INDEX
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TOPIC
ABDOMINL PARACENTESIS
THORACENTESIS
LUMBAR PUNCTURE
BONE MARROW ASPIRATION AND
BIOPSY
BARIUM ENEMA
EEG
SURGICAL DRESSING
NEBULIZATION
POSTURAL DRAINAGE
COLOSTOMY CARE
GASTROJEJUNOSTOMY FEEDING
TPN
PREOPERATIVE PREPRATION OF
PATIENTS
POST OPEARTIVE CARE
TRACHEOSTOMY CARE
NG TUBE FEEDING
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PAGE
NUMBER
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47
ABDOMINAL PARACENTESIS
Preparation of Articles
A covered sterile tray containing:
1. Sponge holding forceps to clean the skin
2. Syringe (5 ml) with needles to give local anaesthesia
3. Syringe (20 ml) with leur lock for aspiration of fluid
4. Three-way adaptor and tubing
5. Trocar and cannula or aspiration needles
6. B.P. handle with blades to make a small skin incision for the introduction of trocar and
cannula.
7. Suturing needles (if incision is made)
8. Small bowls to take cleaning lotions
9. Dissecting forceps – toothed 1, non toothed 1
10. Specimen bottles
11. Sterile dressing towels or slits
12. Cotton balls, guaze pieces, and cotton pads
13. Gloves, gown and mask
An unsterile tray containing:
1. Mackintosh and towels
2. Kidney tray and paper bag
3. Spirit, iodine, tr. Benzoin etc
2
4. Lignocaine 2 percent
5. Apron for the doctor
6. Drainage receptacle to collect the fluid
7. Pint measures to measure the fluid
8. Low stool to raise the drainage receptacle and adjust the height
PROCEDURE
The abdominal paracentesis is done under strict aseptic techniques. If it is done for
diagnostic purposes, the fluid withdrawn by a large syringe may be sufficient. If the
procedure is done for relieving pressure symptoms, a trocar and cannula are used. After
giving a local anaesthesia, a small skin incision is made at the site selected and the trocar
and cannula are introduced. After the trocar and cannula are in position the trocar is
removed and the cannula is attached to the tubing that reaches the drainage receptacle.
Occasionally, a soft catheter is passed through the cannula into the peritoneal cavity for the
removal of fluid. After enough fluid is withdrawn, the cannula is removed and opening is
sealed.
GENERAL INSTRUCTIONS
1. Give adequate explanations to win the confidence and co-operation of the client. Client’s
co-operation is very necessary, for the prevention of injury to the adjacent organs.
2. Strict aseptic technique should be followed to prevent introduction of infection into the
peritoneal cavity.
3. Ask the client to void 5 minutes before the procedure to prevent injury to the bladder.
Catheterize the client if any doubt exists.
4. Keep the client warm and comfortable to prevent chills.
5. Be prepared to treat shock. Shock can be prevented by :
a. Withdrawing the fluid slowly. Apply clamps on the tubing.
b. Withdrawing small quantity of fluid at a time
c. Applying pressure on the abdomen with many tailed bandage and tightening it from
above downwards as the fluid is drained.
d. Keeping the client warm
e. Observing the vital signs continuously during the procedure.
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6. The drainage receptacle should be raised on the stool. The greater the vertical distance
between the tapping needle and the end of the tubing in the drainage receptacle, the greater
is the pull on the fluid in the cavity and more quickly the cavity is drained and the client
may go into a state of shock.
7. Use a tapping needle/trocar of smaller gauge possible. This will reduce the puncture
wound as small as possible and thereby reduce the chances of fluid leaking from the
peritoneal cavity after the procedure is over.
8. The flow of fluid can be controlled by the application of clamps on the tubing.
9. The nurse should remain with the client throughout the procedure to observe the client’s
general condition. Changes in colour, pulse, respiration, blood pressure etc. should be
noted and reported to the doctor immediately. These are the indications that the client is
going into vascular shock and collapse.
10. Repeated aspirations of the ascitic fluid result in hypoproteinaemia. The client should
be given plasma proteins if he develops such a condition.
11. The wound should be sealed immediately after the procedure to prevent infection and
leakage of peritoneal fluid.
12. The specimens collected should be sent to the laboratory without delay. The usual test
that are carried out are specific gravity, cell count, bacterial count, protein concentration,
culture, acid fast stain. In most disorders, the fluid is clear and straw colored. Turbidity
suggests infection. Sanguineous fluid usually signals neoplasm or tuberculosis. The rare
milky (chylous) fluid is due to lymphoma. A protein concentration of less than 3gm/100 ml
suggests liver diseases or a systemic disorder; a higher protein content suggests an
exudative cause such as tumor or an infection.
Preparation of the Client
1. Explain the procedure to the client and his relatives to obtain their understanding, cooperation and acceptance of the treatment.
2. Get a written consent from the client or his relatives.
3. Prepare the skin as for a surgical procedure.
4. Record the blood pressure, pulse, respiration and weight of the client on the nurse’s
record before sending the client to the operation room. This may be used to compare the
similar data obtained during or after the procedure and to determine the effect of the
procedure on the client.
5. Empty the bladder just before the procedure to prevent injury to the distended bladder.
When there is doubt, catheterize the bladder.
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6. Protect the client from chills by keeping him warm. Cover the client with a blanket.
Close the windows and doors to prevent draught. Put off the fan.
7. Change the client’s garments with hospital dress. Put on loose gowns. The upper
garments may be pinned up to prevent its falling over the abdomen during the procedure.
8. Bring the client to the edge of the bed to prevent over reaching. Place him in a Fowler’s
position supported with a back rest and pillows.
9. Maintain privacy with screens and drapes. Drape the client exposing the abdomen only.
10. Protect the bedding with a mackintosh and towel.
11. Place a many tailed bandage under the client to apply over the abdomen during the
procedure in order to maintain the intra-abdominal pressure. This will help to prevent
shock and collapse as the fluid is drained from the abdominal cavity.
12.The nurse should remain with the client throughout the procedure encouraging him to
co-operate and diverting his attention away from the procedure. She should note the color,
pulse, respiration and blood pressure during the procedure to detect the early signs of
shock and collapse.
After Care of the Client
1. As soon as the needle is removed, a sterile dressing and a pressure bandage is applied at
the puncture site to prevent leakage of fluid.
2. The abdominal bandage is tightened to maintain intra-abdominal pressure.
3. Check the client’s general condition after the procedure. Any change in the color, pulse,
respiration and blood pressure should be reported immediately. The vital signs are checked
half hourly for two hours; then hourly for 4 hours followed by 4 hourly for 24 hours.
4. The specimen collected should be sent to the laboratory with labels and requisition form.
5. Examine the dressing at the puncture site frequently for any leakage. Re-enforce the
dressing if leakage is present.
6. Serum proteins are estimated to detect hypoproteinaemia. If hypoproteinaemia is
present, plasma proteins are administered.
7. Record the procedure on the nurse’s record with date and time. Note the amount and
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character of the fluid drained, its color, effects of treatment on the client (both desired and
undesired effects) and the general condition of the client during and after the treatment.
8. Clean all the articles used. Wash with cold water and then with warm soapy water and
rinse them in clean water. Dry and send for autoclaving.
THORACENTESIS
DEFINITION
A thoracentesis is a surgical puncture of the chest wall to aspirate fluid or air from the pleural
cavity. A pleural effusion is an abnormal accumulation of fluid in the pleural space.
PURPOSE
 To remove excessive pleural fluid (serous fluid, blood or pus)
 To drain fluid/air from pleural cavity for diagnostic or therapeutic purposes
 To introduce medications
 To aid in full expansion of lung
 To obtain specimen for biopsy
 To take pleural biopsy for diagnostic examination
 To relieve pain
 To relieve breathlessness caused by accumulation of fluid or air in the pleural space
 To aid in diagnosis and treatment (chemical, bacteriological, cellular, composition and
malignancy)
GENERAL INSTRUCTIONS
 The patient should be prepared physically and psychologically for the procedure
 Thoracentesis is indicated in case of pleural effusion due to infection, traumatic injury,
cancer or cardiac diseases, etc
 Common site for thoracentesis is just below the scapula at the seventh or eighth
intercostals space
 The patient should be warned that any sudden movements during the procedure may
cause injury to the lungs, blood vessels, etc
 The level of the aspiration needle should be short to prevent pricking of the lungs
 Usually upright position is used during the procedure as it helps collect the pleural fluid
at the base of the pleural cavity and hence facilitates to remove the fluid easily
 Maintain strict aseptic technique to prevent introduction of infection into the pleural
space
 The 3 way adaptor should be fitted with the needle before it is introduced into the chest
cavity. The adaptor should be in a closed position to prevent the entry of air into the
pleural cavity
 The nurse should check the syringes and needle for air-tightness. If these are not air-tight,
air may be entering the pleural cavity and collapse
 Remove the fluid slowly and not more than 1000 ml at the time, if the tap is therapeutic
to prevent mediastinal shift
 Use water: seal drainage system, if pleural fluid is purulent and difficult to drain
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The specimen should be sent to the laboratory soon after it collected
The aspiration should be discontinued if any signs of complications are noted such as
sharp pain, respiratory distress, excessive coughing, crepitus, haemoptysis, circulatory
collapse, etc
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PRELIMINARY ASSESSMENT
Check
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Doctors order for any specific instructions
Written informed consent of the patient or relative
General condition and diagnosis of the patient
Review fresh erect chest X-ray
Confirm the diagnosis, location and extent of the pleural air/fluid/pus
Acute respiratory insufficiency (tension pneumothorax, rapidly developing effusion
without dyspnea) may demand thoracentesis without X-ray
 Mental status of the patient to follow instructions
 Articles available in the unit
PREPARATION OF THE PATIENT AND ENVIRONMENT
 Explain the sequence of the procedure
 Provide privacy
 Chest X-ray should be taken before thoracentesis is done to diagnose the location
 Check the vital signs and record it on the nurse’s record for reference
 A mild sedation may be given to the patient before starting the procedure
 Maintain the desired position during the procedure
 The nurse should remain near the patient to observe him and to remind him not to move
during the procedure
 Arrange the articles at the bedside or in the treatment room
 Premedication – inj. Atropine sulfate 0.65 mg intramuscularly or intravenously half an
hour before procedure
EQUIPMENT
A sterile tray containing:
Sponge holding forceps – 1
Dissecting forceps – 1
Syringe (5 ml) and 2 needles for giving local anesthesia
20 ml syringe with 1 leur lock to aspirate the fluid
Aspiration needle No. 16 (long and short)
3 way stopcock
Small bowls – 2 to take the cleaning lotions
Specimen bottles and slides
Cotton swabs, gauze pieces and cotton pads
Gown, masks and gloves for the doctor
Sterile dressing towels/slit
An unsterile/clean tray containing:
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Mackintosh and towel
Kidney tray and paper bag
Spirit, iodine, tincture benzoin
Lignocaine 2%
Suction apparatus with water seal drainage system
PROCEDURE
 Position the patient in Fowler’s. bring patient to one side of bed with feet supported, arms
and head leaning forward on cardiac table with pillows
 Unite gown to expose site for aspiration
 Instruct patient to avoid coughing and to remain immobile during procedure
 Explain that a feeling of deep pressure will be experienced while fluid is being aspirated
from pleural space
 Provide sterile gloves to doctor
 Open sterile set and assemble 20 ml, 50 ml syringes, 20-22 G needles and aspiration
needles
 Pour antiseptic solution to clean site
 After showing label to doctor clean top of local anesthetic bottle and assist to withdraw
mediation
 Reassure patient and instruct to hold breath during insertion of aspiration needle
 As physician does procedure, observe for signs and symptoms of complications
 After fluid is withdrawn from pleural space, transfer to specimen container
 After needle is withdrawn, apply pressure over puncture site. Assist in sealing site with
tincture benzoin swab
AFTER CARE
 Instruct patient to lie on on-affected site for 1 hour. Ensure bed rest for 6-8 hours
 Monitor vital signs every half hour until stable
 Observe patient for signs and symptoms of hemothorax, tension penumothorax,
subcutaneous emphysema, and air embolism
 Administer analgesics and antibiotics as prescribed
 Instruct patient to carry out deep breathing exercises
 A chest X-ray may be taken to determine the effects of the procedure
 The puncture site should be treated aseptically to prevent contamination of the wound
 The container with aspirated fluid should be lab led and sent to the laboratory with
requisition form
 Replace the articles after cleaning
 Wash hands thoroughly
 Record the procedure in the nurse’s record sheet
LUMBAR PUNCTURE
DEFINITION
Lumbar puncture is a percutaneous puncture entering the spinal column’s subarachnoid space at
the vertebral interspaces L3-L4 or L4-L5. A lumbar puncture is performed for cerebrospinal fluid
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(CSF) pressure measurement, withdrawal of a CSF specimen for analysis and the introduction of
contrast media for diagnosis tests
PURPOSE
 To obtain cerebrospinal fluid analysis and to evaluate for signs of infection or
hemorrhage
 To measure the intracranial pressure and relive the pressure if it is high
 To administer spinal anesthesia for surgeries
 For intrathecal injection of antibacterial and other drugs
 For evaluation of spinal dynamics for signs of blockage of CSF flow due to tumor or
other pathology of spinal cord
INDICATIONS
 To reduce intracranial pressure (ICP) after a spontaneous hemorrhage, by releasing CSF
 To help diagnosis diffuse or disseminated infections of the nervous system or meninges,
subarachnoid hemorrhage or demyelinating diseases
 To introduce anesthetic, antibiotics or other therapeutic drugs into the area
 To identify degree of subarachanoid blockage
GENERAL INSTRUCTIONS
 Follow the strict aseptic technique
 Site used for lumbar puncture is between third and fourth and fifth lumbar vertebra in
adults and still lower in children
 The position used is side lying with knees drawn to the chin or sitting position with head
and knees are flexed
 All the articles used for lumbar puncture should be autoclaved
 The client should be placed near the edge of the bed or table for the convenience of the
doctor
 The lumbar puncture needle should be sharp and straight
 The client should empty his bowel and bladder before the procedure
 Use restrain the uni-cooperative clients and children
 The pressure reading taken when the client is relaxed and the fluid level remains fairly
constant in the monometer
 Inform the client not to move during the procedure
 Vital signs should be recorded before and after the procedure
 CSF collected should be sent to laboratory immediately along with laboratory request
form
 The drug to be injected must be warmed to the body temperature before administration
SPECIAL CONSIDERATIONS
 Do not perform when increased ICP may be caused by a expanding lesion, such as a
subdural hematoma after a head injury
 Perform cautiously in client with suspected spinal cord or brain tumor. Procedure may
cause fatal cerebellar tonsillar herniation or compression of medulla of the client:
Explain the procedure to the client and relatives to reduce their fear and anxiety
Obtain a written consent for the client or relatives
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Instruct the client not to move during the procedure
Help the client to wear a clean and loose garment
EQUIPMENT NEEDED
 A sterile tray containing – LP needles (19-21), sponge holding forceps, 5 ml syringe with
needle, two small sterile bowls, three specimen bottles, a spinal sheet, sterile cotton balls,
gauze pieces and cotton pads, a three way adapter and monometer tubing, sterile gown,
mask and gloves
 A tray containing – Mackintosh and a towel, kidney tray and paper bag, skin antiseptics
(spirit, betadine and tincture benzoine), local anesthetic agent xylocaine 1-2 percentage),
sterile normal saline, band aid, hand washing articles and screen
Procedure: (done by the doctor and nurse has to assist)
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Explain the procedure
Position the client
Wash hands and wear sterile gloves
Ask the assistant to open the sterile LP set
Clean the site with spirit and betadine
Spread the sterile center hole towel
Puncture the subarachnoid space by accurate identification of L4 and L5 intervertebral
spaces
 The initial pressure reading is obtained by measuring the level of the fluid column after it
comes to rest
 Collect 2-3 ml of spinal fluid in each of the three test tubes
 After the needle is withdrawn apply pressure at the site for a few minutes
 Apply tincture benzoin seal
QUECKENSTEDT’S TEST (LUMBAR MANOMETRIC TEST)
 This test is done when a spinal subarachnoid block (by tumor, vertebral fracture or
dislocation) is suspected
 Pressure may be applied manually by pressing firmly and simultaneously upon the
jugular veins on the each side of the neck for a period of 10 seconds or blood pressure
cuff may be placed around the client’s neck and inflated to a pressure of 20 mm Hg
 The increase in the pressure caused by the compression is noted
 Then the pressure is released and pressure reading is made at 10 second intervals
 In normal persons, the cerebrospinal fluid pressure rises rapidly in response to
compression of the jugular veins and returns quickly to normal when the compression is
released
 A slow rise and fall in pressure indicates a partial block due to a lesion compressing the
spinal subarachnoid pathways
 If there is no pressure change, a complete block is indicated. This test is done if an
intracranial lesion is suspected
AFTER CARE
 Place the client flat for at least 6 hours
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Frequently monitor the neurological vital signs
Encourage the client to drink plenty of fluids
Observe puncture site for edema, hematoma and CSF leakage
Foot end of the bed should elevated
Replace the articles after washing
CONTRAINDICATIONS
 Cutaneous or osseous infection at the site of lumbar puncture
 When the client has drastically increased LCP, lumbar puncture may result in brainstem
compression
BONE MARROW BIOPSY AND ASPIRATION
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Bone marrow aspiration is a diagnostic procedure performed in blood dyscrasias in which a
specimen of bone marrow is taken from the sternum, iliac crest posterior superior iliac spine or
tibia (children) by means of a hollow thick needle.
PURPOSE
 To diagnose blood dyscrasia, such as aplastic anemia, leukemia, thrombocytopenia, etc
 To diagnose metastatic neoplasm
 To diagnose deficiency states of vit-bitz, folic acid, iron, pyridoxine, etc
 To diagnose toxic states producing bone marrow depression or destruction
 To determine the number, size and shape of red cells, white cells and platelets
 To follow course of disease and patient’s response to treatment
INDICATIONS
Diagnostic: Bone marrow examination is essential for diagnose of a plastic, megaloblastic
anemia, multiple myeloma, myelofibrosis, myelosclerosis and aleukemic leukemia.
Bone marrow examination is helpful but not essential for diagnosis of anemia, leukemia,
thrombocytopenic purpura, agranulocytoma, tropical diseases; malaria, kala-azar, etc
Prognostic: agranulocytosis, leukemia and anemia
Therapeutic: bone marrow transplant
SITE AND POSITION OF THE PATIENT
Sternal puncture: the usual puncture site is either the manubrium sterni or the upper part of the
body of sternum. The patient lies in the dorsal recumbent position (supine) with a pillow under
the shoulders to raise the chest.
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Iliac puncture: the bone marrow biopsy is taken from the iliac crest 2 cm posterior and 2 cm
interior to the anterior superior iliac spine. Alternately, the posterior iliac spine is also used. For
iliac puncture, the patient lies either on his side or abdomen.
Spinous process aspiration: in the spinous process of the lumbar vertebrae, usually L3 or L4 is
the puncture site. The patient is placed in the lumbar puncture position.
Tibial puncture in children: in children up to the age of two years the proximal end of tibia, just
below the tibial condyles and medial to the tibial tuberosity is selected.
GENERAL INSTRUCTIONS
 The procedure should be done under very strict aseptic technique, since the infection can
be introduced into the bone cavity through the puncture site
 The penetration of the needle beyond the bone cavity is prevented by a guard attached
PRELIMINARY ASSESSMENT
Check
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The doctors order for any specific instructions
General condition and diagnosis of the patient
Self-care ability of the patient
Mental status to follow instructions
Availability of articles in the unit
Location and type of insertion
PREPARATION OF THE PATIENT AND ENVIRONMENT
 Explain the sequence procedure of the patient
 Provide privacy
 A thorough preparation of skin to prevent infection introduced in to the bone cavity
 Place the patient in a correct position according to the site used
 Sedation may be given to the patient
 Arrange the articles at the bedside or in the treatment room
 Check the vital signs of the patient and record it in the nurse’s record sheet
 The nurse should remain with the patient to reassure him and to observe him during the
procedure
EQUIPMENT
A sterile tray containing:
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Sponge holding forceps – 1
Dissecting forceps – 2
The complications should be watched for injury to associate organs
The vital signs should be checked throughout the procedure and reassure the patient
The nurse should remain with the patient throughout the procedure and observe for signs
of complications
Smear is made on 3-4 slides. Specimens are sent to the laboratory without delay
Marrow puncture needle with obturator – 1
Aspiration syringe – 1
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Syringe for local anesthesia – 1, needle – 2,
Small bowls – 2, to take cleaning solutions
Cotton swabs, gauze pieces, cotton pads, etc. in containers
Dressing towels or slit to create a sterile field
BP handle with blade – 1, to make a small incision on the skin
Slides to make smears
An unsterile tray containing:
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Mackintosh and towel
Lignocaine 2%
Adhesive tape and scissors
Kidney tray and paper bag
Spirit, iodine, tincture benzoin, etc
PROCEDURE
 Transfer the patient from bed to treatment room
 Position the patient and assess the doctor to locate and mark the site
 Open small dressing pack and slides, syringes, needles and scalpel blade into pack
 Assist the doctor to clean site with antiseptic solution and drape with sterile towels
 A small incision may be made with scalpel blade. Bone marrow needle with stillete is
introduced through incision and marrow is aspirated
 Inform patient that a brief episode of sharp pain during aspiration will be experienced
 Syringe with aspirated marrow is handed over to technician and collect into various
containers as indicated
 Collect bone marrow tissue in small bottle containing FAA solution
 Apply pressure over punctured site until bleeding ceases
 Assist doctor to seal punctured site with tincture benzoin and apply small from dressing
POST-PROCEDURE CARE
 Keep the patient in supine or lateral position
 Allow the patient to rest for few hours after the procedure
 Check the vital signs and observe for signs and symptoms of complications
 The puncture site should be treated as a surgical wound. The dressing should be done
under strict aseptic techniques
 Give mild analgesics if needed
 Label specimen and send to laboratory
 Replace the articles after cleaning
 Wash hands
 Record the procedure in the nurse’s record sheet
COMPLICATIONS
According to the site
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Sterna puncture: injury to the pericardium, myocardium, lungs and to the large blood
vessels of the mediastinum
Iliac site: injury to the sacroiliac ligament, dural sac and cauda equina
Vertebral site: injury to the dural sac and the spinal cord
Tibial sac: damage to the tibial collateral ligament of the knee
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BARIUM ENEMA
When barium is instilled rectally to visualize the lower GI tract, the procedure is called a barium
enema
PURPOSE
 To detect the presence of polyps, tumors, and other lesion of the large intestine
 To demonstrate any abnormal anatomy or malfunction of the bowel
 To detect diverticula, stenoses, obstructions, inflammation and ulcerative colitis
 For the radiographic examination of the large intestine
TYPES
 Barium sulfate (single-contrast technique) or barium sulfate
 Air (double-contrast technique)
PRINCIPLE
 Clear liquid diet for two days before the test
 Procedure takes about 15-30 minutes during which time X-ray images are taken
 If bowel is clear, clear images are obtained
PRELIMINARY ASSESSMENT
 See the doctor’s order or prescription
 See the patient’s condition
 See the whether any allergic reaction is there for patient
 See whether the patient can follow the orders
 Check for all articles in the patient unit
PREPARATION OF THE PATIENT
 Explain the procedure to the patient
 Do colonic irrigation
 Take the ultrasonography and colonoscopy
 Check all the prescriptions of the patient
EQUIPMENT
 Barium sulfate
 Sterile water
 Enema and tubings
 Syringe with needle
 A water-soluble iodinated contrast agent
 Laxatives
 Fluoroscopy screen
 X-ray instruments
 Warm water, air pump, pint measuring jar
PROCEDURE
 Prepare the patient, equipment and seat the patient to the X-ray section
 Barium is mixed with equal amount of water to the suspension used for barium meal
 The enema is set and is allowed to sum slowly through the rectal tube while the
radiologist examines the patient under the fluoroscopic screen
 The mixture should be at body temperature and stirred continuously during
administration
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It should not be further given without instruction
Various X-rays are taken to diagnose the problem
Then, it is removed by cleansing enema or by a laxative
AFTER CARE
 A laxative or cleansing enema is often given after the test to empty the large bowel
 Stools are white for 24 to 72 hours after the examination
 Encourage the client to increase the liquid intake to prevent fecal impaction
 Instruct the client to report any pain, bloating, absence of stool or bleeding
COMPLICATION
 Fecal impaction if the bowel is not cleaned immediately
 Pain bleeding, etc can occur
ELECTROENCEPHALOGRAM
Electroencephalogram (EEG) is a noninvasive procedure, in that electrodes are placed over the
skull in many areas and the electric activity of the various segments of the brain is recorded
Electroencephalogram is painless and a safe technique for evaluating the brain pathology such as
brain tumors, brain abscess and epilepsy
PURPOSE
 To detect any abnormality in the brain such as space occupying lesion (SQL)
 EEG serves best to identify seizure disorders by type and area of origin within the brain
 To measure the cerebral oxygen, glucose, and blood flow in the brain
MECHANISM
An EEG is an instrument of electrical activity of the superficial layers of the cerebral cortex. It
demonstrates the electrical potentials from neuron activity, within the brain in the form of wave
patterns. The intensity and pattern of electrical activity is influenced by the reticular activating
system. The characteristics of the wave depend on the degree of cortical activity
Brain activity as recorded on an EEG correlates with the cerebral blood flow
A constant supply of oxygen, blood and glucose is needed to meet the metabolic demands of the
brain. Decrease cerebral blood flow causes changes in mentation and decreased electrical activity
on the EEG
WAVE PATTERNS
 Alpha: alpha waves are found during period of wake-fullness, prominent over the cortical
and parietal areas
 Beta: beta waves are recorded with in turns activation of the CNS, prominent over frontal
and parietal areas
 Theta: theta waves are recorded during periods of emotional stress or drowsiness,
prominent over the temporal and parietal areas
 Delta: delta waves are recorded during periods of deep sleep
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EEG Measures in Seizure
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Breathing deeply for several minutes to produce alkalosis
Producing a sleep deprivation syndrome
Producing a sleep either naturally or by drugs
Photostimulation by flashing lights, etc
PRELIMINARY ASSESSMENT
Check
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Doctors order for any specific instructions
General condition or diagnosis of the patient
Mental status of the patient to follow instructions
PREPARATION OF THE PATIENT AND THE ENVIRONMENT
 Explain the procedure to the patient to gain cooperation. This procedure talks half an
hour to two hours
 The purpose of the test an procedure should be explained to the client and the family
 The client and family may need to be reassured that electricity does not enter the brain
 Air shampoo is indicated on previous day, this helps the jelly to be fixed in the scalp
 This test can be done in sitting or lying position, so place according to the technician’s
instructions
 The client will be asked to relax during the test, because anxiety can block alpha rhythms
 The nurse should be sure to send adequate supplies (i.e. intravenous fluids or oxygen to
the laboratory)
 The EEG room should be kept – quite, minimum light, appropriate temperature and less
distraction
 The client may keep awake the night preceding the test or sedation to induce sleep
EQUIPMENT
 EEG machine with electrodes
 Jelly
 Tissue paper
 Cotton balls
 Bed with adequate linen
PROCEDURE
 The patient is taken to an EEG room, where the technician does this test
 Electrodes are attached to the client’s scalp
 Electrodes are applied to the scalp and the ear loop with collodion
 Lead scan also be placed in nasopharynx to assist disorders in the temporal lobe
 The first portion of the test is performed with the clients as relaxed as possible to obtain a
baseline recording
 Further readings are taken while the client is hyper-ventilating, sleeping or viewing
flickering lights
 The wave forms are amplified and recorded on a moving paper strip, similar to an ECG
 EEGs are interpreted according to brain wave characteristics, frequency and amplitude
 If the client is comatose or unable to move, EEG can be performed at the bedside
INTERPRETATION
16

Hyperventilation alters acid base balance (respiratory alkalosis) decreases cerebral blood
flow
 Flickering lights may trigger seizures
 Sleep may evoke abnormal EEG patterns not present while the client is awake
 Absence of EEG waves (flat line) on EEG may be one of the criteria for defining brain
death
NURSING IMPLICATIONS
 The preparation of the patient for EEG is extremely important because it can directly
affect the accuracy of the test results. The patient should be explained about the
procedure and reassured that EEG is no way painful and dangerous. He should be told tha
tit is not a form of shock treatment or a way of hypnotizing the patient
 The explanation should be satisfactory to the patient to win his confidence and
cooperation. ‘TO RECORD EEG, a relaxed and cooperative patient is necessary
 Withhold all medications, especially the nerve stimulants and depressants for 3 days prior
to the test. This should include tranquilizers, anticonvulsions, analgesics, hypnotics, and
sedatives
 The patient should not take coffee, tea, alcohol, alcoholic beverages, etc. on the day of
the test, since these are stimulants to the central nervous system
 The patient should not be disturbed mentally before the test. Mental excitement and
depression can alter the EEG tracings
 The patient should not sleep prior to the test this may induce sleep in the patient during
the procedure. Sometimes, a sleep EEC is indicated to detect temporal lobe epilepsy. In
such cases, sedation is administered 45 minutes prior the EEG and the procedure is
performed when patient is sleeping
 The hair should be cleaned thoroughly with a shampoo. No oil or metal appliances should
remain in the hair. No need to cut the hair
SURGICAL DRESSING
Surgical dressing is a sterile technique used to promote wound healing. It is a protective covering
placed on the wound.
Factors Influences in Surgical Dressing
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Patient acceptance
Ease of application/removal
Bleeding control
Exudate control
Pain management
Prevent allergic reaction/blistering
Conformable
Comfortable
Cost effective
PURPOSE
17
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To protect the wound from mechanical injury
To splint or immobilize the wound
To absorbs drainage
To prevent contamination from bodily discharges (feces, urine)
To debride the wound by combining capillary action and the end wining of necrotic tissue
and in its mesh
 To inhibit or kill microorganism by using dressings with antiseptics, antimicrobial
properties
 To provide a physiologic environment conductive to healing
 To provide mental and physical comfort for the patient
TYPE OF DRESSING
Dry-to-dry Dressing


It is used primarily for wounds closing by 1 degree intention
Offers good wound protection, absorption of drainage and esthetics, e.g. patient provides
pressure for homeostasis
 Disadvantage – they adhere to wound surface when drainage dries, removal can cause
pain and disruption of granulation tissue
Wet-to-dry Dressing

They are particularly useful for untidy or infected wounds that must be debride and
closed by 2-degree intension
 Gauze saturated with sterile saline or an antimicrobial solution in packed into the wound,
eliminating dead space
 The wet dressings are then covered by dry dressings
 As drying occurs, wound debris and necrotic tissue are absorbed into the gauze dressing
by capillary action
 The dressing is charged when it became dry
Wet-to-wet Dressings

Used on clean open wounds as on granulating surfaces. Sterile saline as an antimicrobial
agent may be read to saturate the dressings
 Provide a more physiologic environment, which can enhance the local healing process as
well as ensure greater patient comfort
 Disadvantage: surrounding tissues can become macerated, the risk of infection may rise
and bed linens become damp
GENERAL INSTRUCTIONS
 The procedure of changing dressings, examining and closing the wound, use principles of
asepsis
 The initial dressing change in frequently done by the physician especially for craniotomy
orthopedic or thoracotomy procedure; subsequent dressing changes are the nurse’s
responsibility
EQUIPMENT
Sterile
18
Gloves – disposable
Scissors, forceps
Appropriate dressing materials
Sterile saline
Cotton dipped swabs
Culture tubes (infection)
For draining wound add extra-gauze and packing material absorbent and pad and
irrigation set
Unsterile
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Gloves
Plastic bag for discarded dressings
Tape proper size and type
Pads to protect patient bed
Gown for nurse, if wound is infected
PROCEDURE
Pre-preparation
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Inform the patient of dressing change. Explain procedure and have patient lie in bed
Avoid changing dressing at mealtime
Ensure privacy by drawing the curtains on closing the door. Expose dressing site
Respect patient modesty and prevent patient from being chilled
Wash hands thoroughly
Place dressing supplies on a clean, flat surface
Place clean towel or plastic bag under part of the body where wound is located
Cut off pieces of tape to be. Used in dressing change
Place disposable bag nearby to collect soiled dressings
Determine what types of dressing are necessary
CLEANING THE SURGICAL WOUND
 Use aseptic technique
 Open package of sterile gloves; open sterile cleaning sterile supplies
 Wear sterile gloves
 Clean along wound edges using a small circular motion from one end of incision to the
other do not scrub back and forth across the incision line
 Sterile saline in the cleansing agent of choice. Topical antiseptics (alcohol, basic a may
be used on intact skin surrounding the wound but should never be used within the wound)
 Repeat same process with drain site separately
 Discard used cleaning supplies in disposable
 Pad the incision site and drain site dry with sterile dressing sponge
DRESSING THE WOUND
 Maintain asepsis with use of sterile gloves
 After wound in dry apply appropriate dressing
 Tape dressing, using only the amount of tape required for secure attachment of dressing
Use premade drain sponge (can be prepared by making 5 cm slit with sterile scissors in 4
multiply 4 inches gauzes sponge)
19
Dressing the drainage tube insertion tube: be sure that one sponge in place at a right angle to
the second sponge. So the slits are going in different direction if drainage in heavy, a sterile
absorbent pad or extra gauze may be placed overall

When dressing an excessive draining wound
Consider need for extra dressings and packing materials
Use Montgomery straps if frequent dressing are required
Protect skin surrounding wound from copious on irritating drainage by applying some type of
skin barriers
AFTER CARE (Follow-up Care)
 Assess patient’s tolerance to the procedure and help patient more comfortable
 Discard disposable items according to hospital protocol and clean equipment that is to be
recessed
 Wash hands
 Record nature of procedure and condition of wound, as well as patient reaction
NEBULIZATION THERAPY
Nebulization therapy is to liquefy and remove retained secretions from the respiratory tract. A
nebulizer is a device that produces a stable aerosol of fluid and/or drug particles.
PURPOSE
 To relieve respiratory insufficiency due to bronchospasm
 To correct the underlying respiratory disorders responsible for bronchospasm
 To liquefy and remove retained thick secretion from the lower respiratory tract
 To reduce inflammatory and allergic responses the upper respiratory tract
 To correct humidify deficit resulting from inspired air by passing the upper airway during
the use of mechanical ventilators in critically ill and post-surgical patients
TYPES
 Jet nebulizers
 Ultrasonic nebulizer
JET MEDICATION NEBULIZER
A jet medications nebulizers utilize a high velocity gas flew to generate practice from the
prescribed solution either O2 of compressed air powers the nebulae.
EQUIPMENT
 O2 cylinder/wall O2 outlet of flew metals
 A clean tray with O2 nipple adapted to bit the connection tubing
Nebulizer kit consent of: (face mask/mouth piece)
Nebulized jet and nebulizer cap O2 supply tubing
20
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Physician orders
Prescribed nebulizer solution
The 0.9% NaCl ampoules as diluent if prescribed
A 5 ml syringe with needle
Disposable spectrum cup
Box of disposable leisters
PROCEDURE
 Unscrew the nebulizer jar and instill the prescribed dose of solutions
 Rescrew cap on nebulizer jar
 Connect one end of the O2 tubing to the nebulizer and attach the other end of the supply
tubing to the O2 flew maters
 Place the patient in a comfortable sitting on semi-Fowler’s positions
 Adjust the O2 to flow rate 5 to 6 units per minute or until a fine must appears
 Place the mask snugly over the patients face to cover the nose, mouth and chin and adjust
the elastic sharp around the patients
 Instruct the patient to take deep breath, repeat hold breath briefly this exhale unit all the
medications is nebulized
 Observe expansion of the patient chest during therapy
 Observe the patient. Though out the procedure and give constant reassurance
 Thin oil the O2 when all the solution has vaporized and remove the face mask
 Encourages the patient to length after several deep breaths
 Assist the patient to a comfortable position and wipe off the moisture from the face to
face with towel or disposable tissue
 Dismantle the nebulizes kit and decontaminate in both soapy water
ULTRASONIC NEBULIZER
The ultrasonic nebulizer utilizes fluid contained in two chambers, which is rapidly vibrated,
causing the fluid to breathe into small particles.
It works on the principles that high adequacy sound waves can break up water into aerosol
particles by means of two transducers
EQUIPMENT
 Ultrasonic equalizers and manufacturers instruction
 Circulating set-up
 Disposable aerosol mask
 Sterile water
 Physicians writes codes
 Prescribed solution
 Disposable sputum cup
 Box of disposable tissue
PROCEDURE
 Fill ultrasonic chamber, and the prescribed solution to the appropriate lay with sterile
water
 Assemble circulating according to manufacture instructions and plug the cord into an
electrical outlet
 Turn on the machine and adjust the selling until the described amount of mist is obtained
21
Position the client, in a comfortable sitting or semi-Fowler’s positions
Place the mask singly over the patient to cover the base
Observe the patient, for any adverse reaction to the treatment
Encourage the patient to partially cough and expectorate any secretions loosed during the
treatment
 Turn off the machine and discontinue the procedure
 Remove the facemasks and decontaminate in hot soapy water
 Wash and dry mask bands
PRELIMINARY ASSESSMENT
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Check the general condition of the patient
Check the doctor’s orders
Check the correct position of the patient
Check the articles available in the patient unit
COMPLICATIONS
 Combustion
 CO2 necessaries
 O2 toxicity
 Absorption atelectasis
 Infection
 Chronic O2 therapy it home
POSTURAL DRAINAGE
DEFINITION
Drainage of secretion from lung segments by gravity utilizing specific positioning techniques
PURPOSE
 To drain lung secretion before and after surgery
 To aid for easy breathing in bronchial or lobar pneumonia, lung abscess
 To treat patient with, e.g. bronchiectasis, chronic bronchitis and cystic fibrosis
 To assist patient who are unable to cough and bring out sputum, via. Unconscious,
debilitated, quadriplegic patient
EQUIPMENT
 Pillows: 3:4
 Sputum cup
 Tissue paper
 Sputum measuring glass
GENERAL INSTRUCTIONS
 Perform postural drainage for patient on empty stomach before meals
 Avoid postural drainage for patient with hemoptysis
PROCEDURE
 Explain purpose an procedure to patient
 Locate affected lung with help of X-rays, auscultation and percussion
 Administer bronchodilators before procedure
 Give steam inhalation to patient after obtaining doctor’s written order
 Position patient according to lung segment to be drained
22
Postural drainage techniques:
Upper lobes:
Upper segments: place patient in high Fowler’s position in chair or bed
Anterior segments: place patient in semi-Fowler’s position in chair or bed
Posterior segments: place patient in Fowler’s position in chair or bed, provide a cardiac table
Lateral segments: place patient in lateral position elevated to about 45 degree celcius, first to one
side and then to other side. When out of bed ask patient to lean on arm, resting on chair or table
for support.
Right middle lobes
Anterior segment (right side): place patient flat on left side with a pillow under chest. Right
shoulder and body are kept forward
Posterior segment: place patient in prone with chest and abdomen elevated
Lower lobes
Anterior segments: place patient in supine, Trendelenburg with hips elevated with pillows, so
that hips are higher than shoulders
Posterior segments: place patient prone, Trendelenburg or hips elevated with pillows so that hips
are higher than shoulders
Lateral segments: place patient in right side lying Trendelenburg for left lung and left side lying
Trendelenburg for right lung or hips elevated with pillows to keep hips higher than shoulders
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Perform chest percussions and vibrations on areas to be drained
Encourage patient to cough out secretions and collect in sputum container
Do suctioning if coughing is not possible
Make patient comfortable and ask to rest flat for ten to fifteen minutes before allowing
sitting or getting out of bed
Dispose sputum container in infectious waste container. Replace articles
Document, time, amount and color of sputum drained, response of patient to therapy
23
CHANGING A POUCHING SYSTEM/OSTOMY APPLIANCE
(ILEOSTOMY OR COLOSTOMY)
Safety considerations:

Pouching system should be changed every 4 to 7 days, depending on the patient and type of pouch.

Always consult a wound care specialist or equivalent if there is skin breakdown, if the pouch leaks, or if there are
other concerns related to the pouching system.

Patients should participate in the care of their ostomy, and health care providers should promote patient and family involvement.

Encourage the patient to empty the pouch when it is one-quarter to one-half full of urine, gas, or feces.

Ostomy product choices are based on the patient’s needs and preference.

Follow all post-operative assessments for new ostomies according to agency policy.

Medications and diet may need adjusting for new ileostomies/ colostomies.

An ostomy belt may be used to help hold the ostomy pouch in place.

Factors that affect the pouching system include sweating, high heat, moist or oily skin, and physical exercise.

Always treat minor skin irritations right away. Skin that is sore, wet, or red is difficult to seal with a flange for a proper
leakproof fit.
STEPS
1. Perform hand hygiene.
ADDITIONAL INFORMATION
This prevents the spread of microorganisms.
Hand hygiene with ABHR
2. Gather supplies.
Supplies include flange, ostomy bag and clip, scissors, stoma measuring guide,
waterproof pad, pencil, adhesive remover for skin, skin prep, stomahesive paste or
powder, wet cloth, non-sterile gloves, and additional cloths.
24
Ostomy supplies
3. Identify the patient and review the Proper identification complies with agency policy.
procedure. Encourage the patient to
Encouraging patients to participate helps them adjust to having an ostomy.
participate as much as possible or
observe/assist patient as they
complete the procedure.
4. Create privacy. Place waterproof
pad under pouch.
The pad prevents the spilling of effluent on patient and bedsheets.
5. Apply gloves. Remove ostomy
bag, and measure and empty
contents. Place old pouching system
in garbage bag.
Remove ostomy bag from flange
6. Remove flange by gently pulling
Gentle removal helps prevent skin tears. An adhesive remover may be used to decrease
it toward the stoma. Support the skin skin and hair stripping.
with your other hand. An adhesive
remover may be used.
If a rod is in situ, do not remove.
Remove flange
A rod may be used during the formation of a stoma. It can only be removed by a
physician or wound care nurse. If a rod is in place, it can be slid to allow the pouch to be
removed.
7. Clean stoma gently by wiping
Aggressive cleaning can cause bleeding. If removing stoma adhesive paste from skin,
25
with warm water. Do not use soap.
use a dry cloth first.
Clean stoma and peristomal skin
8. Assess stoma and peristomal skin.
A stoma should be pink to red in colour, raised above skin level, and moist.
Assess stoma
Skin surrounding the stoma should be intact and free from wounds, rashes, or skin
breakdown. Notify wound care nurse if you are concerned about peristomal skin.
9. Measure the stoma diameter using
the measuring guide (tracing
template) and cut out stoma hole.
The opening should be 2 mm larger than the stoma size.
Keep the measurement guide with patient supplies for future use.
Trace diameter of the measuring
guide onto the flange, and cut on the
outside of the pen marking.
Trace template
traced onto back of flange, cut out size to fit stoma
Assess flange for proper fit to stoma
26
Once size is
10. Prepare skin and apply
accessory products as required or
according to agency policy.
Accessory products may include stomahesive paste, stomahesive powder, or products
used to create a skin sealant to adhere pouching system to skin to prevent leaking.
Wet skin will prevent the flange from adhering to the skin.
Peristomal skin prep
11. Remove inner backing on flange
and apply flange over stoma. Leave
the border tape on. Apply pressure.
Hold in place for 1 minute to warm
the flange to meld to patient’s body.
Then remove outer border backing
and press gently to create seal.
Stomahesive paste
The warmth of the hand can help the appliance adhere to the skin and prevent leakage.
If rod is in situ, carefully move rod
back and forth but do not pull up on
rod.
Remove backing from flangeApply flange around stomaPress gently to create seal
27
12. Apply the ostomy bag. Attach
the clip to the bottom of the bag.
This step prevents the effluent from soiling the patient or bed.
Apply ostomy pouchAttach clip to bottom of bag
13. Hold palm of hand over ostomy
pouch for 2 minutes to assist with
appliance adhering to skin.
The flange is heat activated.
14. Clean up supplies, and place
patient in a comfortable position.
Remove garbage from patient’s
room.
Removing garbage helps decrease odour.
15. Perform hand hygiene.
This minimizes the transmission of microorganisms.
16. Document procedure.
Follow agency policy for documentation. Document appearance of stoma and peristomal
skin, products used, and patient’s ability to tolerate procedure and assistance with
procedure.
Special Considerations

When patients are discharged from an acute care facility, ensure they have referrals to
a community nurse, are able to empty their pouch system independently or with
28
assistance from a caregiver, have spare supplies, and know the signs and symptoms of
complications and where to seek help.

Patients should be seen by the wound care or ET nurse and have a dietitian referral for
new dietary needs related to the ileostomy or colostomy (Registered Nurses
Association of Ontario, 2009).

The ostomy bag may become filled with gas from the intestine and may let out a
“farting” sound that is usually quiet, but uncontrollable. Patients may “burp” the bag
through the opening at the top in a two-piece system by opening a corner of the ostomy
pouch from the flange to let the air out. Dietary restrictions may also help decrease the amount of
gas produced by the intestines
GASTROJEJUNOSTOMY FEEDING
Gastrojejunostomy feeding is defined as enteral nutrition is a liquid food preparation directly into
the stomach or small intestine via a tube
It is an ideal method of providing nutrition for the person who is unable to swallow food and
drink normally but has intact gastrointestinal function
It is the introduction of liquid good through a tube or catheter which the surgeon has already
introduced into the stomach through the abdominal wall
Indications

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
Tumors or operations on the upper gastrointestinal tract
Cancer of the esophagus
Stricture of the esophagus caused by poisoning in case of fistula
General Instructions
 It is essential that the area of the skin around the tube be kept clean and dry
 A water proof ointment such as zinc oxide may be applied around the tube to protect the
skin from the irritation of the hydrochloric acid
 Foods given through the gastrostomy tube are some as those given by nasogastric tube
and the same amounts are given at the same intervals
Methods of Administration
 Intermittent feeding: given four to six times a day rather the continuously is delivered as
a bolus through a longer lumen tube. Volume for formula usually 250-450 ml is placed in
a large syringe and inserted into the proximal end of the tube
 Intermittent gravity drip: administration delivers a similar volume 250-450 ml of feeding
over 20-30 ml a minute, four to six times a day
 Continuous administration: delivers fluid through a small lumen tube at a constant rate
via orogastric and nasogastric routes. The rate of flow is carefully regulated. The nurse
should calculate the amount of fluid to be infused during an hour and regulates the
infusion pump accordingly
Preliminary Assessment
29
Check
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The doctors order for specific instruction
Level of consciousness of the patient
Self-care ability of the patient
Mental status to follow instructions
Articles available in the unit
Operation of the Patient and Environment
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Explain the sequence of the procedure
Provide privacy
Arrange the articles at the bedside
Place the patient in a comfortable position
Keep the environment clean and tidy
Keep ready with feed to be given
Equipment
A clean tray containing
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A funnel, rubber tubing, glass connection screw and a clamp
A glass of drinking water
Required amount of fed, temperature 100 degree F
Sterile lubricant to protect surrounding area
Sterile dressing and forceps in a dressing tray
Medicine as per odor
Kidney tray
Many tailed binder if required
Mackintosh and towel
Stethoscope
Syringe
Procedure
 Wash hands thoroughly
 Place the mackintosh or towel; clean the surrounding area of the opening. Cover the
wound with sterile piece of gauze
 Unscrew the clamp from the gastrostomy tube and attach the funnel and rubber tubing;
keep the tube pinched to prevent air from setting in
 Aspirate the gastric contents by attaching a syringe
 Pour some clean water into the funnel and lower a little to let our air
 Then pour the feed before the funnel is empty
 If any medicines are ordered, these are given after feed
 Give water after giving medicines
 Disconnect the tabbling and funnel
 Clean and apply sterile instrument around the wound, dress it with sterile dressing and
apply the binder
After Care
 Remove the Mackintosh and towel
30
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Position the patient comfortable
Secure the tube with plaster
Replace the articles to utility room
Hand wash
Record the procedure in nurse record sheet
COMMENCING TPN IN ADULTS (ADULT TPN SOLUTIONS)
Equipment
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Personal protective equipment (goggles/safety glasses)
Alcohol based hand rub (ABHR)
TPN flask (as per medical prescription) with light protective cover
Clean non sterile gloves
Clean gown
Light protected intravenous giving set (in outpatient settings, standard intravenous giving set
can be used)
Infusion pump device attached to IV pole
Sterile dressing pack
Sterile gauze
Sterile gloves
Chlorhexidine 2% alcohol 70% swabs x 3
10mL 0.9% Sodium Chloride x 1
Blunt drawing up needle
10mL luer lock syringe
Clinical waste bin
General waste bin
Sharps bin
Procedure
1.
2.
3.
4.
5.
Attend hand hygiene
Clean dressing trolley with detergent impregnated wipes
Collect equipment
Remove TPN from refrigerator and place on trolley
Check TPN prescription order against the prepared TPN with another Registered Nurse or
Enrolled Nurse
6. Attend hand hygiene
7. Explain the procedure to the patient and obtain verbal consent
8. Attend hand hygiene
31
9. Attend patient identification check with second staff member at the patient’s bedside utilising
the three core identifiers. Confirm patient information on
a. patient identification band
b. TPN prescription
c. TPN light sensitive cover, and
d. TPN bag with verbal confirmation from patient.
10. Attend hand hygiene
11. Roll up light protective cover to allow access to TPN access port
12. Attend hand hygiene
13. Apply clean non sterile gloves
14. Access insertion port on TPN bag by removing blue tab (when using ‘SMOF Kabiven’ brand
flask)
15. Swab insertion port on TPN bag vigorously with chlorhexidine 2% alcohol 70% swab for 10
seconds. Allow to dry for 30 seconds.
16. Spike the prepared TPN bag utilising standard aseptic non touch technique (ANTT)
17. Hang the bag on the intravenous pole and re-apply light protect cover
18. Prime intravenous giving set
19. Select the TPN setting on the infusion pump
20. With the clinician who completed the initial prescription check, set infusion rate and volume
to be infused as per the TPN prescription
21. Remove gloves and attend hand hygiene, don safety goggles and gown
22. Set up sterile field
23. Attend hand hygiene
24. Apply sterile gloves
25. Draw up 0.9% Sodium Chloride flush using blunt drawing up needle (maintaining sterile
ANTT)
26. Using sterile gauze, lift dedicated TPN CVAD lumen and place sterile towel underneath
27. While still holding CVAD lumen, swab CVAD bung vigorously with chlorhexidine 2%
alcohol 70% swab for 10 seconds. Allow to dry for 30 seconds
28. Flush lumen with 10mLs of 0.9% Sodium Chloride using pulsatile action to ensure patency
29. While still holding CVAD lumen, swab CVAD bung vigorously with chlorhexidine 2%
alcohol 70% swab for 10 seconds, allow to dry for 30 seconds, place on sterile towel and
discard gauze.
30. Using sterile gauze in your dominant hand, lift TPN infusion line
31. With non-dominant hand, use sterile gauze to remove infusion line cap and discard cap and
gauze
32. Using sterile gauze in your non-dominant hand, lift lumen and connect to TPN infusion line
33. Remove sterile gloves and perform hand hygiene
34. Commence TPN infusion
35. Dispose of used equipment in line with organisational requirements
36. Sign TPN administration order with second staff member and document in notes as per the
Clinical Record Documentation procedure located on the Policy Register
The Nurse caring for the patient having TPN must:

Ensure that the patient has blood monitoring as ordered (usually daily biochemistry initially
and at least weekly full blood counts and liver function tests).
32


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Measure and record the patient’s Blood Glucose Level (BGL) four times a day (QID) on
commencement of TPN, then daily when BGLs are stable (as determined by the patient’s
treating team).
Measure and record the patient’s weight on the weight chart on commencement of TPN,
then twice weekly.
Maintain at least 4 hourly vital signs on patients for the duration of TPN, unless otherwise
ordered by the treating medical team.
Disconnecting TPN
Equipment
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Personal protective equipment (goggles/safety glasses)
Alcohol based hand rub (ABHR)
Clean non sterile gloves
Chlorhexidine 2% alcohol 70% swab x 1
0.9% Sodium Chloride flush – either 10mL syringe, drawing up needle and 10mL 0.9%
Sodium Chloride or a 10mL 0.9% Sodium Chloride Posiflush
Clinical waste bin
General waste bin
Procedure
1.
2.
3.
4.
Attend hand hygiene
Ensure patient privacy
Confirm order to cease infusion
Confirm patient identification using the three core identifiers on the TPN prescription order,
patient identification band and verbal confirmation from patient
5. Explain procedure to patient and obtain consent
6. Attend hand hygiene
7. Apply clean non sterile gloves
8. Disconnect TPN line from CVAD
9. Swab CVAD bung vigorously with chlorhexidine 2% alcohol 70% swab for 10 seconds.
Allow to dry for 30 seconds.
10. Flush lumen with 10mLs of 0.9% Sodium Chloride using pulsatile action
11. Dispose of TPN flask into the clinical waste bin
12. Attend hand hygiene
PREOPERATIVE PREPARATION OF PATIENTS
Specific activities such as the preoperative history and physical examination are completed and
documented before the patient arrives in the OR. This process can be performed before
admission to the hospital or ambulatory care facility; other activities are performed when the
33
patient arrives in the preadmission testing area (PAT). The preoperative physical preparation is
designed to help all patients overcome the stresses of anesthesia, pain, fluid and blood loss,
immobilization, and tissue trauma. Preparation often begins before the patient’s hospital
admission with the institution of nutritional or drug therapy. An attempt is made to bring all
patients to their best possible physical status before surgery. Appropriate consultations, such as a
cardiac workup, are sought when necessary.
Preadmission procedures
Some of the preoperative preparations can be performed in the surgeon’s office. Patients are then
referred to the preoperative testing center of the hospital or ambulatory care facility. Tests and
records should be completed and available before the patient is admitted the day of the surgical
procedure. Preadmission tests (PATs) are scheduled according to the guidelines of each facility.
Some tests are acceptable only for a 30-day period or are repeated before admission. The type of
testing performed depends on the patient’s known or suspected condition and the complexity of
the surgical procedure.1 The preoperative preparations include the following:
1. Medical history and physical examination. These are performed and documented by a
physician, nurse practitioner, physician assistant (PA), or the registered nurse first assistant
(RNFA). Allergies and sensitivities should be noted.7 The preoperative nurse establishes the
baseline for the patient’s vital signs (Fig. 21-1).
2. Laboratory tests. Testing should be based on specific clinical indicators or risk factors that
could affect surgical management or anesthesia.1 Tests include age, sex, preexisting disease,
magnitude of surgical procedure, and type of anesthesia. Ideally these tests should be
completed 24 hours before admission so the results are available for review. Some facilities
perform laboratory studies the morning of the procedure.8
a. Hemoglobin, hematocrit, blood urea nitrogen (BUN), and blood glucose may be
routinely tested for patients ages 60 years or older.
b. Hematocrit is usually ordered for women of all ages before the administration of a
general anesthetic.
c. Complete blood count and blood chemistry profile may be indicated. Differential,
platelet count, activated partial thromboplastin time, and prothrombin time also may
be ordered.
d. Urinalysis may be indicated by the type of surgical procedure, medical history, and/or
physical examination.
3. Blood type and crossmatch. If a transfusion is anticipated, the patient’s blood is typed and
crossmatched. Many patients prefer to have their own blood drawn and stored for
autotransfusion.8 Patients should be advised that blood banks charge an additional fee to store
and preserve blood for personal use.
Even if the patient is to have an autotransfusion, his or her blood should still be typed and
crossmatched in the event that additional transfusions are needed. If the patient refuses to
accept blood transfusions, the appropriate documentation of refusal should be completed
according to the policies and procedures of the facility.
4. Chest x-ray. A preoperative chest x-ray study is not routinely required for all patients. It may
be required by facility policy or medically indicated as an adjunct to the clinical evaluation of
patients with cardiac or pulmonary disease and for smokers, patients age 60 years or older,
and cancer patients.12
34
5. Electrocardiogram (ECG). If the patient has known or suspected cardiac disease, an ECG is
mandatory. Depending on the policy of the facility, an ECG may be routine for patients ages
40 years or older.
6. Diagnostic procedures. Special diagnostic procedures are performed when specifically
indicated (e.g., Doppler studies for vascular surgery).9,10
7. Written instructions. The patient should receive written preoperative instructions to follow
before admission for the surgical procedure. These instructions should be reviewed with the
patient in the surgeon’s office or in the preoperative testing center.
Sample written preoperative instructions for the patient.
35
a. To prevent regurgitation or emesis and aspiration of gastric contents, the patient should
not ingest solid foods before the surgical procedure. These instructions are usually
stated as NPO after midnight. (NPO is the Latin abbreviation for nil per os, or nothing
by mouth.) Solid foods empty from the stomach after changing to a liquid state, which
may take up to 12 hours.
Clear fluids may be unrestricted until 2 to 3 hours before the surgical procedure, but only
at the discretion of the surgeon or anesthesia provider in selected patients. NPO time
usually is reduced for infants, small children, patients with diabetes, and older adults
prone to dehydration.
b. The physician may want the patient to take any essential oral medications that he or she
normally takes. These can be taken as prescribed with a minimal fluid intake (a few
sips of water) up to 1 hour before the surgical procedure.
c. The skin should be cleansed to prepare the surgical site. Many surgeons want patients
to clean the surgical area with an antimicrobial soap preoperatively or have the patient
shower with an antimicrobial sponge, commonly chlorhexidine, the morning of
surgery.2 Patients should be told not to allow the soap to get in the eyes. Chlorhexidine
preparations can harm the corneas and tympanic membranes. Patients who will
undergo a surgical procedure on the face, ear, or neck are advised to shampoo their
hair before admission, because this may not be permitted for a few days or weeks after
the procedure.
d. Nail polish and acrylic nails should be removed to permit observation of and access to
the nailbed during the surgical procedure. The patient should be advised to uncover at
least one fingernail if the anesthesia provider will use these monitoring devices during
the procedure. Either the finger or toe can be used when a digit is desired, but the
finger is usually more accessible.
Some sensors are adhesive and can be placed on an earlobe or across the bridge of the
nose. The nailbed is a vascular area, and the color of the nailbed is one indicator of
peripheral oxygenation and circulation. The Oxisensor (optode) of a pulse oximeter may
be attached to the nailbed to monitor oxygen saturation and pulse rate. A finger cuff
may be used for continuous blood pressure monitoring. Nail polish or acrylic nails
inhibit contact between these devices and the vascular bed.
e. Jewelry and valuables should be left at home to ensure safekeeping. If electrosurgery
will be used, patients should be informed that all metal jewelry, including wedding
bands and religious artifacts, should be removed to prevent possible burns. Loss
prevention is a consideration as well.
f. Patients should be given other special instructions about what is expected, such as when
to arrive at the surgical facility. A responsible adult should be available to take the
patient home if the procedure, medication, or anesthetic agent renders the patient
incapable of driving. Family members or significant others should know where to wait
and where the patient will be taken after the surgical procedure.
8. Informed consent. The physician should obtain informed consent from the patient or legal
designee. After explaining the surgical procedure and its risks, benefits, and alternatives, the
surgeon should document the process and have the patient sign the consent form. This
documentation becomes part of the permanent record and accompanies the patient to the OR.
Policy and state laws dictate the parameters for ascertaining an informed consent.
36
9. Nurse interview. A perioperative/perianesthesia nurse should meet with the patient to make a
preoperative assessment.11 Ideally an appointment with the perioperative nurse is arranged
when the patient comes to the facility for preoperative tests. Through physiologic and
psychosocial assessments, the nurse collects data for the nursing diagnoses, expected
outcomes, and plan of care.
From the assessment data and nursing diagnoses, the nurse establishes expected outcomes
with the patient. The nurse develops the plan of care, which becomes a part of the patient’s
record. The nurse reviews the written preoperative instructions and consent form with the
patient to assess the patient’s knowledge and understanding. The nurse also provides
emotional support and teaches the patient in preparation for postoperative recovery. Before
or after the interview, the patient may view a videotape to reinforce information.
10. Anesthesia assessment. An anesthesia history and physical assessment are performed before a
general or regional anesthetic is administered.11 The history may be obtained by the surgeon,
and/or the patient may be asked to complete a questionnaire for the anesthesia provider in the
surgeon’s office or in the preoperative testing center.
An interview by an anesthesia provider or nurse anesthetist may be conducted before
admission if the patient has a complex medical history, is high risk, or has a high degree of
anxiety. All patients should understand the risks of and alternatives to the type of
anesthetic to be administered. After discussion with the anesthesia provider, the patient
should sign an anesthesia consent form.
A preoperative phone call by a perioperative nurse to the patient several days in advance of the
scheduled surgical procedure may prevent cancellation because of inadequate preoperative
testing. Testing requirements are reviewed with the patient, and arrangements for additional tests
can be made as needed. The importance of preoperative preparations is reiterated, especially
NPO status and the availability of a responsible adult for transportation home after the surgical
procedure (if having ambulatory surgery).
Evening before an elective surgical procedure
In addition to the preadmission procedures described, the surgeon may write specific orders for
other appropriate preoperative preparations. All preadmission assessment and testing procedures
may be performed after the patient is admitted to a surgical unit before the surgical procedure.
Some patients may require the following:
1. Bowel preparation. “Enemas till clear” may be ordered when it is advantageous to have the
bowel and rectum empty (e.g., gastrointestinal procedures such as bowel resection or
endoscopy, and surgical procedures in the pelvic, perineal, or perianal areas). An intestinal
lavage with an oral solution that induces diarrhea may be ordered to clear the intestine of
feces. Solutions such as GoLYTELY or Colyte normally will clear the bowel in 4 to 6 hours.
Because potassium is lost during diarrhea, serum potassium levels should be checked before
the surgical procedure.4,5,8,9 Geriatric, underweight, and malnourished patients are prone to
other electrolyte disturbances from intestinal lavage.
2. Bedtime sedation for sleep in select circumstances.
37
POST OPERATIVE CARE
The postanesthesia nurse must understand the patient’s risks for complications and be prepared
to implement interventions should there be a change in the patient’s status.
Nursing interventions include monitoring vital signs, airway patency, and neurologic status;
managing pain; assessing the surgical site; assessing and maintaining fluid and electrolyte
balance; and providing a thorough report of the patient’s status to the receiving nurse on the unit,
as well as the patient’s family.
Post-Anesthesia Care Unit (PACU)
The patient must be stable and free from symptoms of complications in order to transfer from the
PACU to the clinical unit or home. However, the potential for developing complications goes
beyond the immediate postoperative phase and ongoing nursing assessment is essential on the
postoperative nursing floor as well. In this video, we will be focusing on the immediate
postoperative care in the PACU.
The PACU should be located near the operating rooms. It is usually a large open room, divided
into individual patient care spaces. There are usually 1.5 to 2 patient care spaces per operating
room. Each patient care space is supplied with a blood pressure monitoring device, cardiac
monitor, pulse oximeter, oxygen, airway management equipment, and suction. Emergency
equipment and medications are often centrally located.
The length of stay in the PACU is determined on a case-by-case basis, there is not a mandated
minimum stay requirement. The American Society of PeriAnesthesia Nurses (ASPAN)
recommends that critically ill patients do not recover in the same area as ambulatory surgical
patients.
Registered nurses in the PACU demonstrate in-depth knowledge of patient responses to
anesthetic agents, surgical procedures, pain management, and potential complications.
Stages of Post-Anesthesia Care
There are three phases of postanesthesia care.
Phase 1 is the immediate post-anesthesia period, when the patient is emerging from anesthesia
and requires one-on-one care. The PACU nurse assesses the level of consciousness, breath
sounds, respiratory effort, oxygen saturation, blood pressure, cardiac rhythm, and muscle
strength. The patient is being prepared for transfer to phase 2, ICU, or an inpatient nursing unit.
38
Phase 2 is continued recovery; when the patient’s consciousness returns to baseline and the
patient has stable pulmonary, cardiac, and renal functioning. Many patients bypass phase 1 and
go directly from the OR to phase 2; this process is known as “fast-tracking.” The patient then
moves to phase 3, home, or an extended care facility.
Phase 3 is ongoing care for patients needing extended observation and intervention after phase 1
or 2, such as a 23-hour observation unit or in-hospital unit. Nursing care continues until the
patient completely recovers from anesthesia and surgery and is ready for self-care.
Patient Assessment
The PACU nurse will receive a detailed verbal report from the circulating OR nurse and/or
anesthesiologist that is bringing the patient to recovery. The PACU nurse performs an immediate
assessment of the patient’s airway, respiratory, and circulatory status, then focuses on a more
thorough assessment. Immediate post-anesthesia nursing care (phase 1) focuses on maintaining
ventilation and circulation, monitoring oxygenation and level of consciousness, preventing
shock, and managing pain. The nurse should assess and document respiratory, circulatory, and
neurologic functions frequently.
Neurologic functions can be assessed by the patient’s response to verbal stimuli, pupils’
responsiveness to light and accommodation, ability to move all extremities, and strength and
equality of a hand grip. A level of consciousness assessment is also helpful, such as the AVPU
scale or the Glasgow Coma Scale. The AVPU scale assesses if the patient is alert and oriented,
responds to voice, responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective
way to record the conscious state of a patient, examining eye, verbal, and motor responses. The
lowest possible score is 3, indicating deep coma or death, while the highest score is 15, a fully
awake person.
Assessment of the respiratory status may include pulse oximetry, arterial blood gases, and chest
x-ray. Respiratory complications exist for all patients and include airway obstruction,
hypoxemia, hypoventilation, aspiration, and laryngospasm. Airway obstruction is a serious
complication after general anesthesia, and commonly results from the movement of the tongue
into the posterior pharynx; changes in the pharyngeal and laryngeal muscle tone; or
laryngospasm, edema, and secretions of fluid collecting in the pharynx, bronchial tree, or
trachea. Symptoms include gurgling, wheezing, stridor, retractions, hypoxemia, and hypercapnia.
Treatment includes administering 100% oxygen, suctioning of secretions, jaw-thrust maneuver to
maintain airway, and insertion of an oral or nasal airway. If none of these interventions are
successful, then endotracheal intubation, cricothyroidotomy, or tracheostomy may be necessary.
Patients with obstructive sleep apnea have a complete or partial collapse of the pharynx during
inspiration and are at an increased risk of airway obstruction from the effects of anesthesia. They
are also at risk for hypoxemia because of the residual effects of anesthetic agents. The nurse
should monitor the patient for apnea and dysrhythmias and continuously monitor oxygen
saturation.
39
Hypoxemia is a common complication in the immediate postoperative period when pulse
oximetry is less than 90% and PO2 is less than 60 mmHg per ABG. It may be a result of
hypoventilation, related to:
Opioids – causing respiratory center depression
General anesthesia
Insufficient reversal of neuromuscular blocking agents – resulting in residual muscle
paralysis
 Increased tissue resistance – from emphysema or infections
 Decreased lung and chest wall compliance – from pneumonia
 Obesity or gastric and abdominal distention
 Incision site close to the diaphragm
 Constrictive dressings
 Postoperative pain
Aspiration is when gastric contents or blood is inhaled into the tracheobronchial system. It is
usually caused by regurgitation; however, blood may result from trauma or surgical
manipulation. Risk for aspiration is the reason patients need to be NPO prior to surgery, so there
is nothing in the stomach. Aspiration of gastric contents can cause pneumonitis, chemical
irritation, destruction of tracheobronchial mucosa, and secondary infection.
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Laryngospasm is another respiratory complication, in which the laryngeal muscle tissue spasms,
and causes a complete or partial closure of the vocal cords, resulting in airway obstruction. If not
treated, laryngospasm can result in hypoxia, cerebral damage, and death. If the patient is
extubated too quickly, they are at risk for airway spasm, aspiration, coughing, and airway
obstruction. If there is repeated suctioning and irritation by the ET tube or artificial airway,
laryngospasm can occur after extubation. Symptoms of laryngospasm include dyspnea, crowing
sounds, hypoxemia, and hypercapnia. Treatment includes removing the irritating stimulus,
hyperextending the patient’s neck, elevating the head of the bed, giving oxygen, suctioning if
necessary, and positive pressure ventilation by bag and mask. Medication may be given to reduce
swelling and airway irritation, or a muscle relaxant may be needed. Re-intubating is only done as
a last resort.
Maintaining circulation and assessing for cardiac complications in the immediate post-op period
is a priority for nursing care. The most commonly encountered cardiovascular complications are
hypotension, hypertension, and cardiac dysrhythmias that occur as a result of anesthetic agents
affecting the central nervous system, myocardium, and peripheral vascular system. The signs of
hypotension include increased heart rate, systolic pressure of 90 mmHg or less, decreased
urinary output, pale extremities, confusion, and restlessness. A common cause of postoperative
hypotension is blood loss or inadequate fluid replacement. The PACU nurse should be ready to
return the patient to the OR if excessive bleeding or hemorrhage occurs.
Hypertension can also occur postoperatively, due to pain, pre-existing hypertension, sympathetic
stimulation, bladder distention, anxiety, or reflex vasoconstriction due to hypoxia, hypercarbia,
or hyperthermia. Untreated hypertension may lead to cardiac dysrhythmias, left ventricular
40
failure, myocardial ischemia and infarction, pulmonary edema, and cerebrovascular accident.
The hypertension must be adequately treated before the patient is discharged from the PACU.
Cardiac dysrhythmias commonly occurring in the immediate postoperative period include sinus
tachycardia, sinus bradycardia, and supraventricular and ventricular dysrhythmias. The nurse
should assess for airway patency, adequate ventilation, and administer medications and
supplemental oxygen as needed. A crash cart should be readily available.
The PACU nurse is also responsible for monitoring the patient’s temperature, as normal
thermoregulation is often disrupted due to medication, anesthesia, and the stress of surgery.
Many patients experience hypothermia, which can extend recovery, delay wound healing, and
increase postoperative morbidity. Shivering increases oxygen demands up to 400%, which
results in an increased metabolic rate and myocardial workload. Hypothermia also impairs
coagulation, causes decreased cerebral blood flow, and vasoconstriction. Signs of hypothermia
include shivering, tachypnea, and tachycardia. Rewarming is essential in the immediate
postoperative care of the patient in PACU.
Hyperthermia, when core temp gets above 102.2°F, may be caused by infection, sepsis, or
malignant hyperthermia, which can occur for 24-72 hours after surgery. If unrecognized or
untreated, malignant hyperthermia results in death.
Fluids are lost during surgery through blood loss, hyperventilation, and exposed skin surfaces.
Volume may be replaced with IV fluids, and excessive blood loss replaced with blood, blood
products, colloids, or crystalloids. The body naturally retains fluid for at least 24 to 48 hours
after surgery, due to the stimulation of antidiuretic hormone as part of the stress response and the
effects of anesthesia. The patient should be monitored for fluid and electrolyte imbalances,
pulmonary edema, and water intoxication. Fluid intake usually exceeds output during the first 24
to 48 hours. Even if the IV fluid intake is 2,000-3,000 mL, the first void may not be more than
200 mL, and total urinary output for the surgery day may be less than 1500 mL. As the body
stabilizes, fluid and electrolyte balance returns to normal within 48 hours.
Nausea and vomiting is a common postoperative problem and can also lead to fluid and
electrolyte imbalance. It is often caused by the effects of general anesthesia, abdominal surgery,
opiate analgesics, and history of motion sickness. Nausea and vomiting usually occurs in the first
24 hours, with the highest incidence in the first 2 hours. It can prolong recovery time, sometimes
resulting in an unplanned hospital admission for an outpatient surgery patient.
Pain is a common occurrence after most all types of surgical procedures and is probably the most
significant postoperative problem in the eyes of the patient. Prompt and adequate pain relief is a
critical nursing intervention. Unresolved acute pain has many negative effects, including more
complications, longer hospital stays, greater disabilities, and the potential for chronic pain. There
is an association between high pain scores and nausea, respiratory complications, slower return
of GI function, and increased risk of DVT. Effective methods of postoperative pain relief include
preemptive analgesia (which is given prior to surgery or prior to pain), giving around-the-clock
analgesics, PCA (patient-controlled analgesia, PRN (as needed) dosing, management of
breakthrough pain, and nonpharmacologic interventions. Assessment of the patient’s pain is the
41
first priority. The patient’s report is the most reliable indicator of pain intensity, and using a
numeric or faces pain rating scale is a reliable tool.
Other important assessments include:
Surgical site – dressing dry and intact
Proper draining of drainage tubes
Rate and patency of IV fluids
Level of sensation after regional anesthesia
Circulation/sensation in extremities after orthopedic or vascular surgery
Patient safety
During the patient’s stay in PACU, the nurse documents all assessments and interventions.
Patients usually remain in the PACU until their vital signs are stable and they are reasonably
capable of self-care. Discharge from the PACU is usually determined by a numeric scoring
system; the most common one in use is the Aldrete score. There is a phase 1 Aldrete score that
measures activity, respiration, circulation, consciousness, and oxygen saturation (or color). Each
measurement is scored from 0 to 2, with a total score of 9 or 10 qualifying for discharge from the
PACU.
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TRACHEOSTOMY CARE
DEFINITION
A tracheostomy is an incision into the trachea the 2nd, 3rd, or 4th tracheal ring
USE OF TRACHEOSTOMIES
 To facilitate prolonged artificial ventilation
 To bypass serious upper respiratory obstructions
 To prevent aspiration of blood, secretions or food into the lungs
 To provide easier access to the lower airways than that is possible through nose or mouth
PARTS OF THE TRACHEOSTOMY TUBE
 Outer tube or outer cannula
 The inner tube or inner cannula
 The obturator or pilot. It is used as a guide to the outer tube
INDICATIONS FOR TRACHEOSTOMY
 Apnea
 Respiratory obstruction
 Circulatory arrest
 Exsanguinating hemorrhage
 Carcinoma of the larynx
 Diphtheria, Ludwig’s angina
 Head injury, neck injury or chest injuries
 Respiratory failure
 Fracture of the larynx or trachea
 In case of foreign body in hypopharynx or larynx
 Patient with severe burns, especially around hand, neck, and face
 Patients who have had thyroidectomy or radical neck resection
42

Patients with neurological disorders, drug overdose, bulbar paralysis, or cerebrovascular
accidents
 Patients with severe pulmonary edema
 Patients with severe emphysema
 Weak, feeble patients
 Canine biting
COMPLICATIONS OF TRACHEOSTOMY
 Subcutaneous emphysema
 Pneumothorax
 Mediastinal emphysema
 Obstruction of tracheostomy tube
 Respiratory insufficiency
 Displacement of the tube from its position on the tracheal turner
 Hemorrhage
 Pulmonary infection
 Atelectasis
 Tracheoesophageal fistula
Tracheomalacia
Constant pressure exerted by the cuff causes tracheal dilation and erosion
Signs and Symptoms
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An increased amount of air is required in the cuff to maintain the seal
A large tracheostomy tube is required to prevent air leak at the stone
Food particles are seen is tracheal secretions
The client does not receive the set tidal volume of the ventilator
Management
No special management is needed unless bleeding occurs
Prevention
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Use and uncuffed tube as soon as possible
Monitor cuff pressure and air volumes closely and detect changes
Tracheal Stenosis
Narrowed tracheal lumen is due to scar formation from irritation of tracheal mucosa by the cuff
Signs and Symptoms
Stenosis usually is seen after the cuff is deflated or the tracheostomy tube is removed. The client
has increased coughing, inability to expectorate secretions or difficulty in breathing or talking
43
Management
Tracheal dilation or surgical intervention is used
Prevention
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Prevent pulling of and traction on the tracheostomy tube
Properly secure the tube in the midline position
Maintain proper cuff pressure
Minimize oronasal intubation time
Tracheoesophageal fistula (TEF)
Excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created
between the trachea and the anterior esophagus. The client at highest risk also has a nasogastric
tube present
Signs and Symptoms
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Manually administer oxygen by mask to prevent hypoxemia
A small soft feeding tube is used instead of a nasogastric tube for tube feedings
A gastrostomy or jejunostomy may be performed
Monitor the client with a nasogastric tube closely; assess for TEF and aspiration
Prevention
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Maintain cuff pressure
Monitor the amount of air needed for inflation and detect changes
Progress to a deflated cuff or cuffless tube as soon as possible
Trachea-innominate artery fistula
A malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy.
Continued pressure causes necrosis and erosion of the innominate artery. This is a medical
emergency
Signs and Symptoms
The tracheostomy tube pulsates in synchrony with the heartbeat. There is heavy bleeding from
the stoma. This is a life-threatening complication
Management
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Remove the tracheostomy tube immediately
Apply direct pressure to the innominate artery at the stoma site
44
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Prepare the client for immediate surgical repair
Prevention
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Use correct tube size and maintain tube in midline position
Prevent pulling or tugging on the tracheostomy tube immediately notify the physician of
the pulsating tube
CARE OF THE TRACHEOSTOMY PATIENT
 Maintain an open airway. Suction and clean the tube as indicated. Prevent aspiration, e.g.
of water, solutions, etc. through the tracheostomy. Keep materials which may occlude the
tracheostomy, away from the opening, e.g. clothing, bedsheets
 Observe the patient carefully for indication of respiratory difficulty, e.g. noisy respirators,
restlessness, cyanosis, intercostals and substernal retraction, alternations in respiratory
rate, labored respiration
 Practice asepsis. Strict aseptic technique should be followed while suctioning, cleaning
and dressing the wound
 Observe for complications of tracheostomy. If the airway is obstructed, do suctioning, if
the tracheostomy outer tube has come out, put the tracheal dilator inside and inform the
doctor. Never try to push a blown out tracheostomy tube back into its place. Tracheal
dilator and tracheal hook, sterile, should be present near the patient all the time
 Ensure maximal humidification of the inspired air and approximately warm inspired air.
Sterile wet gauze covering the tracheostomy will help in humidification
 Provide adequate hydration to help liquefy pulmonary secretions. At least 3,000 ml of
intravenous fluids are ordered daily if adequate oral intake is not possible
 Maintain fluid and electrolyte balance. Keep an accurate intake and output chart
 Be gentle. The tracheal mucosa is easily traumatized during suctioning
 Keep the necessary articles like extra sterile inner tracheostomy tube, tracheal dilator,
tape, Vaseline, gauze, sterile gauze pieces, suction nozzles, sterile water and suction
apparatus nearby
 Prevent pressure and trauma to the tracheobronchial tree. If a cuffed tube is being used,
see that the cuff is deflated, as ordered, to relieve pressure periodically on the tracheal
wall
 Periodically inspect the tracheostomy for trauma or infection
 Ensure use of a fresh tracheostomy tube as needed. Clean the inner cannula of mucus and
encrustations as indicated. The inner tube is changed by nurses and outer tube by doctors
 Change the dressings and tracheostomy tube as necessary
 Provide appropriate skin care. Keep skin clean and dry
 Provide adequate nourishment
 Provide frequent mouth care to minimize possible infection. Plenty of water should be
given orally
 Administer medications as ordered. Narcotics and sedatives are usually avoided. To
minimize apprehension, only mild tranquilizers are given
 For long-term cases, the patient and his relatives are taught how to take care of the tube
 Alleviate the patient’s apprehension by closely observing him, providing care in a calm
but efficient manner and helping him communicate by providing a call bell
The suction procedure is as follows:
45
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Auscultate the chest before and after suctioning
Wash hands and use sterile gloves
Place a sterile towel across the patient’s chest just below the tracheostomy tube
Clean the skin around the tube and the adaptors with a recommended antiseptic
Select the catheter, attach it to the suction apparatus and lubricate it with sterile normal
saline, gently insert into the tracheostomy tube and do the suctioning. It should not be
continued more than 5 seconds at a time
 After suctioning, discard the catheter and gloves and also the saline. Note the amount and
the character of the secretions aspirated
 Wash hands after completion of the procedure
Cleansing the Inner Cannula
It is changed every 2 to 4 hour, but in some cases, only twice. It can be cleaned with cold water
and soap and also with hydrogen peroxide solution. After cleaning, it can be sterilized and can be
used again. Do not leave the inner cannula out for longer than 5 to 10 m while removing or
cleaning it
If left out for longer periods, secretions and crust begin to form in the outer cannula, making it
difficult to reinsert the inner cannula
The following conditions should be reported to the doctor if they occur during the postoperative
period:
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Tube displacement
Indications of shock, hemorrhage, respiratory insufficiency and hypoxia
Respiratory obstruction
Excessive restlessness or apprehension
Cyanosis, in case of cyanosis, oxygen should be given
Rhinorrhea
Development of tracheoesophageal fistula
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ENTERAL/NASOGASTRIC
Nasogastric feeding or gastric gavage is the instillation of specially prepared nutrients into the
digestive tract through a tube that is inserted through one of the nostrils, down the nasopharynx
and into the alimentary tract
Enteral tube feedings are delivered to the distal duodenum or proximal jejunum when it is
necessary to bypass the esophagus and stomach
PURPOSE
 To supply the body with adequate nourishment, when the patient is unable to take food
by mouth (e.g. unconscious, semiconscious and delirious patients) or for patients who
will not eat
 To supply with adequate nutrients when conditions of mouth or esophagus make the
chewing or swallowing difficult or impossible, e.g. patients with fracture jaw, structure
esophagus, surgery of mouth and esophagus
ADVANTAGES OF ENTERAL TUBE FEEDING
 Intraluminal delivery of nutrients preserves gastro-intestinal integrity
 Tube feedings preserve the normal sequence of intestinal and hepatic metabolism prior to
nutrient delivery to the arterial circulation
 The intestinal mucosa and liver are important in fat metabolism and are the only sites of
lipoprotein synthesis
 Normal insulin – glucagon ratios are maintained with the intestinal administration of
carbohydrates
GENERAL INSTRUCTIONS
 Patient receiving internal tube feedings should be in an upright position to avoids
aspiration or reflux
 If the patient is ambulatory, he is encouraged to walk, since movement facilitates
absorption of the feeding
 Fluid balance is carefully recorded to identify decreased intake or excessive diarrhea
 Feeding are delayed for 2 hours if gastric residue is greater than to 150 ml. if this amount
persists, the physician is notified
 During the feeding monitor for signs of intolerance which includes cramping, diarrhea,
nausea, vomiting, aspiration, glycosuria and diaphoresis
 Always check the placement of the tube. Gently aspirate gastric contents with a syringe,
and measure the pH of the gastric contents
 If the feeding solution does not initially flow through a bulb syringe, attach the bulb and
squeeze it gently to start the flow. Then remove the bulb. Never use the bulb to force the
formula through the tube
 If the patient becomes nauseated or vomits, stop the feeding immediately
 During continuous feedings, assess the patient frequently for abdominal distension
 Flush the tubing by adding about 50 ml of water to the gavage bag or bulb syringe. This
maintains the tube’s patency by removing excess formula, which could occlude the tube
 If the patient develops diarrhea, administer small frequent, less concentrated feedings to
administer bolus feeding over a long time
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Drugs can be administered through the feeding tube. Except for enteric coated drugs
PRELIMINARY ASSESSMENT
 Check the doctor’s order
 Type of formula
 Time, frequency amount of feeding
 Specific indications for the client
PREPARATION OF THE PATIENT AND ENVIRONMENT
 Explain procedure to patient
 Ask patient for any history of allergies
 Auscultate for bowel sounds before feeding
 Check placement of gastric tube by means of aspiration of gastric juice is by checking
with stethoscope while introducing air into the stomach
 Position patient to high Fowler’s position or elevate head if bed 30 degrees
 Place a towel under the chin
 Examine the appearance of aspirated contents
EQUIPMENT
A clean tray containing:
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Large volume syringe
Required feed a fluid
Kidney tray
Stethoscope
A glass with water for flushing the tubing
Continuous infusion set in continuous drip method is ordered
Disposable gloves
Measured glass to measure to fluid intake
PROCEDURE
 Wash hands and put clean gloves
 Pinch proximal end of the feeding tube and elevate to 18 inches above the patients head.
Fill the syringe with the required feed. Allow syringe to empty gradually, refill until
prescribed amount has been given to the patient
 If continuous drip method is used hang the feeding bag to the pole above 18 inches above
patients head and connect end of the bag to the proximal end of the feeding tube and set
rate
 Regulate the drip rate to permit the formula to infuse over 20-30 minute by adjusting the
height of the feeding bag or adjusting the rate of flow
 When the tube feedings are not being administered, clamp the proximal end of the tube
 Rinse the tube with pain water at the end of feeding
 Reclamp the gastric tube
 Remove gloves and wash hands
POST-PROCEDURE CARE
 Cover the end of the feeding tube with its plug or cap to prevent leakage and
contamination of the tube
 Leave the patient in semi-Fowler’s or high Fowler’s position for at least 30 minutes
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Rinse all reusable equipment with warm water. Dry it and store it in a convenient place
for the next feeding. Change the equipment every 24 hours or according to your facility’s
policy
 The patient and family members are gradually included in these activities
 Weight is checked daily and watch for sudden gain in weight
 Observe for signs of dehydration (dry mucous membranes, thirst, and decreased urine
output)
 Watch for possible complications
 Record amount of feeding, patient’s response to tube feeding and untoward effects in
nurse’s notes and record intake in fluid balance chart
COMPLICATIONS OF TUBE FEEDING
 Mechanical: nasopharyngeal, luminal obstruction, mucosal erosions, tube displacement,
aspiration
 Gastrointestinal: cramping/distention, vomiting/diarrhea
 Metabolic: hypertonic dehydration, glucose intolerance, hyperosmolar nonketotic coma,
hepatic encephalopathy, renal failure, cardiac failure
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