NCM 118 SKILLS

NR Care of Clients with Life Threatening Conditions, Acutely Ill, Multi-organ

Problem, High Acuity & Emergency Situations, Acute and Chronic
R L E / PROF. Fernandez, Malicsi, Medrano, Benito
______________________________________________________________________________________________________________

PRELIMS

3. Avoid using cotton-filled gauze squares and avoid the 4x4

WEEK 1 - OUTLINE gauze. The client might aspirate cotton lint which could create
I. Tracheostomy tracheal abscess.
Parts of Tracheostomy 4. If the client coughs and the tube is dislodged accidentally, the
Types of Tracheostomy Tubes initial nursing action is to grasp the retention sutures, and spread
Procedure the opening. If the agency policy permits the nurse, then attempt
immediately to replace the tube.
TRACHEOSTOMY PARTS OF TRACHEOSTOMY TUBE
A surgical incision into the trachea to insert a tube through which the 1. Obturator - Used to insert the outer tube. Removed once
patient can breathe more easily and secretions can be removed. the outer tube is in place.
2. Outer Cannula - Curved and has a flange near the opening
Tracheostomy Procedure which rests against the surface of the neck. Ties attached to
● A small, horizontal incision is made just below the 1st tracheal this flange secures the cannula to the patient’s neck.
ring and tracheostomy tube is inserted . 3. Inner Cannula - Fitted inside the outer tube. A latch usually
● Can be temporary or permanent. In most cases, this is for holds cannula securely and allows it to be removed for
temporary measures. cleaning.
● Once the patient can tolerate temporary closure referred to as
“buttoning”, tracheostomy tube is removed, and incision heals.

PURPOSES
1. To maintain a patent airway.
2. To maintain cleanliness and prevent infection at the
tracheostomy site.
3. To facilitate healing and prevent skin excoriation around
tracheostomy incision.
4. To promote comfort.

TYPES OF TRACHEOSTOMY TUBE

1. Single-Lumen Tube
2. Double-Lumen Tube
3. Cuffed Tube
4. Cuffless Tube
5. Fenestrated Tube
6. Metal Tracheostomy Tube
7. Talking Tracheostomy Tube

PROCEDURE
1. Determine the need for tracheostomy care. Assess the patient's
pain and administer pain medication, if indicated. Signs and
symptoms are related to presence of secretions at stoma site
or within tracheostomy tube.
2. Bring necessary equipment to the bedside. Prepares
equipment and allows for smooth, organized completion of
tracheostomy.
3. Wash hands. Reduces transmission of microorganisms.
4. Explain the procedure to the client. Encourages cooperation
and prevents accidental extubation of tracheostomy tube.
CONSIDERATIONS
5. Close curtains around bed and close the door to the room, if
1. Sterile technique is always used for infection control. possible. Provides privacy.
✓ Hyperoxygenate client before, during, and after 6. Position the patient.
suctioning. ○ If conscious, place in a semi-Fowler‘s position.
✓ 100% oxygen for 3 minutes or 3 deep breaths. ○ If unconscious, place in the lateral position, facing you.
2. Suction no more than 10 sections. Promotes clients comfort and prevents nurses muscle
strain.
NOTE: 7. Auscultate lung sounds, apply pulse oximeter, and note
Establish a way of communicating. oximeter reading, check skin integrity, site drainage, and pain.
● Patients with tracheostomy usually cannot speak. The 8. Move the overbed table close to your work area and raise to
tracheal opening prevents air from reaching the vocal cords, waist height. Place a trash receptacle within easy reach of the
so speech is not possible. work area.
● Later, the patient will be able to speak by placing a button 9. Place a bath towel or prepackaged drape under tracheostomy
or finger of the opening thus forcing air around the tube. and across the chest. Reduces transmission of microorganisms
by protecting gown from secretions.

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 10. Turn on or increase oxygen. Hyperoxygenation before and after ○ Use wipes that are free from lint around the tracheal
suctioning decreases occurrence of arterial oxygen opening.
desaturation. 29. Replace cotton ties and dressing:
11. Turn on suction ○ Bring clean ties around the back of neck.
○ Adults: 100-120 mmHg ○ Untie one side of the outer cannula and replace it with
○ Pedia: 80 -100 mmHg the clean ties.
12. Open sterile tracheostomy kit and sterile suction catheter kit ○ Untie the other side of the outer cannula and replace it
with aseptic technique. Prepares equipment and allows for with another end of the clean ties.
smooth, organized completion of tracheostomy. ○ While holding the faceplate firmly in place, have the
13. Apply sterile gloves. Put sterile gloves and keep dominant hand second person tie the ties around the outer cannula in
sterile. place, positioning knots appropriately.
14. Remove drape and place on an overbed table. Serves as a ○ Insert fresh tracheostomy dressing under clean ties and
sterile field. faceplate. Absorbs drainage. Dressing prevents pressure
15. Place suction catheter onto sterile field, remove sterile supplies on clavicle heads.
from tray, place on sterile drape. Ensures sterility of equipment. 30. Auscultate breath sounds, monitor oxygenation, read pulse
16. Prepare and arrange equipment. Allows for smooth, organized oximeter
completion of tracheostomy. ○ Some clients may require post-tracheostomy care
○ Arrange sterile 4x4s, trach dressing, brush, cotton-tipped suctioning.
swabs on sterile field in order of use. 31. Provide oral care. Promotes hygiene
○ Pour cleansing solution; Equal parts hydrogen peroxide 32. Dispose of used equipment
and sterile normal saline/water into individual containers. 33. Position the patient comfortably.
○ Pour rinsing solution (sterile saline or water) into the two 34. Wash hands. Reduces transmission of microorganisms.
other containers.
17. Unlock and remove inner cannula with non-dominant hand,
place it in a basin with hydrogen peroxide cleaning solution. INDICATIONS FOR SUCTIONING TRACHEOSTOMY
Removes inner cannula for cleaning. ● Presence of mucus in airway
○ Keep the dominant hand sterile throughout the ● Increased pulse
procedure. ● Increased respirations
○ Hydrogen peroxide loosens secretions from the inner ● Noisy respirations
cannula. ● Restlessness
18. Prepare to suction:
○ Pick up a sterile suction catheter with a dominant (sterile) COMPLICATIONS
hand. ● Airway obstruction
○ Aspirate sterile rinsing solution through catheter by ● Accidental decannulation
occluding suction control with thumb. To lubricate the ● Infection
catheter.
19. Hyperoxygenate patient; Have the patient take several breaths.
○ If the patient is unable to take a breath, have a second
person hyperoxygenate the patient with an Ambu bag
(second person). Maintains oxygen supply to the client.
20. Suction the patient:
○ Remove thumb from suction control to stop occlusion.
○ Insert catheter into tracheostomy until resistance is met
or patient coughs.
■ Coughing occurs or resistance is felt when the
catheter touches the carina.
○ Pull back 1 cm with sterile dominant hand.
○ Apply intermittent suctioning while rolling the catheter
between the thumb and forefinger.
○ Encourage the patient to cough during suctioning.
○ Suction patient for a maximum of 10 seconds.
21. Reapply oxygen, encourage deep breathing, and allow to rest
between each suction episode.
22. Assess pulse oximeter.
23. Rinse catheter with sterile saline/water. Removes secretion and
hydrogen peroxide from inner cannula.
○ Repeat if necessary, no more than 3 suction passes
○ Hyperoxygenate patient before repeating procedure.
24. Assess pulse oximeter.
25. Turn off suction, disconnect suction catheter, and dispose of
catheter while maintaining sterility of dominant hand.
26. Clean and replace the inner cannula.
○ Pick up the plastic faceplate of the inner cannula with
non-sterile, non-dominant hand and cleanse the inner
cannula with sterile, dominant hand
■ Use pipe cleaners and brush to clean the inside
inner cannula with hydrogen peroxide using the
dominant hand.
■ Rinse inner cannula and its inner aspect with
sterile rinsing solution and rinse thoroughly.
○ Inspect inner and outer aspect of inner cannula and
remove excess solution with sterile 2x2 using dominant
hand to wipe from clean to dirty.
27. Rinses hydrogen peroxide from surfaces. If not removed from
skin, hydrogen peroxide can promote tissue injury.
28. Clean skin around tracheostomy and tabs of outer cannula with
sterile saline/water. Prevents tissue injury

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 4. Never lift drainage bottle above level of the client’s chest
WEEK 2 - OUTLINE
I. CHEST TUBE DRAINAGE EQUIPMENT
A. Purposes 1. Prescribed drainage system
B. Purposes and Reason 2. Water suction system and sterile water
C. Objectives 3. Chest tube tray
D. Nursing Consideration 4. Dressing sterile gloves
E. Nursing Alert 5. Rubber-tipped hemostats for each test tube (2)
F. Equipment 6. 1 inch adhesive tape
G. Sites for chest tube insertion
H. types of chest drainage units
II. -
III. -

CHEST TUBE DRAINAGE

- A chest tube is a surgical drain that is inserted through the
chest wall and into the pleural space in order to remove
undesired substances such as excess fluid, blood or pus
from the intrathoracic space

3 Types of Bottle System (Glass Bottle System)

PURPOSES
A. Therapeutic
● To remove air from the thoracic cavity
● To facilitate re Expansion of the lungs
B. Diagnostic
● To determine presence of intrathoracic bleeding and to
measure the amount and rate of hemorrhage.

PURPOSES AND REASON

● A collapsed lung
● a lung infection like bacterial pneumonia complicated by
collection of pus
● pneumothorax, which is air around or outside the lung 1. 1 Bottle - The simplest form of underwater seal drainage
● bleeding around your lung, especially after a trauma (like a systems. To collect and a one-way valve that prevents air or
car accident) fluid from returning to the chest.
● fluid buildup due to another medical condition, like cancer or 2. 2 Bottle - This system is suitable for the drainage of air and
pneumonia fluid.
● breathing difficulty due to a buildup of fluid or air 3. 3 Bottle - Suction is required when air or fluid needs a
● surgery, especially lung, heart or esophageal surgery greater pressure gradient to move from the pleural space to
the collection system.
OBJECTIVES
● identify the indications for chest tube placement.
● Explain the importance of monitoring patients with a chest
tube
● Summarize the management of a chest tube
● Review the importance of improving care coordination
amongst the interprofessional team to enhance care delivery
for patients with a chest tube

NURSING CONSIDERATION
● To prevent dislodgement and infection
● To know management of effective suction and drainage, pain
relief.
● To monitor the respiratory status
● To provide over all supportive care
SITES FOR CHEST TUBE INSERTION
NURSING ALERT
1. Make certain that bottles are tight Placement: A thoracostomy tube is usually placed between the mid to
2. Tubing should be free of kinks and dependent loops anterior axillary line in the fourth or fifth intercostal space tracking
3. Be sure that the tube from the pleural cavity is attached to above the rib so as not to injure the intercostal bundle (artery, vein,
the tubing connected to a glass tube and ends under sterile nerve)
water.

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 TYPES OF CHEST DRAINAGE UNITS

TYPES OF CHEST DRAINAGE UNITS (CDU)

SMALLER PORTABLE CDU
Description Indications
● Drainage without use of suction
● Dry seal system that prevents air leaks
use Standard CDU Drainage of Following surgery that impacts ● No lung re expansion occurs
pleural cavity for air or any type on ● 500mL max drainage
of fluid with or without the use of ● Emptied when used in home
the continuity of the thoracic
suction Up to 2,000mL capacity
cavity (e.g., thoracic, cardiac, FOR AMBULATORY PATIENTS
Replaced when full esophageal surgery)
● Home care
Pneumothorax ● Chronic conditions

Hemothorax
WHAT IS CHEST DRAINAGE UNIT
Pleural effusion
● The water seal drainage system is a single unit with three
Pleurodesis chambers.
● 1st chamber: "collection chamber"; receives
● fluid and air from the chest cavity through the collecting tube
attached to the chest tube. 2nd chamber: "water-seal
TYPES OF DRAINAGE UNITS (CDU) chamber"; with
● Description Indications for use Standard CDU Drainage of ● 2cm of water acting as a one-way valve, allowing drainage
pleural cavity for air or any type of fluid with or without the out but preventing backflow. 3rd chamber: "controlled
use of suction suction":
● Up to 2,000mL capacity Replaced when full ● Type 1-Continuous wall suction unit Type 2-Water-seal unit
("no wall suction")
INDICATIONS ● Type 2-Water-seal unit (“no wall suction”)

● Following surgery that impacts on the continuity of the TYPES OF CHEST TUBE DRAINAGE UNITS
thoracic cavity (e.g., thoracic, cardiac, esophageal surgery) ● Small-size chest tube or pigtail catheter (smaller ☐ than
● Pneumothorax standard 14Fr)
● Hemothorax ● Can be irrigated if occluded by health care provider
● Pleural effusion ● Less traumatic
● Pleurodesis ● Pneumothorax
● Chronic drainage of fluid
WHAT IS A CHEST DRAINAGE UNITS (CDU) ● Not for trauma or blood
● Most commonly used chest ● Can be used for pleurodesis
● Drainage units use the water seal principle. (e.g. Pleur Evac)
● Continuous wall suction unit HEIMLICH VALVE
● Water-sealed unit ("no wall- suction") ● One-way "flutter valve"
● Removes air as patient exhales
This system: ● Valve opens when pleural space pressure is greater than
● collects drainage atmospheric pressure & closes when the reverse occurs
● creates a water seal ● Evacuates air from the pleural space
● controls suction ● Used for emergency transport, homecare, and long-term
● allows air and fluid to escape from the pleural cavity but care units.
doesn't allow air to re-enter to restore negative pressure
PROCEDURES

Preparatory Phase

1. Determine whether informed consent has been signed.

Check the consent form signed by the patient. Written
permission for chest tube insertion is required, as this is
an invasive procedure
2. Set-up the prescribed Open system. Check the equipment
needed, manufacturer's guidelines when Physician is ready
to insert the chest tube. Premature opening of the sterile

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 chest drainage system increases risk of contamination Assessment
of sterile equipment
a. while maintaining sterility of the drainage tubing 12. Assessment after chest-tube is done every 15 mins for the
add sterile water or NS to the appropriate first 2 hrs. Permits timely and efficient account of the
compartment. Reduce possibility of amount of drainage from the chest tube chest tube are
contamination clamped under specific circumstances
● For a 2 chamber system (without suction) 13. Provide two rubber- tipped hemostat for each tube; hemostat
- Add sterile solution to the water seal chamber (2nd are usually attached to the bottom of the clients bed with
chamber), bringing fluid to the required level as indicated. adhesive tape.
Maintain water seal. ● To assess for an air leak.
● For 3 chamber system( with suction) ● To Empty or change the collection bottle or change
- Add sterile solution to the water- seal chamber (2nd the chamber.
chamber) Add amount of sterile solution prescribed by ● To change disposable system
Physician to the suction control(3rd Chamber) Usually 14. Assist clients in a comfortable position. Reduce client’s
20cm.Connect tubing from suction control chamber to anxiety and promote comfort.
Suction source. Depth fluid level dictates the highest 15. Wash hands. For your safety
amount of negative pressure that can be present within
the system (ex. 20 cm of water = 20cm of water NURSING ROLES AND RESPONSIBILITIES: HOW TO MANAGE
pressure) *safety device prevents damage to pleural A PATIENT WITH A CHEST TUBE DRAINAGE
tissue from an unexpected surge of negative pressure
from the suction source
INITIAL ASSESSMENT:
3. tape all connections with 1 inch tape. Prevent atmospheric
air from leaking in to the system and the client's
intrapleural space ● Assess patient's clinical status and vital signs. Encourage
the patient to report breathing difficulty immediately.
Performance phase ● Check the rate and the quality of the patient's respirations
Auscultate breath sounds EVERY shift.
● Diminished or absent breathe sounds may indicate that the
4. Wash hands and apply gloves.Reduces transmission of
lung has not yet re-expanded.
microorganism
● Observe and immediately report signs of rapid, shallow
breathing.
Medication administration
● cyanosis, pressure in the chest subcutaneous emphysema
or symptoms of hemorrhage
5. Administration premedication, as ordered. Reduced client
anxiety and pain during procedure Second: CHECK the Drainage Unit
Assisting the Physician
● Do an initial assessment of the drainage unit.
● Check the suction control dial to ensure that it is in the
6. Assist physician attached drainage tube to chest tube. correct setting. If the suction is ordered, check to see if the
Connect drainage system and suction to the chest tube orange float appears in the suction indicator window.
● Make sure that the drainage unit is balanced and stabilized
Secure chest tube to drainage around the patient
7. Tape the tube connection between the chest and drainage Third: Check the connections
tubes. Secure chest tube to drainage system and
reduces the risk of air leaks causing breaks in the
● Check the tube connections periodicallyMake sure all tube
airtight system
connections are sealed air tight and secured.
● Tape, if necessaryThe tube should be as straight as possible
Check patency
and coiled below level of chest without dependent loops.
● Make sure the tubing does not loop or interfere with the
8. Check patency of air vents in system. Water Seal vent must
movement of the patient
not be occluded.* Permits the displaced air to pass into
the att Suction control chamber vent must not be
FOURTH: Check for fluctuations
occluded when suction is used. Provide a safety factor
of releasing excess negative pressure into the
atmosphere. ● In a continuous wall suction, the unit is connected to a
suction source and gentle bubbling will be heard.
Secure safety pin/ system clamp ● Check for fluctuation in the water-seal chamber as the
patient breathes.
9. Coil excess tubing on mattress next to the client. Secure with ● Normal fluctuations of 5-10 cm reflect pressure changes in
a rubber band and safety pin or the system clamp. Prevent the pleural space during respiration
excess tubing from hanging over the edge of the
mattress in a dependent loop. Drainage could collect in FIFTH: For bubbling
the loop and occlude drainage system
● If excessive bubbling is present in the water-seal chamber,
Adjust tubing to hang in straight line especially if suction is being used, rule out a leak in the
drainage system.
10. Adjust tubing to hang in straight line from the chest tube to
the drainage chamber. Promotes drainage and prevent SIXTH: The drainage
fluid or blood from accumulating in the pleural cavity
● NOTE: Character, consistency, and amount of drainage.
Indicate the date and time Mark the date and time of the original fluid level, then every
shift on the CDU.
11. If the chest tube is draining fluid indicate the date and time ● Don't forget to chart on the nurse's notes and I/O flowsheet
that drainage begun. Provide a baseline for continuous every shift.
assessment of the type and quantity of drainage ● NEVER leave a chest tube clamped for more than a minute.
● DO NOT clamp chest tubes of neonates who are on positive
pressure ventilation.

BSN-4C 5
SEVENTH: Range of motion

● Put the arm and shoulder of the affected side through ROM
exercises several times dailySome pain medication may be
necessary.
● Encourage the patient to assume a position of comfort.
● Encourage good body alignment.
● Encourage the patient to change position frequently

EIGHTH: The dressing

● Check the chest tube dressing at least every 8 hours

● Palpate the area surrounding the dressing for crepitus or
subcutaneous emphysema which indicates that air is leaking
into the subcutaneous tissue surrounding the insertion site.
● Change the chest tube dressing as ordered or when
necessary

NINTH: Chest tube WHAT IS T-TUBE?

● a tubular device in the shape of a T, inserted through the
● If the chest tube gets dislodged, do not push tubes back into skin into a cavity or a wound and used for drainage
the patient. To prevent air from being sucked into the
pleural cavity.
● Apply a sterile pressure dressing and notify immediately MD.

TENTH: Check the order

NURSING
NURSING CARE FOR PATIENTS WITH A CHEST TUBE
INCLUDES ASSESSMENT OF THE CHEST TUBE SITE

● To prevent dislodgement and infection management of

effective suction and drainage
● Pain relief
● Monitoring the respiratory status and;
● Providing overall supportive care.

CARING FOR T TUBE (BILIARY DRAINAGE)

INDICATIONS OF T-TUBE?
● An external port that is placed into the common bile duct and
extends to the outside of the body. The port is an easy
access to allow for drainage of bile and stones from the bile
duct and for injecting contrast to view the ducts.
○ injecting contrast helps to have direct visualization
of the bile duct

TWO TYPES OF VISUALIZATION:

1. Choledoscopy - direct visualization of bile duct (diagnostic);
done in OR; procedure that can be used to dissolve gallstones
that have been retained once visualized (intervention)
2. Cholangiogram - done in XRAY dept; x-ray of the bile duct with
the use of contrast medium (not a direct visualization since its thru
x-ray)
● common to patients that undergone; laparoscopic surgeries - procedure used to pull out t-tube when patient is up and
● Other term: Biliary drainage = common bile duct - produced about (the patient is ok)
in the liver and stored in gallbladder - same with cholangioscopy = injecting dye
● T-Tube is also called biliary drainage tube, placed in the
common bile duct after cholecystectomy or
choledochostomy. The tube facilitates biliary drainage during
healing. The surgeon inserts the short end (crossbar) into
the common bile duct and draws the long end through an
incision in the skin. The tube is then connected to a closed
gravity drainage system. Post operatively it remains in
place between 7 to 14 days.
○ in the first 24 hrs of surgery, normally there will be
300-500ml of bile drainage but it should progress
to normal after 1 day
○ normal daily bile drainage: should decrease less
than 300-500ml (yellowish, greenish and brown)
once 24hrs has passed
○ patients can take a bath with t-tube as long as
covered (with tegaderm patch)

BSN-4C 6
 12. Carefully measure and note the characteristics of the drainage.
Discard the drainage appropriately. To ensure proper recording
and reporting observation and findings to physician.
● note the rate, amount, and type of drainage
● drainage can be discarded in the toilet bowl
13. Remove gloves and Wash hands. Reduces transmission of
microorganisms and protects staff from infections

Cleaning the Drain Site:

1. Put on clean gloves. Check the position of the drain or drains

before removing the dressing.
2. Gently remove the soiled dressings. Use small amounts of
sterile saline to help loosen and remove dressing that sticks
to the underlying skin. Do not reach over the drain site.
3. Note the presence, amount, type, color, and odor of any drainage
on the dressings. Place soiled dressings in the appropriate waste
receptacle.
4. Remove gloves and dispose of appropriately
5. Inspect the drain site for appearance and drainage. Assess if any
pain is present.
COMPLICATIONS OF T-TUBE 6. Using sterile technique, prepare a sterile work area and open the
needed supplies.
1. infection
7. Open the sterile cleaning solution. Pour the cleansing solution into
2. dislodgement (can lead to severe abdominal pain)
the basin. Add the gauze
3. leaking of bile
8. Put on sterile gloves.
9. Cleanse the drain site with the cleaning solution. Use the forceps
EQUIPMENT and the moistened gauze or cotton-tipped applicators. Start at
● Graduated collection container the drain insertion site, moving in a circular motion toward the
● Small plastic bag - wound care periphery. Use each gauze sponge only once. Discard and use
● Sterile gloves and clean gloves - sterile for wound care, new gauze if additional cleansing is needed.
clean gloves for draining ○ clean from innermost (cleanest) to the outermost (most
● Clamp - for wound cleaning contaminated)
● Sterile 4x4 gauze pads - cover incision site ○ after using from inner to outer, discard and repeat using
● Transparent dressings (tegaderm) another gauze sponge
● Rubber band ○ at least 2-3 times of cleaning
● Normal saline solution - for cleaning 10. Dry with new sterile gauze in the same manner. Apply skin
● Sterile cleaning solution - betadine protectant to the skin around the drain; extend out to include the
● Two sterile basins area of skin that will be taped.
● Povidone - iodine pads - cleaning wound site 11. Place a pre split drain sponge under the drain. Apply gauze pads
● Sterile precut drain dressings over the drain.
● Hypoallergenic paper tape (micropore) ○ pat dry using a new sterile gauze
● Skin protectant ○ Secure the dressings with tape as needed. Alternatively,
before removing gloves, place a transparent dressing over
the tube and insertion site. Be careful not to kink the tubing.
PROCEDURE 12. Label dressing with date and time. Remove all remaining
equipment; place the patient in a comfortable position
1. Check the Doctor's order for wound care. Ensures correct
○ promotes sense of well-being
procedure is performed to correct patient.
13. Remove gloves. Wash hands
2. Gather the necessary supplies and bring to the bedside stand or
14. Check drain status at least every four hours.
overbed table. Saves time, energy, and effort.
○ Check every 4 hours or at least twice a shift.
3. Wash hands. Reduces transmission of microorganisms
4. Identify the client. Ensures correct administration procedure
5. Provide Privacy by closing room door. Provides sense of well JACKSON-PRATT DRAIN
being and prevent unnecessary embarrassment
6. Explain the procedure to client. Promotes clients cooperation. ● A closed system drain that uses bulb suction to prevent
7. Place a waste receptacle near the working area. Ensures easy wound drainage from collecting around the surgical site. The
disposal of soiled materials. benefits
8. Assist the patient to a comfortable position that provides easy
access to the drain and/or wound area. Semi-fowler’s position.
Promotes client’s comfort and reduces strain to the nurse.
Place a waterproof pad under the wound site.

Emptying drainage:

9. Put on clean gloves; put on mask or face shield if necessary.

● to prevent possible contact of spilling from the
drain
10. Open a gauze pad, making a sterile field with the outer wrapper.
11. Place the collection container under the outlet valve of the
drainage bag. Without touching the outlet, pull the cap off and
empty the bag‘s contents completely into the container. Use the
gauze to wipe the outlet, and replace the cap. Permits measuring
and discarding of wound drainage. Reduces transmission of
microorganisms into drainage evacuation.
● before recapping use 4 by 4 gauze to wipe the
outlet

BSN-4C 7
 10. Place the graduated collection under the outlet of the drain.
Without contaminating the outlet valve, pull the cap off. The
chamber will expand completely as it draws in air. Empty the
chamber's contents completely into the container. Use the
gauze pad to clean the outlet. Fully compress the chamber
with one hand and replace the cap with your other hand.
Empty drainage and re-established vacuum.
→ complete emptying
→ no air should enter; air leads to crepitus and emphysema

11. Check the patency of the equipment. Make sure the tubing is
free from twists and kinks.
12. Secure the Jackson-Pratt drain to the patient’;s gown below
the wound with a safety pin, making sure that there is no
tension on the tubing. vPinning drainage tubing to client’s
gown will prevent tension or pulling and insertion site.
13. carefully measure and record the character color and
amount of the drainage. discard the drainage according to
facility policy. Remove gloves

PURPOSE
● To prevent fluid (blood or other) build-up in a closed space,
which may cause disruption of the wound and the healing
process or become an infected abscess
● To evacuate an internal abscess before surgery when an
infection already exists.

14. Put on clean gloves. If the drain site has a dressing, redress
the site. Include cleaning of the sutures with the gauze pad
moistened with normal saline. Dry sutures with gauze before
applying new dressing.
15. If the drain site is open to air, observe the sutures that
secure the drain to the skin. Look for signs of pulling, tearing,
swelling, or infection of the surrounding skin. Gently clean
normal and expected after surgery
the sutures with the gauze pad moistened with normal
saline. Dry with a new gauze pad. Apply skin protectant to
PROCEDURE the surrounding skin if needed.
1. Check doctor’s order for wound care 16. Remove and discard gloves. Remove all remaining
2. Gather the necessary supplies and bring to the bedside equipment; place the patient in a comfortable position, with
stand or overbed table side rails up and bed in lowest position.
3. Wash hands 17. Remove gloves. Wash hands.
4. Identify the client 18. Check drain status at least every four hours.
5. Provide privacy - drain at 50 ml to avoid pulling at insertion site.
6. explain the procedure to client Record at I&O
7. Place a waste receptacle near the working area
8. Assist the patient to a comfortable position that provides
easy access to the drain and/or wound area. Place a
waterproof pad under the wound site.
9. put on clean gloves; put on mask or face shield if necessary
○ Personal protective equipment reduces the
transmission of microorganisms and protects
against an accidental body fluid exposure.

BSN-4C 8
 PENROSE DRAIN 24. Document. Check all wound dressings every shift

A Penrose drain is named after American gynecologist Dr. Charles

Bingham Penrose, it is a surgical drain which is left in place after a WEEK 4 - OUTLINE
procedure to allow the site of the surgery to drain. I. IV Therapy
A. Description
B. Clinical Skills
C. Procedure
D. 12 Rs Of Medication Administration (Dear
Pt Red)
E. Information As Legal Protection
F. Label The Iv Solution
G. Documentation
H. Infection Control
I. Materials
J. Consideration
K. Site Of Iv Insertion
L. Potential Complications Of Peripheral Iv
Therapy
PURPOSE M. Initiate Peripheral Venous Access
● To promoting drainage of blood, lymph, and other fluids N. (Handbook Based - Pg 87)
● Helps reduce the risk of infection II. Purpose
● Keeps the patient more comfortable III. IV Changing
IV. IV Discontinuing
PROCEDURE
1. Check the Doctor's order for wound care. INTRAVENOUS THERAPY (ANSAP BASE)
2. Gather the necessary supplies and bring to the bedside
stand or overbed table. ANSAP BASE - an organization where nurses go through a 3-day
3. Wash hands seminar regarding IV insertion. A Certificate and an ID will be given
4. Identify the client and explain the procedure after the seminar.
5. Provide privacy ● Association of Nursing Service Administrators of the
6. Place a waste receptacle near the working area Philippines (ANSAP)
7. Assist the patient to a comfortable position that provides
easy access to the drain and/or wound area. Place a Objective
waterproof pad under the wound site. - At the end of the lecture/demonstration,. the students will be
a. Waterproof pad prevents scattering of the drains in able to understand the principles behind IV therapy and be
the bedsheet. able to completely perform the procedure.
8. Put on clean gloves; put on mask or face shield if necessary
9. Check the position of the drain or drains before removing the IV THERAPY
dressing. Carefully and gently remove the soiled dressings. If
any part of the dressing sticks to the underlying skin, use ● A method of supplying fluids directly into the intravascular
small amounts of sterile saline to help loosen and remove fluids compartment thereby replacing electrolyte loses.
10. Note the presence, amount, type, color, and odor of any ● Insertion of a needle or a catheter/cannula into a vein, based
drainage on the dressings. on the physician’s written prescription/order
11. Place soiled dressings in the appropriate waste receptacle ○ there should be a written prescription from the
12. Inspect the drain site for appearance and drainage. Assess if physician in order to start iv therapy
any pain is present. Role Definition: the IV nurses are RN’s committed to ensure the
13. Using sterile technique, prepare a sterile work area and open safety of all patients receiving IVT
the needed supplies. (IVT → an invasive procedure → pain → needs training)
14. Open the sterile cleaning solution. Pour the cleansing
solution into the basin. Add the gauze sponges.
→ sterile cleaning solution: soapy water / normal saline /
DESCRIPTION OF PRACTICE
hydrogen peroxide / povidone-iodine

15. Put on sterile gloves. 1. Ethico Legal implications ANSAP. Inc upholds quality nursing
16. practice and is going to continue with the IV training for the
17. Cleanse the drain site with the cleaning solution. Use the following reasons:
forceps and the moistened gauze or cotton-tipped 1.1. Nursing curriculum does not provide in-depth training in
applicators. Start at the drain insertion site, moving in a parenteral IV drug administrations.
circular motion toward the periphery. Use each gauze 1.2. The nurse administrator has the common responsibility for
sponge or applicator only once. Discard and use new gauze the whole nursing practice in the health care facility
if additional cleansing is needed. ■ Nurse administrators (e.x): Dean of school of
18. Dry the skin with a new gauze pad in the same manner. nursing
Place a pre-split drain sponge under the drain. Closely ■ Violation against ANSAP
observe the safety pin in the drain. If the pin or drain is 1.3. Globally, the IVT certification is a mandatory requirement
crusted, replace the pin with a new sterile pin. Take care not for the nurse practitioner.
to dislodge the drain. Pin prevents drain from being pulled 1.4. IVT is voluntary; Only those nurses who are adequately
below the skin‟s surface. trained and have completed the training requirements in
19. Apply gauze pads over the drain. Apply Abdominal pads the IVT program for nurses as prescribed by ANSAP will
over the gauze be issued an IV Certificate of training and IVT card of
20. Remove and discard gloves. Apply tape, Montgomery straps, ANSAP.
or roller gauze to secure the dressings. 2. Basis of Practice
21. After securing the dressing, label dressing with date and 2.1. Legal therapeutic prescription of a licensed physician
time. 2.2. Through knowledge of the vascular system,
22. Remove all remaining equipment; place the patient in a interrelatedness of the body system with proficiency in the
comfortable position. skill of IV therapy.
23. Remove gloves. Wash hands 2.3. Recognition of holistic approach to patient care.

BSN-4C 9
 2.4. Collaboration with members of the health care team ○ check medical condition, check the vein before
2.5. Networking and linkages with external environments. choosing the right IV cannula
2.6. Individual professional accountability. ● Date and time of insertion
2.7. Utilization of the nursing process. ○ To know when to change IV cannula
● Name of person who inserted the IV catheter.
CLINICAL SKILLS
● The IVT nurses shall be proficient and competent in all LABEL THE IV SOLUTION
clinical aspects of the IVT.
● Type of Fluid
PROCEDURES ● Medication additives and flow rate
● Electronic infusion device
A. Carry out doctor’s order for IVT ○ KCl - must be accurate
● Check what type of solution is ordered: ● Duration of therapy and nurse signature
isotonic, hypotonic, or hypertonic
● Route of administration DOCUMENTATION
● Dose of Medication
● What solution is compatible with the ordered ● Location and condition of insertion site
medication ● Complications, patients response and nursing interventions
● Duration (time) and Rate of infusion (flow rate) ○ Infiltration - px will complain coldness at the
○ DROP FACTOR: insertion site
○ Macroset - 10, 15, 20 (commonly 20) ○ Hematoma - hot compress
○ Microset - 60 ● Patient teaching and evidence of patient understanding
B. Perform peripheral venipuncture instructions
● Distal down to the arm ● Signature of the nurse
C. Based on the doctor’s order, prepare, initiate, and terminate
IVT INFECTION CONTROL
D. Determine solution and medication incompatibilities
● KCl + Hypertonic Solution (High concentration
● Wash hands
containing electrolytes) = Complications or Shifting
● Use antiseptic for cleaning patient’s skin
interstitial and intercellular of our blood stream
○ 70% alcohol is usually used in clinics
● KCL + PNSS = Good Dilution
● Clip hair in venipuncture site
● DIclofenac Sodium (analgesic) + PNSS = Good
○ Needs consent
Dilution
○ If not permitted, it could either cause dislodgement
● Depending on the doctor’s order (strictly comply)
brought by unsecure tape or difficulty in locating
E. Change of IV site, tubings, dressings according to IVT
vein access.
standards
● Do not reuse a catheter or needle
● Following infection control: IV Set is only allowed
until 72 hours. After that, it needs to be changed.
MATERIALS
F. Establish flow rates of solutions, medications, blood, and
blood components as prescribed
● Packed RBC every four hours ● IV cannula/Catheter – the larger the gauge number, smaller
G. Proficient technical ability in the use, care, maintenance, and the diameter of the shaft
evaluation of IV equipment ● IV Starter pack
H. Nursing management of patients receiving IV therapy and ● IV extension set
peripheral/central/parenteral nutrition in various setups. ● IV pole
● Stop the infusion then remove the cannula ● Posiflush
● Pag namamaga/swollen = Cold / Hot Compress ● Splint
I. Adherence to established infection control practices ● IV solutions
● Follow the policy of infection control after ● IV tubing
procedure
● After care - all sharp objects in proper waste bins
J. Observation and assessment of all adverse reactions.
K. Appropriate documentation relevant to the preparation,
administration, termination of all forms of IVT
● After rendering care, proper documentation must
be done
● Assess for the IV Order status: Continue or
Discontinue
● Document in the IV forms the number of bottles
and date and time

12 Rs OF MEDICATION ADMINISTRATION (DEAR PT RED)

1. Documentation
2. Evaluation
3. Assessment
4. Reason
5. Patient
6. Time GAUGE INDICATION
7. Route; refuse (Smallest to Biggest Diameter)
8. Expiration date ; education
9. Drug;dose 26 G - VIOLET For Neonates
INFORMATION AS LEGAL PROTECTION
24 G - YELLOW Pedia and older adults
● Size, type and length of iv cannula

BSN-4C 10
 ➢ Avoid Further use of vein
22 G - BLUE For Children, and older adults ➢ Restart in another vein

20 G - PINK For Adults: rapid fluid replacement, trauma, or

routine blood transfusion

18 G - GREEN rapid fluid/blood replacement, trauma

16 G - GRAY all rapid treatment; Fluid resuscitation

14 G - ORANGE Trauma; Surgical procedures

CONSIDERATION 3. CIRCULATORY OVERLOAD

● Condition cause when a large volume of fluid is infused
IN THE SELECTION OF THE SITE ● Causes: flow rate exceeds cardiovascular system’s
● Select a vein large enough to accommodate the needle that capability to adjust to the increased fluid volume
will be used ➢ check the fluid volume + rate of infusion
● Type of Solution ● Signs and symptoms: dyspnea, crackles, distended
● Client’s age neck veins, increased blood pressure
● Note for the following like patient comfort and mobility, other ● Prevention:
medical conditions, viscosity and content of the solution ● Nursing Consideration :
● An IV should not be inserted in the joints ➢ slow the rate of infusion to KVO
★ KVO rate: 30 cc/hr
SITE OF IV INSERTION ➢ notify physician
★ to troubleshoot immediately (VITAL)
● Dorsal metacarpal, cephalic, basilic, radial median cubital, ➢ monitor vital signs
accessory cephalic vein
4. HEMATOMA
● Collection of blood outside of blood vessels
● Causes: injury to the wall of blood vessel, promoting
blood to seep out of the blood vessel into the surrounding
tissues
● Signs and Symptoms: ecchymosis, swelling, resistance
to flush, inability to advance catheter
● Nursing Considerations:
➢ Remove catheter
➢ Apply 2x2 Gauze Pressure
➢ Elevate Extremities (For proper Circulation)

5. THROMBOSIS
POTENTIAL COMPLICATIONS OF PERIPHERAL IV THERAPY
● inflammation of the vein with clot formation and danger
of embolism
1. INFILTRATION / EXTRAVASATION ● Causes:
● Escape of fluid into the subcutaneous tissue ➢ slowed/stopped infusion.
● Causes: dislodged needle, penetrated vessel wall ➢ Inability to flush catheter
● Signs and symptoms: swelling, pallor, coldness of ● Signs and Symptoms : swelling
skin site, edema, (-) backflow of the blood, pain around ➢ masyado makulit si px, lagi tinataas yung kamay
the infusions site, significant on flow rate ● Nursing Consideration:
● Prevention: ➢ Discontinue IVF
➢ Stabilize catheter ➢ Cold compress over IV site
➢ Place Catheter in appropriate site ➢ Assess for circulatory impairment
➢ Avoid ante cubital fossa site
● Nursing considerations
➢ Check the infusion site often for symptoms
➢ Discontinue IV infusion if symptoms occur
★ For Presence of leakage = Discontinue
➢ Restart IV infusion at a different site
➢ Limit movement of the extremity with IV
★ Place an arm splint to limit motion and
secure IV in place.
2. PHLEBITIS
● Inflammation of a vein
● Causes: mechanical trauma from needle or catheter /
chemical trauma from solution septic
● Signs and symptoms: redness at the site, site warm to
touch, local swelling, sluggish infusion (slow drop flow) ,
and pain
6. INFECTION
➢ sa Infiltration - malamig
● Cause: not following infection control policy
➢ sa Phlebitis - mainit and may localized na
➢ hindi nag palit ng cannula, hindi nag gloves
pamamaga (sa site lang)
● Signs and symptoms: Fever, swelling, discharge at IV
● Nursing considerations:
insertion site
➢ Discontinue IV
● Nursing Consideration
➢ Apply Warm Compress
➢ Use aseptic technique when starting an infusion

BSN-4C 11
 ➢ change the dressing regularly 5. Apply a tourniquet 3 to 4 inches above the venipuncture.
➢ do handwashing Tourniquet impedes venous return but should not occlude arterial
flow.
7. AIR EMBOLISM ● Close-open fist to dilate vein
● A bubble that becomes trapped in a blood vessel and ● massage/rub from distal to proximal to dilate the vein
blocks it 6. Ask the client to open and close the fist Muscle contraction
● Cause: 20-50 ml of air rapidly infused increases the amount of blood in the extremity. Observe and
● Signs and symptoms: lightheadedness, dyspnea, palpate for a suitable vein.
cyanosis, tachypnea, expiratory wheezes, cough, ● Try the following techniques if a vein cannot be felt:
murmur, chest pain, hypotension, changes in mental ○ Massage the patient‘s arm from proximal to distal end
status, coma and gently tap over intended vein. Increased the
● Nursing Consideration: volume of blood in the vein at the venipuncture site.
➢ call for help, ○ Remove tourniquet and place warm, moist
➢ place client in Trendelenberg position, compresses over intended vein for 10 to 15 minutes.
➢ Monitor vital signs Increases blood supply and foster venous dilation.
➢ O2 administration ★ Form of contraction for thin veins and cold
➢ Notify doctor environment
★ Usage of Gravity to flow towards hand.
8. SPEED SHOCK ○ Light tapping over a vein. May help to foster venous
● Sudden adverse physiological reaction to IV medication dilation.
that is administered too quickly. 7. Cleanse site with an antiseptic solution using a back and forth
● Cause: IV medication administered too quickly friction scrub for at least 30 seconds. Do not wipe or blot. Allow to
● Signs and symptoms: dizziness, facial flushing, dry completely. Drying prevents chemical reactions between
headache, chest pain, hypotension, irregular pulse, agents and allows time for maximum microbicidal activity of
progression of shock agents.
● Nursing Action: Get resuscitation medicine ● antiseptic solution - alcohol swab (back and forth or circular
motion - from inner to outer)
INITIATE PERIPHERAL VENOUS ACCESS 8. Use the nondominant hand, placed about 1 or 2 inches below the
(HANDBOOK based - Pg 87) entry site, to hold the skin taut against the vein. Avoid touching
the prepared site. Ask the patient to remain still while performing
1. Place patient in low Fowler‘s position in bed. Place protective the venipuncture. Stabilizes vein for needle insertion.
towel or pad under patient‘s arm. Prevents soiling of bed. ● non dominant hand will hold the cannula
● ask the patient their preference kung saan ilalagay yung IV ● use dominant hand to hold and insert the catheter
● low fowler’s or lying position with head elevated to 45 9. Enter the skin gently, holding the catheter by the hub in your
degrees dominant hand, bevel side up, at a 10 to 15 degree angle. Insert
2. If long extension tubing is used, remove protective cap and the catheter from directly over the vein or from the side of the
attached to distal end of IV tubing, prime extension tubing. vein. While following the course of the vein, advance the needle
● if gagamit ng extension tubing, prime the tubing as well or catheter into the vein. When blood returns through the lumen of
● use of trifuse the needle or the flashback chamber of the catheter, advance
● prime the extension tubing using a saline either device into the vein until the hub is at the venipuncture site.
3. Select and palpate for an appropriate vein. Select distal site in Increased venous pressure from tourniquet increases bloodflow of
nondominant arm if possible. Venipuncture should be performed blood into catheter. Reinsertion of the stylet can cause catheter
distal to proximal, which increases the availability of other sites for breakage in the vein.
future IV therapy.
● how to choose appropriate vein? vein that is visible,
straight, palpable, and large
● In the non-dominant hand

● better if may backflow → nakapasok sa vein

● No backflow → Adjust placement / Locate another vein
● NO PHISHING : wag in and out sa pagpasok kasi possible
ma-damage yung vein
10. When blood returns through the lumen of the needle or the
flashback chamber of the catheter, advance either device into the
vein until the hub is at the venipuncture site.
● Blood return → Pull back needle
11. Stabilized catheter with nondominant hand, release tourniquet
with the other hand. Permits venous flow, reduces blood flow of
blood and allows connection with the administration set with
minimal blood loss.
● Sometimes we apply tape to secure on the wings of cannula
while holding the end of the catheter to apply pressure
(prevent blood leakage)
12. Connect luer-lock end of set to end of catheter. Secure
connection. Prompt connection of infusion set maintains patency
of vein and prevents risk of exposure to blood.
kakalalat yung blood kapag hindi na-connect agad
13. Flush primed extension set, begin infusion by opening clamp or
4. Apply gloves. Decreases exposure to blood-borne organisms. adjusting roller clamp of IV tubing.
● Clean gloves for infection control ● make sure the tubing has no presence of bubbles
● Prior, do handwashing

BSN-4C 12
 14. Loop the tubing near the site of entry, and anchor with tape ● Peripheral IV access should not be used for administration of
(nonallergenic) close to the site. Prevents accidental removal of medications that are irritants or vesicants.
catheter from vein. Prevents back and forth motion, which can ○ kasi there are some medications that can’t pass
irritate the vein and introduce bacteria on the skin into the vein. through the iv access since it can cause irritation

EQUIPMENT
● Correct IV solution
● Administration set
○ microset - may needle sa drip chamber (60 drop
factor)
■ used for pediatric and geriatric patients
○ macroset - no needle (15 or 20 drop factor)
■ 1 macrodrop = 4 microdrops
● Extension tubing
● Alcohol
● Disposable gloves
● Tourniquet
15. Secure catheter and apply appropriate sterile dressing over site ● Arm board
properly. Occlusive dressing protects site from bacterial ● Non-allergic tape
contamination. ● IV pole
16. Set the flow rate and begin the fluid infusion. Adjust until the ● Sharps container
correct drop rate is achieved. Assess the flow of the solution and ● Sterile gauze sponge
function of the infusion device. Inspect the insertion site for signs ● Transparent dressing
of infiltration. Maintains correct rate of flow for IV solution. ● Tag / time tape
● Assess for leakages and any complication to insertion site.
17. Remove equipment and return the patient to a position of comfort. IV SOLUTIONS
Enhances well-being
18. Remove gloves and wash hands. Reduces transmission of
microorganisms and protects staff from infections and injury.
sharp container itapon yung needles
needle prick injury is very common
19. BONUS: Document procedure such as time of insertion,date,
possible complications observed, etc.

PURPOSE
● To supply the body with fluids when the patient is unable to
take adequate amounts by mouth.
● To maintain the fluids and electrolytes balance of the body. - IV solutions are color coded
● To provide water-soluble vitamins and medications.
● To provide IV access for intermittent or rapidly needed Solution should be sterile and in proper condition
emergency medications. ● check expiration date
● there should be no particulate matter in the solution
CONSIDERATIONS ● check for any leaks indicative of contamination
● Peripheral IV access should be changed every 48 to 72
hours.‘ ADMINISTRATION SET
○ sa tubing put a label kung kailan nag-start ang iv 1. Macrodrip or macroset
○ change the set since it could be the source of ● (10, 15, 20 drops/ml of solution)
infection 2. Microdrip or microset
● (60 drops/ml of solution)
a. insertion spike - inserted into the solution container
and kept sterile
b. Drip Chamber - to prevent air from entering the
line
c. roller or screw clamp - to control the rate of flow of
the solution
i. kapag tinaas - bibilis
ii. kapag binaba- babagal
● No more than 3 attempts at initiating the IV access should be
iii. need to adjust the rate based on the
made by a single nurse.
doctor’s order
○ look for another nurse/anesthesiologist if hindi
d. Tubing
talaga kaya
e. Protective cap - maintains the sterility of the end of
● Vigorous friction and multiple tapping of veins, especially in
the tubing so that it can be attached to a sterile
older adults, may cause hematoma and/or venous
needle inserter in the client’s vein.
constriction.
f. Needle adapter
○ you have to avoid vigorous friction and multiple
3. Volume
tapping
● control set or Soluset
● Do not shave area. Shaving may cause microabrasions and
● used to incorporate medication
can predispose client to infection.
i. e.g → piptaz (Piperacillin/ Tazobactam).
○ pick an area with a lesser hair
antibiotics, mannitol
● Instruct client about signs and symptoms of infiltration,
● either 100 ml or 120 ml
phlebitis and inflammation. Client can report early onset to
nurse.
4. IV POLES
○ give health teaching.
● the higher the solution container is suspended, the
greater the force of the solution as it enters the
client and the faster the rate of the flow

BSN-4C 13
 5. Intravenous needle or catheter 6. Open and disinfect rubber port of IV solution to follow.
● catheter or Angiocatheter Permits quick, smooth and organized change from old to
● the larger the gauge number, the smaller the new solution.
diameter of the shaft 7. Lift empty container off IV pole and invert it. Quickly remove
the spike from the old IV container, being careful not to
contaminate it. Discard old IV container. Reduces risk of
solution in drip chamber running dry and maintains sterility.
8. Using a twisting and pushing motion, insert the
administration set spike into the entry site of the IV container.
Hang the container on the IV pole. Allows gravity to assist
with delivery of fluid into drip chamber.
9. If using gravity infusion, slowly open the roller clamp on the
administration set and count the drops. Adjust until the
correct drop rate is achieved. Maintains measure to restore
fluid balance and deliver IV fluid as ordered.
10. Discard all waste materials. Reduces risk of infection.
● iv tubing - yellow bin (infectious waste)
● needles - sharps container

DISCONTINUING IV INFUSION
1. Verify written Doctor‘s order to discontinue IV. Order is
required for procedure.
2. Prepare necessary materials. Ensure smooth flow of
green - used for patients who are for surgery. procedure
adult - 20, 22 ; pediatric - 24 ; OR - 20 ; usual 18 3. Wash hands. Reduces transmission of microorganisms.
4. Inform the client about the order Ensures cooperation during
IV TRAY the procedure.
● Sterile swabs 5. Moisten adhesive tapes around the IV catheter with
● Antiseptic solution cottonballs and alcohol. Exposes needle or catheter with
● Plaster minimal discomfort.
● Tourniquet ● moisten para mas mabilis tanggalin
● Splint - usually used for pediatric patients since makukulit 6. Close IV clamp of IV tubing and remove plaster gently.
sila Prevents spillage of IV fluid.
● Local anesthetic - minsan optional 7. Without applying pressure pull IV cannula then apply
● Sterile 2x2 gauze squares pressure with cottonballs and tape, or apply dressing if
indicated. Prevents damage to client‟s vein. Controls
bleeding and hematoma formation.
8. Inspect catheter for completeness. Determines if catheter tip
is intact.
9. Discard all waste materials appropriately. Reduce
transmission of microorganisms.
10. Document
● IV fluid sheet - ilalagay kung anong oras tinanggal
at pinalit yung iv
● kung nag-palit, ilagay kung pang-ilan bottle na

IV THERAPY COMPLICATIONS

LOCAL SYSTEMIC

The initiation of iv therapy is upon the prescription of a licensed Infiltration Embolism

physician which is check for the:
● type of solution Phlebitis Hematoma
● flow rate
● amount of solution Thrombophlebitis Systemic infection
● dose and frequency of medicine to be incorporated
Extravasation Circulatory overload
IV CHANGING
1. Verify Doctor‘s order. Countercheck IV label, IV card, bottle
Allergic reaction
number , bottle sequence, type, amount, additives (if any),
and duration of infusion. Ensures that correct solution will be
used.
2. Prepare necessary materials. To facilitate smooth flow of
procedure
3. Wash hands. Reduces transmission of microorganisms.
4. Explain procedure to client Decreases anxiety and promotes
cooperation and assess IV site for redness, swelling and
pain. Pain or burning may be early indications of
phlebitis.check if right patient pa ba ang papalitan ng iv
● check the iv site when changing
5. Check sterility and integrity of IV solution Maintains sterility
of IV fluid.
● also check for the expiration date

BSN-4C 14
 ○ Don’t disclose cause of death just to anyone
3. Determine the needs and desires of the family as the body is
prepared for transfer to the funeral home or morgue.
4. Be certain of the religious beliefs of the client.
SIGNS AND SYMPTOMS OF COMMON LOCAL 5. Ensure that the deceased’s belongings are given to
COMPLICATIONS OF INFUSION THERAPY significant others.

PLANNING

1. Collect necessary equipment

○ bathing supplies
■ use a small towel - the one used for bed bath
○ shroud or morgue bag (color coded) - in some hospitals,
we use a mortuary bag (white), but in some hospitals
they use linen
○ 3 identification tag
■ bago binabalot na ang patient nilalagay na ang
identification tag → wrist, foot (big toe/ankle),
mortuary bag (chest)
○ roll of gauze
■ for different contraptions leaks
○ paper/plastic bag for personal belongings
■ Itemize
○ morgue cart
○ Additional
■ plastic bag (Black) - for hazardous waste
2. If there are visitors in the room, carefully explain the situation and
ask them to temporarily leave the room if possible
○ deliver and explain to the relatives that we will
Infiltration - tumutulo pa rin yung fluids performing post mortem care to the patient and ask them
to fix all the bills of the patient
3. Follow the hospital procedure regarding the notification of various
WEEK 5 - OUTLINE dept. and personnel
II. POST-MORTEM CARE
III. Definition SPECIAL CONSIDERATIONS
IV. Purpose
V. Considerations
VI. Equipments ● Safety First - Protective measures
VII. Procedure ○ you should know the status of the px - what is the
diagnosis of the px (e.g. patient might have a
communicable disease → for this px will be
cremated right away, no more post-mortem care)
POST-MORTEM CARE ○ COVID 19 = no post mortem care (under
● Care of a body after death communicable diseases),
● Cleaning up and preparing the body to enhance the ○ Be careful to avoid needle prick injuries
appearance during viewing of the family. ○ Follow hospital infection control
● Ensures proper identification ● Provide privacy
○ This is because when the body is carried to the morgue, the ● Respect the culture and religious practices
body bag is no longer opened that’s why ID tags are used ○ Some culture only wants Male nurses (if the
to identify the body. patient is Male) / Female Nurse (if the patient is
○ there are certain numbers of identification tags (In FEU Female)
NRMF, probably 4 tags)
○ Post-mortem care is an independent action of the nurse MENTAL AND PHYSICAL CHANGES
○ It needs to be done promptly, quietly, and with dignity

PURPOSE

1. To clean and prepare the patient’s body before it is transported to

the morgue
○ needs to be cleaned before the body will be transferred
to the funeral parlor

ASSESSMENT

2. Verify that the patient has been pronounced dead by the

physician These are the signs we see and need to assess on our
○ only the physician can declare the patient’s death patient 2 weeks before (imminent) death:
(attending physician will sign death certificate) ○ Excessive sleep
3. Identify cadaver, and collect his/her belongings for labeling ○ Lower body temperature
○ Recorded and reported for inventory, usually belongings ○ Irregular pulse
are handled to the guard or charge nurse → Relatives ○ Lower blood pressure
(PREVENT THEFT: make sure that relatives sign after ○ Disorientation
receiving the patient’s belongings) ○ Increased perspiration
○ Skin color and breathing changes
Special Considerations
1. Culture and background
2. Practice dignity and respect ADDITIONAL:

BSN-4C 15
 ➢ presence of discoloration because of the
In each aspect = certain nursing interventions to be done breakdown of RC
● Hearing is the last sense to go ➢ 15 minutes to 2 hours
● Decreased touch, taste and smell sensation 2. Algor Mortis | COOL
● No pain perception ○ Cool of death
● Blurring vision, pupils dilate with eyelids half open, ○ After death a human body will no longer be
decreased blinking working to keep warm, and as a result, it will start
● cold clammy and pale skin cooling
● respiratory status is cheynes-stokes → deep irregular ○ About an hour (Post mortem - after death), a
and rapid breathing with apnea human body will have DECREASED around 2
● Urinary system - kidneys start to shut down and degrees celsius until it reaches the temperature of
sphincter muscles relax so, the px urinates → there is the environment around it.
urination and retention as well 3. Rigor Mortis | STIFF
● Musculoskeletal - decreased muscle tone ○ Death stiffness
○ Sagging of Jaw ➢ Important sign for pronouncement of
● Cardiovascular death
○ Irregular beating → decreased blood perfusion ○ About three hours after death a chemical change
● Excessive sleep - due to decreased perfusion to the in the muscles of a human corpse causes the
brain limbs of the corpse to become stiff and difficult to
● Lower body temperature - body thermoregulation is not move
working ➢ Align the body, clean, place the
○ Decreases by one degree from time to time until dentures, and close the patient’s
the body temperature reaches the temperature of eyes/mouth before Rigor Mortis sets in.
the environment ○ Due to decreased perfusion and oxygen
● Disorientation - decreased blood perfusion ○ Peak before the stiffness stops: 12 HOURS
○ “nakakakita daw ng patay”
● Increased perspirations 4. Livor Mortis | POOLING
○ It is the 4th stage of postmortem sign of death
(02) PRONOUNCEMENT OF DEATH ○ Also known as postmortem stain or hypostasis
○ It is the pooling of blood in the lower portion of
dependent parts of the body after death.
● Absence of carotid pulse ○ It takes between 20 - 30 mins for this to set in.
○ During ER, CAROTID PULSE is being assessed
(because this is the biggest pulse)
● Pupils are fixed and dilated
CARE OF THE DYING PATIENT
○ uses penlight to check
● Absent heart sounds
○ using stethoscope 1. The psychological support need of a dying person can be
● Absent of breath sounds summarized as follows:
○ using stethoscope and the movement to check if ● Relief of loneliness, fear and depression.
spontaneous breathing is still present ○ Stay with the patient
○ Psychological support is not only given to the
patient but also to the family
Which one is the first to stop: Respiratory / Heart sound ● Maintenance of security, self-confidence and dignity
- RHS (Respiratory first then Heart Stops) ● Maintenance of hope
- Because during resuscitation, the patient is given ● Meeting the spiritual needs according to his religious
epinephrine so heart will still pump. custom
○ One of the important nursing problem: Grief
○ one of the priorities a nurse should do: refer to
The doctor orders a rhythm strip for conformity: pastor / priest

RHYTHM STRIP - to extremities only Assist the client achieve a dignified and peaceful death
● Red ● Provide relief from loneliness, fear and depression
● yellow ● Maintain the patient’s sense of security, self-confidence,
● green dignity, and self worth
● black ● Maintain hope
Attached to the hand because we’re going to view the cardiac ● Help the patient accept his or her losses
rhythm only (which is found in Lead 2 - gives cardiac rhythm and a ● Provide physical comfort
good view of the P-wave = gives prolonged reading)
● P wave: atrial depolarization Maintain Physiologic comfort
○ no filling below the atrium → so, px is candidate ● Personal Hygiene measures
for RHS ● Pain control - Highest priority
○ When ECG displays flat line = pronouncement ● Relief of respiratory difficulties
of death ○ Give them O2 and refer to the physician, even if
● TIME OF DEATH - is written in the rhythm strip they are in DNR
■ up to 2 Liters only - for independent
ECG - Extremities and chest area nursing action
● Assistance with movement, nutrition,hydration and
elimination
STAGES OF DECOMPOSITION ● Measure related to sensory changes

1. Pallor Mortis | PALE Provide spiritual support

○ Paleness of death ● Searching meaning
➢ First identifier of death ● Sense of forgiveness
○ Almost immediately after death a body of a ● Need for love
person with light skin will begin to grow very pale. ● Need for hope
This is caused by a lack of blood in the capillary
region of the blood vessel CARING FOR THE BODY AFTER DEATH

BSN-4C 16
 ● After the physician has pronounced death legally
documented the death in the medical record, care of the
body is usually performed by the nurse.
● An autopsy consent may be requested & obtained if
required
○ obtained either in the hospital or at Camp Crame
→ authorized to perform autopsy
● If the patient is to be an organ donor arrangements will be
made immediately.
● The family often wishes to view the body before final
preparations are made, they may be allowed.
● If the patient had any valuables, they are handed over to the
● Draw sheet will be put on the chest and abdominal
relatives
area
● Normal body bag is used for normal death / px
PROCEDURE FROM PPT died with no communicable disease

1. Wash Hands ● Black body bag is used for COVID px

2. Provide privacy
3. Apply gloves
4. identify the body
5. Close eyes gently by grasping eyelashes and pulling lids
over the corneas of the eyes
● closing eyes: showing respect and eternal rest
● do not use micropore
6. Remove all tubes (Note considerations below)
7. Dress puncture wounds with dressing and tapes
● lagyan pa rin ng dressing
8. If with dentures, wash and re-insert them
● They remove → relatives → Funeral parlor
9. Place a rolled up towel under chin if mouth fails to close 19. Arrange transportation of the body to the morgue or mortuary
● to close the jaw
● but usually: tying up a gauze (from the jaw up to
the head part of the patient) /cravat PROCEDURE FROM CHECKLIST
10. Place the body in supine position. Avoid placing one hand on
top of the other.
● palm down across the body 1. Wash hands. Reduce transmission of microorganisms.
● Proper alignment before rigor mortis (Stiffening) 2. Provides privacy. Limits exposure of other clients to the
11. Place a small pillow or folded towel under the head or person’s death.
elevate head of bed 10 to 15 degrees 3. Apply gloves, protective barriers. Body excretions may
● to prevent discoloration associated with pooling of harbor infectious microorganisms.
the blood ● according to ma’am: they use clean gloves -
12. Wash body parts soiled by blood, urine, feces,or other double gloving
drainages 4. Identify the body. Ensures proper identification of the body
● before washing the body parts → Take note: for delivery to the morgue.
Remove Accessories/Jewelries prior ● IN FEU-NRMF (4 tags) - use identification tag:
● Procedure is same with Bed bath; use lukewarm wrist, toe / ankle, cadaver bag, and the 4th ID tag
water will be handed over to the morgue personnel
13. Place absorbent pad under buttocks 5. Remove all tubes: Iv, catheter, and oxygen. Dress puncture
● Because of the relaxation of the sphincter muscle wounds with dressing and paper tape as directed by agency
= so the body will continue to excrete fluids policy, some require that all tubes in the body remain in
● place the client in a lateral recumbent: clean the place .Creates a normal appearance. Paper tape minimizes
back of the patient and then “isuksok sa baba skin trauma.
lahat ng damit ni patient” for easy removal ● Not all tubes are removed by the nurses
14. Removed soiled dressing and replaced with clean gauze ● Nurses are allowed to remove the ff: Only IV fluids,
dressings. Use paper tape. indwelling catheter, ET tubes, NGT tubes
● Addition for this step: Put the identification tag ● Tubes that nurses cannot remove include: CVC
in place (central venous catheter), IJ catheter, subclavian,
15. Place a clean gown on the client hemoral catheter, gastrostomy tube, chest tube,
16. Brush and comb hair. Remove any clips, hair pins or rubber surgical drains
bands ○ Chest tube & Surgical Drains: removed
17. Place Body in body bag or apply shroud by the doctors because suture is needed
18. Label the body
● put the 3rd identification tag at the bag 6. If with dentures, wash and reinsert them. If mouth fails to
close, place a rolled-up towel under the chin. Dentures
maintain natural facial expression. It is difficult to insert
dentures after rigor mortis.
● depending on the area:
● If at the ER: dentures are removed, bc it might cause
aspiration if chest tube will be inserted
● If with DNR and waiting: dentures are remained or let
the funerary insert it
7. Position client, straighten the body in supine position. Avoid
placing one hand of top of the other. Placing one hand on top
of the other can lead to discoloration
of the skin.

BSN-4C 17
 8. Place small pillow under the head or elevate head of
bed 10 to 15 degrees. Prevents blood from discoloring the
face.
9. Close eyes gently by grasping eyelashes and pulling lids
over corneas of the eyes. Closed eyes presents a more
natural appearance. Pressure on lids can lead to
discoloration.
10. Wash body parts soiled by blood, urine, feces or other
drainage. Prepares body for viewing and reduces odors.
11. Place absorbent pad under buttocks. To take up any feces
and urine released because of the relaxation of the sphincter
muscle.
12. Remove soiled dressings and replace with clean gauze
dressings. Use paper tape. Changing dressings helps to
control odors caused by microorganisms and to create more
acceptable appearance.
13. Place a clean gown on the client. Prepares the body for
viewing.
14. Brush and comb hair. Remove any clips, hairpins or rubber
bands. The client should appear well-groomed. Hard objects
such as pins can damage or discolor the face and scalp.
15. Place body in body bag or apply the shroud. Prevents injury
to skin and extremities. Avoids unnecessary exposure of
body parts.
16. Label the body. Ensures proper identification of the body.

17. Arrange transportation of the body to the morgue or mortuary

POST MORTEM CARE: Performing, Caring, and Respecting -

Youtube video posted on Moodle:
POST MORTEM CARE: PERFORMING, CARING AND RESPE…

QUESTION AND ANSWER

How many hours can a cadaver stay in the morgue?
● In FEU-NRMF, within 12 - 24 hours (reality: until 6 hours
only until the bills are settled)
○ Standard: 12 hours (6-12 hours to claim)
○ COVID case: it should be claimed within 6
hours
● Depending on the case, some cadavers stay in the
morgue for about days to weeks depending on the
institution protocol and availability of a freezer/cold
storage
● Then, the family will choose the funerary of their choice

BSN-4C 18
 NCM 118
CRITICAL CARE NURSING A.Y. 2024 - 2025
PROF. FERNANDEZ & BENITO FIRST SEMESTER

PRELIMS
TYPES OF TRACHEOSTOMY TUBE
OUTLINE
1. SINGLE-LUMEN TUBE
1 Tracheostomy Care
● A single lumen tracheostomy tube is good for patients that need
mechanical ventilation nocturnally.
2 Chest Tube Drainage
● During the day, the cu can be deflated and the patient is able to breathe
around the tube with less resistance since the cu lies “tight-to-shaft”.
3 Surgical Drains

4 Peripheral IV Insertion

5 Post-Mortem Care

6 Care of the Dying and the Dead

2. DOUBLE-LUMEN TUBE
TRACHEOSTOMY CARE
● Dual Lumen tracheostomy tubes have a main cannula that remains in
TRACHEOSTOMY position.
● It is a surgical incision into the trachea to insert a tube through which the ○ A removable inner cannula allows for easy cleaning and replacement
patient can breathe more easily and secretions can be moved. of a fresh cannula.
○ Expect the patient to not be able to talk, as the air cannot reach the ● The benefit to a dual-lumen tracheostomy tube is that daily care can be
vocal cords.
accomplished quickly and easily.
● A small horizontal incision is made just below the 1st tracheal ring and
tracheostomy tube is inserted 一 it can be a temporary measure.
○ Once the patient can tolerate temporary closure referred to as
“buttoning”, tracheostomy tube is removed and incision heals.
■ Weaning: If the patient can breathe on his/her own. Using the
patient’s mouth for inhaling and exhaling. Ready for pull-out.
3. CUFFED TUBE
■ Decannulation: The process of removal.
● A cu when inflated seals the airway.
TRACHEOSTOMY PROCEDURE ● Cu – prevents aspiration of fluids.
○ Inflated during continuous mechanical ventilation, during and after
eating, during and 1 hour after tube feeding.

● The cu blocks any air from flowing around the tube and assures that the
patient is well oxygenated.
○ Afterwards the air must therefore flow in and out through the tube
itself.
○ A pilot tube attached to the cu stays outside the body and is used to
inflate or deflate the cu .

● NOTE:
○ Temporary - obstruction
○ Permanent - cancer, smoker (prone to laryngeal CA)
4. CUFFLESS TUBE
PARTS OF THE TRACHEOSTOMY TUBE
● This is usually worn over a long period of time.
● Obturator
○ also known as ‘Stylet’ ○ Cu ess tubes are primarily used in non–ventilated patients that have
● Outer Cannula no danger of aspiration.
● Inner Cannula

● Since there is no cu , it allows air to pass into the upper trachea and larynx
so the patient can cough and speak normally.

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● Changing outer dressing.
● Replacing the tracheostomy ties.

PURPOSES
● To maintain a patient airway
● To maintain cleanliness and prevent infection at the tracheostomy site.
● To facilitate healing and prevent skin excoriation around tracheostomy
incision.
5. FENESTRATED TUBE ● To promote comfort.

● A fenestrated tube has an opening (fenestration) in the back of the outer INDICATION FOR TRACHEOSTOMY TUBE
cannula. ● Obstruction of the mouth or throat.
○ It allows the patient to breathe normally and to speak or cough ● Breathing di culty caused by edema, injury, or pulmonary conditions.
through the mouth. ● Airway reconstruction following tracheal or laryngeal surgery.
● Airway protection from secretions or food because of swallowing problems.
● Airway protection after head and neck surgery.
● Long-term need for ventilator support.

INDICATION FOR SUCTIONING TRACHEOSTOMY

● Presence of mucus in airway
● Increased pulse
● Increased respirations
● A fenestrated tube is often used as the final step before trach tube removal. ● Noisy respirations
● Restlessness

CONSIDERATIONS
● Sterile technique is always used for infection control.
● Hyperoxygenate client before, during, and after suctioning.
○ 100% oxygen for 3 minutes or 3 deep breaths.
○ Suction no more than 10 seconds.
○ Ambubag gives 100% of oxygen.
6. METAL TRACHEOSTOMY TUBE ■ Patient with tracheostomy usually cannot speak, establish a way
● This is used for permanent tracheostomy. of communication. The trachea opening prevents air from
○ Popular types are the Jackson and Holinger tubes. reaching the vocal cords so speech is not possible.
■ Later the patient will be able to speak by placing a button or
finger over the opening thus forcing air around the tube.
● Avoid using cotton-filled gauze squares and avoid cutting the 4x4 gauze.
○ The client might aspirate cotton lint which could create tracheal
abscess.
● If the client coughs and the tube is dislodged accidentally, the initial
nursing action is to grasp the retention sutures and spread the opening.
○ If agency policies permits the nurse then attempts immediately to
● NOTE: Disposable is more commonly used in the area because metal needs replace the tube.
to be sterile. ■ Instruments needed: An instrument to spread the opening.
7. TALKING TRACHEOSTOMY TUBE COMPLICATIONS
● This provides a means of communication for the client who is using a ● Airway obstruction
ventilator on a long-term basis. ● Accidental decannulation
● Infection

EQUIPMENTS
● Bedside Table
● Towel
● Tracheostomy suction supplies
● Sterile Tracheostomy care kit
● Hydrogen peroxide
● Fig. 1. Note that gas flow exits above the cu and provides flow through the ● Normal saline solution
upper airway to facilitate speech. The arrow indicates the point of gas flow ● Sterile cotton-tipped swabs
into the trachea above the cu . ● Sterile dressing (pre cut and sewn surgical dressing)
● Sterile basin
● Small sterile brush
● Roll of twill tape, tracheostomy ties, etc.

PROCEDURE
1. Observe for signs and symptoms of need to perform tracheostomy care:
excess peristomal secretions, soiled tracheostomy ties, soiled dressing,
diminished airflow, or signs and symptoms of airway obstruction.
➢ Signs and symptoms are related to presence of secretions at stoma
site or within tracheostomy tube.
● Fig. 2. Placement of a speaking valve between the ventilator and the 2. Check when tracheostomy care was last performed.
tracheostomy tube results in the exhaled gas passing through the upper ➢ Tracheostomy care is provided at least 2 hours and more often if
indicated.
airway (rather than into the ventilator circuit).
3. Explain the procedure to the client; have another nurse or a family member
TRACHEOSTOMY CARE to assist in the procedure.
➢ Encourages cooperation and prevents accidental extubation of
ROLES OF NURSES tracheostomy tube.
● Changing and replacing the inner cannula. 4. Assist in a comfortable position usually supine or semi-fowler’s.

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➢ Promote client’s comfort and prevent nurse’s muscle strain. CHEST TUBE
5. Place the towel across the chest.
● A chest tube is a surgical drain that is inserted through the chest wall and
➢ Reduces transmission of microorganisms.
into the pleural space in order to remove undesired substances such as air,
6. Wash hands, apply gloves, and face shield if applicable.
➢ Reduce transmission of microorganisms. excess fluid, blood or pus from the intrathoracic space.
7. Suction tracheostomy. Before removing gloves, remove tracheostomy soiled
dressing; discard in glove with coiled.
➢ Removes secretions to avoid occluding outer cannula while inner
cannula is removed. Reduce the need for client to cough.
8. Open sterile tracheostomy kit. Open gauze packages aseptically and pour
normal saline on one package and hydrogen on another. Leave the third
package dry. Open two cotton-tipped swab packages, and pour normal saline
on one package and hydrogen peroxide on another. Open sterile
tracheostomy dressing package. Unwrap sterile basin and pour ½ inch
hydrogen peroxide into it. Open the sterile brush package and place it into SITES FOR CHEST TUBE INSERTION
the sterile basin. Cut tape and lay aside in a dry area. ● Placement: A thoracostomy tube is usually placed between the mid to
➢ Prepares equipment and allows for smooth, organized completion of anterior axillary line in the fourth or fifth intercostal space, tracking above
tracheostomy care. the rib so as not to injure the intercostal bundle (artery, vein, nerve).
9. Apply gloves. Keep the dominant hand sterile throughout the procedure.
10. Remove oxygen source and inner cannula with non-dominant hand. Drop into
the hydrogen peroxide basin.
➢ Removes inner cannula for cleaning. Hydrogen peroxide loosens
secretions from the inner cannula.
11. Place a tracheostomy collar, T-tube or ventilator oxygen source over the
cannula.
➢ Maintains oxygen supply to the client.
12. Quickly pick up the inner cannula and use small brush to remove secretions ● Sites for chest tube placement include:
inside and outside inner cannula. ○ For pneumothorax (air) – 2nd or 3rd interspace along
➢ Prevents oxygen desaturations; tracheostomy brush provides
midclavicular or 4th intercostal space anterior axillary.
mechanical force to remove thick or dried secretions.
○ For hemothorax (fluid) – 6th or 7th lateral interspace in the
13. Hold the inner cannula over the basin and rinse with normal saline.
➢ Removes secretions and hydrogen peroxide from inner cannula. midaxillary line.
14. locking mechanism, if applicable. Reapply trach collar, T to avoid occluding
outer cannula while inner cannula is removed. Reduce the need for the
client to cough.
➢ Secures inner cannula and re-establishes oxygen supply.
15. With hydrogen peroxide saturated cotton-tipped swabs and gauze, clean
exposed outer cannula surfaces and stoma under faceplate extending 2 to 4
inches in all directions from the stoma. Clean in circular motion from stoma
outside.
➢ Aseptically removes secretions from stoma site. Moving in an outward ● NOTE: Mas mataas yung air kesa sa pneumothorax, kasi mas mabigat yung
circle pulls mucus and other contaminants from stoma to periphery. fluid kesa air.
16. With normal saline saturated cotton-tipped swabs and gauze, rinse hydrogen
CHEST DRAINAGE
peroxide from trach tube and skin surfaces.
➢ Rinses hydrogen peroxide from surfaces. If not removed from skin, TYPES OF BOTTLE SYSTEM
hydrogen peroxide can promote tissue injury.
● (Glass bottle system) Water suction system and sterile water:
17. With 4x4 inch gauze, pat lightly at skin and exposed outer cannula surfaces.
➢ Dry surfaces prohibit formation of most environments for ONE BOTTLE/ SINGLE BOTTLE SYSTEM
microorganism growth and skin excoriation. ● The simplest form of underwater seal drainage systems.
18. Ask the assistant to hold tube in place. Cut ties.
● The chamber serves as a fluid collector and a water seal.
➢ Secure trach tube. Reduces risk of incidental extubation.
● During normal respiration in the fluid in the chamber ascends with
19. Cut twill tape long enough to go around the client's neck twice (24 to 30
inspiration and descends with expiration.
inches). Cut ends on diagonal.
➢ Cutting ends of ties on diagonal aids in inserting through the eyelet. ● This is used for smaller amounts of drainage such as empyema.
20. Insert one end of the tie through the faceplate eyelet and pull ends even.
21. Slide both ends of the tie behind the head and around the neck to the other
eyelet and insert one tie through the second eyelet.
22. Pull snugly.
➢ Ensures tracheostomy will not come out.
23. Tie ends securely in a double square knot, allowing space for only.
➢ One finger-length of slack prevents movement of the trach tube in the
lower airway.
24. Insert fresh tracheostomy dressing under clean ties and faceplate.
➢ Absorbs drainage. Dressing prevents pressure on clavicle heads. TWO BOTTLE SYSTEM
25. Position the client comfortably and assess respiratory status. (Assess the ● This system is suitable for the drainage of air and fluid.
comfortability first before leaving.) ● The use of two chambers permits any fluid to flow into the collection
➢ Promotes comfort. Some may require post-tracheostomy care chamber as air flows into the water-seal chamber.
suctioning.
● Fluctuations in the water-seal tube are anticipated.
26. Remove gloves and face shield and discard.
● Two chambers allow for more accurate measurement of chest drainage and
27. Wash hands.
are used when larger amounts of drainage are expected.
➢ Reduces transmission of microorganisms.

- END OF TRACHEOSTOMY CARE -

CHEST TUBE DRAINING

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SMALLER PORTABLE CDU
● Drainage without the use of suction
● Dry seal system that prevents air leaks
● No lung re-expansion occurs 500 mL max drainage
● Emptied when used in home
● For ambulatory patients
● Home care
● Chronic conditions

THREE BOTTLE SYSTEM INDWELLING PLEURAL CATHETER

● When a volume of air or fluid needs to be evacuated with controlled suction, ● Small-size chest tube or pigtail catheter (smaller than standard 14 Fr)
all three chambers are used. ● Can be irrigated if occluded by a health care provider with less traumatic
● Suction is required when air or fluid needs a greater pressure gradient to pneumothorax.
move from the pleural space to the collection system. ● Chronic drainage of fluid not for trauma or blood.
● Mark the suction control with centimeter readings to adjust the amount of ● Can be used for pleurodesis
suction. ○ Procedure performed to obliterate the pleural space to prevent
● Usually 15 to 20 cm of water pressure is used for adults. recurrent pleural e usions, pneumothorax, or to treat a persistent
pneumothorax.

HEIMLICH VALVE
CHEST DRAINAGE UNITS (CDU)
● One-way “flutter valve”
STANDARD CDU ● Removes air as the patient exhales.
● Drainage of pleural cavity for air or any type of fluid with or without the use ● Valve opens when pleural space pressure is greater than atmospheric
of suction. pressure and closes when the reverse occurs.
○ Up to 2,000 mL capacity. ● Evacuates air from the pleural space.
○ Replaced when full. ● Used for emergency transport, homecare, and long term care units.
● Most commonly used chest drainage units use the water seal principle. (e.g.
pleur evac)
○ Continuous wall suction unit
○ Water-sealed unit (“no wall suction”)
● This system:
○ Collects drainage.
○ Creates a water seal that controls suction.
○ Allows air and fluid to escape from the pleural cavity but doesn’t allow
air to re-enter to restore negative pressure.
WATER SEAL DRAINAGE SYSTEM
● The water seal drainage system is a single unit with three chambers:
○ 1st Chamber – “collection chamber”
■ receives fluid and air from the chest cavity through the
CARING FOR CLIENT WITH CHEST DRAINAGE SYSTEM
collecting tube attached to the chest tube.
○ 2nd Chamber – “water-seal chamber” PURPOSES
■ with 2 cm of water acting as a one-way valve, allowing drainage
THERAPEUTIC
out but preventing backflow.
● To remove air and fluid from the thoracic cavity.
○ 3rd Chamber – “controlled suction”
● To facilitate re-expansion of the lung.
■ Type 1: Continuous wall suction unit
■ Type 2: Water-seal unit (“no wall suction”) DIAGNOSTIC
● To determine presence of intrathoracic bleeding; and
● To measure the amount and rate of hemorrhage.

INDICATIONS
● Following surgery that impacts on the continuity of the thoracic cavity.
○ (e.g. thoracic, cardiac, esophageal surgery, etc.,)
● Pneumothorax
● Hemothorax
● Pleural e usion
● Pleurodesis
OTHER REASONS
● A collapsed lung.
● A lung infection like bacterial pneumonia is complicated by a collection of
pus.
● Pneumothorax, which is air around or outside the lung.
● Bleeding around the lung, especially after a trauma (like a car accident).
● Fluid build-up due to another medical condition, like cancer or pneumonia.

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● Breathing di culty due to a build-up of fluid or air. ➢ To prevent air from being sucked into the pleural cavity, apply a sterile
● Surgery, especially lung, heart, or esophageal surgery. pressure dressing and notify MD immediately.

NURSING CONSIDERATIONS NURSING CARE

● To prevent dislodgement and infection. ● Assessment of the chest tube site;
● To know management of e ective suction and drainage, pain relief. ○ To prevent dislodgement and infection
● To monitor the respiratory status. ○ Management of e ective suction and drainage
● To provide overall supportive care. ● Pain relief
NURSING ALERT ● Monitoring the respiratory status and providing overall supportive care.

● Make certain that the bottles are tight. EQUIPMENTS

● Tubing should be free of kinks and dependent loops. ● Prescribed drainage system
● Be sure that the tube from the pleural cavity is attached to the tubing ● Water suction system and sterile water.
connected to a glass tube and ends under sterile water. ● Chest tube tray
● Never lift a drainage bottle above the level of the client’s chest. ● Dressing sterile gloves
● Rubber-tipped hemostats for each test tube (2)
NURSING RESPONSIBILITIES
● 1-inch adhesive tape.
How to Manage a Patient with a Chest Tube Drainage

1. Initial Assessment: PROCEDURES

➢ Assess the patient’s clinical status and vital signs. 1. Review the patient chart for the reason for the chest tube and location and
➢ Encourage the patient to report any breathing di culty immediately. insertion date.
2. Check the rate and quality of the patient’s respirations. 2. Bring equipment to the bedside.
➢ Auscultate breath sounds EVERY shift. 3. Wash hands.
➢ Diminished or absent breath sounds may indicate that the lung has 4. Explain procedure and rationale to the client.
not yet re-expanded. 5. Complete respiratory assessment, ensure the patient has minimal pain, and
➢ Observe and report immediately signs of rapid, shallow breathing, measure vital signs. Place the patient in a semi-fowler's position for easier
cyanosis, pressure in the chest, subcutaneous emphysema or breathing.
symptoms of hemorrhage. 6. Move the patient’s gown to expose the chest tube insertion site. Keep the
3. Check the drainage unit. patient covered as much as possible. Observe the dressing around the
➢ Do an initial assessment of the drainage unit. insertion site and ensure that it is dry, intact, and occlusive.
➢ Check the suction control dial to ensure that it is in the correct 7. Check that all connections are securely taped. Gently palpate around the
setting. insertion site, feeling for subcutaneous emphysema, a collection of air or
➢ If the suction is ordered, check to see if the orange float appears in gas under the skin.
the suction indicator window. 8. Check the drainage tubing to ensure that there are no dependent loops or
➢ Make sure that the drainage unit is balanced and stabilized around the kinks. Position the drainage collection device below the tube insertion site.
patient. 9. If the chest tube is ordered to be suctioned, note the fluid level in the
4. Check the tube connections periodically. Make sure all tubes are suction chamber and check it with the amount of ordered suction. Look for
sealed, air tight and secured. bubbling in the suction chamber. Temporarily disconnect the suction to
➢ Tape, if necessary. The tube should be as straight as possible and check the level of water in the chamber. Add sterile water or saline, if
coiled below the level of chest without dependent loops. necessary, to maintain the correct amount of suction.
➢ Make sure the tubing does not loop or interfere with the movement of 10. Observe the water-seal chamber for fluctuations of the water level with the
the patient. patient’s inspiration and expiration (tidaling). If suction is used, temporarily
5. Check for fluctuations. disconnect the suction to observe for fluctuation. Assess for the presence of
➢ In a continuous wall suction, the unit is connected to a suction source bubbling in the water-seal chamber. Add water, if necessary, to maintain the
and gentle bubbling will be heard. level at the 2 cm mark.
➢ Check for fluctuations in the water-seal chamber as the patient 11. Assess the amount and type of fluid drainage.
breathes. 12. Measure drainage output at the end of each shift, mark the level on the
➢ Normal fluctuations of 5 - 10 cm reflect pressure changes in the container or place a small piece of tape to indicate date and time.
pleural space during respiration. 13. Remove gloves.
6. Check for bubbling. 14. Assist the patient to a comfortable position.
➢ If excessive bubbling is present in the water-seal chamber especially 15. Wash hands.
if suction is being used, rule out a leak in the drainage system.
CHANGING THE DRAINAGE SYSTEM
NOTE: Character, consistency, and amount of drainage.
★ Mark the date and time of the original fluid level, then every 1. Obtain two padded kelly clamps, a new drainage system, and a bottle of
shift on the CDU. sterile water. Add water to the water-seal chamber in the new system until
★ Don’t forget to chart on the nurse's notes and I/O flowsheet it reaches the 2 cm mark. Follow manufacturer’s directions to add water to
every shift. the suction system if suction is ordered.
★ NEVER leave a chest tube clamped for more than a minute. 2. Wear gloves.
7. Check the range of motion. 3. Apply kelly clamps 1.5 to 2.5 inches from insertion site and 1 inch apart,
➢ Put the arm and shoulder of the a ected side through ROM exercises going in opposite directions.
several times daily. Some pain medication may be necessary. 4. Remove the suction from the current drainage system.
➢ Encourage the patient to assume a position of comfort. 5. Unroll or use scissors to carefully cut away any foam tape on the connection
➢ Encourages good body alignment. of the chest tube and drainage system. Using a slight twisting motion,
➢ Encourage the patient to change position frequently. remove the drainage system. Do not pull on the chest tube.
8. Check for the dressing. 6. Keeping the end of the chest tube sterile, insert the end of the new drainage
➢ Check the chest tube dressing at least every 8 hours. system into the chest tube.
➢ Palpate the area surrounding the dressing for crepitus or 7. Remove kelly clamps. Reconnect suction, if ordered. Apply plastic bands or
subcutaneous emphysema, which indicates that air is leaking into the foam tape to the chest tube / drainage system connection site.
subcutaneous tissue surrounding the insertion site. 8. Assess the patient and the drainage system.
➢ Change the chest tube dressing as ordered or when necessary. 9. Remove gloves. Wash hands.
9. Check for the chest tube.
➢ If the chest tube gets dislodged, do not push tubes back into the - END OF CHEST TUBE DRAINAGE -
patient.

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SURGICAL DRAINS PROCEDURE

1. Check the doctor’s order for wound care.
CARING FOR A T-TUBE DRAIN ➢ Ensures the correct procedure is performed to the correct patient.
T-TUBE 2. Gather the necessary supplies and bring to the bedside stand or overhead
table.
● A tubular device in the shape of a T, inserted through the skin into a cavity
➢ Saves time, energy, and e ort.
or a wound and used for drainage.
3. Wash hands.
➢ Reduces transmission of microorganisms.
4. Identify the client.
➢ Ensures correct administration procedure.
5. Provide privacy by closing the room door.
6. Explain the procedure to the client.
➢ Promote client’s cooperation.
7. Place a waste receptacle near the working area.
➢ Ensures easy disposal of soiled materials.
● T-tube is also called biliary draining tube, placed in the common bile duct 8. Assist the patient to a comfortable position that provides easy access to the
after cholecystectomy or choledochostomy. drain and/or wound area.
● The tube facilitates biliary drainage during healing. ➢ Promotes client’s comfort and reduces strain on the nurse. Place a
waterproof pad under the wound site.
● The surgeon inserts the short end (crossbar) into the common bile duct and
draws the long end through an incision in the skin. EMPTYING DRAINAGE
● The tube is then connected to a closed gravity drainage system. 9. Put on clean gloves.
● Post operatively it remains in place between 7 to 14 days. ➢ Put on a mask or face shield if necessary.
10. Open a gauze pad, making a sterile field with the outer wrapper.
T-TUBE CHOLANGIOGRAM
11. Place the collection container under the outer
● A T-tube cholangiogram is an x-ray of the biliary duct.
valve of the drainage bag. Without touching
● An external part that is placed into the common bile duct and extends to the
the outlet, pull the cap o and empty the
outside of the body.
bag’s content completely into the container.
○ The part is an easy access to allow for drainage of bile and stones
Use the gauze to wipe the outlet, and replace
from the bile ducts and for injecting contrast to view the ducts.
the cap. Permits measuring and discarding of
● Outer part is where the bile comes out; thus we measure.
wound drainage.
➢ Reduces transmission of
microorganisms into drainage
evacuation.
12. Carefully measure and note the characteristics of the drainage. Discard the
drainage appropriately.
➢ To ensure proper recording and reporting observation and findings to
the physician.
13. Remove gloves and wash hands.
➢ Reduces transmission of microorganisms and protects sta from
infections.

OBSTRUCTIVE JAUNDICE CLEANING THE DRAIN SITE

14. Put on clean gloves. Check the position of the drain or drains before
removing the dressing.
15. Gently remove the soiled dressings.
➢ Use small amounts of sterile saline to help loosen and remove
dressing that sticks to the underlying skin. Do not reach over the drain
site.
16. Note the presence, amount, type, color, and odor of any drainage on the
dressings. Place soiled dressings in the appropriate waste receptacle.
17. Remove gloves and dispose of them appropriately.
18. Inspect the drain site for appearance and drainage. Assess if any pain is
present.
19. Using sterile technique, prepare a sterile work area and open the needed
supplies.
20. Open the sterile cleaning solution. Pour the cleansing solution into the
basin. Add the gauze
21. Put on sterile gloves
EQUIPMENT 22. Cleanse the drain site with the cleaning solution. Use the forceps and the
● Graduated collection container moistened gauze or cotton-tipped applicators. Start at the drain insertion
● Small plastic bag site, moving in a circular motion toward the periphery. Use each gauze
● Sterile gloves and clean gloves sponge only once. Discard and use new gauze
● Clamp if additional cleansing is needed.
● Sterile 4x4 gauze pads 23. Dry with new sterile gauze in the same
● Transparent dressings manner. Apply skin protectant to the skin
● Rubber band around the drain; extend out to include the
● Normal saline solution area of the skin that will be taped.
● Sterile cleaning solution 24. Place a pre split drain sponge under the
● Two sterile basins drain. Apply gauze pads over the drain.
● Povidone-iodine pads 25. Secure the dressing with tape as needed.
● Sterile precut drain dressings Alternatively, before removing gloves, place a
● Hyperallergenic paper tape transparent dressing over the tube and insertion site. Be careful not to kink
● Skin protectant the tubing.
● Montgomery strips

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26. Label dressing with date and time. Remove all remaining equipment; place PURPOSE
the patient in a comfortable position. ● To promote drainage of the blood, lymph, and other body fluids.
27. Remove gloves. Wash hands. ● Helps to reduce the risk of infection.
28. Check drain status at least every four hours. ● Keeps the patient more comfortable.
CARING FOR A JACKSON-PRATT DRAIN PROCEDURE
● A closed system drain that uses bulb suction to prevent wound drainage 1. Check the doctor’s order for wound care.
from collecting around the surgical site. 2. Gather the necessary supplies and bring to the bedside stand or overbed
table.
3. Wash hands.
4. Identify the client and explain the procedure.
5. Provide privacy.
6. Place a waste receptacle near the working area.
7. Assist the patient to a comfortable position that provides easy access to the
drain and wound area. Place a waterproof pad under the wound site.
8. Put on clean gloves. Put a mask or face shield if necessary.
9. Check the position of the drain or drains before removing the dressing.
Carefully and gently remove the soiled dressing. If any part of the dressing
sticks to the underlying skin, use a small amount of sterile saline to help
loosen and remove.
10. Note the presence, amount, type, color, and odor of any drainage on the
dressings.
11. Place the soiled dressings in the appropriate waste receptacle.
12. Inspect the drain site for appearance and drainage. Assess if any pain is
Fig. 1. Example of drainage present.
● Note that the characteristics should be documented. 13. Using sterile technique, prepare a sterile work area and open the needed
PURPOSE supplies.
● To prevent fluid (blood or other) build-up in a closed space, which may 14. Open the sterile cleaning solution. Pour the cleaning solution into the basin.
cause disruption of the wound and the healing process or become an Add the gauze sponges.
infected abscess. 15. Put on sterile gloves.
● To evacuate an internal abscess before surgery when an infection already 16. Cleanse the drain site with the cleaning solution. Use the forceps and the
exists. moistened gauze or cotton tipped applicators. Start at the drain insertion
site moving in a circular motion towards the periphery. Use each gauze
PROCEDURE sponge or applicator only once. Discard and use new gauze if additional
1. Check the doctor’s order for wound care. cleaning is needed.
2. Gather the necessary supplies and bring to the bedside stand or overbed 17. Dry the skin with a new gauze pad in the same manner. Place a pre split
table. drain sponge under the drain. If the pin or drain is crusted, replace the pin
3. Wash hands. with a new sterile pin. Take care not to dislodge the drain.
4. Identify the client. ➢ Pin prevents drain from being pulled below the skin’s surface.
5. Provide privacy. 18. Apply gauze pads under the drain. Apply abdominal pads over the gauze.
6. Explain the procedure to the client. 19. Remove and discard sterile gloves. Apply tape, Montgomery straps, or roller
7. Place a waste receptacle near the working area. gauze to secure the dressing.
8. Assist the patient to a comfortable position that provides easy access to the 20. After securing the dressing, label dressing with date and time.
drain and/or wound area. Place a waterproof pad under the wound site. 21. Remove all remaining equipment; place the patient in a comfortable
9. Put on clean gloves; put on a mask or face shield if necessary. position.
➢ Personal protective equipment reduces the transmission of 22. Remove clean gloves and wash hands.
microorganisms and protects against an accidental body fluid
23. Document. Check all wound dressings every shift.
exposure.
10. Place the graduated collection container under the outlet of the drain.
Without contaminating
- END OF SURGICAL DRAINS -

PERIPHERAL IV INSERTION
GOAL
● To provide information to the healthcare practitioner about peripheral IV
cannula insertion, including the proper technique, skin preparation and use
of the over-the-needle technique.
● Education for the patient and for the family is also included.
OBJECTIVES
CARING FOR A PENROSE DRAIN
● Describe the purpose of peripheral IV cannula insertion.
● It is a surgical drain which is left in place after a procedure to allow the site
● Identify veins that are suitable for peripheral IV cannula insertion.
of the surgery to drain.
● Identify the site to avoid during IV insertion.
● Describe the proper technique used during IV cannula insertion.
● Identify the signs of phlebitis, infiltration, or infection, etc.,

BEFORE INITIATING VENIPUNCTURE

FACTORS TO CONSIDER
● Type of solution
● Condition of vein
● Duration of therapy
● Presence of disease or previous surgery
○ Avoid inserting on an a ected arm, because it has lesser venous
return.
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● Catheter size
IV NEEDLE GAUGES SIZE CHART
● Patient age
○ Need ample time to assess vein and manage it properly especially on
pedia patients.
● Patient activity
○ E.g. patients who use crutches, there is a tendency to dislodge when
they hold the crutch, thus inserting the cannula higher than
metacarpal.
VEIN DILATION TECHNIQUES
● Make sure to do the insertion only once.
○ Use of tourniquet
■ Can impede circulation, thus vein will dilate (visible)
○ Use of gravity
■ Below the heart
○ Fist clenching
■ Another technique for the vein to dilate.
○ Tapping the vein
○ Warm compress
■ Considering room temperature (if cold), the vein won’t dilate.
Thus, apply warm compress.
○ Blood pressure cu
■ 30 mm Hg for 2 minutes - use this technique for fragile veins ● Sharps with built-in safety mechanisms such as retractable needles should
TIPS FOR SELECTING VEINS be used to reduce risk of needlestick.
● Suitable veins should feel relatively smooth, straight, visible, palpable and REDFLAGS
resilient. ● Do not use peripheral IVs for routine blood sampling because their small
● Do not use hard, cord-like veins or veins at flexion points such as diameter can increase the risk of clotting.
antecubital veins or veins on dominant limb and extremities with impaired Especially for pediatric (24g).
circulation or injury such as lymphedema, post operative swelling or recent ● Monitor for complications of peripheral IV insertion including infiltration,
trauma. thrombosis, hematoma, and extravasation.
○ Do not attempt to insert on site that flexes; thus only metacarpal and ○ Constant monitoring is needed because these signs usually takes time
basilic only. to appear.
● Start with distal veins and work proximally.
MATERIALS
● In children, use hand or foot veins versus leg, arm or antecubital fossa sites.
● Non sterile gloves
● Use vascular visualization technology such as ultrasound or near infrared
● Other PPE if you anticipated
light devices for patients with di cult IV access.
● IV start pack
○ The last option is to start the central line.
○ Posiflush
INSERTING PERIPHERAL VENOUS ACCESS ● IV cannula (gauge 24, 20, 22)
PURPOSE ● Pre-filled sterile normal saline flush syringe
● For hydration ● Short extension tubing
● For medication ● Transparent, occlusive dressing
● For blood transfusion ● Splint or arm board or pedia patient.
○ To keep vein open for possible BT anytime (esp. since it take time) ● Sterile gauze, scissors, non-allergenic tape
● For parenteral nutrition PROCEDURES
NURSING CARE AND CONSIDERATIONS PRE-PROCEDURE STEPS
● Site care, including skin antisepsis and dressing changes should be
● Check care plan, treating clinicians order and facility protocols on inserting
performed per facility protocol and immediately if the integrity becomes
peripheral IV cannula.
compromised.
● Patient Assessment and Psychological Preparation
● Peripheral IVs are removed if signs of complication are observed or if no
● Patient Information to consider.
longer needed for therapy.
○ If no longer used, it can cause infection. IV CANNULA SELECTION
● Peripheral IV cannulas are easier to insert and care for than central lines. ● Use a catheter slightly smaller than the chosen vein.
● A small-gauge, shorter cannula usually causes less trauma to the vessel and ● Use the smallest gauge catheter that can deliver prescribed therapy at
is easier to insert than a larger or longer cannula. desired rate.
○ Violet 26g - for infants or adults who have small veins ● Use an 18 to 20 gauge cannula for rapid infusion of IV fluids, blood
○ Yellow 24g - pedia, adult or infusion components or viscous medications.
○ Blue 22g - commonly used; if the px won’t receive BT or not ● Use a short 22 to 24 gauge cannula for older adults and pediatric patients.
severely dehydrated; can be used for infusion. ● Use longer cannula for obese patients with veins deep in subcutaneous
○ Pink 20g - adult, geria, BT, hydration. tissue.
○ Green 18g - rapid re-dehydration; for surgery, BT, dehydration, ● Thicker catheters cause more painful insertion.
○ other severe cases. ● The tip of the catheter should be inspected for integrity prior to
○ Gray 16g - for severe cases, burn, BT, for puncturing skin venipuncture. Only 2 attempts at venipuncture is recommended.
(e.g. thoracentesis), insertion for umbilical (to
withdraw when px has di culty in urinating).

Fig. 1. Veins of Forearm and Hand

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INITIATE PERIPHERAL VENOUS ACCESS STAGES OF DECOMPOSITION

1. Place the patient in low Fowler's position in bed. Place a protective towel 1. PALLOR MORTIS
or pad under the patient's arm.
● Paleness of death
2. If long extension tubing is used, remove the protective cap and attach it to
● Almost immediately after death a body of a patient with light skin will begin
the distal end of IV tubing, prime extension tubing.
to grow very pale.
3. Select and palpate for an appropriate vein. Select distal site in
○ This is caused by a lack of blood in the capillary region of the blood
nondominant arm if possible.
vessel.
4. Apply gloves.
5. Apply a tourniquet 3 to 4 inches above the venipuncture. 2. ALGOR MORTIS
6. Ask the client to open and close the fist. Observe and palpate for a suitable ● Cool of death.
vein. Try the following techniques if a vein cannot be felt: ● After death, a human body will no longer be working to keep warm, and as a
a. Massage the patient's arm from proximal to distal end and result will start cooling.
gently tap over intended vein. ● About an hour (after death), a human body will have decreased around 2
b. Remove tourniquet and place warm, moist compresses over degrees celsius until it reaches the temperature of the environment around
intended vein for 10 to 15 minutes. it.
7. Cleanse site with an antiseptic solution using a back and forth friction 3. RIGOR MORTIS
scrub for at least 30 seconds. Do not wipe or blot. Allow to dry completely.
● Death sti ness
8. Use the nondominant hand, placed about 1 or 2 inches below the entry
● About three hours after death, a chemical change in the muscles of a human
site, to hold the skin taut against the vein. Avoid touching the prepared
corpse causes the limbs of the corpse to become sti and di cult to move.
site. Ask the patient to remain still while performing the venipuncture.
9. Enter the skin gently, holding the catheter by the hub in your dominant CARING FOR THE BODY AFTER DEATH
hand, bevel side up, at a 10- to 15-degree angle. Insert the catheter from ● After the physician has pronounced death legally documented the death in
directly over the vein or from the side of the vein. While following the the medical record, care of the body is usually performed by the nurse.
course of the vein, advance the needle or catheter into the vein. ● An autopsy consent may be requested and obtained if required.
10. When blood returns through the lumen of the needle or the flashback ● If the patient is to be an organ donor, arrangements will be made
chamber of the catheter, advance either device into the vein until the hub immediately.
is at the venipuncture site. ● The family often wishes to view the body before final preparations are made,
11. Stabilized catheter with nondominant hand, release tourniquet with the they may be allowed.’
other hand. ● If the patient has any valuables, they are handed over to the relatives.
12. Connect the luer-lock end of the set to the end of the catheter. Secure POST-MORTEM CARE
connection
13. Flush primed extension set, begin infusion by opening clamp or adjusting PURPOSE
roller clamp of IV tubing. ● To clean and prepare the patient’s body before it is transported to the
14. Loop the tubing near the site of entry, and anchor with tape (non morgue.
allergenic) close to the site. CONSIDERATIONS
15. Secure catheter and apply appropriate sterile dressing over site properly ● Determine the needs and desires of the family as the body is prepared for
16. Set the flow rate and begin the fluid infusion. Adjust until the correct drop transfer to the funeral home or morgue.
rate is achieved. Assess the flow of the solution and function of the ● Consider the well being of the roommates and others in the unit.
infusion device. Inspect the insertion site for signs of infiltration. ○ Be certain of the religious belief of the patient if catholic.
17. Remove equipment and return the patient to a position of comfort. ○ Prepare communion equipment at bedside if patient desires to receive
18. Remove gloves and wash hands. the sacrament.
DOCUMENTATION ○ When there is danger of a child or fetus dying without baptism,
● Update patient’s plan of care and medical record as appropriate include: anyone can administer
○ Date and Time of IV insertion ● Ensure that the deceased’s belongings are given to significant others.
○ Description of IV cannula insertion ● Implement Standard Precautions: Use
○ Patient tolerance of IV cannula insertion ● If there are visitors in the room carefully explain the situation and ask them
○ Any unexpected patients events or outcomes intervention performed to temporarily leave the room if possible.
○ you may allow at least 1 or 2 relative to stay behind the room if
and whether the treating clinician was notified.
requested to watch or help
● Follow the hospital procedure regarding the notification of various dept. and
- END OF PERIPHERAL IV INSERTION - personnel.

MATERIALS
POST-MORTEM CARE
● Bathing supplies
● Care of a body after death. ● Shroud or morgue bag orr mortuary bag
● Cleaning and preparing the body to enhance the appearance during viewing ● 3 identification tag
of the family. ● Roll of gauze
● Ensures proper identification. ● Paper/plastic bag for personal belongings
PRONOUNCEMENT OF DEATH ● Morgue cart
● Absence of carotid pulses ● Disposable gloves, gown and other protective clothing
● Pupils are fixed and dilated ● Plastic bag for hazardous waste disposal
● Absent heart sounds ● Wash basin, washcloth, warm water and bath towel
● Absent breath sounds ● Clean gown
● Absorbent pads
MENTAL AND PHYSICAL CHANGES UP TO 2 WEEKS BEFORE DEATH
● Scissors syringes for removing Foley Catheter
● Excessive sleep
● Body bag or plastic shroud
● Lower body temperature
● Paper tape, gauze dressings
● Irregular pulse
● Receptacle for client's belongings
● Lower blood pressure
● Valuable envelope
● Disorientation
● Increased perspiration
● Skin color and breathing changes
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○ Alamin ang faith ng dying patient because you need to consider it.
PROCEDURE
○ If Catholic,
1. Wash hands.
■ Prepare a communion equipment at bedside if patient desires to
○ Reduce transmission of microorganisms.
receive the sacrament.
2. Provides privacy.
○ Limits exposure of other clients to the person's death. ■ Call the priest.
3. Apply gloves, protective barriers. ■ When there is danger of a child or fetus dying without baptism,
○ Body excretions may harbor infectious microorganisms. anyone can administer baptism as follows:
4. Identify the body. ➭ “I BAPTIZE THEE __________ IN THE NAME OF THE FATHER,
○ Ensures proper identification of the body for delivery to the morque. AND OF THE SON, AND OF THE HOLY SPIRIT.”
5. Remove all tubes: Iv, catheter, and oxygen. Dress puncture wounds with ● Ensure that the deceased’s belongings are give to their significant others.
dressing and paper tape as directed by agency policy, some require that all ○ Be mindful kung sino kinakausap at pinagbibigyan mo ng mga gamit.
tubes in the body remain in place. ■ Mahirap hanapin saatin yung mga gamit ng dying patient.
○ Creates a normal appearance. Paper tape minimizes skin trauma. ● Implement Standard Precautions: Use protective equipment for the level of
6. If with dentures, wash and reinsert them. If the mouth fails to close, place a anticipated body substance exposure.
rolled-up towel under the chin. ○ Take care of yourself so that you can take care of others.
○ Dentures maintain natural facial expression. It is di cult to insert EQUIPMENT
dentures after rigor mortis.
● Disposable Gloves, Gown, and Other Protective Clothing
7. Position client, straighten the body in supine position. Avoid placing one
● Wash Basin, Wash Cloth, Warm Water, and Bath Towel
hand on top of the other.
○ Placing one hand on top of the other can lead to discoloration of the ● Plastic Bag for Hazardous Waste Disposal
skin. ● Clean Gown
8. Place a small pillow under the head or elevate the head of bed 10 to 15 ● Absorbent Pads
degrees. ● Scissors and Syringes for Removing Foley Catheter
○ Prevents blood from discoloring the face. ● Body Bag or Plastic Shroud
9. Close eyes gently by grasping eyelashes and pulling lids over corneas of the ● ID Tag
eyes. ● Paper Tape and Gauze Dressings
○ Closed eyes present a more natural appearance. Pressure on lids can ● Receptacle for Client’s Belongings
lead to discoloration.
● Valuable Envelope
10. Wash body parts soiled by blood, urine, feces or other drainage.
○ Prepares the body for viewing and reduces odors. [INSERT TEXT]
11. Place absorbent pad under buttocks. 1. Wash hands.
○ To take up any feces and urine released because of the relaxation of ➢ Reduces transmission of microorganisms.
the sphincter muscle. 2. Provide privacy.
12. Remove soiled dressings and replace with clean gauze dressings. Use paper ➢ Limits exposure of other clients to the person’s death.
tape. 3. Apply gloves, protective barriers.
○ Changing dressings helps to control odors caused by microorganisms ➢ Body excretions may harbour infectious microorganisms.
and to create a more acceptable appearance. 4. Identify the body.
13. Place a clean gown on the client. ➢ Ensures proper identification of the body for delivery to the morgue.
○ Prepares the body for viewing. 5. Remove all tubes: IV, catheter, and oxygen. Dress puncture wounds with
14. Brush and comb hair. Remove any clips, hairpins or rubber bands.
dressing and paper tape as directed by agency policy, some require that all
○ The client should appear well-groomed. Hard objects such as pins can
damage or discolor the face and scalp. tubes in the body remain in place.
➢ Creates a normal appearance. Paper tape minimizes skin trauma.
15. Place the body in a body bag or apply the shroud.
○ Prevents injury to skin and extremities. Avoids unnecessary exposure 6. If with dentures, ask and reinsert them. If mouth fails to close, place a
of body parts. rolled-up towel under the chin.
16. Label the body. ➢ Dentures maintain natural face expression. It is di cult to insert
○ Ensures proper identification of the body. dentures after rigor mortis.
17. Arrange transportation of the body to the morgue or mortuary. 7. Position client, straighten the body in supine position. Avoid placing one
hand on top of the other.
➢ Placing one hand on top of the other can lead to discoloration of the
- END OF POST-MORTEM CARE - skin.
8. Place a small pillow under the head or elevate the head of the bed 10 to 15
degrees.
CARE OF THE DYING AND THE DEAD
➢ Prevents discoloration of the face.
PURPOSES 9. Close eyes gently by grasping eyelashes and pulling lids over corneas of the
● To monitor the mental, spiritual, and physical needs of the dying person. eyes.
○ When you will be assigned to those very sick client, you really need to ➢ Closed eyes prevents a more natural appearance. Pressure on the lids
stay put at bedside kasi minomonitor mo yung status ng patient. can lead to discoloration.
■ every 15 minutes usually ang monitoring, lalo na sa ICU 10. Wash body parts soiled by blood, urine, feces, or other drainage.
● To prepare the body after death with dignity and respect. ➢ Prepare body for viewing and reduce odors.
○ Take care of the body. 11. Place absorbent pad under the buttocks.
● To conserve the physical contour. ➢ To take up any feces and urine released because of the relaxation of
○ Be patient and ask the family member/s kung nasaan ang mga sphincter muscle.
personal gamit like dentures (or anything that will keep the patient’s 12. Remove soiled dressings. Help and replace with gauze dressings. Use tape.
contour). ➢ Changing dressings help control odor caused by microorganisms to
■ always have self-control to what is happening create more acceptable appearance.
● To make the body presentable and to give accurate means of identification. 13. Place a clean gown on the client.
○ If people are dying at the same time, make sure to identify the ➢ Prepares the body for viewing.
patients correctly. 14. Brush and comb hair. Remove any clips, hairpins, or rubber bands.
CONSIDERATIONS ➢ The client should appear well-groomed. Hard objects, such as pins,
can damage or discolor the face and scalp.
● Determine the needs and desires of the family as the body is prepared for
15. Place body in body bag or apply the shroud.
transfer to the funeral home or morgue. ➢ Prevents injury to skin and extremities. Avoids unnecessary exposure
○ Kausapin ang pinaka-malapit na significant family member kasi of body parts.
madalas nagkakagulo na sila kapag pinag-uusapan ang funeral.
16. Label the body.
● Consider the well-being of the roommates and others in the unit. ➢ Ensures proper identification of the body.
○ Take a curtain na may gulong to provide privacy sa other patients
17. Arrange transportation of the body to the morgue or mortuary.
inside the unit.
● Be certain of the religious belief of the client.

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