 full minute) between suction
Excessive suction passes contribute to
passes for ventilation and
complications.
re-oxygenation.
 Suctioning sometimes induces
dysrhythmias, hypoxia, and
21. Assess patient's cardiopulmonary
bronchospasm and impairs cerebral
status between suction passes.
circulation or adversely affects
hemodynamics. (AARC, 2010a)

Upper airway is “clean”, and lower

22. When pharynx and trachea are
airway is “sterile”. Therefore you can
sufficiently cleared of secretions.
use the same catheter to suction from
Perform oropharyngeal suctioning to
sterile to clean areas but not from
clear mouth of secretions.
clean to sterile areas. (Potter, 2012)

23. Remove towel and place in laundry Reduces transmission of organisms.

or appropriate receptacle (Potter, 2012)

24. Coil suction catheter in the dominant

hand. Disconnect suction catheter from Reduces transmission of
connecting tubing. Remove sterile microorganisms. Do not touch clean
gloves with the used suction catheter equipment with contaminated gloves.
inside to prevent contamination and (Potter, 2012)
discard in appropriate waste receptacle.

Proper positioning based on patient’s

condition promotes comfort,
25. Reposition patient. encourages secretion drainage, and
reduces risk of aspiration. (Potter,
2012)
26. Discard remainder of normal saline
Solution is contaminated; this reduces
into appropriate receptacle. If basin is
transmission of microorganisms.
reusable, rinse and place in soiled utility
(Potter, 2012)
room.

Reduces transmission of
microorganisms. (Potter, 2012).
27. Wash hands and place unopened Provides for immediate access of
suction kit on suction machine or at suction catheter and equipment in
head of bed. event of an emergency or for next
suctioning procedure. (Potter, 2012)

Evaluation:
1. Auscultates the clients breath sounds to ensure they are clear of
secretions, observes skin color, dyspnea
2. Measure heart rate, BP, RR, and Oxygen Saturation
3. Records the patient’s tolerance of procedure, amount, consistency, color
and odor of sputum of secretions removed and complications
4. Reports ant patient’s intolerance of procedure (Changes of vital signs,
bleeding, laryngospasm, upper airway noise)