NCMB 219-217 RLE

219 SKILLS LAB 1: IV THERAPY & 219 SKILLS LAB 2: ADMINISTERING

INFUSION PUMP BLOOD TRANSFUSION
I. HOW TO START AN INFUSION PUMP I. DIFFERENT BLOOD PRODUCTS
- EQUIPMENTS NEEDED 1. WHOLE BLOOD
o IV fluids - Replaces all blood products
o Infusion set. - REQUIRES – blood typing & crossmatching
o IV cannula or needle - USE IN – massive blood loss & extreme cases of
o Tourniquet acute hemorrhage (Vehicular acc)
o Clean gloves - TRANS. TIME – 4 hrs.
o Alcohol swabs 2. PRBC
o Dressing & stabilization supply - 80% of plasma is removed
o IV pole - Increases O2 carrying capacity of blood
o Infusion pump. - REQUIRES blood typing & crossmatching
- GAUGE SIZES - USE IN – anemia, surgery & disorder w/ slow
bleeding
SIZE COLOR RECOMMENDED
14G Orange In massive trauma situations - TRANS. TIME – 1.5-4 hrs. (2-3 hrs. w/ NSS)
16G Gray Trauma, surgeries, or multiple large- - S. TIME – 42 days in ref.
volume infusions 3. AUTOLOGOUS RBC
18G Green Blood transfusion, or large volume - Coming from the patient itself donated as
infusions.
advance; 4-5 weeks prior to surgery; SELF-
20G Pink Multi-purpose IV; for medications,
hydration, and routine therapies. DONATION
22G Blue most chemotherapy infusion patient - REQUIRES – NO blood typing & crossmatching
with small veins - USE IN – surgery
24G Yellow very fragile veins: elderly and - TRANS. TIME – 1.5-4 hrs. (2-3 hrs. w/ NSS)
Pediatrics
26G Violet Infant
- S. TIME – 42 days in ref.
- PROCEDURES 4. FRESH FROZEN PLASMA
1. Determine the type and amount of solution to - RBC, platelets & leukocytes are removed: FLUID
be used, exact amount of medications (if any) to PORTION
be added, and flow rate or time the infusion will - Increase the level of any clotting factor by 2% to
be completed. 3%
2. Prepare the patient by proper patient - REQUIRES – NO blood typing & crossmatching
identification, explaining the procedure, and - USE IN – surgery, clotting impairment
providing privacy. - TRANS. TIME – 30 mins.
3. Perform hand hygiene or hand washing. - S. TIME – 1 yr. in blood bank; once thawed –
4. Open and prepare the infusion set and IV used immediately: room temp – 4 hrs.
solution. 5. PLATELETS
5. Spike the IV solution container. - Replaces platelets to help blood clots
6. Apply an IV label indicating name and room no. - REQUIRES – NO blood typing & crossmatching
of patient, name of IV solution, amount, - USE IN – bleeding disorders & platelet
flowrate, name of added medication (if any), deficiency (Thrombocytopenia & dengue
and the time IV will be infused. hemorrhagic fever)
7. Hang the solution container on the IV pole. - TRANS. TIME – rapidly infused for max. benefit
8. Partially fill the drip chamber with solution and - S. TIME – 5 days in ref.
prime the tubing 6. ALBUMIN
9. Fix the infusion pump on the stable IV pole - Provides plasma protein & serves as blood
10. Power on the infusion pump. Set up information volume expander
(IV fluid, flowrate, amount of IV, and # of hours - REQUIRES – NO blood typing & crossmatching
- USE IN – shock, burns, hypoproteinemia &
to run) into the infusion pump.
dengue hemorrhagic fever
11. Insert the IV tubing into the loading set
- TRANS. TIME – 1.5-4 hrs. (2-3 hrs. w/ NSS)
properly.
- S. TIME – n/a
12. Unclamp or open the roller clamp
7. CRYOPRECIPITATE
13. Connect to tubing to the patient’s IV cannula
- Contains large amount of clotting factor VII
14. Press start on the infusion pump to start the
(fibrinogen)
infusion.
- REQUIRES – NO blood typing & crossmatching
15. Document the procedure and relevant data.
- USE IN – clotting factor deficiency
- TRANS. TIME – 4-10 ml/min.
- S. TIME – 1 yr. in freezer

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 NCMB 219-217 RLE
8. PLASMA PROTEIN FACTOR
- Portion of plasma after fibrinogen
- REQUIRES – blood typing & crossmatching &
compatibility test
- USE IN – replacement of intravascular volume
- TRANS. TIME – rapidly infused for max. benefit
- S. TIME – 5 days in ref.
- CONSIDERATION
- Avoid hemolytic reactions – compatibility test
should be done (Blood typing & crossmatching)
o Reaction is evident 5-15 mins. (Golden
Period) – should stay with the pt.
o If reaction is seen – stop infusion, open the
line with normal saline
▪ Do not use the saline to the Y-
set tubing (for BT only)
▪ Disconnect and replace new
tubing
▪ DO NOT PIGGYBACK
▪ Hydrate client w/ NSS & notify
physician
▪ Continue monitor VS
o 1 unit of blood = 500 ml
o 1 unit of PRNC = 200-250 ml
o Do not store blood products in the nursing
unit’s refrigerator (lacks temp)
o Administer blood once removed from the
storage (depends on the product)
o At least 2 nurses must check the label of
the blood product before administering
▪ Serial number, blood
component, blood type, Rh
factor, expiration date, and
screening tests done
o Use #18-20 G (smaller than that may cause
hemolysis when transfusing); children
requires smaller G (fragile veins)
o One arm for BT, one arm for PNSS (using Y
set)
o Saline solution is use to prime the set &
flush the needle before administering
blood; keeps the vein open (if transfusion
reaction happens)
o BT should be completed 4 hrs. (risk for
sepsis if more than 4 hrs. the blood hangs)
o New administration set with each blood
component
o New IV tubing used for administering other
IVF following transfusion.
o 1 BAG INCREASES BLOOD PRODUCT BY 4%
II. PROCEDURES
1. ASSESS THE CLIENT’S VITAL SIGNS, PHYSICAL
EXAMINATION
- Including fluid balance and heart and lung
sounds as manifestations of hypo or
hypervolemia, status of infusion site, blood test
results (hemoglobin or platelet count), and any
unusual symptoms
2. VERIFY DOCTOR’S ORDER
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- For the number and type of units and the
desired speed of infusion. Note and schedule to
administer pre-medication ordered by physician
(usually 30 minutes prior to transfusion).
3. PREPARE THE PATIENT
- By introducing self, verifying client’s identity,
explain the procedure and its purpose,
instructions on what to report by client during
procedure, provide privacy, and assist to a
comfortable position.
- If the client has an IV solution infusing, check
whether the IV catheter and solution are
appropriate to administer blood. If the client
does not have an IV solution infusing, check
agency policies. In some agencies an infusion
must be running before the blood is obtained
from the blood bank. In this case, the nurse
need to perform a venipuncture on a suitable
vein and start an IV infusion of normal saline.
4. PERFORM HAND HYGIENE and observe
appropriate infection prevention procedures.
5. PREPARE THE INFUSION EQUIPMENT.
- Apply gloves and close all the clamps on the Y-
set. Spike into the saline solution and hang the
container on the IV pole about 1 meter above
the venipuncture site.
6. OPEN THE UPPER CLAMP
- On the saline solution tubing and squeeze the
drip chamber until it covers the filter and 1/3 of
the drip chamber above the filter. Then prime
the tubing. Close both clamps.
7. START THE SALINE SOLUTION.
- If an IV solution incompatible with blood is
infusing, stop the infusion and discard the
solution and tubing according to agency policy.
Attach the blood tubing primed with normal
saline to the IV catheter. Open the saline and
main flow rate clamps and adjust the flow rate.
Use only the main flow rate clamp to adjust the
rate. Allow a small amount of solution to infuse
to make sure there are no problems with the
flow or with the venipuncture site.
8. OBTAIN THE CORRECT BLOOD COMPONENT for
the client. Check for the following:
a. Doctor’s order with the requisition
b. Requisition form and the blood bag label
with a laboratory technician (Client’s name,
ID number, blood type and Rh group, blood
donor number, and expiration date) at the
blood bank. Observe blood for abnormal
color, RBC clumping, gas bubbles, and
extraneous material.
c. With another nurse, verify the doctor’s
order, transfusion consent form, client
identification, blood unit identification,
blood type, expiration date, compatibility,
and appearance.
d. If any of the information does not match
exactly, notify the charge nurse and the
 NCMB 219-217 RLE
blood bank. Do not administer blood until
discrepancies are corrected or clarified.
e. Sign the appropriate form with the other
nurse according to agency policy. Make sure
that the blood is left at room temperature
for no more than 30 minutes before starting
the transfusion. Blood must be returned to
the blood bank if it has not been started
(depends on agency protocol).
9. PREPARE THE BLOOD BAG.
- Invert the blood bag gently several times to mix
the cells with the plasma. Expose the port on
the blood bag and spike the remaining Y-set
into the bag. Hang the bag on the IV pole.
10. ESTABLISH THE BLOOD TRANSFUSION.
- Close the upper clamp below the saline solution
and open the upper clamp below the blood bag.
Readjust the flow rate with the main clamp.
11. REMOVE AND DISCARD GLOVES.
12. PERFORM HAND HYGIENE.
13. OBSERVE THE CLIENT CLOSELY
- For the first 15 minutes (Initial flow rate:1-
2ml/minute), assess for any transfusion
reaction. Check the vital signs 15 minutes after
initiating the transfusion. If no reactions were
observed, establish the required flow rate as
per doctor’s order or hospital policy. If client
has a reaction, discontinue the transfusion and
send the bag and tubing to the laboratory for
investigation of the blood.
14. DON’T MIX MEDICATIONS WITH BLOOD
TRANSFUSION
15. ADMINISTER 0.9 NACL (before, during & after)
16. TERMINATE THE TRANSFUSION once blood is
fully infused.
17. DOCUMENT THE PROCEDURE AND RELEVANT
DATA
a. Record date and time the procedure
started, including vital signs, type of blood,
blood unit number, sequence number, site
of the venipuncture, size of the catheter,
and drip rate.
b. Record completion of the transfusion, the
amount of blood absorbed, the blood unit
number, and the vital signs. If the primary
IV infusion was continued, record
connecting it. Also record the transfusion
on the IV flow sheet and intake and output
record.
219 SKILLS LAB OXYGEN THERAPY,
SUCTIONING & TRACHEOSTOMY
TUBE
I. OXYGEN THERAPY
- Oxygen therapy is prescribed by the physician,
who orders the;
o Concentration
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o Method of delivery, depending on the
method
o Liter flow per minute (L/min).
- Determining the effectiveness of oxygen
therapy involves several measures, including
checking vital signs and peripheral blood oxygen
saturation (pulse oximetry).
- INDICATIONS
o Hypoxemia
o Reduced ability for diffusion of oxygen
through the respiratory membrane
o Hyperventilation
o Substantial loss of lung tissue due to
tumors or surgery.
- OTHERS WHO MAY REQUIRE OXYGEN ARE
THOSE WITH:
o Severe anemia or blood loss, or similar
conditions in which there are inadequate
numbers of RBCs or hemoglobin to carry
the oxygen.
- OXYGEN SUPPLY WAYS
1. Portable systems (cylinders or tanks)
2. Wall outlets
- Oxygen administered from a cylinder or wall-
outlet system is dry. Dry gases dehydrate the
respiratory mucous membranes.
- Humidifying devices that add water vapor to
inspired air are thus an essential adjunct of
oxygen therapy, particularly for liter flows
over 4 L/min. Humidifiers prevent mucous
membranes from drying and becoming
irritated and loosen secretions for easier
expectoration. Oxygen passing through water
picks up water vapor before it reaches the
client.
- SAFETY PRECAUTIONS
1. Does not burn or explode.
2. Facilitates/supports combustion.
- Oxygen is not completely harmless to the
client. Clients can receive an inadequate
amount or an excessive amount of oxygen
and both can lead to a decline in the client’s
condition.
- An inadequate amount of oxygen (hypoxia)
will lead to cell death, and if left untreated
can ultimately lead to death. Excessive
amounts of oxygen can lead to pulmonary
tissue damage, increased duration of
mechanical ventilation, and longer ICU and
hospital stays.
- FLOW SYSTEMS
1. LOW-FLOW SYSTEMS – deliver oxygen via
small-bore tubing.
- LOW-FLOW ADMINISTRATION DEVICES
a. Nasal cannulas
b. Face masks
c. Oxygen tents
d. Transtracheal catheters.
 NCMB 219-217 RLE
- With these types of devices room air is also
inhaled along with the supplemental oxygen,
the FRACTION OF INSPIRED OXYGEN (FIO2)
will vary depending on the respiratory rate,
tidal volume, and liter flow.
2. HIGH-FLOW SYSTEMS – supply all the oxygen
required during ventilation in precise amounts,
regardless of the client’s respirations. The high-
flow system used to deliver a precise and
consistent FiO2 is the VENTURI MASK with
LARGE-BORE TUBING.
- ARTIFICIAL AIRWAYS
- are inserted to maintain a patent air passage for
clients whose airways have become or may
become obstructed.
- A patent airway is necessary so that air can flow
to and from the lungs. Clients who need airway
support due to a temporary or permanent
condition may have a tracheostomy. A
tracheostomy is an opening into the trachea
through the neck. A tube is usually inserted
through this opening and an artificial airway is
created.
- 2 TECHNIQUES
o Percutaneous insertion – The
percutaneous method can be done at the
bedside in a critical care unit. A curved
tracheostomy tube is inserted to extend
through the stoma into the trachea.
o Traditional open surgical method – The
open technique is done in an operating
room where a surgical incision is made in
the trachea just below the larynx.
- When the client breathes through a
tracheostomy, air is no longer heated,
humidified, and filtered as it is when passing
through the upper airways; therefore, special
precautions are necessary. Humidity may be
provided with a mist collar.
II. SUCTIONING
1. DETERMINE THE NEED FOR SUCTIONING and
the time last suctioning was done.
2. INTRODUCE SELF AND VERIFY THE CLIENT’S
IDENTITY.
- Explain the procedure, its purpose, and how
client can participate. Inform the client that
suctioning usually causes some intermittent
coughing and that this assists in removing the
secretions.
3. PERFORM HAND HYGIENE and observe other
appropriate infection prevention procedures.
4. PROVIDE PRIVACY AND PLACE CLIENT IN SEMI-
FOWLERS POSITION (if not contraindicated) to
promote deep breathing, maximum lung
expansion, and productive coughing.
5. PREPARE THE EQUIPMENT for an open suction
system.
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a. Attach the resuscitation bag (Ambu Bag) to
the oxygen source. Adjust the oxygen flow to
100% (12- 15L/min).
b. Open sterile supplies (suction kit or catheter/
sterile basin or container)
c. Pour sterile normal saline or sterile water
into the basin
d. Place sterile towel across the client’s chest
below the tracheostomy
e. Turn on the suction apparatus and set the
pressure in accordance to agency policy.
f. Apply personal protective equipment (gown,
goggles, and mask) if necessary.
g. Wear sterile gloves.
6. HOLD CATHETER USING DOMINANT HAND and
the suction connector by the non-dominant
hand. Attach the catheter and the suction
tubing connector.
7. FLUSH AND LUBRICATE THE CATHETER.
8. HYPERVENTILATE THE LUNGS using the
resuscitation bag before suctioning. Compress
the bag 3-5 times as the client inhales. NOTE: If
client has copious secretions, do not
hyperventilate with a resuscitation bag, instead
keep the regular oxygen delivery device on and
increase the liter flow or adjust the FIO2 to
100% for several breaths before suctioning.
9. QUICKLY BUT GENTLY INSERT the suction
catheter without applying any suction. Insert
the suction catheter about 0.5cm to 1 cm past
the distal end of the tube for an open system or
until the client coughs. If resistance is felt,
withdraw the suction catheter about 1 to 2 cm
before applying suction.
10. PERFORM SUCTIONING. Apply suctioning for 5
to 10 seconds in a rotating motion (rolling
catheter between thumb and forefinger) while
slowly withdrawing it. Once suction catheter is
completely withdrawn, release the suction.
11. HYPERVENTILATE THE CLIENT.
12. SUCTION AGAIN, IF NEEDED.
13. REASSESS THE CLIENT’S OXYGENATION STATUS
and repeat suctioning. Encourage the client to
breathe deeply and to cough between suctions.
Allow 2-3 minutes with oxygen between
suctions when possible. Flush the catheter and
repeat suctioning until the air passage is clear
and the breathing is relatively effortless and
quiet.
14. AFTER EACH SUCTION, ventilate the client with
no more than 3 breaths.
15. DISPOSE EQUIPMENT USED and ensure
availability for the next suction.
16. WRAP THE CATHETER around the one gloved
hand and peel the glove off inside out over the
catheter. Remove the other glove and discard
the gloves in the moisture-resistant bag or the
infectious waste can.
17. PERFORM HAND HYGIENE.
 NCMB 219-217 RLE
18. BE SURE that ventilator and oxygen settings are tubes can be damaged by using hydrogen
returned to pre-suctioning settings. peroxide. The outer cannula of the
19. ASSIST CLIENT to a comfortable and safe tracheostomy tube remains in place to
position. maintain a patent airway
20. DOCUMENT PROCEDURE and relevant data.
Record the suctioning, including the amount
and description of secretions and assessments
before and after the suctioning.
III. TRACHEOSTOMY TUBE
- TRACHEOSTOMY
o A tracheostomy is an opening into the
trachea through the neck. A tube is usually
inserted through this opening and an
artificial airway is created
o A tracheostomy is performed using one of
two techniques: the traditional open
surgical method or via a percutaneous
insertion
o PERCUTANEOUS METHOD – can be done
at bedside in Critical care unit
o OPEN TECHNIQUE – done in OR where
surgical incision is made in the trachea just
below the larynx
- A CURVED TRACHEOSTOMY TUBE is inserted to
extend through the stomach into the trachea
o Available in different sizes and may be
plastic, silicone, or metal, and cuffed,
uncuffed, or fenestrated. A fenestrated
tracheostomy tube has an opening that
allows air to pass through to the vocal
cords, thus allowing the client to
communicate
o Tracheostomy tubes have an outer cannula
that is inserted into the trachea and a
flange that rests against the neck. The
flange allows the tube to be secured in
place with tracheostomy tapes/twill ties or
Velcro collars
o All tubes also have an obturator, which is
used to insert the outer cannula and is
then removed
o The obturator, along with a spare
tracheostomy tube of the same size and
smaller, is kept at the client’s bedside in
case the tube becomes dislodged and
needs to be reinserted
o Some tracheostomy tubes have an inner
cannula that is inserted and locked into
place inside the outer cannula. The
purpose of the inner cannula is to prevent
tube obstruction by allowing regular
cleaning or replacement. Many plastics
inner cannulas are cleaned with a solution
of full or half-strength hydrogen peroxide
and sterile water. Although some agency
recommends using normal saline only. It is
important to check the manufacturer’s
instructions for cleaning tracheostomy
tubes because silicone tubes and metal

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