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- 1. 1 Nasogastric tube (NGT) -Is tube inserted via nasal passage into the stomach 1. Purpose of Nasogastric tube o To assess GI function o To instill medication/feeding o To decompress stomach/ to drain unwanted fluid & air from stomach o To monitor GI bleeding o To remove undesired substances such as poisons o To help to treat intestinal obstruction 2. Indication of NGT Uncontrolled vomiting pre & post-operatively Drug/poison ingestion Upper GI bleeding Analysis of gastric contents Administration of medication or nutrients Severe PEM Pre-maturing Unconscious When the pt is unable to swallow as in paralysis of throat (in diphtheria) After surgery on mouth, throat, or a fractured jaw 3. Contraindication of NGT pt with facial or skull fracture any obstruction or narrowing in the upper alimentary tract tetanus or any disease that cause spasm 4. Complication of NGT Prolonged intubations with a NGT cause Skin erosion at the nostril Sinusits,esophagitis, pharyngitis Aspiration pneumonia & death if tracheal entry is not detected Coiling of the tube in the pharynx followed by aspiration Esophagotracheal fistula Gastric ulceration Oral infection Perforation & hemorrhage due to aggressive intubations Precautions 1. Don’t tape the tube to the pt’s forehead, it resulting pressure on the nostril could cause necrosis 2. Never place the in container of water if the tube in trachea 3. While advancing the tube, observe for signs that it entered the trachea, such as choking/breathing difficulties in a conscious pt or cyanosis in an unconscious/ a pt with out a cough reflex Equipment used of NG tube 1) Nasogastric tube
- 2. 2 2) stethoscope 3) small basin 4) water- soluble lubricant 5) tongue blade 6) syringes 5-50ml 7) flashlight 8) glass of water with straw 9) clamp/spigot 10) bathe towel 11) emesis basin 12) safety pin 13) clean gloves 14) ph paper Procedure: Nasogastric Tube (NGT) Insertion Equipment: Large or small bore nasogastric tube Solution basin filled with warm water (if using a plastic tube) or ice (if using a rubber tube) Tape/plaster Safety pin and elastic band Clean gloves Stethoscope Water soluble lubricant Tissue/soft Glass of water 20-50 ml syringe with adapter Action Rationale Verify doctor’s orders To ensure the correct treatment is given to the correct patient Verify correct patient As above Perform hand hygiene Hand hygiene prevents the spread of microorganisms. Explain the procedure to the patient: It will not be painful but it is uncomfortable because the gag reflex is activated To ensure that the patient understands the procedure Arrange a signal by which the patient can communicate if he wants the nurse to stop e.g. by raising his hand The patient is often less frightened if he feels able to have some control over the procedure Screen the patient Provides privacy Assist the patient to a high fowler’s position if health permits, and support the head on a pillow Drape chest with a towel and have emesis basin and tissue (soft) available It will be easier to swallow in this position and gravity helps the passage of the tube Provides protection if the patient vomits Passage of the tube may stimulate gagging and tearing of the eyes Assess the patient’s nares: -ask the patient to breathe through one nostril while occluding the other -select the nostril that has the greater air flow To identify any obstructions that would make the insertion more difficult Prepare the tube: if rubber is being used, place it on ice; if plastic tube is being used, place it in warm water Ice will stiffen the tube making it easier to insert Warm water makes the tube more flexible making the insertion easier Measure and mark the tube: mark the distance from the tip of the patient’s nose to the tip of the ear lobe and then from the tip of earlobe to the tip of the sternum and mark the tube with adhesive or with a pen To ensure that the appropriate length of tube is passed into the stomach Put on clean gloves Universal precautions. Nurse may be exposed to body fluids Lubricate the tip of the tube well with water-soluble lubricant or plain water to A water-soluble lubricant dissolves if the tube accidentally enters the lungs. Lubrication
- 3. 3 make the insertion easier reduces friction and eases the passage of the tube Ask the patient to slightly push the head back against the pillow. Gently insert the tube sliding it backward and inwards along the floor of the nose to the nasopharynx. If an obstruction is felt, withdraw the tube and start again in a slightly different direction or use the other nostril To make it easier for the tube to pass by following the natural anatomy of the nose The tube should never be forced against resistance because of the danger of injury As the tube passes down into the nasopharynx, ask the patient to start swallowing and sipping water To focus the patient’s attention on something other than the tube. A swallowing action closes the glottis, enabling the tube to pass into the esophagus If the patient gags, stop passing the tube for a moment. Have the patient rest, take a few breaths, and take sips of water To calm the patient’s gag reflex When the pharynx is reached instruct the patient to touch chin to chest. Encourage the patient to sip water or swallow if fluids are not allowed. Stop when patient breathes. If gagging and coughing increase stop moving the tube and check placement of the tube with tongue blade and flashlight. If tube is curled in the back of the throat, straighten the tube and attempt to advance again Bringing the head forward helps close the trachea and open the esophagus Excessive coughing and gagging may happen if the tube has curled in the back of the throat With each swallow pass the tube 5 - 10 cm until the indicated length is inserted To advance to the required length If the patient shows signs of distress, e.g. gasping or cyanosis, remove the tube immediately The tube may have accidentally been passed down the trachea instead of the pharynx Distress may indicate that the tube is in the bronchus Stabilize the tube with one piece of tape while position is being determined Check the position of the tube using more than one method to confirm that it is in the stomach Method 1: aspirate 2 ml of stomach contents. If unable to obtain specimen, reposition the patient and flush the tube with 30 ml of air Method 2: Measure the pH of aspirate fluid using pH paper Method 3: Visualize aspirate contents, checking for colour and consistency Current literature recommends that the nurse ensures proper placement of the NG tube by relying on multiple methods and not on one method alone The tube is in the stomach if its contents can be aspirated. This action may be necessary several times pH of aspirate can be tested to determine gastric placement The pH of gastric aspirate is 5.5 If the patient is taking an acid inhibiting agent, the range may be 4.0-6.0. The pH of intestinal fluid is 7.0 or higher. The pH of respiratory fluid is 6.0 or higher. This method will not differentiate between intestinal fluid and pleural fluid Gastric fluid can be green with particles, off- white, or brown if old blood is present. Intestinal aspirate is clear or straw coloured, or a deep golden-yellow color. Intestinal aspirate may be greenish-brown if stained with bile. Respiratory
