TRANSES

Subject Code: NRG 401 Mode of Class: RLE Semester: 1st Term: Prelims
c. BLS/CPR Sequence
LESSON OUTLINE
4. Capillary Blood Glucose (CBG)
1. Oxygen Administration a. Diabetes
a. Administering Oxygen by Cannula and Face Mask, or Face Tent i. Type of Diabetes
b. Partial Pressure of Oxygen (PaO2) ii. High risk for Diabetes
c. Oxygen Delivery System iii. Blood Sugar Chart
d. Assessment b. Capillary Blood Glucose
e. Nursing Considerations: Oxygen Therapy i. Purpose
f. Equipment ii. Types of Test
g. Preparation iii. Assessment
h. Oxygen Safety iv. Planning
i. Client Education v. Implementation
j. Procedure vi. Lifespan Consideration
k. Nursing Responsibility
l. Artificial Airways

2. Suctioning
a. Suctioning
i. Types of Suction Catheter
ii. Types of Suctioning
iii. Purposes
iv. Assessment
v. Equipment
vi. Implementation
vii. Lifespan Considerations
b. Suctioning a Tracheostomy or Endotracheal Tube
i. Complications
ii. Techniques to Minimize Complications
iii. Purposes
iv. Systems
v. Additional Equipment
vi. Implementation
vii. Lifespan Considerations
c. Summary of Key Differences and Similarities of the Routes for
Suctioning
d. Approximate Recommended Suction

3. Basic Life Support

a. Basic Life Support
b. Cardiopulmonary Resuscitation
i. High Quality CPR
ii. Chain of Survival
iii. CAB Approach

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 ROUTE ● Nasal cannula
● Face masks
LESSON 1: ● Oxygen tent

Oxygen Administration ● Oxygen hood

SIDE EFFECTS ● Suppression of hypoxic respiratory drive

By: Danica Faye Dayap ● Oxygen toxicity: severe coughing, dyspnea, death

CONTRAINDICATIONS AND ● Prolonged use

LESSON OUTLINE CAUTIONS ● Use with caution in clients with COPD

1. Administering Oxygen by Cannula and Face Mask, or Face Tent

2. Partial Pressure of Oxygen (PaO2)
3. Oxygen Delivery System
Partial Pressure of Oxygen (PaO2)
4. Assessment
5. Nursing Considerations: Oxygen Therapy ● PaO2 is the partial pressure of oxygen in the alveoli
6. Equipment ● The pressure of oxygen dissolved in the arterial blood
7. Preparation
8. Oxygen Safety ● Measurement of how well oxygen is moving from the lungs to the
9. Client Education blood
10. Procedure ● Normal range is 80-100 mm Hg
11. Nursing Responsibility
12. Artificial Airways
Oxygen Delivery System
1. CANNULA
Administering Oxygen by Cannula and Face Mask, or Face Tent
➔ Indication:
Before administering oxygen, check THE FOLLOWING: ◆ To deliver a relatively low concentration of oxygen
1. The order for oxygen, including the administering device and the liter when only minimal O2 support is required
flow rate (L/min) or the percentage of oxygen; ◆ To allow uninterrupted delivery of oxygen while the
2. The levels of oxygen (PaO2) and carbon dioxide (PaCO2) in the client ingests food or fluids
client’s arterial blood (PaO2 is normally 80 to Administering Oxygen ➔ Flow: 1-6 L/min
by Cannula, Face Mask ➔ FiO2: 25-40%
3. Whether the client has COPD. Note: If the client has not had arterial ➔ (~4%/L of flow)
blood gases ordered, oxygen saturation should be checked using a
non-invasive oximeter. 2. FACE MASK
DRUG NAME oxygen
➔ Indication:
◆ To provide moderate O2 support and a higher
CLASS Medical Gas concentration of oxygen and/or humidity than is
provided by cannula
MECHANISM OF ACTION Administer supplemental oxygen; restore oxygen restoration;
pulmonary vasodilator
◆ To provide a high flow of O2 when attached to a
Venturi system
INDICATIONS ● Lung disease; pneumonia, chronic obstructive ➔ Flow: 5 - 10 L/min
pulmonary disease (COPD), sleep apnea
● Blood problems (e.g., anemia) ➔ Fi02: 40 - 60%
● Heart problems: heart failure

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3. FACE TENT g. Biot’s - Rapid, deep respirations (gasps) with short pauses
➔ Indication: between sets (Spinal meningitis, many CNS causes, head
◆ To provide high humidity injury)
◆ To provide oxygen when a mask is poorly tolerated h. Kussmaul’s - Tachypnea and hyperpnea (Renal failure,
➔ Flow: 10 - 15 L/min metabolic acidosis, diabetic
➔ Fi02: ~40% ketoacidosis)
3. Chest movements: Note whether there
4. VENTURI MASK are any intercostal, substernal,
➔ Flow: 2 - 15 L/min (based on valve) suprasternal, supraclavicular, or tracheal
➔ Fi02: 24 - 60% (precisely controlled) retractions during inspiration or expiration

5. NON-REBREATHER
➔ Flow: 10 - 15 L/min
➔ Fi02: 80 - 95%
4. Chest wall configuration (e.g., kyphosis, unequal chest expansion,
6. HIGH FLOW NASAL CANNULA barrel chest).
➔ Flow: up to 60 L/min
➔ Fi02: 21 - 100%

Assessment
1. Skin and mucous membrane color: Note whether cyanosis is
present, presence of mucus, sputum production, and impedance of
airflow.
2. Breathing patterns: Note depth of respirations and presence of 5. Lung sounds audible by auscultating the chest and by ear.
tachypnea, bradypnea, or orthopnea.
a. Eupnea - normal breathing rate and pattern
b. Tachypnea - increased respiratory rate (Fever, anxiety,
exercise, shock)
c. Bradypnea - Fever, anxiety, exercise, shock (sleep, drugs,
metabolic disorder, head injury, stroke)
d. Apnea - absence of breathing (Deceased patient, head
injury, stroke)
e. Hyperpnea - Normal rate, but deep respirations (emotional
6. Presence of clinical signs of hypoxemia: tachycardia, tachypnea,
stress, diabetic ketoacidosis)
restlessness, dyspnea, cyanosis, and confusion. Tachycardia and
f. Cheyne-Stokes - Gradual increases and decreases in
tachypnea are often early signs. Confusion is a later sign of severe
respirations with periods of apnea (Increasing intracranial
oxygen deprivation.
pressure, brain stem injury)
7. Presence of clinical signs of hypercarbia (hypercapnia):
restlessness, hypertension, headache, lethargy, tremor.

