Practical Exam
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Suctioning (Oral, ET)
Hemoglucose test
Electrocardiogram
Nasogastric Tube
Arterial Blood Gas
Tracheostomy Tube Care
Suctioning
Tracheostomy tube care
Materials
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Tracheostomy care kit (hydrogen peroxide,
sterile water, q tips, buckets, and cannula
cleaners, fenestrated tissue,)
There are cuffed or uncuffed cannulas
Sizes for adults are 6-8
Procedure
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Prepare your equipment
Wash hands
Don sterile gloves
Establish sterile field
Put sterile water into the three buckets
Remove mask
Remove inner cannula and put the mask back
to oxygenate the patient
Clean the cannula with cannula cleaners and
sterile water (hydrogen peroxide)
Put the inner cannula back
Clean the mask and the outer cannula with
the tissues if there are mess
Use q tips to clean the outer part of the
cannula
Apply the fenestrated gauze underneath the
canula
patient can still breathe even without the oxygen
mask.
Mechanical Ventilation
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It is a life sustaining therapy in which a
ventilator provides partial or full support for
patients with respiratory failure
Main goals: maintain adequate gas exchange, to rest
respiratory muscles, and to decrease the oxygen cost
of breathing.
Mechanical Ventilator
- it is a positive- or negative- pressure breathing
device that can maintain ventilation and oxygen
delivery for a prolonged period.
Indications:
Laboratory Values
PaO2 <55 mmHg
PaCO2 >50mmHG and
pH <7.32
Vital Capacity <10
ml/kg
Negative inspiratory
force <25 cm H20
FEV1 <10 mL/kg or
respiratory rate of
>35/min
Clinical Manifestations
Apnea or bradypnea
Respiratory distress with
confusion
Increased work of
breathing not relieved
by other interventions
Confusion with need for
airway protection
Circulatory shockcontrolled
hyperventilation (e.g.,
patient with a severe
head injury
Classification of Ventilators
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Negative pressure
Positive pressure
o Most widely used approach to
mechanical ventilation is to deliver
gas to the lung with positive-pressure
ventilation (PPV) applied through an
endotracheal tube, a tracheostomy,
or a tight-fitting mask.
 Volume-cycled Ventilators
 Pressure-Cycled Ventilators
 High-frequency oscillatory
support ventilators
 Noninvasive positive-pressure
ventilation
Questions:
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What is a mechanical ventilation’s purpose?
What are the types of mechanical ventilators
ABG (Arterial Blood Gas) Analysis
Is used to evaluate respiratory function and
provide a measure for determining acid-base
balance.
An acid-base balance must be maintained in
the body because alterations can result in
alkalosis or acidosis.
Why does acid-base imbalance occur?
they occur because there is an
underlying problem that causes
homeostatic problems. This then
causes the kidney and/or the lungs to
compensate.
Hysteria
Pain
Blood Gas
pH
PaCO2
HCO3Pa02
Ranges
7.35 – 7.45
35 – 45 mmHg
22 – 26 mEq/L
75 – 100 mmHg
Neurological injuries
Embolism or edema in the lungs
Asthma due to hyperventilation
What is the S/Sx of Respiratory Alkalosis?
Respiratory Acidosis
This occurs when the lungs cannot excrete
carbon dioxide from the body and causes the
excess CO2 in the lungs to merge with the
water in the blood to form acid (common in
Emphysema). This causes the blood pH to
become acidic and causes the kidney to
release more bicarbonate acid through urine
to heighten the pH level of the blood.
2 types of respiratory acidosis, Acute and
Chronic
What causes Respiratory Acidosis?
Hypoventilation, COPD, Respiratory
conditions, Drug intake (opium)
Muscle cramps (due to lack of
calcium)
Tetany, involuntary muscle
contractions (due to lack of calcium)
Palpitations (fast heart rate)
Positive Chvostek Sign (twitching of
cheek muscles when touched near
the ear)
How to manage Respiratory Alkalosis?
Give paper bag, Control Anxiety,
medications for lowering respirations,
manage underlying conditions
What is the S/Sx of Respiratory Acidosis?
Confusion, Altered LOC, muscle
jerking, Coma
Potassium levels rise (>5.0)
How to manage Respiratory Acidosis?
Bronchodilators, Weightloss,
Kayexalate, Adequate hydration, and
Mechanical ventilation
Respiratory Alkalosis
Happens when the body excretes too much
carbon dioxide (hyperventilation)
What causes Respiratory Alkalosis?
Metabolic Acidosis
What causes Metabolic Acidosis?
Addition of large amounts of fixed
acids to body fluids.
Lactic acidosis (circulatory failure),
Ketoacidosis (diabetes, starvation),
Phosphates and sulfates (renal
disease),
Acid ingestion (salicylates),
Secondary to respiratory alkalosis,
Adrenal insufficiency
What is the S/Sx of Metabolic Acidosis?
Hyperventilation
Confusion, Altered LOC, muscle
jerking, Coma
TACHYPNEA
Potassium levels rise
Temperature increase
Kussmaul breathing (heavy fast
breathing)
Aspirin toxicity
Controlled ventilation
(hyperventilates)
Hyperventilation
How to manage Metabolic Acidosis?
Bronchodilators, Weightloss,
Kayexalate, Adequate hydration, and
Mechanical ventilation
Metabolic Alkalosis
What causes Metabolic Alkalosis?
Retention of base or removal of acid
from body fluids
Vomiting, excessive gastric drainage,
potassium depletion (diuretic
therapy), burns, excessive NAHCO3
administration
What is the S/Sx of Metabolic Alkalosis?
Confusion,
How to manage Metabolic Alkalosis?
Bronchodilators,
ABG procedure
Equipment
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Cotton wool and tape
Arterial blood gas syringe,
Tray with sharps bin
gloves (sterile and unsterile),
skin preparation solution (2%
chlorhexidine in 70% isopropyl alcohol),
A patient label, and pen to write down
their details including the inspired oxygen
concentration.
Apron
Steps to follow
1. Give a full explanation to the patient in simple
terms and ensure that they consent to the
procedure
2. Set up your trolley
3. Prepare your trolley as a sterile field. Wear a
plastic disposable apron and non-sterile
gloves and take alcohol hand rub with you.
4. Attach a 21G or 23G needle to the syringe. A
21G needle is likely to be required for femoral
access.
Radial Site Collection
1. Conduct Allen test
2. Position the wrist; you can use a towel, pillow,
or bag of fluid to extend the wrist (20 – 30
degrees)
3. Feel for the pulse just proximal to the traverse
skin crease at the wrist.
4. Clean the skin with antiseptic solution (2%
chlorhexidine in 70% isopropyl alcohol) and
put on sterile gloves.
5. With the pulp of your fingers, assess the size,
depth, direction and point of maximum
pulsation.
6. Holding the syringe like a pen bevel upwards
at 45 degrees aim at the point of maximum
pulsation, in a proximal direction
Advantages – lies close to the surface, easily
accessible, easy aseptic approach
Disadvantages – end artery, pulse may be hard to
feel in shut down patients or in patients with
atrial fibrillation
Brachial Site Collection
1. Position the arm so the medial aspect of the
antecubital fossa is easily accessible.
2. Clean the skin with antiseptic solution and
don sterile gloves.
3. Feel for the pulse assessing size, depth,
direction and point of maximum pulsation.
4. Holding the syringe at 45 degrees aim at the
point of maximum pulsation in a proximal
direction.
Advantages – can lie close to the surface, easy
aseptic approach, easily compressible
Disadvantages – end artery, quite mobile, close
proximity to the nerve.
Femoral Site collection
1. Make sure the patient is lying flat.
2. Clean the skin with antiseptic solution and
don sterile gloves.
3. Place fingers on the femoral pulse.
4. Aim the needle at the point of maximum
pulsation, distal to your fingers at almost 90
degrees to skin.
5. Slowly advance the needle whilst pulling back
on the plunger until flashback is achieved.
Advantages – reliable position, good landmarks,
can take other bloods at the same time, can be
found in shut down patients with poor or no
pulses
Disadvantages – Dirtier area of the body, may
dislodge plaque in PVD
All site considerations
1. When you enter the artery, the needle should
self-fill; if not keep the needle still and pull
back on the plunger.
2. Collect 1-2 ml of blood.
3. Withdraw needle and compress with cotton
wool.
4. Discard needle (into sharps bin), expel the air
and place the cap on the end.
5. Invert several times and take swiftly to the
ABG analyser.
Results interfering factors
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Drugs that cause an increase in HCO3Drugs that cause an increase in PaCO2
Drugs that cause a decrease in HCO3Drugs that cause a decrease in PaCO2
Bleeding disorders
Recent blood transfusion
Specimens with extreme high WBCs
Specimens after change in inspired O2
Specimens after suctioning
Excessive difference in actual body
temperature
Falsely increased O2 saturation
Excessive heparin amount
Used of citrates as anticoagulant
Air bubbles or blood clots in specimen
Delayed ice slurry placement
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Teach breathing exercises
Administer O2
Teach about incentive spirometer
Instruct to breathe deeply
Water balance needs to be monitored
Reinforce information regarding further
testing
Electrocardiogram
A standard 12-lead ECG uses a series of electrodes
placed on the extremities and the chest wall to assess
a patient’s heart from 12 different views (leads)
P wave and PR interval
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The p wave represents atrial
depolarization. The PR interval represents
the time it takes an impulse to travel from
the atria through the atrioventricular
nodes and the bundle of His
Nursing Responsibilities
Pre-procedure
 Inform patient about the test
 Obtain history of complains
 History of respiratory function
 Note recent procedures
 Obtain lists of medications
 Record temperature
 Indicate type of O2 used
 Perform allen test if site is radial artery
 Review and explain procedure
 Inform collection takes 10-15 minutes
 No restrictions on food and fluids unless
directed
 Prepare ice slurry in a cup
Intra-procedure
 Care is taken if patient is allergic to latex
 Instruct to cooperate and follow
 Observe standard precautions
 Results are manually or computerized
system
Post-procedure
 Applies pressure to site 5 minutes
 Observe for s/sx of respiratory reactions
P wave – atrial depolarization no more than 3 boxes
Rate, regularity, resemblance
10 x number of p wave in a 6 seconds strip =
rate
P-R interval – time that the signal took from sinus
node to atrioventricular node 3-5 boxes (0.12 – 0.20)
P-R segment – should be isoelectric (no depression
and elevation) represents the time that the
atrioventricular node blocks the conduction
(gatekeeps it) no more than 3 boxes
Could indicate that there is a heart block if it
takes too long.
QRS interval – ventricular depolarization and atrial
repolarization 3 boxes
T -wave – ventricular repolarization
J point, S-T segment – finishing of ventricular
depolarization
Q-T interval – time of conduction to ventricular
repolarization 0.35 – 0.44 seconds
Atrial Fibrillation
Atrial Flutter
Ventricular fibrillation
Ventricular tachycardia
Supraventricular tachycardia