ESSENTIAL

NURSING PROCEDURES

IRA MONIQUE H. CABADEN


One of the pedestals in establishing the
determined nursing objective, involves the conduct
of nursing procedures. It is carried out to effectively
meet client healthcare demands, to keep track of
their well-being, and to identify any current or
upcoming healthcare issues.
Venous pressure is the average blood pressure
within the venous compartment of circulation.
There are several measurements of venous blood
pressure that exist in various locations within the
heart. Including, jugular venous pressure, portal
venous pressure and central venous pressure.
• Internal jugular line. This line is placed into a large
vein in the neck.
• Femoral line. This line is placed in a large vein in the
groin.
There are different types of Central Venous
Catheter. There are single, double or triple lumen
catheters, there are also tunneled catheters for long
term use. The most commonly used catheter on the
other hand, is the Triple lumen catheters as it allows
multiple infusions given separately continuous
pressure monitoring. Triple lumen catheter has 3
ports, distal, medial and proximal.

Central Venous Pressure (CVP) referred as “filling

pressure”, the pressure of blood returning to or
filling thee right atrium. The CVP reflects the
amount of blood returning to the heart and the
ability of the heart to pump blood back into the Retrieved from:
arterial system. https://www.slideshare.net/DRSHADABKAMAL/intracat
heters
The purpose of CVP monitoring are the following:

• estimation of the right atrial pressure and cardiac

preload – volume of blood in the ventricles at end
of diastolic pressure.
• Assessment of hemodynamic status, particularly in
the intensive care unit.
• Used to assess cardiac function
• To monitor fluid therapy and, in particular, to avoid
overzealous fluid administration.
Retrieved from: https://www.mountnittany.org/wellness-
CVP is measured through the use of a Central
article/central-line-central-venous-access-device
Venous Catheter. Central Venous Catheter is also
known as central line. A long, soft, thin, hollow tube Central line placement is not only indicated to
that is placed into a large, central vein. It is passed client’s that needs central venous pressure
along until tip sits in the large vein near the heart monitoring. It is also indicated to client’s receiving
(vena cava). Which vein is used depends on the drugs that are irritants, or that has the potential
client’s needs and overall health. to damage peripheral veins, drugs such as
vasopressors, chemotherapeutic agents, or
Types of central lines include:
hypertonic solutions. Central line placement is
• Peripherally inserted central catheter (PICC). This indicated to client’s receiving prolonged
line is placed in a large vein in the upper arm, or intravenous therapies, with Difficult peripheral
near the bend of the elbow. venous access, or in special treatments like
• Subclavian line. This line is placed into the vein that hemodialysis, and plasmapheresis.
runs behind the collarbone.
 However, central line placement is also
contraindicated to client’s with embolic issues
(existing central venous clots), increase risk of
bleeding, skin trauma or clients with existing
infection (infection at the site)
Methods to measure CVP
1. Indirect measurement – this method of
measurement includes inspection of the jugular
venous pulsations in the neck.
2. Direct measure – this method of measurement
utilizes a manometer and a transducer.
Monitoring CVP using a Pressure transducer
10. For accurate pressure detection, position the
Retrieved from: https://journals.rcni.com/nursing-
standard/role-of-central-venous-pressure-monitoring-in-
critical-care-settings-ns.2018.e10663
Equipment:
• -500ml normal saline
• -pressure bag
• -Transducer Kit (comes along with flush
tubing, pressure tubing)
• -Transducer Holder
• -Transducer Pressure cable
Procedure:
1. Gather the needed equipment to save time and
energy.
2. Identify the client, using to identifiers (ID
band/asking the patient his/her name). To
ensure that care will be delivered to the right
client.
3. Provide privacy.
4. Wash hands and don gloves. To reduce the
spread of microorganism.
5. Open the transducer set and set up all the
tubing. Make sure that connections are all
tighten, to obtain an accurate measurement.
Then, spike the bag (500ML NS) with tubing,
then place it into the pressure bag. Then,
inflate it to 300 mmHg, to sufficiently contract
the pressure.
6. The nurse will turn the bag upside down, then
prime the tubing. Make sure that there will be
no air bubbles left before connecting the line
to the client’s tubing.
7. The nurse will turn the stopcock to upward
position, clamp IV tubing and place the
transducer holder to
IV pole. The nurse makes sure that tubing that
is going
to the client is facing upwards, the cable for
the transducer is facing downwards.
8. Connect the pressure tubing tip to the distal
lumen of the central venous catheter.
9. Then connect the transducer cable to the
transducer and the monitoring device
client in a supine position and the transducer
needs to be leveled at the patient’s
phlebostatic axis - located by drawing an
imaginary line, from the 4th intercoastal space
and the sternum, then finding its intersection
with an imaginary line down the center of the
chest below the axilla.
11. Close the stopcock towards the patient
and open it to the atmospheric pressure as
seen on the video. Press zero on the monitor
and wait until the actual zero appears on the
screen.
12. Turn the three-way stopcock back to its
starting position with closed cap. Then begin
pressure reading.
Check the waveform. Assess waveform for
dampness. Dampness may distort systolic and
diastolic readings.
 13. Maintain tight luer-lok connections and non-
vented caps on stopcocks of pressure tubing.
Prevents risk of air embolism.
14. Record CVP pressure from the monitor. CVP
reflects a mean pressure in the right atrium.
Monitoring CVP using Water Manometer
Retrieved from:
https://www.britishjournalofnursing.com/content
/clinical/central-venous-pressure-monitoring-in-
critical-care-settings/
Equipment
• Disposable CVP manometer set
• Leveling device (such as rod from reusable CVP
pole holder or carpenter's level or rule)
• Additional stopcock (to attach CVP
manometer to catheter)
• Antiseptic pad
• Extension tubing, if needed
• IV pole
• IV solution (usually normal saline)
• IV drip chamber and tubing
Procedure:
1. Gather the necessary equipment. To save time and
energy.
2. Identity the client using two identifiers, according
to facility's policy. Checking identity guarantees
client protection.
3. Provide privacy and explain the procedure to the
client. Explanation protects client's rights and
reduces anxiety.
4. Wash hands and don gloves. Handwashing and
wearing of gloves reduce transfer of
microorganisms.
5. The nurse will connect the IV tube to the
manometer. Set up the manometer and prime
IV
tubing. The tubing should be free from all air
bubble. Attach the water manometer to an IV
pole. It is important that tubing should be free
from all air bubbles, as it affects CVP readings.
6. The nurse will then swab the injection port with
an antiseptic. Allow the injection port to dry.
Antiseptic prevents introduction of
microorganisms during flushing.
7. Connect the IV tubing to the CV line. Change the
IV solution every 24 hours and the IV tubing every
96 hours, or depends on the facility's policy. Label
the IV solution, tubing, and dressing with the
date, time, and initials.
8. With the CV line in place, client will be position on
flat, with the bed in its lowest position. The CVP
reflects right atrial pressure; health care providers
must align the right atrium (the zero-reference
point) with the zero mark on the manometer. To
find the right atrium, locate the fourth intercostal
space at the midaxillary line. Mark the
appropriate place on the client's chest. Align the
base of the manometer with the zero-reference
point by using a leveling device and secure it in
place. Marking client's chest ensures all
subsequent recordings will be made using same
location.
9. If the client cannot tolerate a flat position, client
will be place in a semi-Fowler's position. When
the head of the bed is elevated, the phlebostatic
axis remains constant but the midaxillary line
changes. Each time client changes position,
positioning of manometer will need to be
readjusted to zero reference point.
10. Typically, markings on the manometer range from
-2 to 38 cm H2O. However, manufacturer's
markings may differ. The directions should be
read before setting up the manometer and
obtaining readings.
11. The nurse will turn the stopcock off to the client
and slowly fill the manometer with IV solution
until the fluid level is 10- to 20-cm H2O higher
than the client's expected CVP value. Healthcare
providers make sure that the tubing should not be
overfilled. If tube is overfilled, fluid that spills over
top can become a source of contamination.
12. The nurse will turn the stopcock off to the IV
solution and open to the client. The fluid level in
the manometer will drop. When the fluid level
comes to a rest, it will fluctuate slightly with
respirations. Fluid will drop during inspiration and
rise during expiration.

13. The nurse will record CVP at the end of expiration,
when intrathoracic pressure has a negligible
effect and the fluctuation is at its highest point.
Depending on the type of water manometer used
the value at the bottom of the meniscus or at the
midline of the small floating ball will then be
noted.
14. After obtaining the CVP value, the nurse will turn
the stopcock to resume the IV infusion, if
indicated.
15. Verify that the IV solution port, CVP column
port, and client port are all open by turning the
stopcock. Healthcare professionals should be
aware that infusing the IV solution raises CVP
while the stopcock is in this position. Expect
greater readings as a result than those obtained
with the stopcock to the IV fluid switched off.
With IV solution infusing at a steady pace, the
first CVP value will be greater. Even if the first
reading was higher, it is crucial to assess the
client carefully to detect any changes in CVP as
the client's condition changes.
16. After the first CVP assessment, nurses
periodically reassess readings to create a
baseline for the client. To create a baseline,
authorities advise taking readings every 15
minutes, every 30 minutes, and every 60
minutes.
17. Then, the client will be placed in comfortable
position.
18. To reduce the transfer of microorganisms, the
nurse is responsible to remove gloves and
wash hands.
19. Documentation of the CVP reading on the flow
sheet will be done. The nurse will note the
condition of the catheter insertion site, any
complications and actions taken.
Normal CVP is between 0 and 8 cmH2O (1–6 mmHg).
Other references also suggest that the Normal CVP is 5-
10 cmH20 (2-6mmHg) when taken from the mid-
axillary line at the fourth intercostal space.
If the central venous pressure goes beyond the
normal range. A CVP greater than 6mmHg indicates
VENTRICULAR PRELOAD. There are many problems
that causes an elevated CVP, some are the following,
cardiac tamponade, constrictive pericarditis,
pulmonary hypertension, increase stroke volume,
renal failure and most common is hypervolemia and
right-sided heart failure. Clients with an elevated
CVP, may experience tachycardia, hepatomegaly.
Ascites, and edema. In this cases, health care
provider’s goal includes identifying and treating the
underlying cause in order to reduce the elevated
CVP.
NURSING INTERVENTIONS FOR CLIENT’S WITH
INCREASED CPV VALUE
✓ Fluid restriction.
✓ Administration of Diuretic to enhance fluid
elimination.
✓ Reduction of IV infusion rates.
✓ Assessment of urine output to see if there are any
obstructions to urine flow or evidence of acute
renal failure.
✓ Assessment of laboratory work for possibility of
renal failure.
If the central venous pressure on the other hand,
falls below the normal level, indicates REDUCED
RIGHT VENTRICULAR PRELOAD, which is often
caused by hypovolemia, dehydration, vomiting,
diarrhea, excessive blood loss, excessive use of
diuretics. Clients with a decreased CPV level, may
experience, tachycardia, hypotension, oliguria, or
anuria .
NURSING INTERVENTIONS FOR CLIENT’S WITH
DECREASED CPV VALUE
✓ Encourage patient to drink more fluids.
✓ Fluid resuscitation or Increase the IV fluid
infusion rate until CVP returns to normal range.
✓ Blood transfusion if indicated.
✓
POTENTIAL COMPLICATIONS RELATED TO CVP
MONITORING
When a CVC is put in place, complications can
occur both during and after the procedure and
subsequently, even if the CVC is not being used.
The following are some potential complications.
1. Central Line-Associated Bloodstream Infection
(CLABSI) - At the location where the CVC line is
inserted, bacteria from the skin might enter the
body. That is why, a scheduled sterile dressing
change and skin cleansing at the CVC insertion site
should be considered to avoid infection.
2. Artery Puncture - This can occur when the needle is medications and typically terminates in the
inserted and accidentally punctures an artery rather vena cava or right atrium.
than a vein. Hematomas, which happen when blood
2. Blue port – the right atrial pressure port, another
gathers outside the artery, can be brought on by a
vascular lumen that is slightly distal to the white port.
ruptured artery. The utilization of an ultrasound
This port is transduced to obtain a continuous
reduces the likelihood of such a problem as it aids in
measure of the client’s right atrial pressure which is
guiding the needle to the right vein and can tell a vein
what CVP is used to represent . This is also the port
from an artery.
that health care providers can inject fluid to get a
3.Blood clot (Thrombus) - The CVC can cause a blood cardiac output measurement .
clot, which can restrict or decrease blood flow. In
3. Yellow port – is a Pulmonary artery distal lumen, the
general, it needs prompt care, especially if the blood
most distal lumen as it terminates the very end of the
clot passes through blood arteries and blocks blood
pulmonary artery catheter inside the pulmonary
flow to the heart, lungs, brain, or other organs
artery. This port is transduced to get a continuous
(pulmonary embolism).
measurement of pulmonary artery pressure as well as
to get a PA occlusive pressure or a PA wedge pressure.

4. Red port – a balloon port that has a connected

Pulmonary Capillary Wedge Pressure is the pressure
that is obtained when a catheter equipped with an
inflated balloon is inserted into a minor branch of the
pulmonary artery.
Pulmonary Capillary wedge pressure monitoring Is
frequently used to assess left ventricular filling,
represent left atrial pressure, and assess mitral valve
function.
A Swan-Ganz catheter (a multi-lumen balloon catheter)
, or also known as the “PACATH – Pulmonary Artery
Catheter”, with a balloon tip is inserted into a central
vein and advanced into a
branch of the pulmonary
artery to measure it. The
pulmonary artery branch is
subsequently blocked by the
balloon's inflation, which
results in a pressure reading
that is equal to the left atrium's
pressure.
syringe and an on-off valve that is used to inflate the
balloon near the distal tip of the catheter.
The invasive process of pulmonary artery
catheterization has inherent risks. Following the
surgery, several difficulties have been reported;
according to research, the likelihood of complications
is 5% to 10%. Arrhythmias, thromboembolism,
pulmonary ischemia, hemoptysis, pulmonary
hemorrhage, perforation of the pulmonary artery,
knotting of the catheter, arterial puncture,
hematoma, and local infection are the most frequent
complications that can develop as a result of this
procedure. These complications can happen during or
after the procedure.

retrieved from:
https://standardofcare.com/pulmonary-wedge-
pressure/ Retrieved from:
https://www.rnceus.com/hemo/pac_purp21.html
There are 4 basic lumens a PA CATH consist of.
PCWP Measurement is indicated in confirming the
1. White-Proximal Infusion port – is a vascular
diagnosis of pulmonary arterial hypertension,
lumen that is the most proximal port. Used to
assessing the severity of mitral stenosis, for measuring
infuse fluids or
 the key hemodynamic parameters and to assess10. The empty syringe will be reconnected to the
client’s response to therapy. However, this syringe gate port. The, syringe gate port will be left
open.
contraindicated to client’s with Right-sided
endocarditis and Tumors or masses on the right side 11. The nurse will select “Edit wedge” smart key. Then,
of the heart. edit wedge at end expiration of respiratory cycle.
PROCEDURE ON OBTAINING A PULMONARY
CAPILLARY WEDGE PRESSURE
Equipment:
-Volume limiting syringe supplied in PA catheter
insertion kit
Procedure:
1. The nurse will position the patient in a supine
position.
2. Then, the nurse will verify if the transducer is
properly leveled and zeroed at phlebostatic axis.
3. The nurse will check sedation and ventilation
parameters if stable, and there should be no
significant fluctuation in the PA pressure secondary to
client’s movement, breathing or any other factor.
4. The nurse will Fill pulmonary artery (PA) syringe
with 1.5 ml of air (only use volume limiting 3cc syringe
provided with PA catheter kit).
5. “Wedge” smart key will be selected on the bedside
monitor.
6. The nurse will then observe for the prompt message
“Ready for balloon inflation”
7. The nurse will use PA syringe to slowly inflate
balloon with no more than 1.5 mL of air while
observing PA waveform change to a PAWP waveform.
If there is resistance, with no wedge trance, syringe
will be deflated and the nurse will try to re-inflate it
again – if resistance is still present, the head nurse or
ICU consultant will then be informed.
8. The balloon will be kept inflated for no more than 8-
15 seconds (2-4 respiratory cycles).
9. The nurse will disconnect syringe from balloon-
inflation port to allow syringe to passively deflate
12. Then, the nurse will store the pressure by pressing
“store wedge” smart key when cursor is in correct
position.
Take note:
• Use only enough air to convert PA waveform to a
PAWP waveform.
• Over inflation of balloon can cause pulmonary
infarct or rupture.
• If < than 1 mL of air generated a PAWP tracing, PA
catheter has migrated distally and needs to be
withdrawn slightly by physician for proper
placement.
• If no resistance is felt during balloon inflation, it
should be assumed that balloon has ruptured. The
procedure will be discontinued immediately and
physician will be notified.
• Only use syringe supplied by manufacturer as it
does not allow for overfilling.
• Filling syringe with more than 1.5 mL of air may
cause rupture of PA and balloon, leading to
pulmonary arteriole rupture or hemorrhage.
• Leaving balloon inflated for more than 8-12
seconds {2-4 respiratory cycles} may lead to PA
infarction, rupture or hemorrhage.
• Physician should be notified immediately if PA
wedge waveform is present when not performing
procedure (spontaneous wedge). Patient is at risk
for PA rupture, infarction or hemorrhage.
• If unable to obtain PAWP, utilize PA diastolic
pressure (PADP) for cardiac output studies if
previous PAWP and PADP were within 0-4 mmHg
of each other.
• Frequency of PAWP is ordered by physician.
The normal pulmonary capillary wedge pressure is
between 4 to 12 mmHg.
Elevated levels of PCWP might indicate severe left
ventricular failure or severe mitral stenosis. Moreover,
increased pulmonary capillary pressure generally
 reflects pulmonary venous hypertension or occlusion care nurses (CCNs) frequently do endotracheal
of pulmonary veins. Therefore, improving ventricular suctioning (ETS).
function and lessening the severity of the pulmonary

hemodynamic abnormalities are the main therapeutic

INDICATIONS FOR ET SUCTIONING
objectives in this case. The PCWP can be lower than
LVEDP in situations with decreased left ventricular • Increased respiratory rate
compliance (diastolic dysfunction, • Respiratory distress (tachycardia, gasping,
positive pressure ventilation, cardiac tamponade, or and trouble speaking)
myocardial ischemia) or in conditions such as aortic OPEN TECHNIQUE CLOSED TECHNIQUE
stenosis that result in premature mitral valve -Suction catheter of -Closed-suction setup
closure. appropriate size with a catheter of
-Sterile saline or sterile appropriate size
water solution -Sterile saline solution
-Sterile gloves lavage containers
Clients that are going to undergo general anesthesia,
-sterile solution -Individually packaged
or clients with congenital malformations, diseases of
container suction catheters for
the upper airway, in need for mechanical ventilation, -Source of suction (wall oral care
perinatal resuscitation and clients with various forms mounted or portable) -source of suction
of acute respiratory distress are indicated for -Connecting tube (wall mounted or
ENDOTRACHEAL TUBE INTUBATION – this is medical -Googles, mask, eye portable)
technique in which a tube is inserted via the mouth shield -Connecting tube
or nose into the windpipe (trachea). -Nonsterile gloves
-Googles, masks, eye
shield
• if there is a rise in resistance, a drop in SPO2,
an increase in PEEP, and an increase in FiO2.
•
• Materials for ET Suctioning:

Additional equipment, to have available as

needed are the following:

Retrieved from: https://blog.sscor.com/the- -Manual self-inflating manual resuscitation bag

importance-of-negative-pressure-for-
endotracheal-suctioning
Intubated patients may be unable to adequately
cough up secretions. That is why, endotracheal
suctioning is therefore important in order to
reduce the risk of consolidation and atelectasis
that may lead to inadequate ventilation.
ENDOTRACHEAL SUCTIONING (ET SUCTIONING)–
is a procedure done to remove accumulated
pulmonary secretions, promote airway patency for
appropriate ventilation and oxygenation, and
prevent atelectasis in intubated patients, critical
valve device connected to an oxygen flow meter.
-Positive end expiratory pressure (PEEP) valve for
patients on >5cm H20 PEEP and who must be hyper
oxygenated with a self-inflating manual
resuscitation bag.
PATIENT EDUCATION
-The procedure should be explained to the patient
Explanation reduces the patient’s anxiety.
-The nurse should explain that suctioning may be
uncomfortable and could cause, shortness of
breath. This information reduces anxiety and elicits
patient’s cooperation.
 PATIENT ASSESSMENT AND PREPARATION
by suctioning a small amount of sterile solution from
-The patient first will be assessed for signs and
the container. This ensures that the equipment is well
symptoms of airway obstruction, including
functioning.
secretions in the airway, inspiratory wheezes, restless,
ineffective coughing. Airway blockage and insufficient
gas exchange lead to physical symptoms and
indications.
Procedure on ET Suctioning:
1. Gather the need equipment
2. Verify the correct client using 2 identifiers. This
ensures the correct identification of the patient
intended for this intervention.
2. Establish rapport, provide privacy and explain the
procedure to the client.
3.Position the patient in a semi-fowler’s or fowler’s
position with the bed elevated at nurse’s waist level.
This positioning promotes comfort, lung expansion and
reduces train (for the nurse’s part)
4. The nurse should monitor the client’ s
cardiopulmonary status before, during and after the
suction.
OPEN-SUCTION TECHNIQUE
1. Open sterile catheter package on a clean surface,
with the inside of the wrapping used as a sterile field.
This prepares the catheter and prevents transmission of
microorganisms.
2. Depending on the manufacturer, the nurse will set up
the sterile solution container or sterile filed. The nurse
will use prefilled solution container or open empty
container, taking care not to touch the inside of the
container. Fill with approximately 100mL of sterile
normal saline solution or sterile water.
3. Don sterile gloves. This lessens the spread of
microorganisms.
4. The nurse will pick up suction catheter, with care to
avoid touching nonsterile surfaces. With the
nondominant hand, the nurse will pick up the
connecting tubing. The suction catheter will then be
secure to the connecting tubing. This maintains
catheter sterility.
5. The equipment will then be check for proper function
CLOSE SUCTION TECHNIQUE
1.The nurse will connect the suction tubing to the
closed system suction port or unlock the thumb
valve according to manufacturer’s guidelines.
2. The patient will be hyper oxygenate for at least 30
seconds, with these following methods, increase the
baseline Fio2, press the suction hyperoxygenation
button, attachment of self-inflating manual
resuscitation bag-valve device. This procedure is
essential as it prevents a sudden decrease in arterial
oxygen levels during the suctioning.
3. Then, the self-inflating manual resuscitation bag-
valve or ventilator circuit will be removed with the
nondominant hand. The nurse will swiftly put the
catheter into the artificial airway with the dominant
hand until resistance is met, then draw back 1-2 cm
before administering suction. The control vent of the
suction catheter should be open to the air. To reduce
declines in arterial oxygen levels, suction should only
be used when absolutely necessary to remove
secretions, and for as little time as feasible.
4. The suction catheter's control vent will then be
covered by the non-dominant thumb in order to
deliver either continuous or intermittent suction. As
you completely withdraw the catheter for less than
or equal to 10 seconds into the sterile catheter
sleeve (closed-suction technique) or out of the open
airway (open-suction technique), place and hold it
between the dominant thumb and forefinger.
5. As mentioned, hyper oxygenate for 30 seconds. In
order to avoid a drop in arterial oxygen levels during
the suctioning technique, hyperoxygenation with
100% oxygen is performed.
6. Suction the oropharynx once the airway has been
sufficiently cleansed of secretions. If secretions are
present, suctioning the oropharyngeal region may
improve patient comfort and need to be done as
part of oral hygiene.
 7.Rinse the catheter and connecting tubing with an increased heart rate, hypertension, and cardiac
sterile saline or sterile water solution until clear. arrhythmias.

Open suction – suction the unused sterile solution

until tubing is clear.

Closed -suction technique – instill sterile saline or

water solution into side port of in-line suction
catheter, taking care not to lavage down
endotracheal tube, while applying continuous
suction until catheter is clear.

This removes secretions in the connecting tubing.

8.Open-suction technique only; on completion of

upper-airway suctioning, wrap the catheter around
the dominant hand. Pull glove off inside out.
Catheter remains in glove. Pull off other glove in
same fashion and discard. Turn off suction device.
This reduces transmission of microorganism. POSSIBLE COMPLICATIONS ET SUCTIONING

9. Document effectiveness of and tolerance to
suctioning. Change closed suction system weekly
and place provided sticker determining next change
OPEN VS CLOSED SUCTION
There is some indication that using a closed suction
technique can assist in shortening the de-recruitment
period of mechanical breathing in newborns.
• Suctioning can stimulate the vagal nerve,
predisposing the patient to bradycardia and
hypoxia.
• Hypoxia can be profound from occlusion,
interruption of oxygen supply, and prolonged
suctioning.
• Mucosal trauma, physical injuries, and
bleeding can result from blunt or penetrating
trauma.

As well as lowering the potential of bacterial and viral

colonization inside the ventilation circuit, closed
suctioning safely shields nursing and medical
professionals from contact with patient body fluids.
Therefore, this strategy is appropriate when treating
individuals with infectious respiratory diseases.
The closed suctioning technique allows passage
of the suction catheter into the airway without
disconnection from the ventilator.
Advantages of the closed suctioning technique include:
-Ventilator settings can be maintained, especially
positive end-expiratory pressure (PEEP) Fewer episodes
and severity of hypoxia.
A chest tube is inserted the pleural space
( the space between the lungs and chest wall)
usually connected to a drainage system in order
to drain air or fluid from the chest. These systems
can be allowed to drain passively or can have
suction applied to them. Chest tubes comes in
variety of sizes and shapes, they also defer in
diameter depending on its use.

Open Suction: Suction is performed by means of

disconnecting the patient ETT from the ventilation
device during the procedure and then reconnecting it
following the procedure. Open suctioning is reportedly Retrieved from:
associated with inadequate arterial saturation, inability https://www.medicalnewstoday.com/articles/32216
to maintain a Positive End-Expiratory Pressure (PEEP), 1
 Physicians/Doctors are responsible for inserting 5. The doctor will make an incision about 2–3
these chest tubes. The following are the indications, centimeters (cm) through the skin. Using a
surgical instrument called a Kelly clamp, the
Empyema - An infection that appears in the pleural
doctor will widen the incision and gain access to
area is known as an empyema.
the pleural space. The clamp insertion should be
Hemothorax - is a condition in which there is an slow to avoid puncturing the lung.
accumulation of blood in the chest cavity, typically as
6. Placing a gloved finger inside the wound, to
a result of an accident, tumor, or bleeding problem. In
confirm that the area is the pleural space.
order to avoid a hemothorax during chest surgery,
doctors may introduce a chest tube. 7. The doctor will then insert the chest tube via
the incision site. if fluid starts to drain down the
Pleural effusion - is the accumulation of fluid in the
tube, this indicates that the tube is in proper
pleural space. Heart failure, lymphatic fluid, a lung
position. The tube might alternatively be
tumor, or diseases like TB and pneumonia can all
connected to a water chamber that moves in
contribute to it.
response to breathing. If not, the tube might
Pneumothorax - The term "pneumothorax" refers to a need to be repositioned.
collapsed lung. Spontaneous pneumothorax is the
8. Suturing the tube in place so that the seal is as
medical term for when a lung suddenly collapses. A
airtight as possible. Covering the tube insertion
chest injury, such as a gunshot or stab wound, can also
site with gauze pads.
result in a pneumothorax.
A chest X-ray can also help to confirm the tube’s
A chest tube may also be inserted to carry a procedure
placement
called PLEURODESIS, in which chemicals is delivered
into the pleural area, in order to cause an intentional NURSING RESPONSIBILITIES
scarring as these substances has the tendency to
Nursing care for patients with a chest tube
irritate the lining of the lung. It is done to prevent
consists of assessing the location of the chest
recurrent pleural effusion or pneumothorax or to treat
tube to avoid dislodgment and infection,
a persistent pneumothorax.
managing adequate suction and drainage,
PROCEDURE ON CHEST TUBE INSERTION relieving discomfort, keeping track of the
patient's respiratory state, and providing all-
1. The client’s bed will be elevated about 30 and 60
around supportive care.
degrees or positioned in a semi-fowler. Usually, the
afflicted side's arm will be raised above the head. Other specific interventions include the
following:
2. Identifying the tube insertion site. This is typically
located between the fourth and fifth ribs or between 1. Administration of medication, as indicated. A
the fifth and sixth ribs, just behind the pectoralis (chest) local anesthetic is frequently given after the
muscle. region has been sterilized. In cases of trauma or
extreme pain, an IV opioid may also be
3. The site will be cleaned using chlorhexidine or
administered. Additionally, a nerve block might
povidone-iodine. Before covering the patient with a
be used to lessen the requirement for
sterile drape, doctors will wait for the skin to dry
postoperative painkillers.
4. Numbing the insertion location using local
2. Teaching the client about splinting. .The usage
anesthetic. A doctor may use a deeper needle insertion
of auxiliary respiratory and abdominal muscles
once the region has become entirely numb to try and
during coughing and breathing might be painful
draw back fluid or air. This will demonstrate that they
following chest tube insertion. Pain can be
are where they should be.
lessened by splinting the place where the chest
tube is implanted.
3. Encouraging the client to obtain adequate rest connections. Verify the insertion area to
periods in between interventions. Adequate rest ensure the tube hasn't come loose. When an air
intervals aid in recovery, lower oxygen leak is present, it may be a sign of a developing
consumption, lessen pain, and save energy. problem, such as a deteriorating pneumothorax.
If the tube has become loose or you cannot find
4. To avoid fluid returning to the client's chest,
or stop an external leak, you should immediately
make sure the system is kept below the client's
contact the healthcare professional.
chest and upright. If floor stands are present,
make sure they are drawn out and perpendicular COMPLICATIONS
to the unit. Floor stands are sometimes included
• Pain – chest wall/ neck / shoulder.
in drainage systems to keep the unit from
toppling over. If there is a stopcock, make sure it • Failure to enter the pleural space.
is set up to allow drainage into the drainage • Infection at insertion site or intrapleural.
system. • Penetration / lacerations to lungs.
• Penetration of peritoneal space -
5. Make sure the tubing is not kinked to prevent laceration of the diaphragm.
clot formation. Any existing drainage must be • Hemorrhage.
freely flowing into the collecting chamber. Do • Blocked drains.
not, however, "strip" the tubing—that is, swiftly
occlude the chest tube with one hand while
squeezing and pushing the other hand down the
tube to send fluid into the drainage chamber.
High intraluminal pressures brought on by doing
this may result in a pneumothorax, which is
potentially fatal.

6. Ensure the chest tube is firmly attached to the

client's chest wall and all tubing connections are
taped to ensure the system stays closed (i.e.,
without air leaks).

7. Examine and record the volume, color, and

characteristics of the fluid present in the
collecting chamber. On the exterior of the
collecting chamber, note the drainage level and
the time and date for easy future reference
during your shift.

8. Ensure the water seal chamber is filled with

sterile water to the 2 cm mark (or as specified by
the manufacturer). Tidaling should be seen in the
water seal chamber. If tidaling is not occurring,
the system may not be working properly, the
tubing may not be patent, or the client’s lung may
have re-expanded.

9. The water seal chamber shouldn't continuously

bubble since this might indicate a leak. Try as
soon as possible to locate and fix the sources of
external leaks, such as improper tubing
References:
Central Venous Pressure Management. Measuring Central Venous Pressure with a Water
Manometer. 2020.
http://downloads.lww.com/wolterskluwer_vitalstream_com/sample-
content/9780781788786_craven/samples/mod10/topic3a/text.html

Centers for Disease Control. (2002). Guidelines for the prevention of intravascular catheter-
related infections. MMWR, 51(RR10), 1-26.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

Central Venous Pressure (CVP). Truman State University. 2023.

https://shadwige.sites.truman.edu/hemodynamic-monitoring-front-page/pulmonary-
artery-catheters/central-venous-pressure-cvp/

Kendrick (2020). Endotracheal tube suction of ventilated neonates. Clinical Guidelines

(Nursing)
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/endotracheal_tube_suct
ion_of_ventilated_neonates/

Klabunde (2023). Pulmonary Capillary Wedge Pressure. Cardiovascular Physiology Concepts

https://cvphysiology.com/heart-failure/hf008

Lindsay Dusselier et. al. 2015. Nursing Procedure

https://rqhealth.ca/service-lines/clinical-quality-professional-practice/files/P.7.pdf

Matthew Ball Abhishek Singh.(2023). Care of A Central Line. National Library of Medicine.
https://www.ncbi.nlm.nih.gov/books/NBK564398/

Merkle, A. (2022). Care of a chest tube. StatPearls.

https://www.statpearls.com/ArticleLibrary/viewarticle/41781

RegisteredNurseRN. (2016, August 3). Chest tubes nursing care management assessment
NCLEX review drainage system

Wagner (2023). Chest Tube Insertion Nursing Diagnosis & Care Plan.
https://www.nursetogether.com/chest-tube-insertion-nursing-diagnosis-care-
plan/#:~:text=Nursing%20care%20for%20patients%20with,and%20providing%20overall%2
0supportive%20care.