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 ● Monitor pressure points for skin breakdown: provide skin care,
padding as needed

Determine
● Vital signs, especially pulse rate and quality, and respiratory rate,
rhythm, and depth.
● Whether the client has COPD. A high carbon dioxide level in the
blood is the normal stimulus to breathe. However, people with COPD
may have a chronically high carbon dioxide level, and their stimulus
to breathe is hypoxemia. During continuous oxygen administration,
arterial blood gas levels of oxygen (PaO2) and carbon dioxide
8. Presence of clinical signs of oxygen toxicity: tracheal irritation and
(PaCO2) are measured periodically to monitor hypoxemia.
cough, dyspnea, and decreased pulmonary ventilation.
● Results of diagnostic studies such as chest x-ray.
● Hemoglobin, hematocrit, and complete blood count.
● Oxygen saturation levels.
● Arterial blood gases levels, if available.
○ Respiratory Acidosis
■ Hypoventilation (hypoxia)
■ Rapid, Shallow Respirations
■ Lower BP with vasodilations
■ Dyspnea
■ Headache
■ Hyperkalemia
■ Dysrhythmias (increase potassium)
Nursing Considerations: Oxygen Therapy
■ Drowsiness, Dizziness, Disorientation
ASSESSMENT AND MONITORING ■ Muscle Weakness, Hyperreflexia
● Assess for signs of hypoxia: confusion, difficulty speaking, ■ Causes: Low Respiratory Stimul (Anesthesia, Drug
tachycardia, dyspnea, pallor, cyanosis, increased rate and depth of Overdose), COPD, Pneumonia, Atelectasis)
respirations, accessory muscle use, SpO2 less than 92% ○ Respiratory Alkalosis
● Verify oxygen delivery device, flow rate, humidification, target oxygen ■ Hyperventilation (increased rate and depth)
saturation ■ Tachycardia
● Nasal cannula, face mask: kinks, attached to device and oxygen ■ Low or Normal BP
source ■ Hypokalemia
● Monitor response to supplemental oxygen: report worsening ■ Numbness & Tingling of Extremities
oxygenation status ■ Hyper Reflexes & Muscle Cramping
○ Oxygen Saturation ■ Seizures
○ Vital Signs ■ Increased Anxiety, and Increased Irritability
○ Lung Sounds ■ Causes: Hyperventilation (Anxiety, PE, Fear),
○ Skin for color changes Mechanical ventilation
○ Level of consciousness ● Pulmonary function tests, if available

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 Oxygen Safety
Equipment
1. PREVENT OXYGEN FIRES
CANNULA a. TURN THE OXYGEN SUPPLY VALVE TO THE OFF POSITION WHEN
OXYGEN IS NOT IN USE.
1. Oxygen supply with a flow meter and adapter
b. USE AND STORE OXYGEN AT LEAST 10 FT FROM ANY OPEN FLAMES,
2. Humidifier with distilled water or tap water according to agency HEAT SOURCES, SPARKS, AND ELECTRICAL DEVICES.
protocol c. putol akoa diri
3. Nasal cannula and tubing 2. NEVER SMOKE AROUND OXYGEN
4. Tape (optional) a. THERE IS NO SAFE WAY TO SMOKE WHEN OXYGEN IS IN USE. ANY
FIRE THAT STARTS WILL BURN HOTTER AND FASTER THAN USUAL.
5. Padding for the elastic band
b. NEVER SMOKE OR ALLOW ANYONE ELSE TO SMOKE IN AREAS
WHERE OXYGEN IS STORED OR USED.
FACE MASK 3. STORE OXYGEN CYLINDERS SECURELY
1. Oxygen supply with a flow meter and adapter a. ACYLINDER WITH THE VALVE BROKEN OFF CAN ACCELERATE TO
2. Humidifier with distilled water or tap water according to agency 40+ MPH IN UNDER A SECOND, WITH ENOUGH POWER TO BREAK
THROUGH CINDER BLOCK.
protocol
b. STORE ALL OXYGEN CYLINDERS IN AN UPRIGHT POSITION IN
3. Prescribed face mask of the appropriate size RACKS OR STANDS TO PREVENT THEM FROM TIPPING OVER.
4. Padding for the elastic band 4. DO NOT USE OIL OR GREASE WITH OXYGEN EQUIPMENT
a. BODY OLS, LIP BALMS, HAND LOTIONS, FACE CREAMS, HAIR
FACE TENT PRODUCTS, SPRAYS, AND OTHER ITEMS CONTAINING OIL AND
GREASE CAN EASILY BURN.
1. Oxygen supply with a flow meter and adapter
b. KEEP HANDS FREE OF OIL AND GREASE WHEN HANDLING OXYGEN
2. Humidifier with distilled water or tap water according to agency EQUIPMENT, AND KEEP OIL AND GREASE AWAY FROM AREA WHERE
protocol OXYGEN IS IN USE
3. Face tent of the appropriate size 5. READ AND FLOW
a. ALWAYS READ AND FOLLOW THE SAFETY
INFORMATION
Preparation
1. Determine the need for oxygen therapy, and verify the order for the
Client Education
therapy.
a. Perform a respiratory assessment to develop baseline data if ● Purpose of oxygen therapy
not already available. ● Oxygen set-up, pulse oximetry
2. Prepare the client and support people. ● Offer emotional support and reassurance for claustrophobia
a. Assist the client to a semi-Fowler’s position if possible. ● Home oxygen therapy
Rationale: This position permits easier chest expansion and ○ How to wear the delivery device and operate the machinery
hence easier breathing. ○ Wash nasal cannula in warm soapy water at least once each
b. Explain that oxygen is not dangerous when safety week; replace it every two to four weeks
precautions are observed. Inform the client and support ○ Supplemental oxygen is a medication; administer their
people about the safety precautions connected with oxygen oxygen at the prescribed rate, not to discontinue therapy
use abruptly
○ Increasing their fluid intake can help reduce dryness of
mucous membranes

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 ○ Safety measures
■ Keep the oxygen at least five feet away from any
heat source
■ Avoid using equipment that could emit a spark
■ Avoid wearing synthetic clothing due to static
electricity
■ Avoid use of flammable liquids
■ No smoking
■ Fire extinguisher readily available
Procedure
FACE MASK
● Guide the mask toward the client's face, and apply it from the nose
downward.
● Fit the mask to the contours of the client's face (see Figure 50-13 A).
○ Rationale: The mask should mold to the face so that very
little oxygen escapes into the eves or around the cheeks and
chin.
● Secure the clastic hand around the client’s head so that the mask is
comfortable but snug.
● Pad the band behind the ears and over bony prominences.
○ Rationale: Padding will prevent irritation from the mask.
Nursing Responsibility
Assess the client regularly.
● Assess the client's vital signs, level of anxiety, color, and ease of
respirations, and provide support while the client adjusts to the
device. Some clients may complain of claustrophobia.
● Assess the client in 15 to 30 minutes, depending on the client's
condition, and regularly thereafter.
● Assess the client regularly for clinical signs of hypoxia, tachycardia,
confusion, dyspnea, restlessness, and cyanosis. Review oxygen
saturation or arterial blood gas results if they are available.
Nasal Cannula
● Assess the client's nares for encrustations and irritation. Apply a
water-soluble lubricant as required to soothe the mucous
membranes.
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● Assess the top of the client's ears for any signs of irritation from the
cannula tubing. If present, padding with a gauze pad may help
relieve the discomfort.
Inspect the equipment on a regular basis.
● Check the liter flow and the level of water in the humidifier in 30
minutes and whenever providing care to the client.
● Be sure that water is not collecting in dependent loops of the tubing.
● Make sure that safety precautions are being followed.
Document findings in the client record using forms or checklists
supplemented by narrative notes when appropriate.
Artificial Airways
● 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
● Four of the more common types of airways are oropharyngeal,
nasopharyngeal, endotracheal, and tracheostomy
OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS
● used to keep the upper air passages open when secretions or the
tongue may obstruct them (e.g. in a client who is sedated, is
semicomatose, or has an altered level of consciousness
ENDOTRACHEAL TUBES (ETT)
● most commonly inserted in clients who have had general anesthetics
or for those in emergency situations where mechanical ventilation is
required.
● Cuffed tracheostomy tubes are surrounded by an inflatable cuff that
produces an airtight seal between the tube and
 2. Open-tipped catheters may be more effective for removing thick
mucous plugs.
LESSON 2:

Suctioning
By: Francine Laurence G. Desabelle

LESSON OUTLINE

1. Suctioning
a. Types of Suction Catheter
b. Types of Suctioning
c. Purposes
d. Assessment 3. Oral suction tube or Yankauer suction tube is used to suction the
e. Equipment oral cavity. This can be assigned to AP and to the client or family, if
f. Implementation appropriate, since this is not a sterile procedure.
g. Lifespan Considerations
2. Suctioning a Tracheostomy or Endotracheal Tube
a. Complications
b. Techniques to Minimize Complications
c. Purposes
d. Systems
e. Additional Equipment
f. Implementation
g. Lifespan Considerations
3. Summary of Key Differences and Similarities of the Routes for
Suctioning
4. Approximate Recommended Suction ● Most suction catheters have a thumb port on the side to control the
suction. The catheter is connected to the suction tubing, which in
turn is connected to a collection chamber and suction control gauge.
Suctioning
- It is an aspiration of secretions through a catheter connected to a
suction machine or wall suction outlet.
● Sterile Technique is recommended.
● Oropharyngeal and nasopharyngeal suctioning removes
secretions from the upper respiratory tract.
● Nasotracheal suctioning provides closer access to the
trachea and requires sterile technique.

Types of Suction Catheter

Suction catheters are flexible, made of plastic:
1. Whistle-tipped catheters are less irritating to respiratory tissues.

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 ❖ Water-soluble lubricant
Types of Suctioning
❖ Y-connector
1. Oral ❖ Sputum trap, if specimen is to be collected
2. Oropharyngeal
3. Nasopharyngeal
Implementation
4. Nasotracheal
Performance:
1. Prior to performing the procedure, introduce self and verify the
Purposes
client’s identity using agency protocol. Explain to the client what you
➢ To remove secretions that obstruct the airway. are going to do, why it is necessary, and how to participate. Inform
➢ To facilitate ventilation. the client that suctioning will relieve breathing difficulty and that the
➢ To obtain secretions for diagnostic purposes. procedure is painless but may be uncomfortable and stimulate the
➢ To prevent infection that may result from accumulated secretions. cough, gag, or sneeze reflex. Rationale: Knowing that the procedure
will relieve breathing problems is often reassuring and enlists the
client’s cooperation.
Assessment 2. Perform hand hygiene and observe other appropriate infection
Assess for clinical signs indicating the need for suctioning: prevention procedures.
❖ Restlessness, anxiety 3. Provide for client privacy.
❖ Noisy respiration 4. Prepare the client.
❖ Adventitious (abnormal) breath sounds when the chest is auscultated ○ Position a conscious client who has a functional gag reflex in
❖ Change in mental status the semi-Fowler’s position with the head turned to one side
❖ Skin color for oral suctioning or with the neck hyperextended for nasal
❖ Rate and pattern of respirations suctioning. Rationale: These positions facilitate the insertion
❖ Pulse rate and rhythm of the catheter and help prevent aspiration of secretions.
❖ Decreased oxygen saturation ○ Position an unconscious client in the lateral position, facing
you. Rationale: This position allows the tongue to fall
forward, so that it will not obstruct the catheter on insertion.
Equipment The lateral position also facilitates drainage of secretions
For Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning (Using from the pharynx and prevents the possibility of aspiration.
Sterile Technique): ○ Place the towel or moisture-resistant pad over the pillow or
❖ Towel or moisture-resistant pad under the chin.
❖ Portable or wall suction machine with tubing, collection receptacle, 5. Prepare the equipment.
and suction pressure gauge ○ Turn the suction device on and set to appropriate negative
❖ Sterile disposable container for fluids pressure on the suction gauge. The amount of negative
❖ Sterile normal saline or water pressure should be high enough to clear secretions but not
❖ Goggles or face shield, if appropriate too high. Rationale: Too high of a pressure can cause the
❖ Moisture-resistant disposal bag catheter to adhere to the tracheal wall and cause irritation or
❖ Sterile gloves trauma. A rule of thumb is to use the lowest amount of
❖ Sterile suction catheter kit (#12 to #18FR for adults, #8 to #10FR for suction pressure needed to clear the secretions.
children, and #5 to #8 FR for infants)

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For Oral and Oropharyngeal Suction
● Apply clean gloves.
● Moisten the tip of the Yankauer or suction catheter with sterile water
or saline. Rationale: This reduces friction and eases insertion.
● Pull the tongue forward, if necessary, using gauze.
● Do not apply suction (that is, leave your finger off the port) during
insertion. Rationale: Applying suction during insertion causes trauma
to the mucous membrane.
● Advance the catheter about 10 to 15 cm (4 to 6 in.) along one side of
the mouth into the oropharynx. Rationale: Directing the catheter
along the side prevents gagging.
● It may be necessary during oropharyngeal suctioning to apply
suction to secretions that collect in the mouth and beneath the
tongue.
● Remove and discard gloves.
● Perform hand hygiene.
For Nasopharyngeal and Nasotracheal Suction
● Open the lubricant.
● Open the sterile suction package.
a. Set up the cup or container, touching only the outside.
b. Pour sterile water or saline into the container.
c. Apply the sterile gloves or apply an unsterile glove on the
nondominant hand and then a sterile glove on the dominant
hand. Rationale: The sterile gloved hand maintains the
sterility of the suction catheter, and the unsterile glove
prevents the transmission of the microorganisms to the
nurse.
● With your sterile gloved hand, pick up the catheter and attach it to
the suction unit.
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6. Test the pressure of the suction and the patency of the catheter by
applying your sterile gloved finger or thumb to the port or open branch
of the Y-connector (the suction control) to create suction.
○ If needed, apply or increase supplemental oxygen.
7. Lubricate and introduce the catheter.
○ Lubricate the catheter tip with sterile water, saline, or water
soluble lubricant. Rationale: This reduces friction and eases
insertion.
○ Remove oxygen with the nondominant hand, if appropriate.
○ Without applying suction, insert the catheter into either naris
and advance it along the floor of the nasal cavity. Rationale:
This avoids the nasal turbinates.
○ Never force the catheter against an obstruction. If one nostril
is obstructed, try the other.
8. Perform suctioning.
○ Apply your finger to the suction control port to start suction,
and gently rotate the catheter. Rationale: Gentle rotation of
the catheter ensures that all surfaces are reached and
prevents trauma to any one area of the respiratory mucosa
due to prolonged suction.
○ Apply suction for 5 to 10 seconds while slowly withdrawing
the catheter, then remove your finger from the control and
remove the catheter. Rationale: Intermittent suction reduces
the occurrence of trauma or irritation to the trachea and
nasopharynx.
○ A suction attempt should last only 10 to 15 seconds. During
this time, the catheter is inserted, the suction applied and
discontinued, and the catheter removed.
9. Rinse the catheter and repeat suctioning as above if necessary.
○ Rinse and flush the catheter and tubing with sterile water or
saline.
○ Relubricate the catheter, and repeat suctioning until the air
passage is clear.
○ Allow sufficient time between each suction for ventilation and
oxygenation. Limit suctioning to 5 minutes in total. Rationale:
Applying suction for too long may cause secretions to
increase or may decrease the client’s oxygen supply.
○ Encourage the client to breathe deeply and to cough
between suctions. Use supplemental oxygen, if appropriate.
Rationale: Coughing and deep breathing help carry
 secretions from the trachea and bronchi into the pharynx,
where they can be reached with the suction catheter. Deep
breathing and supplemental oxygen replenish the oxygen
supply that was decreased during the suctioning process.
10. Obtain a specimen if required.
○ Use a sputum trap as follows:
a. Attach the suction catheter to the tubing of the sputum
trap.
b. Attach the suction tubing to the sputum trap air vent.
c. Suction the client. The sputum trap will collect the mucus
during suctioning.
d. Remove the catheter from the client. Disconnect the
sputum trap tubing from the suction catheter. Remove
the suction tubing from the trap air vent.
e. Connect the tubing of the sputum trap to the air vent.
Rationale: This retains any microorganisms in the
sputum trap.
○ Connect the suction catheter to the tubing.
○ Flush the catheter to remove secretions from the tubing.
11. Promote client comfort.
○ Offer to assist the client with oral or nasal hygiene.
○ Assist the client to a position that facilitates breathing.
12. Dispose of equipment and ensure availability for the next suction.
○ Dispose of the catheter, gloves, water, and waste container.
a. Rinse the suction tubing as needed by inserting the end
of the tubing into the used water container.
b. Wrap the catheter around your sterile gloved hand and
hold the catheter as the glove is removed over it for
disposal.
○ Perform hand hygiene.
○ Empty and rinse the suction collection container as needed
or indicated by protocol. Change the suction tubing and
container daily.
○ Ensure that supplies are available for the next suctioning
(suction kit, gloves, water or normal saline).
13. Assess the effectiveness of suctioning.
○ Auscultate the client’s breath sounds to ensure they are
clear of secretions. Observe skin color, dyspnea, level of
anxiety, and oxygen saturation levels.
14. Document relevant data.
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○ Record the procedure: the amount, consistency, color, and
odor of sputum (e.g., foamy, white mucus; thick,
green-tinged mucus; or blood-flecked mucus) and the client’s
respiratory status before and after the procedure. This may
include lung sounds, rate and character of breathing, and
oxygen saturation.
○ If the procedure is carried out frequently (e.g., every hour), it
may be appropriate to record only once, at the end of the
shift; however, the frequency of the suctioning must be
recorded.
Lifespan Considerations
INFANTS
- A bulb syringe is used to remove secretions from an infant’s nose or
mouth. Care needs to be taken to avoid stimulating the gag reflex.
CHILDREN
- A catheter is used to remove secretions from an older child’s mouth
or nose.
OLDER ADULTS
- Older adults often have cardiac and/or pulmonary disease, thus
increasing their susceptibility to hypoxemia related to suctioning.
Watch closely for signs of hypoxemia. If noted, stop suctioning and
hyperoxygenate.
Suctioning a Tracheostomy or Endotracheal Tube
Following endotracheal intubation or a tracheostomy, the trachea and
surrounding respiratory tissues are irritated and react by producing excessive
secretions.
● It must be sterile.
● Frequency depends on the client’s health and how recently the
intubation.
 Complications Additional Equipment for Tracheostomy or Endotracheal Tube Suctioning
(Using Sterile Technique)
■ Hypoxemia
■ Trauma to the airway ❖ Resuscitation bag (bag valve mask) connected to 100% oxygen
■ Healthcare-associated infection ❖ Sterile towel (optional)
■ Cardiac dysrhythmia, which is related to the hypoxemia ❖ Goggles and mask (if necessary)
❖ Gown (if necessary)
❖ Sterile gloves
Techniques to Minimize Complications
1. Suction only as needed.
Implementation
2. Sterile technique.
3. No saline installation. START WITH USUAL PREPARATION:
4. Hyperinflation. 1. Prepare the client.
5. Hyperoxygenation. ○ If not contraindicated, place the client in the semi-Fowler’s
6. Safe catheter size. position to promote deep breathing, maximum lung
expansion and productive coughing. Rationale: Deep
breathing oxygenates the lungs, counteracts the hypoxic
Purposes effects of suctioning, and may induce coughing. Coughing
➢ To maintain a patent airway and prevent airway obstructions. helps to loosen and move secretions.
➢ To promote respiratory function (optimal exchange of oxygen and 2. Prepare the equipment for an open suction system.
carbon dioxide into and out of the lungs). ○ Attach the resuscitation apparatus to the oxygen source.
➢ To prevent pneumonia that may result from accumulation. Adjust the oxygen flow to 100%.

Systems
1. Open Suction System
- If a client is connected to a ventilator, the nurse disconnects
the client from the ventilator, suctions the airway, reconnects
the client to the ventilator, and discards the suction catheter.

2. Closed Suction System

- The suction catheter attaches to the ventilator tubing and the
client does not need to be disconnected from the ventilator.
The nurse is not exposed to any secretions because the
suction catheter is enclosed in a plastic sheath.
○ Open the sterile supplies:
a. Suction kit or catheter.
b. Sterile basin/container.
○ Pour sterile normal saline or water into the sterile basin.
○ Place the sterile towel, if used, across the client’s chest
below the tracheostomy.
○ Turn on the suction, and set the pressure in accordance with
agency policy. The suction pressure should be set at what is

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 needed to adequately remove secretions. The
recommended suction pressure for the open suction system
is 100–120 mm.
○ Apply goggles, mask, and gown if necessary.
○ Apply sterile gloves. Some agencies recommend putting a
sterile glove on the dominant hand and an unsterile glove on
the nondominant hand to protect the nurse.
○ Holding the catheter in the dominant hand and the connector
in the nondominant hand, attach the suction catheter to the
suction tubing.
3. Flush and lubricate the catheter.
○ Using the dominant hand, place the catheter tip in the sterile
saline solution.
○ Using the thumb of the nondominant hand, occlude the
thumb control and suction a small amount of the sterile
solution through the catheter. Rationale: This determines
that the suction equipment is working properly and lubricates
the outside and the lumen of the catheter. Lubrication eases
insertion and reduces tissue trauma during insertion.
Lubricating the lumen also helps prevent secretions from
sticking to the inside of the catheter.
4. If the client does not have copious secretions, hyperventilate the lungs
with a resuscitation bag before suctioning.
○ Summon an assistant, if one is available, for this step.
○ Using your nondominant hand, turn on the oxygen to 12 to
15 L/min.
○ If the client is receiving oxygen, disconnect the oxygen
source from the tracheostomy tube using your nondominant
hand.
○ Attach the resuscitator to the tracheostomy or ETT.
○ Compress the Ambu bag three to five times, as the client
inhales. This is best done by a second person who can use both
hands to compress the bag.
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○ Observe the rise and fall of the client’s chest to assess the
adequacy of each ventilation.
○ Remove the resuscitation device and place it on the bed or the
client’s chest with the connector facing up.
Variation: Using a Ventilator to Provide Hyperventilation
If the client is on a ventilator, use the ventilator for hyperventilation and
hyperoxygenation. Newer models have a mode that provides 100% oxygen
for 2 minutes and then switches back to the previous oxygen setting as well
as a manual breath or sigh button. Rationale: The use of ventilator settings
provides more consistent delivery of oxygenation and hyperinflation than a
resuscitation device.
5. If the client has copious secretions, do not hyperventilate with a
resuscitator. Instead:
○ Keep the regular oxygen delivery device on and increase the liter
flow or adjust the FiO2 to 100% for several breaths before
suctioning. Rationale: Hyperventilating a client who has copious
secretions can force the secretions deeper into the respiratory
tract.
6. Quickly but gently insert the catheter without applying any suction.
○ With your nondominant thumb off the suction port, quickly but
gently insert the catheter into the trachea through the
tracheostomy tube. Rationale: To prevent tissue trauma and
oxygen loss, suction is not applied during insertion of the
catheter.
○ Insert the catheter about 0.5 to 1 cm past the distal end of
the tube for an open system, and 1 to 2 cm past the distal
end for a closed system (Nance-Floyd, 2011) or until the
client coughs. If you feel resistance, withdraw the catheter
about 1 to 2 cm (0.4 to 0.8 in.) before applying suction.
Rationale: Resistance usually means that the catheter tip
 has reached the bifurcation of the trachea. Withdrawing the
catheter will prevent damaging the mucous membranes at
the bifurcation.
7. Perform suctioning.
○ Apply suction for 5 to 10 seconds by placing the
nondominant thumb over the thumb port. Rationale: Suction
time is restricted to 10 seconds or less to minimize oxygen
loss.
○ Rotate the catheter by rolling it between your thumb and
forefinger while slowly withdrawing it. Rationale: This
prevents tissue trauma by minimizing the suction time
against any part of the trachea.
○ Withdraw the catheter completely, and release the suction.
○ Hyperventilate the client.
○ Suction again, if needed.
8. Reassess the client’s oxygenation status and repeat suctioning.
○ Observe the client’s respirations and skin color. Check the
client’s pulse if necessary, using your nondominant hand. If
the client is on a cardiac monitor, assess the rate and
rhythm.
○ Encourage the client to breathe deeply and to cough
between suctions.
○ Allow 2 to 3 minutes with oxygen, as appropriate between
suctions when possible. Rationale: This provides an
opportunity for reoxygenation of the lungs.
○ Flush the catheter and repeat suctioning until the air
passage is clear and the breathing is relatively effortless and
quiet.
○ After each suction, pick up the resuscitation bag with your
nondominant hand and ventilate the client with no more than
three breaths.
9. Dispose of equipment and ensure availability for the next suction.
○ Flush the catheter and suction tubing.
○ Turn off the suction and disconnect the catheter from the suction
tubing.
○ Wrap the catheter around your sterile hand and peel the glove
off so that it turns inside out over the catheter. Remove the other
glove.
○ Discard the gloves and the catheter in the moisture resistant
bag.
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○ Perform hand hygiene.
○ Replenish the sterile fluid and supplies so that the suction is
ready for use again. Rationale: Clients who require suctioning
often require it quickly, so it is essential to leave the equipment at
the bedside ready for use.
○ Be sure that the ventilator and oxygen settings are returned to
pre-suctioning settings. Rationale: On some ventilators this is
automatic, but always check. It is very dangerous for clients to
be left on 100% oxygen
10. Provide for client comfort and safety.
○ Assist the client to a comfortable, safe position that aids
breathing. If the person is conscious, a semi-Fowler’s position
is frequently indicated. If the person is unconscious, Sims’
position aids in the drainage of secretions from the mouth.
11. Document relevant data.
○ Record the suctioning, including the amount and description of
suction returns and any other relevant assessments.
Variation: Closed Suction System
● If a catheter is not already attached, apply clean gloves, aseptically
open a new closed catheter set, and attach the ventilator connection
on the T piece to the ventilator tubing. Attach the client connection to
the ETT or tracheostomy.
● Attach one end of the suction connecting tubing to the suction
connection port of the closed system and the other end of the
connecting tubing to the suction device.
● Turn suction on, occlude or kink tubing, and depress the suction
control valve (on the closed catheter system) to set suction to the
appropriate level. Release the suction control valve.
● Use the ventilator to hyperoxygenate and hyperinflate the client’s
lungs.
● Unlock the suction control mechanism if required by the
manufacturer.
● Advance the suction catheter enclosed in its plastic sheath with the
dominant hand. Steady the T piece with the nondominant hand.
● Depress the suction control valve and apply continuous suction for
no more than 10 seconds and gently withdraw the catheter.
● Repeat as needed remembering to provide hyperoxygenation and
hyperinflation as needed.
 ● When completed suctioning, withdraw the catheter into its sleeve
it along the floor
and close the access valve, if appropriate. Rationale: If the system of the nasal
does not have an access valve on the client connector, the nurse cavity.
needs to observe for the potential of the catheter migrating into the
airway and partially obstructing the artificial airway. TIME 5-10 secs 5-10 secs 5-10 secs
● Flush the catheter by instilling normal saline into the irrigation port
and applying suction. Repeat until the catheter is clear. Maximum 15 secs 15 secs 10 secs
Time
● Close the irrigation port and close the suction valve.
● Remove and discard gloves. Interval Time 20-30 mins 20-30 mins 2-3 minutes
● Perform hand hygiene.
TOTAL 5 minutes 5 minutes 5 minutes

Lifespan Considerations
INFANTS
- Have an assistant gently restrain the child to keep the child’s hands Approximate Recommended Suction
out of the way. The assistant should maintain the child’s head in the
midline position.
PRESSURE WALL
OLDER ADULTS
INFANT 2-5 mmHg 50-95 mmHg
- Health care–associated pneumonia and ventilator-associated
pneumonia (VAP) can occur because of infected secretions in the CHILD 5-10 mmHg 95-110 mmHg
upper airway. Oral antiseptic rinses (e.g. chlorhexidine gluconate)
reduce the rate of nosocomial pneumonia in critically ill clients ADULT 10-15 mmHg 100-120 mmHg
(Booker, Murff, Kitko, & Jablonski, 2013).
- Do a thorough lung assessment before and after suctioning to
determine effectiveness of suctioning and to be aware of any special
problem

Summary of Key Differences and Similarities of the Routes for Suctioning

OROPHARYNGE NASOPHARYN ET/TT

AL GEAL

POSITION OF Semi-Fowler’s Semi-Fowler’s Semi-Fowler’s

CHOICE (conscious) (conscious) (conscious)
Turn head at side Hyperextend

LEVEL OF Nose to earlobe Nose to earlobe Until resistance

INSERTION (4-6 in or 10-15 (4-6 in or 10-15 (carina) (½-1 in
cm) cm) or advance or 1-2 cm)

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 LESSON 3: High Quality CPR
Basic Life Support ● A compression rate of at least 100/min PUSH FAST
● A compression depth of at least 4 cm in infants and 5 cm in children
By: Shiela Mae L. Calungsod
PUSH HARD
● Allowing complete chest recoil, minimizing interruptions in
LESSON OUTLINE compressions and avoiding excessive ventilation
● For best results, deliver chest compressions on a firm surface
1. Basic Life Support
2. Cardiopulmonary Resuscitation
a. High Quality CPR Continue resuscitation until…
b. Chain of Survival ● Qualified help arrives and takes over
c. CAB Approach ● AED arrives
3. BLS/CPR Sequence ● Victim starts breathing normally
● Rescuer becomes exhausted

Basic Life Support

Chain of Survival
● Cardac arrest : a substantial public health problem.
: a leading cause of death. 1. Early recognition of cardiac arrest
● For best survival and quality of life, pediatric basic life support (BLS) 2. Activation of the Emergency Response System
should be part of a community effort 3. Early CPR, to slow the rate of deterioration of the brain and heart,
● Rapid and effective bystander CPR can be associated with and buy time to enable defibrillation.
successful return of spontaneous circulation (ROSC) and 4. Early defibrillation, to restart the heart.
neurologically intact survival in children following out-of-hospital 5. Comprehensive post-cardiac arrest care, to restore quality of life.
cardiac arrest.
● Sequences of procedures performed torestoe the circulation of
CAB Approach
oxygenated blood after a sudden pulmonary/cardiac arrest
● Acronym in BLS used to guide provider in the appropriate steps.
C - circulation
Cardiopulmonary Resuscitation
A - airway
● Combine rescue breathing and chest compressions B - breathing
● Revives heart and lung function D - defibrilation

Complications of CPR BLS/CPR Sequence

1. Rib Fracture 1. Safety of the rescuer and victim.
2. Internal injuries to organs 2. Check for response and breathing.
3. Laceration related to the tip of the sternum a. If the victim is unresponsive and not breathing (or only
4. Vomiting and aspiration gasping), shout for help.
5. Gastric distention

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 b. If the child collapsed suddenly and you are alone, leave the not rise reposition the head, make a better seal, and try
chid to activate the EMS and get the AED. again.
3. Check the child’s pulse (5-10 seconds).
Bag and Mask Ventilation
a. If, within 10 seconds, you don't a pulse or are not sure if your
feel a pulse, begin chest compressions. ● Bag-mask ventilation is an essential CPR technique for healthcare
b. Inadequate Breathing With Pulse : If there is a palpable providers
pulse ≥60 per minute but there is inadequate breathing, give ● Bag-mask ventilation requires training in the following skills: selecting
rescue breaths at a rate of about 12 to 20 breaths per minute the correct mask size, opening the airway, making a tight seal
(1 breath every 3 to 5 seconds) until spontaneous breathing between the mask and face, delivering effective ventilation, and
resumes. Reassess the pulse about every 2 minutes. assessing the effectiveness of that ventilation
c. If the pulse is <60 per minute and there aresigns of poor ● Use a self-inflating bag with a volume of at least 450 to 500 mL for
perfusion (ie, pallor, mottling,cyanosis) despite support of infants and young children
oxygenation andventilation, begin chest compressions ● In older children or adolescents, an adult self-inflating bag (1000 mL)
4. CPR: may be needed to reliably achieve chest rise
a. The lone rescuer- cycle of 30 compressions and 2 breaths ● To deliver a high oxygen concentration (60% to 95%), attach an
for approximately 2 minutes (about 5 cycles) oxygen reservoir to the self-inflating bag
b. Two rescuer- cycle of 15 compressions and 2 breaths ● Maintain an oxygen flow of 10 to 15 L/min into a reservoir attached to
5. Activate Emergency Response System a pediatric bag and a flow of at least 15 L/min into an adult bag
a. After 5 cycles, if someone has not already done so, activate ● Bag-mask ventilation can be provided effectively during 2-person
the emergency response system and obtain an automated CPR
external defibrillator (AED) ● Effective bag-mask ventilation requires a tight seal between the
6. For a child, lay rescuers and healthcare providers should compress mask and the victim's face.
the lower half of the sternum at least one third of the AP dimension ● Open the airway by lifting the jaw toward the mask making a tight
of the chest or approximately 5 cm (2 inches) with the heel of 1 or 2 seal and squeeze the bag until the chest rises.
hands
7. Opening the aiwray :
a. In an unresponsive infant or child, the tongue may obstruct
the airway and interfere with ventilations. Open the airway
using a head tilt–chin lift maneuver.
b. Two maneuver
i. Head-tilt, Chin-lift Maneuver
ii. Jaw Thrust Maneuver
8. Breaths :
a. To give breaths to an infant, use a mouth-to-mouth-and-nose
technique.
b. To give breaths to an child, use a mouth-to-mouth-and-nose
technique.
c. Make sure the breaths are effective (i.e. the chest rises).
Each breath should take about 1 second. Is the chest does

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 Defibrillation
● VF and pulseless VT are referred to as “shockable rhythm” because
they respond to electric shocks (defibrillation).
● For infants a manual defibrillator is preferred
● If a manual defibrillator is not available, an AED equipped with a
pediatric attenuator is preferred for infants.
● An AED with a pediatric attenuator is also preferred for children <8
year of age. If neither is available, an AED without a dose attenuator
may be used.
● The recommended first energy dose for defibrillation is 2 J/kg. If a
second dose is required, it should be doubled to 4 J/kg.

Defibrillation Sequence Using an AED

1. Turn the AED on.
2. Follow the AED prompts.
3. End CPR cycle (for analysis and shock) with compression
4. Resume chest compressions immediately after the shock. Minimize
interruptions in chest compressions.

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LESSON 4:
CBG: Capillary Blood Glucose
By: Christine P. Angga
LESSON
1. Diabetes
a. Type of Diabetes
b. High risk for Diabetes
c. Blood Sugar Chart
2. Capillary Blood Glucose
a. Purpose
b. Types of Test
c. Assessment
d. Planning
e. Implementation
f. Lifespan Consideration
● Type 2 diabetes starts out as insulin resistance. This means your
body cannot use insulin efficiently, which causes your pancreas to
produce more insulin until it cannot keep up with demand. Insulin
production then decreases, which causes high blood sugar. - The
exact cause of type 2 diabetes is unknown. - Contributing factors
may include:
○ genetics
OUTLINE ○ sedentary lifestyle
○ higher weight or obese
○ other health factors and environmental reasons.
Gestational diabetes
● It is caused by insulin-blocking hormones that are produced during
pregnancy.
● This type of diabetes only happens during pregnancy. It is often
seen in people with preexisting prediabetes and a family history of
diabetes.
● About 50 percent Trusted Source of people diagnosed with
gestational diabetes go on to develop type 2 diabetes

Diabetes
Who is most at risk for developing diabetes?
● is a group of conditions where the body cannot produce enough or
The following categories of people are considered "high-risk" candidates for
any insulin, cannot properly use the insulin that is produced, or
developing diabetes:
cannot do a combination of either.
● Individuals who are overweight or obese
● When any of these things happen, the body is unable to get sugar
● Individuals who are 45 years of age or older
from the blood into your cells. This can lead to high blood sugar
● Individuals with first-degree relatives with diabetes (such as parents,
levels.
children, or siblings)
● A lack of insulin or a resistance to insulin causes sugar to build up in
● Women who developed diabetes while they were pregnant or gave
your blood
birth to large babies (9 pounds or more)
● Individuals who have impaired fasting glucose or impaired glucose
3 Types of Diabetes tolerance
● Individuals who are physically inactive; engaging in exercise less
Type 1 diabetes
than three times a week
● is believed to be an autoimmune condition. This means your
● Individuals who have polycystic ovary syndrome, also called PCOS
immune system mistakenly attacks and destroys the beta cells in
● Individuals who have acanthosis nigricans -- dark, thick and
your pancreas that produce insulin. The damage is permanent. -
● velvety skin around your neck or armpits
There may be both genetic and environmental reasons

Type 2 diabetes

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 Blood Sugar Chart

In addition to testing the above individuals at high risk, the

● American Diabetes Association also recommends screening all
individuals age 45 and older.

BLOOD SUGAR CHART

FASTING

Normal for person without Diabetes 70-99 mg/dl (3.9-5.5

mmol/L)

Official ADA recommendation for someone with 80-130 mg/dl

diabetes (4.4-7.2mmol/L)

2 HOURS AFTER MEALS

Normal for person without Diabetes <140 mg/dl (7.8 mmol/L)

Official ADA recommendation for someone with <180 mg/dl (10.0

diabetes mmol/L)

HBA1C

Normal for person without Diabetes < 5.7%

Official ADA recommendation for someone with
diabetes
Capillary Blood Glucose
● It is the immediate measurement of blood for glucose using a blood
7.0% of less
sample from a fingerstick or heel stick and interpreting it through a
device called a glucometer. This is otherwise known as Capillary
Blood Glucose (CBG) Test.
● Normal blood glucose level (while fasting) ranges within 70 to 99
mg/dL (3.9 to 5.5 mmol/L). Higher ranges could indicate pre-diabetes
or diabetes

Purpose
● To determine or monitor blood glucose levels of clients at risk for
hyperglycemia or hypoglycemia.
● To promote blood glucose regulation by the client.
● To evaluate the effectiveness of insulin administration

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 ● Track Progress in reaching overall treatment goals (medications for
diabetes) T
● o monitor elevation of blood glucose level that is a typical side effect
on patients who are taking steroid medications (e.g., cancer patients)
Types of Test
Fasting Blood Sugar (FBS)
● A test that measures blood sugar levels that requires at least an
8-hour fast prior and is therefore usually taken in the morning
Random Glucose Test
● A test that measures blood sugar levels that can be taken at any
time of the day.
Oral Glucose Tolerance Test (OGTT)
● A test that measures the response of the body to sugar (glucose)that
involves first taking a fasting sample of blood and then taking a drink
containing 75g of glucose. Another test will be taken after 2 hours.
Oral Glucose Challenge Test (OGCT
● A longer test compared to OGTT that measures the response of the
body to sugar (glucose). Involves first taking a fasting sample of
blood and then taking a drink containing 50g of glucose. A series of
HGT will be done hourly for the succeeding 4 hours. An elevated
blood sugar level of 2 out of 4 tests interprets as DM.
Glycosylated Hemoglobin Test (Hemoglobin A1c)
● A blood test can measure the amount of glycosylated hemoglobin in
the blood. The glycosylated hemoglobin test shows what a person's
average blood glucose level was for the 2 to 3 months before the test
● This can help determine how well a person's diabetes is being
controlled over time
● As a person's blood sugar becomes higher, more of the person's
hemoglobin becomes glycosylated. The glucose remains attached to
the hemoglobin for the life of the red blood cell, or about 2 to 3
months.
NORMAL PERSON DM PERSON
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4-5.6% - Normal range <7% - Good Control
%.7-6.4% Pre-DM >9% - Poor Control
>6.5% DM > 12% - Very Poor Control
Assessment
● The policies and procedures for the facility
● The frequency and type of testing
● The client’s understanding of the procedure
● The client’s response to previous testing.
● Assess the client’s skin at the puncture site to determine if it is intact
and the circulation is not compromised. Check color, warmth, and
capillary refill.
● Review the client’s record for medications that may prolong bleeding
such as anticoagulants or medical problems that may increase the
bleeding response.
● Assess the client’s self-care abilities that may affect the accuracy of
test results, such as visual impairment and finger dexterity
Planning
Assignment
● Check the applicable nurse practice act and the facility policy and
procedure manual to determine who can perform this skill. It is
usually considered an invasive technique and one that requires
problem solving and application of knowledge. It is the responsibility
of the nurse to know the results of the test and supervise assistive
personnel (AP) responsible for assisting the nurse
Equipment
● Blood glucose meter (glucometer)
● Blood glucose reagent strip compatible with the meter
● 2*2 gauze
● Antiseptic swab
● Clean gloves
● Sterile lancet (a sharp device to puncture the skin)
● Lancet injector (a spring-loaded mechanism that holds the lancet)
● Warm cloth or other warming device (optional)

Implementation
Preparation
● Review the type of meter and the manufacturer’s
instructions. Assemble the equipment at the bedside.
Performance
1. Prior to performing the procedure, introduce self and verify the
client’s identity using agency protocol. Explain to the client what you
are going to do, why it is necessary, and how to participate. Discuss
how the results will be used in planning further care or treatments
2. Perform hand hygiene and observe other appropriate infection
prevention procedures.
3. Provide for client privacy.
4. Prepare the equipment.
● Some meters turn on when a test strip is inserted into the
meter.
● Calibrate the meter and run a control sample according to
the manufacturer’s instructions and/or confirm the code
number. The newer no-code models do not require
calibration. The technology is integrated into the test strips.
5. Select and prepare the vascular puncture site.
● Choose a vascular puncture site (e.g., the side of an adult’s
finger). Avoid sites beside bone. Wrap the finger first in a
warm cloth or hold a finger in a dependent (below heart
level) position. If the earlobe is used, rub it gently with a
small piece of gauze.
○ Rationale: These actions increase the blood flow to
the area, ensure an adequate specimen, and reduce
the need for a repeat puncture
● Clean the site with the antiseptic swab or soap and water
and allow it to dry completely.
○ Rationale: Alcohol can affect accuracy, and the site
stings when punctured if wet with alcohol 6
6. Obtain the blood specimen.
● Apply gloves.
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● Place the injector, if used, against the site, and release the
needle, thus permitting it to pierce the skin. Make sure the
lancet is perpendicular to the site.
○ Rationale: The lancet is designed to pierce the skin
at a specific depth when it is in a perpendicular
position relative to the skin.
● OR Prick the site with a lancet or needle, using a darting
motion.
● Gently squeeze (but do not touch) the puncture site until a
drop of blood forms. The size of the drop of blood can vary
depending on the meter. Some meters require as little as 0.3
mL of blood to accurately test blood sugar.
● Hold the reagent strip under the puncture site until adequate
blood covers the indicator square. The pad will absorb the
blood and a chemical reaction will occur. Do not smear the
blood.
○ Rationale: Smearing will cause an inaccurate
reading.
● Some meters wick the blood by just touching the puncture
site with the strip.
● Ask the client to apply pressure to the skin puncture site with
a 2*2 gauze.
○ Rationale: Pressure will assist hemostasis.
7. Expose the blood to the test strip for the period and the manner
specified by the manufacturer. As soon as the blood is placed on the
test strip.
● Follow the manufacturer’s recommendations on the glucose
meter and monitor for the amount of time indicated by the
manufacturer.
○ Rationale: The blood must remain in contact with the
test strip for a prescribed time to obtain accurate
results.
● Some glucose meters have the test strip placed in the
machine before the specimen is obtained.
8. Measure the blood glucose.
● Place the strip into the meter according to the
manufacturer’s instructions. Refer to the specific
manufacturer’s recommendations for the specific procedure.
 ● After the designated time, most glucose meters will display
the glucose reading automatically. Correct timing ensures
accurate results.
● Turn off the meter and discard the test strip and 2*2 gauze
in a biohazard container. Discard the lancet into a sharp’s
container
● Remove and discard gloves.
● Perform hand hygiene.
9. Document the method of testing and results on the client’s record. If
appropriate, record the client’s understanding and ability to
demonstrate the technique. The client’s record may also include a
flow sheet on which capillary blood glucose results and the amount,
type, route, and time of insulin administration are recorded. Always
check if a diabetic flow sheet is being used for the client.
10. Check for orders for sliding scale insulin based on capillary blood
glucose results. Administer insulin as prescribed.
Implementation
● Compare glucose meter reading with normal blood glucose level,
status of puncture site, and motivation of the client to perform the
test independently.
● Compare blood glucose reading to previous readings and the client’s
current health status.
● Report abnormal results to the primary care provider. Some agencies
may have a standing policy to obtain a venipuncture blood glucose
level if the capillary blood glucose exceeds a certain value.
● Conduct appropriate follow-up such as asking the client to explain
the meaning of the results or demonstrating the procedure at the
next scheduled test.
● Prepare the client for home glucose monitoring and review
frequency, record keeping, and insulin administration if appropriate
Lifespan Considerations
Infants
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● The outer aspect of the heel is the most common site for neonates
and infants. Placing a warm cloth on the infant’s heel often increases
the blood flow to the area
Children
● Use the side of a fingertip for a young client older than age 2, unless
contraindicated.
● Allow the child to choose the puncture site, when possible.
● Praise the young client for cooperating and assure the child that the
procedure is not a punishment
Older adults
● Older adults may have arthritic joint changes, poor vision, or hand
tremors and may need assistance using the glucose meter or
obtaining a meter that accommodates their limitations.
● Older adults may have difficulty obtaining diabetic supplies due to
financial concerns or homebound status.
● Older adults often have poor circulation. Warming the hands by
wrapping with a warm washcloth for 3 to 5 minutes or placing the
hand dependently for a few moments may help in obtaining a blood
sample
*The diagnosis can be with:
● a fasting plasma glucose level of 126 mg per dL or greater;
● an A1C level of 6.5% or greater;
● a random plasma glucose level of 200 mg per dL or greater; or
● a 75-g two-hour oral glucose tolerance test with a plasma glucose
level of 200 mg per dL or greater.
Fasting Blood Glucose Blood Level
● If your blood glucose level is 70 to 99* mg/dL (3.9 to 5.5 mmol/L).
○ What it means: Your glucose level is within the normal range
● If your blood glucose level is 100 to 125 mg/dL (5.6 to 6.9 mmol/L).
○ What it means: You have an impaired fasting glucose level
(prediabetes**) .
● If your blood glucose level is 126 mg/dl (7.0 mmol/L ) or higher on
more than one testing occasion Fasting blood glucose level .
○ What it means: You have diabetes
● Values between 50 and 70 are often seen in healthy people
The condition of "prediabetes" puts you at risk for developing Type 2
diabetes, high blood pressure, and blood lipid disorders