- 4. 4 Method 4: Obtain an X-ray or tracheobronchial fluid is usually off-white to tan and may be tinged with mucus X-ray is considered the most reliable method for identifying the position of the NG tube Cut 10cm of tape/plaster and split bottom 5cm. Place un-split end over the bridge of the patient’s nose. Wrap split ends under the tubing up and over onto the nose. Be careful not to pull the tube too tightly against the nose To maintain the correct placement of the tape Clamp tube and cap or attach to suction according to the doctor’s orders Suction provides for decompression of stomach and drainage of gastric contents Secure the tube to the patient’s gown by using a rubber band and safety pin or tape. For additional support, the tube can be taped onto the patient’s cheek using a piece of tape This prevents pulling and tugging on the tube Assist with or provide mouth care every 2 to 4 hours. Lubricate the lips, clean the nares Mouth care keeps the mouth clean and moist, promotes comfort and reduces thirst Remove all equipment. Wash hands Hand hygiene decreases the spread of microorganisms Student Notes: Performing gastric lavage Gastric lavage -is washing out /irrigating of stomach with a solution -it is used most frequently as an emergency treatment Purpose of gastric lavage o to remove poison which has been swallowed o to relive congestion, there by stimulating peristalsis e.g. pyloric stenosis o to clean the stomach of undigested food, mucosa, fermented material o to relieve extreme nausea, vomiting, & distress in case of acute dilatation of stomach pyloric stenosis intestinal obstruction o to remove irritant material o to cleanse the stomach as a preparation of surgery o to cleanse the stomach post-operatively to prevent dilatation Indication of gastric lavage poisoning drug over dose gastric / esophageal bleeding abdominal surgery chronic nausea, vomiting due to acute dilatation of stomach, pyloric stenosis, intestinal obstruction Precautions remove false teeth never force passage of tube
- 5. 5 discontinue treatment for any return flow of blood indication of tube in trachea, remove it avoid introducing air into the esophagus watch pt for pallor, feeble pulse, & other sign of exhaustion do not perform a lavage within 3-4hrs after food a meal unless especially ordered in an emergency Solution commonly in use 1. plain water—in case of an unknown poison 2. normal saline solution 3. weak solution of sodium bicarbonate/boric acid in poisoning 4. specific antidotes, if the poison is known -Three types of antidotes a. physical antidotes -it mixed with poison & dilute it or -prevent its absorption -it protects the m.m b. chemical antidotes—it reacts with poison & neutralizes it c. physiologic antidotes—has systemic effects opposite to that of the poison e.g. if the poison has depressive action, it will stimulate effect on the body NB. Antidote is substances used to counteract the effect of poison e.g. large quantity of dilute alkali for acid poisoning Contraindication of gastric lavage -pt’s who have ingested a corrosive substance E.g. lye, ammonia, or mineral acid b/c the NGT may perforate the already compromised esophagus Complication of gastric lavage Brady arrhythmias cardiac arrest due to body temperature lowered inadvertent passing of the Nasogastric tube into trachea respiratory aspiration of gastric contents resulting aspiration pneumonia perforation of the esophagus/stomach NB- for pt with gastric / esophageal bleeding lavage with tepid/iced water/0.9% sadiumchloride solution may used to stop bleeding *action -iced irragating solution stimulates the vagus nerve -these leads to increased HCL secretion -these again stimulate gastric motility, which can irritate the bleeding site -gastric lavage is usually performed in the emergency department / ICU by a a doctor gastroenterologist (most) nurse -chart 1) type & amount of solution used 2) Character & amount of returns 3) Condition of the pt 4) Name of the health professional who giving Rx 5) Time to be noted Procedure: Nasogastric Lavage
- 6. 6 Equipment: Large bore stomach tube (approx. 1.25 cm in diameter and 150 cm in length) Funnel or 50 mL syringe 500 mL jug Pail, plastic apron, clean gloves 4 liters of appropriate solution at room temperature Specimen bottle for laboratory (PRN) Action Rationale Verify the doctor’s order To ensure that the correct procedure is performed on the correct patient Verify the correct patient As above Perform hand hygiene Hand hygiene prevents the spread of micro- organisms Explain the procedure to the patient To ensure that the pt understands the procedure Assist the patient to the correct position as in in in procedure ”Insertion of Nasogastric tube” If the patient is unconscious, place on a firm surface, lying in the semi prone position, with the head down The head must be kept low so that fluid/ vomitus will runs out of the mouth and not down into the trachea Aspirate a specimen of stomach contents for laboratory analysis To obtain information on the poison ingested Attach the funnel to the tube and insert 400 mL of the appropriate tepid solution Dilutes the gastric contents When the solution is in the base of the funnel clamp the tube by pinching with the fingers and lower the funnel over the pail Clamping prevents spillage. Siphoning will not occur if the funnel has been allowed to empty Return the funnel to the upright position and again add 400 mL of the solution A lavage to clean the stomach pre- Operatively needs to be done until the fluid returns clear A lavage performed for a poisoning: a total of 8 liters is to be given When the procedure is completed, remove the tube as per the procedure ” Removal of Nasogastric tube” Following the correct procedure decreases the possibility of complications If the lavage was done because of the Ingestion of poison, continue to monitor the patient for signs and symptoms of poisoning Document: time of the procedure, solution used, amount given, character of the return flow, if a specimen was sent to the lab, condition of the patient before, during and after the procedure Student Notes: Procedure: Nasogastric Gavage Equipment: Correct amount of feeding solution (at room temperature); check expiration date feeding solution to room temperature Syringe if intermittent feeding or feeding bag with drip chamber Measuring container
- 7. 7 Water (60ml unless otherwise specified) Action Rationale Verify the doctor’s order To ensure that the correct procedure is performed on the correct patient. Verify the correct patient As above Explain the procedure to the patient: will not cause discomfort but may prompt a feeling of fullness Adult: intermittent feeding should take 20-30 Minutes To ensure patient understanding of the procedure Screen that patient: Provide privacy for the patient if the patient wants Nasogastric feedings may be embarrassing for some people Assist the patient to a Fowler’s position or sitting position in a chair. If sitting is contraindicated, a slightly right side-lying position is acceptable These positions allow the gravitational flow of the solution and prevent aspiration of fluid into the lungs Assess tube placement. See insertion of NG tube and 4 methods of insuring placement Must insure that feeding solution will not enter the lungs Assess residual feeding contents by Aspirating all the stomach contents. Measure the amount If 50 mL or more of undigested formula is withdrawn in an adult check with the dr before giving the feeding This evaluates absorption of the last feeding. The feeding may be withheld or the amount withdrawn is subtracted from the total feeding and that volume is administered slowly or re-instill the gastric contents into the stomach Administer the feeding Using a bulb syringe: remove the bulb from the syringe and connect the syringe to a pinched or clamped NG tube. Add the feeding solution to the syringe barrel and permit the feeding to flow in slowly at the prescribed rate. Raise or lower the syringe to adjust the flow as needed. Pinch or clamp the tubing to stop the flow if the patient experiences discomfort Using a feeding bag: Hang the bag from an IV pole about 30cm above the tube’s point of insertion into the patient. Clamp the tubing & and add the formula to the bag. Open the clamp, run add the formula through the tubing, and re-clamp the tube. Attach the bag to the NG tube and regulate the drip by adjusting the clamp to the drop factor on the bag ( e.g. 20 10 drops/mL) Pinching or clamping prevents excess air from entering the stomach and causing distention Giving the feedings too quickly can cause flatus, cramps or reflux vomiting Air in the tubing is removed thus preventing air entering into the stomach and intestines Rinse the feeding tube before all the formula has run through the tubing by instilling 60 ml of water through the feeding tube. Add the water before the solution has drained completely Water cleans the tube, preventing future blockage by sticky formula Adding water before the tubing is empty prevents air from entering the stomach and intestines Clamp the feeding tube before all the water is is is is through Cover the end of the tube Prevents leakage and air from entering the tube Covering the tube prevents leakage Ensure the patient’s comfort and safety: Pin the tubing to the patient’s gown. Ask the patient to remain sitting upright in This decreases the pulling of the tube and prevents discomfort and dislodging of the tube. Upright position facilitates digestion and
- 8. 8 Fowlers position or in a slightly elevated right lateral position for at least 10 minutes movement of the feeding from the stomach along the digestive tract and prevents potential aspiration of the feeding into the lungs Dispose of equipment: If the equipment is to be be be reused wash it thoroughly with soap and water. Change the equipment every 24 hrs or according to hospital policy Document: amount and kind of feeding/fluids Duration of the feeding Assessment of the patient Record the amt of the feeding and the water given on the patient’s intake and output record To have an accurate record of the patient’s nutritional intake available for all members of the health care team Monitor the patient for possible problems: tolerance of the feedings, regurgitation & feelings of fullness after feedings, weight gain or loss, bowel movements (diarrhea, flatulence, constipation) skin turgor, and urine output Student Notes: URINARY CATHETERISATION Urinary catheterization is the insertion of a catheter into the bladder to drain urine. This can be done through the urethra, or through a small supra pubic incision. Indications for Catheterization Urinary catheterization may be considered for any of the following reasons: 1. To relieve distension of the bladder when the patient is unable to pass urine 2. For pre or post-operative drainage of urine in patients having abdominal, perineal or pelvic surgery 3. To see if residual urine is present 4. To allow irrigation of the bladder 5. To manage urinary incontinence if other methods fail 6. To monitor urinary output accurately in seriously ill patients 7. To give drugs directly into the bladder 8. To obtain a sterile specimen of urine for laboratory examination CATHETERS Urethral catheters are measured in Charriers (Ch). French Gauge (FG) is the same size as Ch. For women the average catheter size is 12-14 Ch, and for men 14-16 Ch. A larger bore may be required if there are blood clots or debris in the bladder. A smaller size is used for children. 16-18 Ch is generally used for supra-pubic catheterization. Oxygen administration Oxygen therapy –supplementation of oxygen to relieve hypoxemia & preventing damage to the tissue cells as results of oxygen lack Indication Lung diseases and injury • COPD • Pneumonia • Bronchial asthma Blood disorders such as anemia Cardiac insufficiency Hypoxia Hypoxemia saturation < 90% Asphyxia Gas poisoning post anesthesia post cardio pulmonary arrest reduced cardiac out put
- 9. 9 hypotension, tachy cardia, central cyanosis, chest pain, dyspnean, acute neurological dysfunction endotracheal suctioning, broncoscopy,/thoracenthesis severe lower chest wall in drawing Procedure: Female Urinary Catheterization Equipment: Sterile catheterization pack Foley catheter (x2) Sterile gloves (x2) Drainage bag 10 mL syringe + needle Sterile lubricant (KY jelly) Sterile water (10 mL) Cleansing solution (normal saline) Waterproof mackintosh Scissors Tape (plaster) Specimen container (if needed) Screen Unsterile K basin Good light source Action Rationale Check the identification of the pt Explain the procedure to the pt To ensure the correct pt understands & consents to the procedure Screen the bed. Place a garbage container within easy reach. Assist the pt into the dorsal recumbent position. Cover the pt with a sheet. To ensure privacy For ease of access for the nurse Do not expose the pt at this stage Perform hand hygiene To reduce risk of infection Clean and prepare the trolley, placing all equipment on the bottom shelf The top shelf acts as the clean work surface Take the trolley to the pt’s bedside Open the outer cover of the catheterization pack & slide the pack on the top shelf of the trolley To prepare equipment Using aseptic technique, open inner pack. Add sterile supplies: catheter, lubricant, cleaning solutions, drainage bag, clean gloves, etc To reduce the risk of introducing infection Draw up 10 mL sterile water using syringe & needle. Place in K basin within easy reach of the pt Place drainage bag where it is easily accessible Place opened, sterile urine specimen bottle close to the pt (if urine sample is needed) For injection into the balloon of the foley catheter For ease of access during procedure Remove sheet that is covering pt. Assist pt to flex her knees approx. 2 feet apart, with her legs abducted. Place a waterproof mackintosh under her buttocks Proper positioning allows visualization of the urinary meatus To prevent the linen from becoming wet Perform hand hygiene To reduce the risk of cross-infection Put on sterile gloves To reduce the risk of introducing infection to the urinary tract during the catheterization Pick up the corners of the sterile drape & unfold it. Fold back a corner on each side to make a cuff over gloved hands. Ask pt to lift her buttocks and slide the sterile drape under her with gloves protected by cuff The drape provides a sterile field Covering the gloved hands with a cuff will keep the gloves sterile while placing the drape Place the fenestrated drape over the perineal area, exposing the labia (this drape is optional) To expand the sterile field A fenestrated drape may obstruct visualization of the meatus
- 10. 10 Arrange supplies on the sterile field, lubricate the end of the catheter. Place catheter in sterile K basin and place on sterile drape between pt’s legs Lubrication facilitates catheter insertion & reduces tissue trauma For ease of access during procedure With thumb & 1 finger of the left hand, spread the labia & identify the meatus. The left hand is now contaminated and should remain in this position until the catheter is in-situ This manoeuver provides better access to the urethral orifice and help to prevent labial contamination of the catheter Use your right hand to pick up the forceps & gauze soaked in the cleaning solution. Clean one labial fold in one downward motion. Discard the gauze. Use a new gauze for each stroke to clean the other labial fold, then the meatus Cleaning the urinary meatus last helps reduce the possibility of introducing micro-organisms into the bladder Using your right hand, gently introduce the tip of the catheter into the urethral orifice in an upward & backward direction. Advance the catheter until there is a return of urine (approx 5-6 cm).Do not force the catheter through the urethra. Ask the pt to breathe deeply & gently rotate the catheter if resistance is felt The female urethra is approx. 3.5-6 cm long Applying force on the catheter can injure the mucous membranes Hold the catheter securely at the meatus with your left hand. Use your right hand to inflate the balloon with 10 mL of sterile water (from the pre-filled syringe). Your right hand is now contaminated The balloon anchors the catheter in place in the bladder Pull gently on the catheter after balloon is inflated to feel resistance Improper inflation can cause discomfort Collect urine specimen if needed Allow the urine to drain into the sterile K basin To empty the bladder Attach catheter to drainage system; maintaining aseptic technique Closed drainage minimizes the risk of micro- organisms being introduced into the bladder Measure the amount of urine For accurate record of I&O Assist the pt into a comfortable position Remove used supplies & dispose of garbage properly. Remove gloves. Clean hands To prevent the spread of infection Secure the catheter to the pt’s inner thigh. Leave some slack for leg movement. Position of the drainage tubing will depend on the pt’s mobility & comfort of the pt Proper attachment prevents trauma to the urethra from tension on the tubing Secure drainage bag below the level of the bladder. Teach the pt to keep the bag below the level of the bladder; to drink at least 2 L of fld per day (unless contraindicated) & that she may experience a sensation of needing to void Facilitates drainage of urine & prevents backflow of urine into the bladder To prevent urinary tract infection Due to pressure of the balloon Document relevant information (type & size of catheter, amt of fld used to inflate balloon, amt & colour of urine drained, any specimen obtained. (Record amt of urine on I&O record PRN) To record procedure & relevant information for other health care professionals Procedure: Male Urinary Catheterization Equipment:
- 11. 11 Sterile catheterization pack Foley catheter (x2) Sterile gloves (x2) Drainage bag 10 mL syringe + needle Sterile lubricant (KY jelly) Sterile water (10 mL) Cleansing solution (normal saline) Waterproof mackintosh Scissors Tape (plaster) Sterile specimen container (if needed) Screen Unsterile K basin Action Rationale Check the pt’s identification and explain the procedure to the pt To ensure the correct pt understands & consents to the procedure Screen the pt. Place a garbage container within easy reach. Assist the pt into the supine position Cover the pt with a sheet To ensure privacy For ease of access for the nurse Do not expose the pt at this stage Perform hand hygiene To reduce risk of infection Clean and prepare the trolley, placing all equipment on the bottom shelf The top shelf acts as the clean work surface Take the trolley to the pt’s bedside Open the outer cover of the catheterization pack & slide the pack on the top shelf of the trolley To prepare equipment Using aseptic technique, open inner pack. Add sterile supplies: catheter, lubricant, cleaning solutions, clean gloves, drainage bag, etc. To reduce the risk of introducing infection Draw up 10 mL sterile water using syringe & needle. Place in K basin within easy reach of the pt Place drainage bag where it is easily accessible to pt Place opened, sterile urine collection bottle close to the pt (if necessary) For injection into the balloon of the foley catheter For ease of access during procedure Remove sheet that is covering pt. Assist pt to a dorsal recumbent position, legs slightly apart Place a waterproof mackintosh under his buttocks and thighs To prevent the linen from becoming wet Perform hand hygiene To reduce the risk of cross-infection Put on sterile gloves To reduce the risk of introducing infection to the urinary tract during the catheterization Place sterile towels across pt’s thighs The drape provides a sterile field Place the fenestrated drape over the penis To expand the sterile field Arrange supplies on the sterile field, lubricate the end of the catheter. Place catheter in sterile K basin and place on sterile drape between pt’s legs Lubrication facilitates catheter insertion & reduces tissue trauma For ease of access during procedure Wrap a sterile gauze around the penis with the left hand. Retract the foreskin, if necessary. Be prepared to keep this hand in this position until catheter is inserted The hand touching the penis is now contaminated Use your right hand to pick up the forceps & gauze soaked in the cleansing solution. Using a Cleaning the urinary meatus last helps reduce the possibility of introducing micro-
- 12. 12 circular motion, clean the penis, moving from the meatus around the glans. Repeat this cleansing motion x2, using a new gauze each time organisms into the bladder Normal saline has been shown to be an effective cleansing solution Hold penis with slight upward tension, perpendicular (or 90 degrees) to the pt’s body. Use your right hand to gently introduce the tip of the catheter into the urethra for 15-25 cm until urine flows The male urethra is approx. 18 cm long If resistance is felt, increase the traction on the penis slightly & apply steady, gently pressure on the catheter. Ask the pt to strain gently as if passing urine Some resistance may be due to spasm of the external sphincter. Straining gently helps to relax the external sphincter Advance the catheter gently almost to its bifurcation. Hold catheter in place at the meatus with your left hand. With your right hand, inject 10 mL of sterile water into the balloon with the prefilled syringe. Once balloon is inflated gently withdraw the catheter slightly The balloon anchors the catheter in place in the bladder. Improper inflation can cause pt discomfort and damage to the urethra Collect a sterile urine specimen if needed Allow the urine to drain into the sterile K basin To empty the bladder Attach catheter to drainage system maintaining aseptic technique Closed drainage minimizes the risk of micro-organisms being introduced into the bladder Ensure that the glans penis is clean and then reduce or reposition the foreskin Retraction & constriction of the foreskin behind the glans penis may occur if this is not done Make the pt comfortable Ensure that the area is dry If the area is left wet or moist secondary infection or skin irritation can occur Measure the amount of urine For accurate I&O Remove used supplies & dispose of garbage properly. Remove gloves. Clean hands To prevent environmental contamination To reduce risk of infection to the nurse Secure the catheter to the pt’s inner thigh. Leave some slack for leg movement. Position of the drainage tubing will depend on the pt’s mobility & comfort of the pt Proper attachment prevents trauma to the urethra from tension on the tubing Assist the pt into a comfortable position Secure drainage bag below the level of the bladder. Teach the pt to keep the bag below the level of his bladder; to drink at least 2 L of fluid per day (unless contraindicated) and that he may experience a sensation of needing to void Facilitates drainage of urine & prevents backflow of urine into the bladder Prevents urinary tract infections Due to pressure of the balloon Document relevant information (type & size of catheter, amt of fld used to inflate balloon, amt & colour of urine drained, any specimen obtained. Record amt of urine on I&O record PRN) To record procedure & relevant information for other health care professionals
- 13. 13 Oxygen therapy –supplementation of oxygen to relieve hypoxemia & preventing damage to the tissue cells as results of oxygen lack Indication of short term oxygen therapy documented pao2 less than 60mmhg or sao2 less than90% post anesthesia post cardio pulmonary arrest reduced cardiac out put hypotension, tachy cardia, central cyanosis, chest pain, dyspnean, acute neurological dysfunction endotracheal suctioning, broncoscopy,/thoracenthesis severe lower chest wall in drawing Ways of oxygen administration 1. nasal cannula most common used oxygen flow not exceceed2-4L/min 2. tent or mist tent it helps to o moistens air way o minimizes fluid loss from the lung disadvantage make observation of the child difficult b/c of the high humidity oxygen concentration also falls quickly when the tent is opened for routine care & return slowly its previous level difficult to maintain specific oxygen concentration it increases body temperature thus increasing oxygen requirements child is difficult to see & assess 3. mask o comfortable for child, who is quiet & not struggle o gas flow should be a minimum of 7L/ min to ensure adequate carbon dioxide removal o usually delivery inspired oxygen concentration up to 55% Equipment & accessories for oxygen therapy pulse oximeter thermo meter stethoscope oxygen source, flow meter, delivery devices blood pressure monitoring device extra linen & towels * Oximeter- is a photo electric cell used to determine the oxygen saturation of blood * Pulse oximeter- is a non-invasive method for measuring hemoglobin oxygen saturation in the body Purpose • To monitor arterial oxygen saturation non-invasively. • To detect clinical hypoxemia promptly.
- 14. 14 • To assess client tolerance to tapering of oxygen therapy or activity. Norma >90% Complication of oxygen 1. respiratory depression or oxygen induced apnea -b/c of carbon dioxide completely washed of due to high concentration of oxygen; so that respiratory centre is not stimulated sufficiently. Normally a part of the carbon dioxide remaining in the blood, stimulalates respiratory center 2. retrolental fibro plasia -noted in pre mature infants who have high concentration of oxygen 3. substernal pain 4. atlectasis -due to increased oxygen concentration in the inspird air -due to elimination of nitrogen’; normally the nitrogen is not diffused via alveoli membrane . it remain in the alveoli to keep the alveoli expanded 5. pulmonary toxicity 6. drying of the mucus membrane of the respiratory tract -b/c of low humidity Sign & symptom of oxygen toxicity tracheal irritation cough dryness & irritation of m.m substernal pain vomiting & nausea dyspnea restlessness, fatigue, malaise, progressive respiratory difficult Precaution of oxygen therapy 1. oxygen must be ordered by physician 2. post, NO SMOKING 3. don’t allow friction, metal, electrical, or battery operated toys in tent 4. oxygen system should be at least 10 feet away from any fire, including pilot light in stoves, furnaces, water heaters etc 5. avoid using petroleum jelly, faces creams, lip balms, alcohol, or oils ; since all are flammable & have potential to explode in oxygen rich environment 6. fire extinguisher should available & visible Nursing responsibility monitor v/s every 4hrs observe for changes in RR, notify physician for clinical changes auscultate breaths sound for symmetry & advent ion of sound review lab data, chest x-ray, etc position the pt - ensure that tubing associated with oxygen therapy is changed daily regulate body temperature Procedure: Oxygen Administration Equipment: Oxygen cylinder (or machine) Flowmeter Oxygen tubing Humidifier with sterile distilled water Face mask or nasal prongs Follow the steps outlined in “Principles of Medication Administration”. Then:
- 15. 15 Action Rationale Check the pt’s chart for the dr’s order To verify the type of oxygen therapy and flow rate required Identify the patient a the bedside To ensure therapy is administered to the correct patient (O2 is a medication) Explain what you are going to do and the reason to the pt. Explanation relieves anxiety and facilitates cooperation Perform hand hygiene To prevent the spread of microorganisms Connect the oxygen setup (tubing and face mask) with humidification. Adjust the flow rate as ordered. Check that oxygen is flowing. Humidification helps to prevent drying of the mucous membranes. Low flow oxygen (via nasal prongs) does not require humidification Position the pt comfortably with the airway open and the tubing over the ears and cheeks. The mask should fit snugly over the nose and chin. If nasal prongs are used, insert prongs into the pt’s nostrils. Excessive pressure from the tubing will be uncomfortable and can lead to skin irritation or breakdown Use gauze padding between the tubing and the patient’s ears as necessary To prevent discomfort and pressure on the area Encourage the pt to breathe through his/her Nose Nose breathing is best for the delivery of oxygen – the pt will receive less oxygen if he breathes through his mouth Assess and re-assess the pt’s respirations, colour, chest sounds, etc. every hour To assess effectiveness of oxygen therapy and to ensure the oxygen is flowing, the mask or prongs are in the correct position, etc Put on gloves to clean the nasal prongs once per shift. Check nares for irritation or skin breakdown To clear the tubing of secretions which can prevent the delivery of the ordered flow of Oxygen Document procedure and assessment of the pt in the chart To communicate pt findings and intervention Air way suctioning Definition • The removal of secretion from the nasopharynx and oropharynx by using suction catheter and suction machine Purposes • To clear secretions the client cannot remove by coughing. • To relief dyspnea caused by secretion accumulation • To maintain patent air way • To collect sputum or secretions for diagnostic testing • To prevent aspiration Performing Nasopharyngeal and Oro pharyngeal Suctioning Definition The removal of secretion from the nasopharynx and oropharynx by using suction catheter and suction machine Indications For nasopharyngeal suctioning Post operative patient Conscious patients who cannot maintain airway For oropharyngeal Unconscious patients Secretion in oral cavity Precaution Limit suctioning to 3 times per day for adult but if needed consult your physician Never insert the catheter in to nares or mouth while the suction is on and the port is closed
- 16. 16 Never suction more than 15 seconds for adult and 10 seconds at a time to avoid hypoxia. Contraindication For orophringial suctioning Mouth/buccal burn Conscious patient For nasopharyngeal suctioning Head injuries Nosebleeds Procedure: Nasopharyngeal & Oral Suctioning Equipment: Portable or wall suction unit Sterile water or saline Suction tubing Sterile dressing set Sterile gloves Goggles & mask Stethoscope Waterproof mack Action Rationale Check that you have the correct pt Explain the procedure to the pt To ensure the pt understands the procedure & gives his consent Assist the pt into semi-fowler’s if he is conscious Position pt laterally (right or left side) if he is unconscious, with his head facing you Sitting position helps pt to cough and makes breathing easier Lateral position will prevent the airway from becoming occluded & improves drainage of secretions by gravity Perform hand hygiene To prevent the spread of microorganisms Place the waterproof mack under the patient (if he is lateral) or across his chest if he is In semi-fowlers position To prevent the linen from becoming Soiled Connect the tubing (if not already attached) and and adjust the suction to the correct pressure (normally 100 – 150 mmHg for adults) – occlude the tubing to check the amount of pressure Excessive pressure can cause trauma to the mucosa Open sterile dressing pack. Add sterile normal saline or water. Add the sterile suction catheter, maintaining sterile technique Sterile water or saline is used to lubricate the tip of the suction catheter to minimize trauma to the mucosa. It is also used to rinse the catheter between suctioning attempts Put on goggles and mask Put on sterile gloves To protect eyes and mouth from splash of patient’s oral secretions Handling the sterile suction catheter using a sterile glove will decrease the risk of introducing organisms into the respiratory tract Pick up the connecting tube with the left hand (this hand is now contaminated) and with the right hand pick up the sterile suction catheter. Connect the suction tubing to the sterile catheter It is important to maintain the sterility of the suction catheter Place the tip of the catheter in the sterile water and moisten it To lubricate the end of the catheter Encourage the patient to take several deep Breaths The suctioning procedure will produce hypoxemia. Hyperventilation can help prevent this If the pt has oxygen by nasal cannula or mask, remove it. Gently insert the catheter
- 17. 17 through the naris and along the floor of the nostril toward the trachea. Roll the catheter between your fingers to help advance it Insert the catheter approximately 12-14 cm to reach the pharynx Do not apply suction to the catheter when introducing it into the airway If the oropharnyx is being suctioned, insert the suction catheter through the mouth, along the side of the mouth, toward the trachea. Advance the catheter 7 – 8 cm to reach the pharynx Using suction while inserting the catheter can cause trauma to the mucosa and Removes oxygen from the respiratory tract Intermittently occlude the Y port on the suction catheter while gently rotating it as it is being withdrawn Maximum suctioning time: 10-15seconds Occluding the port provides suction Suctioning for more than 15 seconds results in hypoxemia. However, suctioning too quickly may be ineffective in clearing all of the secretions Allow the patient to rest and encourage him to take several deep breaths before proceeding Flush the catheter with saline Assess effectiveness of suctioning and repeat procedure PRN Allow at least a 30-60 second break between each suctioning. Maximum of 3 attempts Be sure to alternate the nares that is used Flushing clears the catheter of secretions and lubricates the tip for future suctioning Time is required to allow for re-oxygenation of the tissues To reduce trauma When suction is finished, remove the gloves by by by pulling them over the coiled catheter, pulling from the inside out Dispose of the gloves Remove goggles and mask Perform hand hygiene This technique reduces the transmission of microorgnanisms To prevent the spread of microorganisms Turn off the suction Re-apply oxygen apparatus PRN Position pt comfortably Offer oral hygiene Assess pt’s respiratory status Document the procedure To evaluate the effect of the procedure To communicate with other health Professionals Tracheostomy -is the surgical creation of an opening /stoma into the trachea /windpipe Purpose of Tracheostomy To pass upper air way obstruction To remove tracheo-bronchial secretions To prevent aspiration To replace endotracheal tube To provide & maintain air way for respiratory support Indication of Tracheostomy o Air way obstruction at /above larynx o Inability to remove secretions from the tracheo-bronchial tree o Need for long term positive pressure ventilation o Broncho pulmonary dysplasia o Pneumonia
- 18. 18 o Hyaline membrane diseases o Diaphragm dysfunction Assessment Placement of Tracheostomy The reason for placement Type & size of the tube C o n d i t i o n o f t h e s k Child’s color v/s, breath sound the consistency & amount of secretions Precaution with tracheostomy o always have extra tracheostomy tube o follow strict aseptic condition o watch for the f/f signs of obstruction of the air way & report them to the doctor immediately ,if they don’t improve with a. suction tracheostomy tube b. changing the tracheostomy tube restlessness, labored breathing, increased RR, NOISY RESPIRATIO N Retraction (in drawing of chest or ribs) Mouth breathing with no air passages the tracheostomy Suction of the Tracheostomy -It is used to clear the tracheostomy tube Indication of tracheostomy suctioning noisy respiration pulling inward of the chest wall pulling inward of the hollow in the neck fast breathing difficulty eating/ sucking mucus bubbling around the tracheo opening flaring nostrils change in color of mouth, lips,( pale,blue,dusky) Emergency care pt with tracheostomy - If the patient stops breathing Suction the tracheostomy tube immediately
- 19. 19 If the tracheostomy tube is plugged with mucus & you can’t suction it out, change the tube If the pt still does not breath when the new tube is inserted, and no pulse begin CPR Call for help. Continue CPR until help arrives or the child responds by breathing on is own -if a strong pulse present but child still not breathing, continue with artificial ventilation breathing General instructions for a pt with tracheostomy Avoid breathing the cold air into tracheostomy b/c it can cause tracheal spasm & form small ice particles in the mucus if exposed for extended period of time Encourage routine food Don’t let the pt take showers Avoid the f/f environmental irritants Pets with fine air feathers, dust, Aerosol sprays Smoke, powder Procedure: Tracheostomy Suctioning Equipment: Suction machine Protective eye wear (goggles) Sterile suction catheters Sterile normal saline + syringe Sterile gloves Waterproof mackintosh Sterile dressing pack Mask Waterproof apron Stethoscope Action Rationale Identify the patient To ensure therapy is administered to the correct patient Explain what you are going to do and the reason to the pt. (even if the pt does not appear to be conscious) Explanation relieves anxiety and facilitates cooperation Perform hand hygiene To prevent the spread of microorganisms Position the pt: Conscious pt – semi fowlers Unconscious pt – lateral position facing towards the nurse Allows pt to breathe easier Prevents airway from becoming obstructed and promotes drainage of secretions Place waterproof pad across the pt’s chest Prevents the linen from becoming soiled Turn suction on to the appropriate level (Portable suction machine: 10 – 15 cmHg Wall suction: 80 – 150 mmHg) Excessive pressure can damage the mucosa, cause hypoxemia & atelectasis Perform hand hygiene To decrease the spread of microorganisms Select the correct catheter size (the diameter of the catheter should be half the tracheostomy tube size) If secretions are very thick or copious, a larger bore catheter will be needed Open the sterile dressing pack to create a sterile field Asepsis must be maintained throughout the procedure Open the suction catheter package using aseptic technique & place the catheter on the sterile field Pour sterile water (or other antiseptic solution as ordered) into the gallipot Sterile water is used to lubricate the suction tubing and clear the lumen between suction attempts Put on goggles, mask & apron To protect the nurse from contamination by secretions during suctioning
- 20. 20 Put on sterile gloves To prevent the introduction of organisms into the the respiratory tract The right (dominant) hand must remain sterile The left hand is considered clean & is used to manipulate the suction valve of the catheter The glove on the left hand is used to protect the the nurse from the pt’s secretions Connect the sterile suction catheter to the suction machine (remember the right hand must remain sterile) Lubricate the tip of the suction catheter with normal saline using the right hand To minimize mucosal irritation when the catheter is introduced Rinse the catheter with sterile Normal Saline Assess the need to repeat the suctioning Flushing clears the catheter of secretions Suctioning should only be repeated as necessary due to the potential risks to the pt Allow at least a 30-60 second interval between suctioning attempts To allow for re-oxygenation of the of the Patient A maximum of 3 suction passes should be Made Excessive suctioning contributes to Complications Remove glove from the right hand over the coiled catheter by pulling it off inside out. Then remove the glove from the left hand; dispose of gloves and catheter and used dressing pack To prevent contamination and the spread of microorganisms Turn off suction Assist pt into a comfortable position Reassess pt’s respiratory status: rate, effort, oxygen saturation & breath sounds To assess effectiveness of suctioning procedure and the presence of any complications Chart procedure and pt’s condition To have a record of the procedure Assisting with thoracentesis Definition: thoracentesis is the procedure in which a puncture is made into the chest wall to withdraw fluid or air from the pleural cavity for diagnostic or therapeutic purposes. Indication A. When unexplained fluid or air accumulates in the chest cavity outside lung. B. Pleural effusions C. Compromised cardiovascular status due to air fluid or blood outside the lung, D. Pleural fluid analysis E. Instillation of medication into the pleural space Purpose Contraindication Uncooperative patient
- 21. 21 that cannot be corrected Precaution: The aspiration should not exceed 1L as there is a risk of development of pulmonary edema. Equipment Sterile: 1 . 2 Gallipots 2. 1 pair of dissecting forceps 3. 1 pair of artery forceps 4. Swabs and gauze in a receiver 5. towel with a hole((fenestrated towel) 6. hand towel 7. Gloves 8. Syringe and needle for local anaesthesia 9. Rubber tube which fit the opening of the two-way tap 10. 10 or 20 cc aspiration syringe and needle 11. two - way tap 12. 2 glass tube for specimen 13. Receiver to collect fluid specimen Clean 1 . Rubber sheet and towel 2. Receiver for used instrument 3. Measuring jug 4. Trolley 5. Local anaesthesia 6. Cleaning lotion such as ether, tincture of iodine 7. Plaster with scissor 8. Sputum mug 9. Lab request-form Procedure: 1. Check clinical record for order and possible allergy 2. Alert physician if any abnormal lab result 3. Explain the procedure to the patient and inform them to try not to cough, not to breathe deeply, and not to move suddenly during the procedure to avoid puncture of the visceral pleura or lung 4. Verify informed written consent 5. Wash hands 6. Collect necessary equipment and bring to patient bedside 7. Take baseline vital sign including pulse oximetry 8. Screen the patient. 9. Remove clothes to expose chest. 10. Position the patient as directed by the physician. The position may be either one of the following or a similar position, as directed by the physician. (a) Position the patient to sit on the side of the bed, facing away from the physician, with feet supported on a chair and the head and arms resting on an over bed table padded with pillows. The arms are elevated slightly to widen the intercostals spaces. (b) If the patient is unable to sit, turn him on the unaffected side with the arm of the affected side raised above his head. Elevate the head of the bed 11. Place the thoracentesis tray on instrument table. Open sterile wrapper cover to provide a sterile field. 12. Place other supplies on adjacent bedside stand or over bed table. Open glove wrapper. 13. Assist with handling of local anesthetic vial. Hold vial with label uppermost so that the physician can personally check the label before withdrawing any of the solution. Cleanse stopper with alcohol swab. Invert vial and hold firmly while the doctor, with gloved hands, withdraws the required solution. 14. Support and help patient to avoid moving and coughing while the thoracentesis needle is introduced. 15. Assist as directed with collection of specimens as the physician manipulates the syringe, the stopcock, and drainage tubing. Use care not to contaminate the end of the tubing, the cap, or the open end of the specimen tubes. Cap the tubes and place them upright in a clean glass provided for this purpose. Label each tube as directed by the physician. 16. If drainage of a large amount of accumulated fluid is necessary, assist the doctor by placing the free end of the tubing in the drainage bottle.
- 22. 22 17. Watch the patient's color; check pulse and respiration. Immediately report any sudden change, as this may indicate damage to the visceral pleura from a nick or puncture by the needle. 18. After the needle is withdrawn, apply a sterile occlusive dressing over the puncture site. 19. Position patient comfortably (usually Fowler's position). 20. Complete entries on appropriate laboratory request forms as directed. 21. Send properly labeled specimens with completed request forms to laboratory immediately if required 22. Measure and record amount of fluid withdrawn and discard this fluid unless directed otherwise. 23. Return used equipment and wash hand 24. Proper documentation Complications Pneumothorax Hemorrhage into the pleural space or chest wall, Vasovagal syncope (fainting) Air emboli Infection puncture of the spleen or liver, Patient assessment Before the procedure 1. patient patient preparation getting informed consent from the patient chest x-ray small dressing local anesthesia 2. assessment of the patient vital sign compliant of chest pain respiratory depth& movement of both chest during inspiration breath sounds dyspnea, type& frequency of cough if present character& amount of sputum During the procedure 1. positioning I. sitting up right position arm in the affected above the head leaning forward over bedside, table, chair II. lie on the unaffected side if unable to sit arm in the affected above the head 2. observation vital sign skin color difficulty breath After the procedure apply dressing observe for vital sign & skin color report for change of respiratory, bloody sputum, severe cough & shock CHEST WATER SEAL DRAINAGE SYSTYM
- 23. 23 - Is the process in which allow air & fluid to escape from pleural space with each exhalation & prevent their return flow with each inhalation -is the process of permitting unidirectional flow of air & fluid out of pleural space but, permitting none to enter from the drainage system - It is called closed chest drainage -it acts as a one way valve NB a water seal means Water in the bottle seal off the atmospheric air, preventing the atmospheric pressure from entering the chest drainage tube & thus from entering the pleural space. Purpose To remove air & fluid from the pleural space To re-establish the normal negative pressure in the pleural space To restore the normal pulmonary ventilation To prevent reflex(return flow) of fluid & air back into the pleural space from the drainage apparatus To prevent shifting of the mediastinum & collapse of the lung tissue by equalizing pressure on both side To promote re-expansion of lung Indication of water seal drainage system After thoracic & thoraco-abdominal surgery After chest injuries Following chest surgery to re-expand the involved lung Trouma,pneumothorax&hemothorax Excessive fluid & air in the pleural space Working of a water seal drainage apparatus -it has the following basic parts a) A sterile bottle which contain About 100ml of sterile normal saline or sterile water Closed tight rubber stopper Two holes at stopper b) Two hollow tubes which are o One short—acts as a air vent o One long—acts as a water seal NB two tubes are inserted via the holes in the stopper Long tube One end kept below the fluid level 3-5cm in the which seal off atmospheric air Other end is attached to the patient’s chest drainage tubing c) drainage tubing connected to the chest catheter -the drainage should be placed below the level of chest Types of chest drainage One bottle gravity system Two bottle gravity system Two bottle suction system Three bottle suction system
- 24. 24 ONE BOTTLE WATER SEAL CHEST DRAINAGE APPARATUS Operates by gravity only(gravity+positive pressure Single bottle serves as both water seal& collection container Air from chest—goes to bottle & bubbles in fluid—escape out via air vent The water seal system affected by the volume of drainage i.e. the fluid level in the bottle -i.e. as the fluid level in bottle increases, it becomes progressively difficult for air & fluid to exit from the chest The fluid in the water seal bottle is not drawn up into the chest tube because the fluid is heavier than the air Two bottle water seal chest drainage apparatus Consists of -One collection chamber (bottle)—collects the drainage from the patients -One water seal chamber (bottle)—function as the water seal bottle Not affected by the volume of the drainage Use gravity &positive expiratory for drainage Effective drainage depends on gravity & the amount of suction added to the system The pressure is constant b/c no mixing of fluid in the water seal bottle Empty drainage is placed b/n the patient & the water seal bottle It makes easy—to observe the amount and character of the drainage from the patient’s chest, since it does not mix with saline/ water in the bottle ---to control pressure with in the system & for fluid& air to leave the pleural space The three bottle water seal drainage system---it has One collection bottle (chamber)(1) Water seal bottle(2) Suction control bottle The suction machine creates a negative pressure throughout the entire closed drainage system Nursing responsibility of the patient with water seal chest drainage Assisting with the insertion and removal of the tube Maintain the water seal and potency of the drainage system Keeping chest forceps & rubber –tipped clamps near to the client . the chest tube will need to be clamped quickly to the insertion site ,if air leak develops in the drainage system Insertion site should be protected with sterile dressing Tubing b/n the pt & water seal bottle should be long enough to allow the pt to move turn Assessing the client’s v/s, cv status & resp status, shallow breathing, cyanosis
- 25. 25
- 26. 26 Procedure: Chest Tubes – Assessment & Care Equipment: Padded Kelly clamps – kept at the bedside at all times Stethoscope Action Rationale Observe the pt for any change in respiratory status by assessing: Colour, RR & pattern, unequal chest movement, capillary refill, breath sounds A change can indicate a worsening in the pt’s condition that may be due to malfunctioning of the closed drainage system Observe the chest tube is well secured with the suture and covered with a dressing To prevent movement of the drain and ensure safety of the patient Ensure the drain is well positioned with no kinks or loops; do not allow the pt to lie on the tubing To prevent occlusion of the drain Ensure drainage tubing is long enough for to allow the pt to turn freely in the bed To prevent the drainage tube from pulling, causing trauma to the pt or risk pulling the tube out Do not use pins to secure the tubing to the linen (use a rubber band or a strip of plaster) Pins can puncture the rubber chest tube, allowing air to enter the pleural cavity Ensure a 2 padded Kelly clamps are kept at the bedside at all times In case of accidental disconnection the chest tube can be clamped Never clamp the tubing without a dr’s order unless specifically indicated (ie: when changing the drainage bottle, for emergencies such as disconnection of the tube from the set-up, etc) Prolonged clamping of the tube can cause air to accumulate in the pleural space, a tension pneumothorax or mediastinal shift Ensure the drainage set-up remains below the level of the pt’s chest at all times To prevent backflow of fluid into the pleural Space Use plaster at all connection sites between tubing and bottles To prevent inadvertent disconnection or leakage which will allow air to enter the pleural space (the entire system must remain airtight at all times) Check the patency of the drainage A blocked tube will prevent air and
- 27. 27 tubing frequently. ‘Milk” the tubes if they become blocked with blood clots or secretions blood from draining out of the pleural cavity and into the drainage bottle Ensure the chest tube is always connected to the tube that is immersed under water If connected to the tube that act as an air vent, the air will be sucked into the pleural cavity causing collapse of the lungs Observe for the following in the drainage set-up: (several times each shift) - fluctuations of the fluid in the water seal tube - intermittent bubbling in the water seal bottle - 1 glass rod in the drainage bottle should be always immersed in 2.5 cm of water, another short glass rod should be open to the air or attached to suction - the colour and amt of drainage in the drainage bottle This indicates the chest tube is patent and will drain properly This should be present during expiration if air is being removed from the pleural cavity This acts to create pressure so that air and fluid will drain from the pleural cavity to the drainage bottle; if the tube is more than 2.5 cm below the water the air or fluid attempting to leave the pleural space must exert more pressure and proper drainage may not occur ; the short glass rod vents air from the set-up to create a negative pressure This information is needed to assess the pt’s on-going condition Maintain strict aseptic technique with the closed drainage system To prevent the introduction of infection into the pleural cavity Change the position of the patient while he Is in bed; encourage semi-fowler’s position To reduce the risk of skin breakdown Semi fowlers position promotes drainage by Gravity Encourage the pt to do deep breathing and coughing q2h while awake To clear the bronchi of secretions, to facilitate the re-expansion of the lungs, and prevent pneumonia Student Notes:
- 28. 28 Procedure: Care of a Chest Drainage System Changing the Drainage Bottle Equipment: 2 padded Kelly clamps Measuring beaker Clean gloves Sterile drainage bottle Action Rationale Identify the patient To ensure therapy is administered to the correct patient Explain what you are going to do and the reason to the pt. Explanation relieves anxiety and facilitates cooperation Perform hand hygiene To prevent the spread of microorganisms Double clamp the chest catheter close to the pt’s chest using the padded Kelly clamps (approximately 3.5 – 5 cm from insertion site, 2.5 cm apart) To prevent air from entering the pleural space through the chest tube Put on clean gloves To prevent contamination with body fluids Disconnect the bottle to be replaced along with the drainage tubing and the glass connections and attach the new set, ensuring aseptic technique is maintained To prevent contamination with microorganisms Make certain that the connections are air tight and the long glass tube in the bottle is below the fluid level & the chest catheter is attached to this tube Use plaster to secure all connections To prevent the inadvertent separation which could can lead to air entering into the pt’s chest cavity Place bottles on a chair or stool, below the level of the pt’s chest To prevent the bottles from accidentally being knocked over if they are on the floor Unclamp the Kelly clamps from the chest catheter and make certain the system is functioning properly To allow the air & secretions to drain freely Remove gloves & perform hand hygiene To prevent the spread of microorganisms Observe the pt’s vital signs and general condition Leave the pt in a comfortable position Any changes in the pt’s condition could indicate malfunctioning of the system Put on clean gloves Note the colour of the fluid and To protect the nurse from body secretions
- 29. 29 measure the amount in the drainage bottle Empty the bottle and send for sterilization Document procedure & amount of fluid in the drainage bottle on the pt’s chart To communicate the intervention and monitor the amount of fluid drained which indicates pt’s progress Student Notes: