Reviewer for NCMB312 Skills Lab FINALS by Ligaya  Anxiety

 Difficulty breathing (Dyspnea)

Pulse Oximetry
Symptoms of Severe Hypoxia
 Pulse oximetry is a noninvasive test that measures the
oxygen saturation level of blood  Slow heart rate
 Oxygen saturation level indicates the amount of oxygen  Extreme restlessness
traveling through the body and shows how efficiently  Blue skin (Cyanosis)
blood is carrying oxygen to the extremities furthest from
the heart Parts of Oximeter
 The pulse oximeter is a noninvasive device attaches to a
body part  Oxygen Saturation (Sp02) – indicates that amount of
 It can rapidly detect even small changes in oxygen levels oxygen traveling through your body with your red blood
cells
Oxygen Saturation Levels  Pulse Rate Bargraph Display – is the pulse rate in beat per
minute (PRBPM). It is the visual representation of the
 95% - 100% - Normal Sp02 heartbeat.
 Below 95% - Hypoxemia  Power Indicator
 85% and below – Critical Level  Pulse Rate Waveform Display
 Pulse Rate – pulse rate beats per minute (PRBPM),
Cerebral hypoxia (low oxygen level in the brain) corresponds with the heart rate.
 Perfusion Index Display – is an indication of the pulse
 May follow in a few minutes and cause irreversible brain
strength at the sensor site. The pi’s values range from
damage. Several vital organs might also be affected. The
0.02% for very weak pulse to 20% for extremely strong
person warrants immediate treatment and oxygenation.
pulse. The perfusion index varies depending on patients,
Medical Conditions that affect Blood Oxygen Level physiological conditions, and monitoring sites.
 Power ON/OFF Button (Setting Switch)
 Heart Conditions
 Congenital heart defects Process of Pulse Oximeter
 Congestive heart failure
 Oxygen that is inhaled from the atmosphere diffuses
 Lung Conditions through the lungs and into the bloodstream to be used up
 Acute respiratory distress syndrome by body tissues for energy
 Asthma  Most of the oxygen is bound to the hemoglobin
 Bronchitis component of a red blood cell
 COPD  Few are dissolved in plasma
 Pneumonia  Pulse oximeter reads the concentration of oxygen bound
 Pulmonary fibrosis to hemoglobin in the blood by shining infrared and red
 Pneumothorax light through a translucent part of the body so that light
 Pulmonary edema emitted from the light transmitter will be received by the
 Pulmonary embolism photodetector on the opposite side
 Sleep apnea
 Strong pain medications (narcotics) Where can Pulse Oximeter be used?
 Anemia
 To get an accurate reading, a pulse oximeter probe must
Symptoms of Hypoxemia be placed on a translucent part of the body so that light
emitted from the light transmitter will be received by the
 Headache photodetector on the opposite side
 Shortness of breath
 Fast heartbeat Fingertip
 Coughing
 Wheezing  Most accessible segment of the body
 Confusion  Nail polish/varnish can affect the measurement of oxygen
 Bluish color of skin, fingernails, and lips saturation, particularly black, green, and blue

Symptoms of Hypoxia Toes

 Restlessness  Helpful in detecting problems in arterial blood flow such

 Headache as in lower extremity arterial disease
 Confusion
 Rapid heart rate (Tachycardia)
 Rapid breathing (Tachypnea)
Earlobe  Appling the pulse oximeter
4.4. Wash hands and clean the site with alcohol
 Can be clipped either on the tip or lower part of the pinna 4.5. Apply the sensor
(earlobe) 4.6. Connect the sensor to the oximeter with sensor
 Medical anomalies with the hands or fingers that hinder cable. Turn on the machine
precise measurement of oxygen saturation 4.7. Set and turn on the alarm
4.8. Inspect and/or move or change the location of the
Forehead adhesive toe or finger sensor every 4 hours and a
spring tension sensor every 2 hours to provide
 Use in rare cases, wherein the digits and ear are client’s safety
inaccessible 4.9. Immobilize the client’s monitoring site to ensure
 Pulse oximeter may be attached low across the forehead accuracy of measurement
and just right above the eyebrows, making sure that it is 5. Documenting the procedure
placed away from a major vessel
Pulse Oximetry Errors & Troubleshooting
Purpose of Pulse Oximetry
Failure to obtain signal
 To assess if blood is well oxygenated
 To monitor the health of people with conditions that  Keep measuring site clean and dry
affect blood oxygen levels, especially while they’re in the  Reposition the user’s finger or the measuring site
hospital  Change the monitoring site to avoid skin breakdown
 These include:  Assess vital signs including the measuring site for
 Chronic obstructive pulmonary disease (COPD) adequate blood flow
 Asthma  Place blood pressure cuff opposite of the measuring site
 Pneumonia  Check for loose wirings or whether the probe is properly
 Lung cancer attached to the base unit and should be connected to a
 Anemia power source
 Heart attack or heart failure
 Congenital heart disease Limitations
 To assess how well a new lung medication is working
 High levels of artificial light could skew reading
 To determine whether someone needs supplemental
 Dirt, open wounds, nail polish may affect the reading
oxygen therapy
 Instant reading could provide false result. Wait at least 5
 To evaluate how helpful a ventilator is fingertip pulse beats to get an accurate reading
 To monitor oxygen levels during or after surgical  Movement, such as shaking or shivering can affect the
procedures that require sedation reading
 To determine how effective supplemental oxygen therapy  Preexisting medical conditions such as anemia, lung or
is, especially when treatment is new heart problems could provide low O2 saturation level
 To assess someone’s ability to tolerate increased physical  Environment or skin temperature could affect the O2
activity saturation level
 To evaluate whether someone momentarily stops  Exposure of measuring probe to ambient light during
breathing while sleeping – like in cases of sleep apnea – measurement
during a sleep study
Incentive Spirometry
Taking Pulse Oximetry Reading
 Also referred to as sustained maximal inspiration (SMI)
1. Assessment of baseline data  It serve as a test that measures ventilation and measures to
1.1. Assess vital signs including the measuring site, improve lung function
whether there is adequate blood flow
1.2. Assess skin color Incentive Spirometer
1.3. Assess nail beds
2. Identifying the patient  Is a medical device used to measure how well the lungs
2.1. Greet the patient fill up with each breath
2.2. Ask her/his name
2.3. Check ID band and bed tag Types of Incentive Spirometer
3. Explaining the procedure
3.1. Explain procedure and its purpose to the patient  Flow-Oriented Incentive Spirometer (Triflow Device)
clearly and completely  Has three chambers with one ball in each chamber.
4. Preparing the pulse oximeter Capacity up to 1200ml
4.1. Check if pulse oximeter is functioning properly  It provides an indirect indicator of the patient
4.2. Check sensor appropriate for the client age (height inspired volume
and weight)  Volume-Oriented Incentive Spirometer
4.3. Select an appropriate site for the sensor  Has one way valve with capacity up to 4000ml
  Requires lesser work of breathing 7. Slide the indicator (located in the left-hand column when
 Improves diaphragmatic and pulmonary function you are facing the spirometer) to the desired level
better compared to triflow 8. Place the mouthpiece into the client’s mouth and instruct
 Incentive spirometer measures how deeply the patient the patient to tightly seal his/her lips around it
breath in 9. With lips tightly sealed around the mouthpiece, breathe in
slowly and as deeply as possible. The piston that is resting
Parts of Incentive Spirometer below the indicator should now rise toward the top of the
column
 Indicator 10. Instruct the patient to hold breath for at least 3 seconds
 Mouth piece and allow the piston to fall back to the bottom of the
 Marker column
 Piston 11. After each set of deep breathing, instruct patient to cough
 Flexible tubing to help clear the airways of mucus. Ask the client to rest
for a few seconds and repeat steps 10-11, 10 times each
Indications of Incentive Spirometry hour while the patient is awake
12. If patient has incision, instruct patient to press firmly
 Presence of conditions predisposing to the development against the incision with a pillow during coughing. It will
of pulmonary atelectasis offer additional support and comfort
 Upper-abdominal surgery 13. Place patient in comfortable position
 Thoracic surgery 14. Instruct patient how to care for the spirometer
 Surgery in patients with chronic obstructive 14.1. After each use, clean the mouthpiece of the
pulmonary disease (COPD) spirometer with warm water and soap. A disposable
 Recovering from severe pneumonia mouthpiece should not be reused for more than 24
 With bronchial asthma hours
15. Document the procedure
Risks and Contraindications
Nebulization
 In general, there are very few risks or possible
complications with regular incentive spirometer usage, - is the process by which a liquid medication is converted into
but it’s important to stop if present of lightheadedness a fine mist that can be inhaled.
 There are rare reports of collapsed lung or pneumothorax
in people with emphysema Nebulizer – the device that is used to convert liquid drug into
 Had recent eye surgery: the pressure of breathing aerosol droplets suitable for patients to inhale.
forcefully may affect the eyes
Nebulizers – uses compressed air or oxygen to make an
 Have a collapsed lung
aerosol (tiny particles of medication in the air)
 Have an aneurysm (ballooning blood vessel) in the chest,
abdomen, or brain Parts of Nebulizer:
 If patient cannot be instructed or supervised to assure
appropriate use of the device o Mouthpiece
 If patient’s cooperation is absent or patient is unable to o Compressor
understand or demonstrate proper use of the device o Tubing
 If patient is unable to deep breathe effectively o Nebulizer Cup
 Not contraindicated to patient with open tracheal stoma
but requires adaptation to the spirometer Indication:

Steps in Incentive Spirometry o Bronchospasms

o Chest tightness
1. Verify the doctor’s order o Excessive and thick mucus secretions
2. Wash hands observed
o Respiratory congestions
3. Gather the materials
o Pneumonia
3.1. Incentive spirometer (may require a prescription
from your doctor) o Atelectasis
3.2. Pillow (if you have an incision) o Asthma
3.3. Comfortable place to sit
3.4. Tissue Contraindication:
4. Greet & identify the patient. Then explain the procedure
o Unstable or increased blood pressure
5. Position the patient in sitting or lying upright in a
o Increased pulse
comfortable position
o History of adverse reaction to medication
Instruct the client to: o Individuals with cardiac irritability (may result to
dysrhythmias)
6. Hold the incentive spirometer upright, with both hands o Unconscious patients
 13. After care:
 Clean and keep equipment in their proper place.
Steps in Nebulization:  Wash hands
 Document the procedure.
1. Verify the doctor’s order properly and accurately
2. Wash hands observing the principles of medical hand Chest Physiotherapy
washing.
3. Gather materials needed. Check compressor if it is 1. Postural drainage
functioning properly. 2. Chest percussion
4. Greet and identify the patient by asking his/her name and 3. Vibration
checking his/her ID band politely. 4. Coughing and deep breathing exercise
5. Explain the procedure clearly and completely to get the
client’s approval. Purpose:
6. Position the patient appropriately and comfortably,
allowing optimal ventilation. Provide privacy during the o To mobilize and eliminate secretions, re-expand lung
entire procedure. Assess and record breath sounds, tissue, and promote efficient use of respiratory muscles.
respiratory status, pulse rate and other significant o To prevent or treat atelectasis or to prevent pneumonia.
respiratory functions.
7. Preparing equipment: Indications:
 Place the air compressor on a sturdy surface that will
support its weight. o Cough with secretions
 Plug the cord from the compressor into a properly o Cystic fibrosis
grounded electrical outlet. o Bronchiectasis
 Carefully measure the medicine exactly as ordered. o Atelectasis
Use a separate, clean measuring device for each o Neuromuscular diseases
medicine. o Pneumonia
8. Placing the medicine in the nebulizer cup:
 Remove the top part of the nebulizer cup. Contraindications:
 Place the medicine inside the nebulizer cup.
 Attach the top portion of the nebulizer cup and o Active pulmonary bleeding with hemoptysis
connect the mouthpiece or face mask to the cup. o Fractured ribs
9. Connecting the tubing: o Lung contusions
 Connect the tubing to both the aerosol compressor o PTB
and nebulizer cup. o Untreated pneumothorax
 Turn on the compressor with the on/off switch. o Acute asthma or bronchospasm
 Check if there is a light mist coming from the back of o Lung abscess or tumor
the tube opposite the mouthpiece. o Bony metastasis
10. Placing the mouthpiece or mask: o Head injury
 If using a mask, position it comfortably and securely o Recent MI
on the client’s face.
 If using a mouthpiece, place it in between the teeth Postural Drainage:
and seal lips around it.
 Take slow deep breaths through mouth. If possible,  Lower and middle lobe bronchi: head-down position
hold each breath for 2-3 seconds before breathing  Upper lobe bronchi: head-up position
out. This allows the medication to settle into the
airways.  If one lung is more affected than the other opposite side.
11. Performing the procedure:  When tipping the child over pillows place under the
 Continue the treatment until the medication is gone pelvis, NOT under the chest.
(about 7-10 minutes)  In babies, it may be more usual for the upper lobes to be
 If the client becomes dizzy or feel “jittery”, stop the affected sitting position.
treatment and rest for about 5 minutes.
 Then continue the treatment, but instruct the patient Upper Lobe:
to breathe more slowly. If symptoms persist, inform
the physician.  Apical Bronchus – sitting upright (a)
12. Ending the procedure:  Anterior Bronchus – lying supine with the knees slightly
 Turn the compressor off. Instruct patient to take flexed. (c)
several deep breaths and cough.
 Continue coughing to clear any surfaces that might Posterior Bronchus:
have in the lungs.
 Cough out the secretions into a tissue and dispose it  Right – lying on the left side and turn his face 45° resting
properly. against a pillow, with another pillow supporting the head.
 Place patient comfortably in bed.
 Left – lying on the right side turning his/her face 45° with
3 pillows arranged to lift the shoulders by 12 inches.

Middle Lobe (Right):

 Lateral and medial bronchus – lying supine with the body Chest Physiotherapy Procedure
a quarter turned to the left maintained by a pillow under
the right side from shoulder to hip and foot end raised by o Perform chest physiotherapy (CPT) in the morning on
14 inches (35cm). arising, 1 hour before meals, or 2 to 3 hours after meals.
Stop CPT if pain occurs.
Lingula (Left): o If the client is receiving a tube feeding, stop the feeding
and aspirate the residual before beginning CPT.
 Superior and inferior bronchus – lying supine with the o Percuss the area for 1 to 2 minutes; vibrate the same area
body a quarter turned the right maintained by a pillow while the client exhales four or five deep breaths.
under the left side from shoulder to hip and foot end o Monitor for respiratory tolerance to the procedure. Stop
raised by 14 inches (35cm) the procedure if cyanosis or exhaustion occurs.
o Maintain the position for 5 to 10 minutes after the
Lower Lobe:
procedure.
 Apical basal bronchus – lying prone with a pillow under o Repeat all necessary procedure until the client is no
the hips. longer expectorates mucus.
 Anterior basal bronchus – lying supine with the buttocks o Dispose of sputum properly. Provide mouth care after the
resting on a pillow and the knees flexed. Foot of the bed procedure.
raised by 18 inches (45cm).
Closed Chest Drainage (Tracheostomy Tube)
Medial Basal:
Pleural Space
 (Cardiac) bronchus – lying on the left side with a pillow
under the hips. Foot of the bed raised by 18 inches  A small space that surrounds the lungs that contains a
(45cm). small amount of serous fluid. This small space is
surrounded by the parietal and visceral pleurae.
Posterior Basal Bronchus
Purpose:
 Lying prone with a pillow under the hips. Foot of the bed
raised by 18 inches (45cm) o To remove air and or fluids from the pleural space
o To re-establish negative pressure and re-expand the lungs
Lateral Basal Bronchus
Indication:
 Lying on the opposite side with a pillow under the hips.
Foot of the bed raised by 18 inches (45cm). 1. Pneumothorax
2. Pleural effusion
Percussion: 3. Chylothorax
4. Empyema
 Striking the chest wall over the area being drained. 5. Hemothorax
 Use of cupped palm to loosen pulmonary secretions. 6. Hydrothorax
 Supine or prone position. 7. Postoperative
 Cupping is never done on bare skin, over surgical
incisions, below the ribs, or over the spine or breasts. Types of Closed Chest Drainage:
 30 to 60 seconds several times a day.
 Tenacious secretions percussed for 3-5 minutes several o One bottle water-seal system
timers per day.  The bottle serves as drainage bottle and water seal
bottle
Vibrations:  Immerse tip of the tube in 2 – 3 cm of sterile NSS to
create water seal.
 The nurse may use one or two hands with vibration,  Keep bottle at least 2 – 3 feet below the level of the
which is performed when the client exhales or cough. chest to allow the drainage from the pleura by gravity
 The purpose is to help loosen respiratory secretions so  Never raise the bottle above the level of the chest to
that they can be expectorated with ease. prevent reflux of air and fluid

Position of hand in performing chest vibration: Nursing Responsibility:

1. Assess for patency of the device

  Observe for fluctuation of fluid along the tube Suctioning:
 Observe for intermittent bubbling of fluid;
continuous bubbling means presence of air-leak  Is aspirating secretions through a catheter connected to a
 Absence of bubbling in the suction control chamber suction machine or wall suction outlet.
indicates that the pressure of suction is not enough.  Is a lifesaving procedure requiring timely and precise
There will be no drainage. methodology.
 Suspect obstruction of the device check for kinks  If done appropriately, it decreases the risk of:
along tubing, milk tubing towards the bottle o Infection
 If there is no obstruction, consider lung re-expansion o Pooling of secretions and
validated by CXR o Prolonged hypoxia
 Air vent should be open to air
Purposes:
o Two bottle water-seal system
 Not connected to the suction apparatus o To remove secretions that obstruct the airway
 The first bottle is drainage bottle; the second bottle is o To facilitate ventilation
water seal bottle. o To obtain secretions for diagnostic purposes
 Expect continuous bubbling in the suction control o To prevent infection that may result from accumulated
bottle; intermittent bubbling and fluctuation in the secretions.
water seal
 Immerse the tip of the tube of the suction control Suctioning is necessary when patients are unable to clear
bottle in 10 – 20 cm of sterile NSS to stabilize the respiratory secretions from the airways by coughing.
normal negative pressure in the lungs
Suctioning Techniques:
o Three bottle system
 Observe for intermittent bubbling and fluctuation 1. Endotracheal Tube (ETT) Suctioning
with respiration in water seal bottle, continuous 2. Tracheostomy Suctioning
bubbling in the suction control bottle indicates air
leak.\ Tracheal suctioning:

Pleur-evac Drainage System:  Is suctioning into the trachea through an artificial

airway such as endotracheal (ET) or tracheostomy
o Suction system tube.
o Underwater seal bottle
Essential Equipment:
o Fluid level in collection chamber
o Oxygen source
Take note:
o Stethoscope / Pulse oximeter
o Encourage to do the following to promote drainage: o Portable or wall suction machine
 Deep breathing and coughing exercises o Appropriately sized suction catheters
 Turn to sides at regular basis o Disposable / Sterile gloves
 Ambulate o Goggles
 ROM exercises of arms o Towel or moisture resistant pad
 Mark the amount of drainage at regular intervals o Sterile water for irrigation
 Avoid milking and clamping of tube to prevent o Sterile disposable container for fluid
tension pneumothorax o Disposable plastic apron
 Removal of chest tube done by physician o Sterile basin (e.g. sterile disposable cup)
o Sterile water or normal saline (about 100 mL)
Prepare:
o Clean towel or paper drape
o Petrolatum gauze o Water soluble lubricant
o Suture removal kit
o Sterile gauze and Adhesive tape
 Endotracheal: Sterile suction catheter / Sterile gloves
o Place client in semi – fowler’s position  Tracheostomy: Sterile suction catheter / Sterile globes
o Instruct client to exhale deeply and do valsalva’s
maneuver as the tube is removed Types of Suction Catheter:

o CXR may be done after the tube is removed A. Open tipped

o Assess for complications: subcutaneous emphysema, B. Whistle tipped
respiratory distress  Less irritating to respiratory tissues
 More effective for removing thick mucus plugs
Endotracheal and Tracheostomy Suctioning
Sizes of Suction Catheter: o Encourage coughing when catheter is introduced.
o Have patient practice coughing if able and splint surgical
1. Infants 5 Fr – 8 Fr incisions (if present)
2. Children 8 Fr – 10 Fr
3. Adults 12 Fr – 18 Fr Procedure:
Parts of Suction Catheter:  Assist patient with assuming comfortable position
(usually semi-fowler’s or sitting upright with head
o Thumb-control valve hyperextended, unless contraindicated).
o Connector for vacuum Rationale:
o Catheter o Reduces stimulation of gag reflex, promotes patient
o Tip with a single opening comfort and secretion drainage, and prevents
o Vacuum tubing aspiration.
o Hyperextension facilitates insertion of catheter into
Guedel Airway / Oropharyngeal Airway trachea. Position facilitates catheter insertion.
Purposes: Stand on patient’s right side if you are right-handed or on
patient’s left if you are left-handed.
o Provide adequate ventilation and oxygenation
o Maintain a patent airway  Position pulse oximeter on patient’s finger. Take reading
o Eliminate airway obstruction and leave pulse oximeter in place.
o Provide access for secretion clearance Rationale:
 Provides baseline SpO2 to determine patient’s response to
For Diagnostic Exam: suctioning
 Place towel across patient’s chess
o Specimen Trap / Specimen Bottle (Sterile) Rationale:
 Reduces transmission of microorganisms by protecting
Suction Device:
gown from secretions.
A. Wall Unit
Tracheostomy Care:
Suction Pressure:
o Adult – 100 to 120 mmHg Tracheostomy:
o Child – 95 to 110 mmHg
o Infant – 50 – 95 mmHg  Is a surgical opening in the trachea (windpipe) to make
breathing easier
B. Portable Unit  Opening is called a Stoma
Suction Pressure:
o Adult – 10 to 15 mmHg Indications:
o Child – 5 to 10 mmHg
o Infant – 2 to 5 mmHg  Mechanical ventilation
 Failed endotracheal intubation
 Large tumor of the head and neck

Position Types of Tracheostomy Tube:

1. Conscious Patient o Uncuffed

o Semi – fowler’s position
2. Unconscious Patient
o Lateral position and the patient facing you
Things to remember!
o Assess the need for suctioning at least every 2 hours
through auscultation of the chest.
o Maintain sterile technique while suctioning.
o Administer supplemental 100% oxygen through the
mechanical ventilator or manual resuscitation bag before,
after, and between.
o Monitor heart rate and auscultate breath sounds before the
procedure.
o Encourage patient to cough out secretions
 May be plastic or metal, which allows for air to flow
around the tube (permanent tracheostomy)
o Cuffed
 Are surrounded by an inflatable cuff that produces an
airtight seal between the tube and the trachea.
 Often used immediately after tracheostomy
 Essential when ventilating a tracheostomy client with
a mechanical ventilator.
o Fenestrated
 Has holes in the outer cannula
 Is used when the client is being weaned (gradual
discontinuation of mechanical support)
Parts of Tracheostomy Tube with inner cannula:
o Neck plate
o Side port  If an inner cannula is present, remove and clean and
o Obturator replace with a new one
o Connector  Sterile technique must be observed all throughout the
o Inned cannula procedure
o Cannula  Assess the peristomal skin and incision site
o Foam cuff  Notify the physician for any abnormalities

Parts of Tracheostomy Tube: Suctioning

o Outer cannula When:

 that is inserted to the trachea  Suction as necessary
o Inner cannula
 may be removed for periodic cleaning
o Neck plate (Flange) o Maintain a patent airway
 rests against the neck and allows the tube to be o Prevent airway obstruction
secured in place with tape or ties o Promote respiratory function (optimal exchange of O2
and CO2 into and out of the lungs)
o Prevent pneumonia that may result from accumulated
o Obturator secretions
 used to insert the outer cannula and then removed
 it is kept at the client’s bedside in case the tube Complications:
becomes dislodged and need to be reinserted
o Cuff o Hypoxemia
 Produces an airtight seal between the tube and the o Trauma to airway
trachea. This seal prevents aspiration of o Cardiac dysrhythmia related to hypoxemia
oropharyngeal secretions and air leakage between the o Stimulates cough reflex and
tube and the trachea o Stimulates mucus production
o Fenestration
 Hole in the outer cannula  It should only be done when breath sounds indicate that
the need is present!
Types:  The diameter of the suction catheter should be about half
the inside diameter of the tracheostomy tube to prevent
 Twill hypoxia
 Velcro
 Metal bead Materials:
Advantages (Tracheostomy Care) o Resuscitation bag (Ambubag) connected to 100% oxygen
o Sterile towel
o Maintains airway patency o Suction machine
o Maintains cleanliness and prevents infection at the o Suction catheter
tracheostomy site o Sterile glovers
o Facilitates healing and prevents skin excoriation around
o Sterile water for flushing
the tracheostomy incision
o Goggles / gown if necessary
o Promotes comfort
Steps:
Disadvantages
1. Assess the need for suctioning
o Air is no longer filtered and humidified; special
2. Greet the patient, explain the procedure
precautions are necessary 3. Place the patient in semi-fowler’s position to promote
Solution: breathing, maximum lung expansion, and productive
 Wear a light scarf or coughing
 4x4 inch gauze held in place with a cotton twill ties 4. Prepare the equipment
over the stoma to filter the air 5. Attach the resuscitation apparatus to the oxygen source
6. Open the sterile supplies in readiness for use
Nursing Responsibilities:
7. Put on sterile glove
 Provide tracheostomy care at least every 8 hours after the 8. Place sterile towel across the patient’s chest
initial inflammatory response. 9. Hyperoxygenation the patient before, during and after the
 Hyper oxygenate the client and perform suctioning to procedure
remove secretions (10 – 15 secs) (total time – 5 mins) 10. Flush and lubricate the suction catheter
11. Press the AmbuBag 3 – 5 times as the client inhales
12. Quickly but gently inset the catheter (6 in., without
applying suction) until the client coughs or if you feel
resistance
13. If resistance is felt, withdraw the tube for about 1 – 2 cm
before applying suction
14. Perform suctioning
15. Apple intermittent suction about 5 – 10 sec
16. Rotate the catheter while withdrawing to prevent tissue
trauma
17. Hyperventilate the patient
18. Allow 2 – 3 minutes between suction as possible to
provide the opportunity for reoxygenation of the lungs
19. Repeat until air passage is clear and the breathing is
effortless and quiet
20. After each suction, ventilate the patient with 5 breaths
21. Dispose equipments
22. Provide client’s comfort and safety
23. Document
Cleaning a Double-Cannula Tube / Chaning a
Tracheostomy dressing and ties
When:
18. Slide folded gauze under tracheostomy string
o To make tracheostomy dressing from a 4x4 gauze,
open gauze to an 8” x 4” size, then fold lengthwise
19. Change ties
20. Document relevant data
Peritoneal Dialysis
Dialysis
 Is a treatment that does some of the things done by
healthy kidneys. It is needed when the kidneys can no
longer perform its functions
Hemodialysis
 Cleans the blood with the use of a machine
 Done 3 to 5 times a week
 Done usually in a dialysis center
 The hemodialysis access is in arm through an AV fistula
 An AV fistula is a surgical procedure where a vein and an
artery is directly connected as a permanent access for
hemodialysis

o Dressing is soiled – harbors microorganisms and source Peritoneal Dialysis

of skin breakdown, and infection
 Collects waste from the blood by washing the empty
o Check order of doctor if there is an order for antibiotic
space in the abdomen (peritoneal activity)
ointment to the stoma.
 Performed in a daily bases
o Excessive secretions, soiled tracheostomy dressing or ties,
 Done at home
labored breathing indication diminished air flow through  A peritoneal dialysis access is the PD catheter surgically
trach tube placed in the lower laparoscopic guidance by surgeon
 A small piece of tubing is left outside of the body that can
Why:
be covered when not in use
o To maintain cleanliness and prevent infection at the
Indications
tracheostomy site
o To maintain airway patency 1. Those unable or unwilling to undergo hemodialysis or
o To prevent skin breakdown around the stoma renal transplantation
2. Those older patients
Steps: 3. Those who are at risk for adverse effects of systemic
heparin
1. Assess the need for cleaning the stoma
4. Those with diabetes or cardiovascular disease
2. Greet the patient, explain the procedure
3. Prepare the equipments Contraindications to Dialysis
4. Don gloves and suction if indicated
5. Remove the soiled dressing using pick up forceps Hemodialysis:
6. Remove the inner cannula (counter clockwise) by gently
pulling it towards you and in line with its curvature o No vascular access
7. Soak the inner cannula in diluted Hydrogen Peroxide to o Severe hemodynamic instability
moisten and loosen secretions o Unavailability of facilities
8. Put oxygen source
9. Clean the flange and the stoma using sterile water/saline. Peritoneal Dialysis:
Pat dry.
10. Change gloves and replace it with sterile gloves. o Unusable peritoneal cavity
11. Remove the cannula from the soaking solution o Incapacity to carry out dialysis
12. Clean the lumen and entire inner cannula thoroughly o Homeless
13. After rinsing the cannula, gently tap it against the inside o Massive central obesity
edge of the sterile solution bowl
14. Dry inside of cannula Clinical Contraindications for PD
15. Inset the inner cannula and secure it
16. Place a sterile dressing  Crohn disease – patchy inflammation throughout small
17. Fold gauze corners up and large bowel
 Ulcerative colitis – continuous and uniform inflammation
in the large bowel
 Current clostridium difficile infection
 End-stage liver disease with ascites
 Unrepaired hernia

Peritoneal Site

Preparing the patient:

1. Explains the procedure and obtains signed consent

Peritoneal Dialysis Process
 The lining of the abdomen (peritoneum) acts as a filter
and removes waste products from the blood
 After a set period of time often 4-6 hours, the fluid with
the filtered waste products (effluent) flows out of the
abdomen and is discarded
Types of Peritoneal Dialysis
Continuous Ambulatory Peritoneal Dialysis (CAPD)
 CAPD is “continuous”, machine-free and done while you
go about your normal activities
 This is done by hooking up a plastic bag of cleansing
fluid to the tube in the belly
 Raise the plastic bag to shoulder level causes gravity to
pull the fluid into the belly
 When the dialysate is empty, the plastic bag is removed
and discarded
 When an exchange is finished and the fluid is drained, the
plastic bag is removed and discards. This process usually
is done 3-5 times in a 24-hour period while the patient is
awake during normal activities
 Each exchange takes about 30 to 40 minutes
Automated Peritoneal Dialysis (APD)
 APD uses automated machine (cycler) to deliver and
drain the cleansing fluid
 The treatment usually is done at night while the patient is
asleep
 Performed in supine position
Daily Routine of Patient
2. Baseline vital signs
3. Empty bladder and bowel
4. Broad-spectrum antibiotic agents may be administered
 Cefazolin
 Tobramycin
 Cotrimoxazole
 Vancomycin
Preparing the equipment:
1. Consults the physician to determine the concentration of
dialysate to be used and the medications to be added to it
2. Before medications are added, the dialysate is warmed to
body temperature to prevent patient discomfort and
abdominal pain and to dilate the vessels of the peritoneum
to increase urea clearance
3. Assemble the administration set and tubing
4. Fill the tubing with the prepared dialysate to reduce the
amount of air entering the catheter and peritoneal cavity
Performing the exchange:
 Peritoneal dialysis involves a series of exchanges or
cycles
 An exchange is defined as the infusion, dwell, and
drainage of the dialysate
 INFUSION: In adults, 2 to 3 L (in children, 30 to 40
mL/kg) of dialysate, warmed to 37° C, is infused over 10
to 15 minutes
 DWELL: Equilibration time allows diffusion and osmosis
to occur peaks in the first 5 to 10 minutes. Allowed the
dialysate to dwell in the peritoneal cavity for 30 to 40
minutes
Drainage:
o The tube is unclamped and the solution drains from the
peritoneal cavity by gravity through a closed system
(between 10 to 30 minutes)
o The removal of excess water during peritoneal dialysis is
achieved by using a hypertonic dialysate with a high
dextrose concentration that creates an osmotic gradient
(Dextrose solutions of 1.5%, 2.5%, and 4.25%)

Nursing Responsibility

 Strict aseptic technique

 Vital signs, weight, intake and output
 Monitor the patient for edema
 Checking the patency of the catheter
 Monitor for complications:
 Peritonitis
 Bleeding
 Respiratory difficulty
 Leakage of peritoneal fluid
 Abdominal girth
 The catheter should never be pushed in
 Use a flow sheet

Oncology

Breast Self-Examination
Testicular Self-Examination
 A valuable tool by which women learn the appearance
and feel their own breasts  Performed to detect testicular cancer early
 Performed 5-7 days after the menstrual period  Performed once a month
(Premenopausal)
 Best performed during or after bath or shower
 Menopausal – select the same day each month for BSE o Skin of the scrotum is relaxed
2 Parts of BSE  Stand in front of the mirror and look for swelling
 Hold the penis out of the way and check one testicle at a
1. Inspection time
 Stand in front of the mirror  Feel for any hard lumps or smooth rounded bumps
 Inspect for:  Asses for changes in size, shape, or consistency of the
 Skin changes testicles
 Redness
 Visible bumps Procedure:
 Nipple crusting
 Symmetry 1. Gather equipment (clean gloves)
2. Introduce yourself and verify client’s identity
 Raise arms up and inspect
3. Explain the procedure, why it is necessary and how he
 Breasts should be rise evenly
can cooperate
 Watch for dimpling and retraction
4. Perform hand hygiene and wear gloves
5. Provide privacy. Request the presence of another person
2. Palpation
if needed
 Raise the arm
6. Cover the pelvic area with a sheet
 Feel with the opposite hand 7. Inspect the scrotum for appearance, general size and
 Pay special attention on the outer quadrant symmetry
 Perform with the pads of the fingers 8. Cup testicles
 Tips too sensitive o Its normal that one is lower than the other
 Palm too insensitive o Firm but not hard
 Move fingers in small circles, about the size of the 9. Check one testicle at a time
dime 10. Hold the testicle between the thumb and fingers
 Feel for thickenings the size of a marble 11. Gently roll the testicle between your index and thumb
 Work your way around the breast in a clockwise 12. Feel for any lumps, bumps, or painful areas
fashion, using small circles of the hand as you go 13. At the back you’ll feel the epididymis
 Feel the entire breast 14. Feel up the spermatic cord
 Feel the armpit 15. Document findings
 Use the same circular motions
 Feel for breast lumps and lymph nodes Other Signs to look out for:
 Enlarged lymph nodes are about size of a pencil
eraser, but longer and thinner  Any enlargement of a testicle
 Assess for nipple discharge  A significant loss of size in one of the testicles
 A feeling of heaviness in the scrotum
 Strip the ducts towards the nipple
 A dull ache in the lower abdomen or in the groin
 Normally, one or two drops of clear, milky or green-
 A sudden collection of fluid in the scrotum
tinged secretions
 Pain or discomfort in a testicle or in the groin
 Should not be bloody or in large quantity, squirting
out or staining the inside of a bra Chemo Drug Computation
Breast Quadrants Calculating Dosage Based on BSA
Rule 17-7 Calculating Dosage Based on BSA: