Fundam Nursing Skill Lab Manual

Prepared By
1. Jimma University
2. Wollo University
3. Hawassa University
4. Mekele University
5. Haromaya University
6. University of Gondar
7. Hawassa Health Science college
8. Harar Health Science College
9. Sheba University
10. Alkan University College
11. BahirdarHealth Science College
12. Central University College
13. Ethiopian Nurse Association
1
CHAPTER THIRTEEN
ELIMINATION
Objective: At the end of the chapter, the learner will be able to:-
1. Insert indwelling and plain urinary catheter for male and female clients
2. Perform bladder irrigation
3. Provide care for client with supra-pubic catheter
4. Identify types of enema solution with possible advantage and disadvantage
5. Re-demonstrate proper technique of enema administration
6. Provide care for colostomy appliance
7. Manage colostomy irrigation
Definition- act of voiding or expelling waste material from the bowels
1.1. Urinary elimination

Categories of urethral catheters
1. Straight or Robinson catheter a single lumen tube

2. Retention or Foley catheter contains second lumen ( two and three way catheter)
3. Coude (elbowed):- used for elderly men who have BPH- which is curved tip
Types of Catheterization (routes)
 Urinary catheterization
 Suprapubic catheterization
1.1.1. Urinary catheterization

Learning objective: At the end of the lesson, the learner will be able to
1. Define urinary catheterization

2. List the purpose of urinary catheterization
3. Identify the necessary equipment for catheterization
4. Perform procedure of urinary catheterization
Definition: Urinary Catheterization- involves inserting a small tube/ catheter through the
urethra in to the bladder to allow urine to drain
2
 Catheters: are tubes commonly made of rubber or plastics, although certain types are
made of woven silk or metal.
Purpose
 To empty the bladder in case of retention of urine, occurring as a post operative

complication
 In case of retention due to injury or tumor of the spinal cord
 In case of obstruction due to the blockage of the urethra causing stricture
 To obtain sterile specimen of urine
 To ensure that the bladder is empty before an abdominal or pelvic operation or
Paracenthesis
 To keep incontinent patient dry
 To avoid contamination after operation of vagina or perineum
 To empty bladder irrigation or instillation of the bladder
 To determine if residual urine is present in the bladder
 For an accurate measurement of urinary out put
 To facilitate healing of urethra
1.1.1.1. Straight or plain catheterization
1.1.1.1.1. Catheterization using a straight or plain catheter for female

Definition: introducing plain or straight catheter through the female urethra to the urinary
bladder
Purpose
 To relieve discomfort due to bladder distention
 To obtain a sterile urine specimen
 To empty the bladder prior to surgery
Equipment
Sterile
1. 2 Sterile plain catheter rubber or plastic
3
2. A bowl for antiseptic 5. forceps 3#
3. Gauze 6. Sterile receiver
4. Sterile towel(3#) 7. Kidney dish
8. Sterile urine specimen container if needed
Clean
1. Rubber and draw sheet 5. Flash light

2. Antiseptic solution 6. Screen
3. Receiver 7. Specimen form
4. Measuring jug
Procedure
1. Explain procedure to the patient
2. Screen the bed
3. Wash hands
4. Turn blanket and bedspread down to foot of bed
5. Turn top linen up wards to the patient’s chest to protect form complete exposure.
6. Place patient in dorsal recumbent position with the knees flexed and thigh apart then
7. Put rubber and draw sheet under buttocks, cover patient with the linen(if patient soaked use
examination glove)
8. Apply disposable glove
9. Clean starting from mid-thigh with clean warm water and soap and dry the area
10. Open sterile filed
11. Done sterile gloving
12. Create a sterile field and Drape the client with a sterile drape (bottom far side nearside
pubic area)
13. Prepare the equipment and Put receiver for urine near the genital area
14. Place sterile equipment on drape between patient tight
15. Prepare the equipment and Put receiver for urine near the vulva.
16. Use nondominant hand to separate labia until the catheter is inserted
17. Wash the outer skin folds then inner labia and urethral meatus with antiseptic solution from
front to back. (Starting from outer proceeding to inside)
4
18. Put forceps in the receiver kidney dish
19. Wash and Rinse the area well from outer skin folds then inner labia and urethral meatus
finally with distil water from front to back.
21. Dry the dry gauze the outer skin folds then inner labia and urethral meatus from front to back
23. Lubricate the insertion tip of the catheter (5-7 cm in)
24. Expose the urinary meatus adequately by retracting the tissue or the labia minora in an
upward direction
25. Gently insert the catheter into meatus until urine is noted. Continue inserting for 2.5 to 5cm
additional.
26. Remove catheter after desired duration or all expected urine expelled
27. Measure urine, dry area with dry gauze, remove bed protection
28. Position patient comfortable and cover
29. Remove and clean equipment
30. Send specimen to the laboratory
1.1.1.1.2. Male plain or straight urinary catheterization
Definition: Introducing plain or straight catheter through the male urethra to the urinary bladder
Equipment
Sterile
1. 2 Sterile plain catheter rubber or plastic
2. A bowl for antiseptic 7. forceps ( 3 )
3. Cotton swab 8. Sterile receiver
4. Gauze 9. Kidney dish
5. Large sterile fenestrated towel 10. Lubricant
6. Sterile towel
Clean
1. Rubber and draw sheet 3. Receiver
2. Antiseptic solution 4. Measuring jug
5
5. Flash light 7. Specimen forms
6. Screen
Procedure
2. Screen the bed
3. Wash hands
4. Turn top linen up wards to the patient’s Umbilicus and blanket and bed spread up to mid-
thigh.
5. Place patient in dorsal recumbent position with the knees flexed and thigh apart then put
rubber and draw sheet under buttocks, cover patient with the linen
6. Wash the perennial area with warm water and soap
7. Wash hands
8. Open sterile field
9. Put on sterile gloves
10. Place sterile towel under the patient and fenestrated towel over the patient thigh
11. Prepare antiseptic swabs and Pick up penis with non-dominate hand protract foreskin if
not circumcised, grasp directly behind glans and spread meatus between forefingers and
thumbs.
Figure 39: Male catheterization
12. Cleanse penis using circular motion, starting over meatus and working down wards
glans, repeat procedure twice using new swabs always by the help of forceps.
6
13. Pick up catheter, lubricated at least 7.5cm from distal end. Draw penis upwards and
forwards at 900 angle to the leg insert the catheter, lower penis when feeling resistance at
an angle of 60 degree
14. Insert catheter about 18-20cm till urine flow
15. Remove catheter, replace foreskin to avoid complication
16. Remove catheter measure urine, dry area with dry cotton swab, remove bed protection
position patient comfortable and cover
17. Remove and clean equipment
18. Send specimen to the laboratory
1.1.1.2. Insertions of indwelling Urinary catheter
1.1.1.2.1. Insertions of indwelling catheter for male patient

Learning Objective: At the end of the lesson, the learner will be able to
1. Define insertions of indwelling catheter
2. Identify the necessary equipment for insertions of indwelling catheter
3. Demonstrating the procedure of indwelling catheter
Definition: introductions of indwelling catheter through the male urethra in to the bladder
Purpose
 To prevent retention by use of an indwelling catheter
 To prevent frequent catheterization in case where pt is unable to pass urine
 To prevent bed sore in case of urine incontinence
 To prevent infection in cases of perineal operation
Equipment
1. Indwelling catheter rubber or plastic
2. A bowl for antiseptic 7. Forceps ( 3 )
5. Large sterile fenestrated 10. Syringe
towel 11. Sterile water
6. Sterile towel 12. Lubricant
7
Clean
1. Rubber and draw sheet 4. Urinary drainage bag
3. Receiver 6. Adhesive plaster
Procedure
2. Screen the bed
3. Wash hands
4. Turn top linen up wards to the patient’s chest to protect from complete exposure.
5. Place patient in dorsal recumbent position with the knees flexed and thigh apart then put
rubber and draw sheet under buttocks, cover patient with the linen
6. Wash the perennial area with warm water and soap
7. Wash hands
8. Prepare sterile trolley
9. Uncover patient,
10. Put on sterile gloves, place sterile towel under the patient and fenestrated towel over
the pt thigh
11. Test balloon before insertion on sterile filed with recommended amount of sterile water
12. Prepare antiseptic swabs and Pick up penis with non-dominate hand retract foreskin if
not circumcised, grasp directly behind glans and spread meatus between forefingers and
thumbs.
13. Cleanse penis using circular motion, starting over meatus and working down wards
glans, repeat procedure twice using new swabs always by the help of forceps.
14. Pick up catheter, lubricated at least 7.5cm from distal end. Draw penis upwards and
forwards at 900 angle to the leg insert the catheter, lower penis when feeling resistance at
an angle of 60 degree
15. When catheter is inserted, inflate the balloon with 5-15ml as indicated on catheter
16. Pull gently on the end of the catheter to be sure it will not leave the bladder then push
back 2cm to relieve pressure from sphincter
8
17. Attach drainage tube to catheter and drainage bag
18. Tie tube and drainage bag to the bed ,put the bottle below the patient level
19. Cover and comfort the patient
20. Return the equipment
21. Wash hands and document the procedure
1.1.1.2.2. Insertions of indwelling catheter for Female patient
Leaning objective: At the end of the lesson, the learner will be able to
1. Define indwelling catheter for female pt
2. Identify equipments for insertions of indwelling catheter
3. Demonstrate insertions of indwelling catheter
Definition: Introduction of the indwelling catheter through the female urethra in the bladder
Purpose
 To prevent retention by use of an indwelling catheter
 To prevent frequent catheterization in case where pt is unable to pass urine
 To prevent bed sore in case of urine incontinence
 To prevent infection in cases of perineal operation
Equipment
Sterile
1. Indwelling catheter rubber or plastic
2. A bowl for antiseptic 7. Forceps ( 3)
5. Large sterile fenestrated 10. Syringe
towel 11. Sterile water
6. Sterile towel 12. Lubricant
Clean
1. Rubber and draw sheet 4. Urinary drainage bag
3. Receiver 6. Adhesive plaster
9
Procedure
1. Explain procedure to client and Provide for privacy

2. Set the bed to a comfortable height to work, and raise the side rail on the side opposite
you.
3. Assist the client to a supine position with legs spread and feet together or to a side-lying
position with upper leg flexed.
4. Drape client’s abdomen and thighs.
5. Ensure adequate lighting of the perineum.
6. Wash hands, don disposable gloves, and wash perineal area from the mid thigh.
7. Remove gloves and wash hands.
8. bring urine collection bag ready for attaching near to side of bed
9. Done sterile gloving
10. Create a sterile field and Drape the client with a sterile drape (bottom far side
nearside pubic area)
11. Prepare the equipment and Put receiver for urine near the genital area
12. Place sterile equipment on drape between patient tight
13. Prepare the equipment and Put receiver for urine near the vulva.
14. Use nondominant hand to separate labia until the catheter is inserted
15. Wash the outer skin folds then inner labia and urethral meatus with antiseptic solution
from front to back. (Starting from outer proceeding to inside)
17. Wash and Rinse the area well from outer skin folds then inner labia and urethral meatus
finally with distil water from front to back.
19. Dry the dry gauze the outer skin folds then inner labia and urethral meatus from front to
back
21. Lubricate the insertion tip of the catheter (5-7 cm in)
22. Expose the urinary meatus adequately by retracting the tissue or the labia minora in an
upward direction
10
23. Gently insert the catheter into meatus until urine is noted. Continue inserting for 2.5 to
5cm additional.
24. After catheter insertion, the balloon is inflated to hold the catheter in place within the
bladder.
25. Instruct the client to immediately report discomfort or pressure during balloon inflation;
if pain occurs, discontinue the procedure, deflate the balloon, and insert the catheter
further into the bladder.
26. Gently pull the catheter until the retention balloon is snuggled against the bladder neck
(resistance will be met) re-push back 2cm after the test
27. If laboratory test is prescribed, collect some amount of urine in the sterile specimen
bottle straight from the catheter
28. Secure the catheter to the abdomen or thigh and connect to drainage tube
29. Place the drainage bag below the level of the bladder.
30. Remove gloves, dispose of equipment, and wash hands.
31. Help client adjust position.
32. Assess and document
1.1.1.3. Applying a Condom Catheter
Objective-atthe end of this lesson, the learner will be able to
1. define condom catheter

2. describe the purposes of condom catheter
3. apply condom catheter by following the steps
Definition- The condom catheter is an external drainage system to collect urine from male
clients who have incontinence
Purpose
 Provide a means of collecting urine and controlling incontinence without the risk of
infection that an indwelling urinary catheter imposes
Equipment
1. Condom catheter kit with 3. Clean gloves

adhesive strip 4. Basin with warm water and soap
2. Urinary drainage bag/bed pan 5. Towel and washcloth
11
Procedure
1. Wash hands and apply gloves.
2. Select an appropriate condom catheter.
3. Cleanse the penile shaft.
4. Inspect the penile shaft for excessive hair.
5. Inspect the penis for altered skin integrity.
6. Stretch the shaft of the penis and unroll the condom to the base of the penis.
7. Follow product directions for the application of the sealant
8. Attach the condom to the drainage apparatus,
9. either a leg bag or bedside drainage bag.
11. Remove and reapply the condom catheter every 24 to 48 hours, or when leakage occurs.
1.1.2. Bladder Irrigation (open and closed method)
Objective: at the end of this lesson, the learner will able to :
1. Define bladder irrigation
2. Demonstrate bladder irrigation
Definition: it is the washing out of the bladder to clear the catheter and/or the bladder.
Purpose
 To clean the bladder before operation depending on the surgeons order
 To arrest bleeding from the bladder
 To clean the catheter from mucous or blood clots
 To clean bladder form pus
Precaution
 Care should be taken not air into the balder as it may cause spasm
 Not more than 100-300ml must be instilled at a time after bladder operation capacity may
be limited.
 If the catheter is blocked by blood clots, a suction of the catheter must be proceed the
irrigation
12
Equipment
 a complete set to catheterization  Receiver with plaster to put the catheter
end (open method)
 A sterile bladder syringe for open
method  Rubber and draw sheet
 Irrigation solution e.g. normal saline or  clamp

cold solution to stop bleeding
 pail
 Irrigation solution in a beg, infusion set,
 glove
Y-piece, urine drainage tube and bag
clamp for closed method
Procedure for open method
1. Insert catheter as in catheterization

2. If catheter is already in the bladder
3. Put bed protection
4. Draw solution in the syringe
5. Clamp catheter, attach syringe in the catheter, place drainage tube on a swab
6. Decamp instill the solution gently into the bladder
7. With draw syringe, put end of catheter on the receiver which is placed on the bed
protection
8. Repeat this procedure 2-3 times or more until the return solution is clear
9. Clean catheter and drainage tubing with a swab and connect it again
Closed method
1. Prepare solution bag with IV set
2. Connect Y-place to the catheter and IV set to one end of the “Y” and drainage tube to
the other end
3. Intermittent irrigation clamp the drainage tube and let irrigation solution run in the
bladder (100-200ml) then close the set and open the drainage tube empty the bladder.
4. Repeat this procedure as soften as necessary
13
5. Empty the collection bag frequently
6. Subtract the irrigation solution form the total urinary output if balance
1.1.3. Suprapubic catheter care

Objective: atthe end of this lesson, the learner will able to define Supra-pubic catheter and
demonstrate care of catheter.
Definition: A Suprapubic catheter is inserted through the abdominal wall above the symphysis
pubis into the urinary bladder.
Purpose
o to prevent bladder infection
o To keep skin integrity
Care of clients with Suprapubic catheter include
 Regular assessment of the client’s urine, fluid drainage system.
 Skin care around the insertion site involves sterile technique.
 Periodic clamping of the catheter preparatory to removing it and measurement of
residual urine.
 Leaving the catheter open to drainage for 48to 72 hours then clamping the catheter for
3 to 4 hour periods during the day the client can void satisfactory amounts.
 Dressing should be changed whenever they are soiled.
 A small amount of iodine is used.
1.2. Bowel elimination
Objectives: - After completing this lesson, the learner will be able to
1. Define enema
2. Identify different types of enema
3. Demonstrate different types of enema
4. Demonstrate insertion of flatus tube
5. Perform colostomy care and irrigation
6. Demonstrate digital removal of fecal impaction
14
1.2.1. Enema
Definition:
 Is an injection of a liquid in to the rectum, to be returned or retained.
 The term enema is used to refer to the process of instilling fluid through the anal
sphincter into the rectum and lower intestine for a therapeutic purpose.
Purpose:
 To cleanse the lower bowel,

 To assist in the evacuation of stool or flatus
 To instill medication
1.2.1.1.Cleansing enema/evacuating enema/

Objectives: - At the end of this lesson, the learner will be able to
1. Define enema
2. To perform cleansing enema
Definition:- an enema is the cleansing of a portion of the bowel by insertion of fluid rectally
Purpose
 To relieve gas, constipation or fecal impaction

 To cleanse the bowel prior to surgery, childbirth, or diagnostic examination.
 To evacuate the bowel in patients with neurologic dysfunction.
 Evacuates feces in clients with hemiplegia, quadriplegia or paraplegia
 Delivers medication
Types of liquid used for cleansing enema
1. Tape water = 5000 to 1000 cc

2. Soap solution= 5000 to 1000 cc
3. Normal saline - made by mixing one teaspoon of salt in a liter of water usually contains
1000cc of normal saline.
4. Epsom salt 15 gm - 120 gm in 1000 cc of water
15
Precautions
 No need to use too much soap - this may produce sever irritation of the membrane of the
colon.
 Tap water must be administered consciously for infants or adults who have altered kidney
or cardiac reserve this is to avoid water intoxication.
Contraindications
 Rectal surgery  for a patient with appendicitis

 Rectal /anal/ cancer  Rectal /Ana/ fissure
 Rectal infection
Equipment
1.Container for solution 8.Bed pan and toilet tissue

2.Solution at temperature for adult 40-430c 9.IV pole/stand
3.Bath thermometer for infant (37.70c) 10. Gloves
4.Water proof material /mackintosh/ 11. Receiver /kidney dish/
5.Screen, bath blanket, towel 12. Lubricant
6.Enema can with tube 13. Rectal tube /catheter /
7.Gauze to apply lubricant /swab/ 14. Clamp, connector, funnel
Procedure
1. Check physician's order patient

2. Prepare solution for cleansing enema.
3. Gather equipment
4. Provide privacy
5. Wash your hand
6. Identify correct patient and explain the procedure to the patient.
7. Fill water container with 750 to 100 cc of Luke warm solution
8. Allow solution to run through the tubing so that air is removed
9. Raise bed to high position and lower side rails
10. Place bed protector under patient
11. Place patient on left side /left lateral / in a sim’s position
16
12. Lubricate the tip of the tubing with water soluble lubricant
13. Gently insert tubing 3 to 4 inch (6-8cm) in to patients rectum pass the external and
internal sphincters
14. Raise the water container to a maximum height of 45cm
15. Allow solutions to flow slowly
16. Hold the tubing in place in the patient's rectum at all times. Keep abed pan near by
17. After you have instilled the solution, gently remove the tubing instruct patient to hold
solution for 10 to 15 minutes.
18. Elevate the head of the bed so that the patient can assume as squatting position on the
bedpan or assist to bathroom.
19. Provide privacy until the patient has expelled the total volume of the instilled solution
20. Removal and cover bed pan
21. Assist patient with perineal care and help patient to assume a comfortable position
22. If the patient is on strict input and out measure returns to make sure total volume of the
solution is expelled.
23. Clean all equipment and replace in both room or appropriate vocation
24. Wash your hands
1.2.1.2. Retention enema
Objectives:- At the end of this lesson, the learner will be able
1. To define retention enema

2. To identify the necessary equipments
3. To Perform retention enema
Definition: - it is the injection of a liquid in to the rectum, to be retained in the rectum for some
period of time
Purpose:
 To supply the body with fluid

 To give medication
 To soften impacted fecal matter
17
Equipment
1. Enema can 6. Small enema tube

2. Lubricant 7. Rubber sheet
8. Possible solution
3. Clean bedpan
(normal saline, tab
4. Small enema tube water etc)
5. Towel 9. Ordered medication
Procedure
1. Identify and prepare patient as for any enema
2. Fill the ordered solution to the enema can
3. Position patient
4. Expose anal opening and insert rectal tube tip of container 3-4 inches
5. Squeeze contents slowly and empty entire amount in to rectum
6. Remove rectal tube gently
7. Explain to patient that the solution should be retained for one to three hours
before it is expelled
8. A cleaning enema may need to be given to remove the solution (oil) and stimulate
defecation
9. Clean all equipment and wash your hand
1.2.1.3. Rectal wash out
Objectives:- At the end of this lesson, the learner will be able
1. To define rectal wash out

2. To identify the necessary equipments
3. To Perform rectal wash out
Definition: - is the injection of a liquid in to the rectum to be wash out the rectum and colon
Purpose
 To prepare the patient for x-ray examination and sigmoidoscopy

 To prepare the patient for rectum and colon operation
18
Precaution
 The rectal wash out should not exceed for more than 2 hours
 The rectal wash out should be finished one hour be for examination (e.g. x-ray,
sigmoidoscopy) this is to give time for the large intestine to absorb the rest of the fluid
 Give cleansing enema half hour be for the rectal wash out.
Equipment
1. Pitcher 5. Bucket
2. Newspaper 6. Funnel
3. small jug 7. Bedpan
4. Large mug for fluid
8. Tubing and glass connecting
9. Rectal tube or catheter and clamp
10. lotion thermometer 13. Solution of (40 co)
11. Mackintosh and towel 14. glove
12. swab and Vaseline
Procedure
1. Explain the purposes of the procedure to patient

2. Prepare the solution ordered by the physician
3. Bring equipment to bedside
4. Screen the bed and place the patient in the left lateral position with the buttocks on
the edge of the bed
5. Place the mackintosh and towel underneath the buttocks
6. Check the temperature of the fluid and fill the small jug
7. Lubricate the catheter
8. Run the fluid through to expel air and clamp it.
9. Expose the anal region separate the buttocks, with one hand and insert the rectal tube
in to the rectum 8-10 cm
10. Open the clamp and allow to run about 100 cc of fluid in the bowl, then siphon back in
to the bucket.
19
11. Carry on the procedure until the fluid returned is clear
12. Remove the catheter and leave the patient comfortable
13. The amount returned should be measured to ensure that none has been retained
14. Record or chart the time, result and effect on the patient
1.2.2. Inserting a rectal tube
Objective- at the end of this lesson, the learner will be able to
1. describe fecal impaction

2. describe the necessary equipment for removal of fecal impaction
3. demonstrate removal of fecal impaction
Definition:The insertion of a rectal tube is done to manage flatulence (gas) following abdominal
surgery and/or reduce abdominal distention due to flatulence.
Purpose
 It can be used to alleviate abdominal distention.

 It is used to control diarrhea that cannot be controlled with medical management and/or
the use of rectal pouches, pads, or diapers due to extensive skin breakdown
Equipment
1. Rectal tube or catheter, 22 to 30 French

2. Water-soluble lubricant
3. Bedside drainage bag (optional, if rectal tube used to manage diarrhea)
4. Ostomy odor eliminator or similar product (optional)
5. Clean gloves
6. Disposable pads or towels
Procedure
1. Explain rationale regarding need of tube and its short duration of use.
2. Collect the necessary equipment
3. Wash hands.
4. Assemble equipment.
5. Explain procedure to client.
20
6. Position client in left lateral position with upper leg bent over lower leg
7. Place disposable pads (if not available, use towels).
8. Use odor eliminator per manufacturer (optional).
9. Apply gloves.
10. Apply lubricant to a gloved finger.
11. Insert lubricated finger into rectum to check for possible obstructions prior to insertion of
rectal tube.
12. Change gloves if soiled from rectal exam.
13. Lubricate end of catheter.
14. Gently insert catheter into anal canal approximately 10–15 cm (4–6 inches)
15. Attach plastic bag or drainage bag to end of catheter if needed to control odor or stool
16. Inflate balloon of catheter or tape tube to the lower buttock if rectal tube is not to be removed
within 30 minutes
17. Dispose of pad. Remove soiled gloves and place in appropriate receptacle.
18. Wash hands
1.2.3. Colostomy care and irrigation

Learning objectives: At the end of this session the students will be able to:
1. Define colostomy
2. Explain the importance of colostomy irrigation
3. Collect necessary equipments
4. Perform colon irrigation
Definition: Colostomy: is an opening created as a permanent or temporary diversion of the
bowel at the level of the colon
Equipments
1. Tape, if gauze is used 3. Ostomy odor eliminator

2. Clean gloves 4. Bedpan, toilet, or basin
Purpose: to empty the large colon of stool
21
Procedure
1. Wash hands.
2. Apply clean gloves.
3. Assemble irrigation kit: Attach cone or catheter to irrigation bag tubing.
4. Fill irrigation bag with 1000 cc tepid tap water
5. Open clamp and let water from the irrigation bag fill the tubing.
6. Hang bottom of irrigation bag at height of client’s shoulder, or 18 inches above the stoma
ifclient is supine.
7. Check direction of intestine by inserting a gloved finger into orifice of stoma.
8. Place irrigation sleeve over stoma and hold in place with belt
9. Spray inside of irrigation sleeve and bathroom with odor eliminator (usual dose is two
sprays).
10. Cuff end of irrigation sleeve and place into toilet bowl (if client is in bathroom) or bedpan
(if client is in bed or chair).
11. Lubricate the cone end of the irrigation tubing and insert into orifice of stoma through the
top opening of irrigation sleeve
12. Close top of irrigation sleeve over the tubing.
13. Slowly run water through tubing into colon
14. Remove cone after all water has emptied out of irrigation bag.
15. Close end of irrigation sleeve by attaching it to the top of the sleeve.
16. Encourage client to ambulate to facilitate emptying of remaining stool from colon.
17. Remove irrigation sleeve after 20–30 minutes or when stool is no longer emptying from
colon.
18. Cleanse stoma and skin with warm tap water. Pat todry.
19. Place gauze pad over stoma to absorb mucus from stoma.
20. Secure gauze with hypoallergenic tape.
1.2.4. Digital removal of fecal impaction
22
Objective- at the end of this lesson, the learner will be able to
1. define manual fecal impaction

2. list the necessary equipment for manual removal of fecal impaction
3. demonstrate digital removal of fecal impaction
Definition
Removal of hard and large fecal mass that cannot pass through the anus without tissue damage
by inserting one or two gloved fingers into the rectum.
Purpose
 to make client’s rectum free of feces

Limitation
 This procedure can be uncomfortable and embarrassing for the client.

 Manipulating the rectal mucosa can cause local trauma and possibly bleeding.
 The vagus nerve is easily stimulated rectally and may cause the client’s heart rate to slow
dangerously.
Precaution
This procedure should be performed with caution in clients with a history of cardiac disease,
dysrhythmias, or recent rectal or pelvic surgery.
Equipment
1. Disposable absorbent pads 4. Water-soluble lubricant

2. Bed pan 5. Washcloth, towel
3. Clean gloves 6. Basin of water or perianal cleanser
Procedure
1. Explain the procedure to the client

2. Wash hands.
3. Assemble equipment.
4. Explain procedure to client.
23
5. Position client in the left lateral position (Sims’) with upper leg bent over lower leg
6. Place disposable pads (if not available, use towels) underneath client. Position a bedpan near the
client.
7. Use odor eliminator per manufacturer (optional).
8. Apply gloves
9. Apply lubricant to a gloved finger.
10. Insert lubricated finger into rectum to check for fecal impaction.
11. Gently probe for stool by moving finger upward toward the umbilicus, moving finger back and
forth to dislodge stool
12. Once anus relaxes and opens, several fingers can be inserted into rectal canal to assist in removal
of stool. Be sure to lubricate additional fingers.
13. Manipulate the stool mass with the fingers, breaking it up into small pieces.
14. Move the stool pieces toward the anus and remove them. Place removed stool into appropriate
receptacle (i.e., bedpan or disposable bed pad).
15. Monitor the client for complications such as rectal bleeding or slowed heart rate.
16. With clean gloves, provide pericare
17. Dispose of stool in appropriate receptacle.
18. Assist client to use the bedpan or commode if he needs to defecate.
19. Remove gloves and wash hands
24
CHAPTER FOURTEEN
PERI-OPERATIVE CARE
General objective: At the end of the chapter the learner will be able to
1. Perform preoperative patient assessment
2. Provide preoperative care
3. Apply principle of infection prevention inthe intraoperative care
4. Position patient appropriately for the procedure
5. Assume responsibility of scrub nurse
6. Provide immediate post operative care
Definition: Perioperative care is a period of time that constitutes the surgical experience including
preoperative, intra-operative and post operative phases.
14.1. Pre-operative care
Objectives:At the end of the lesson, the learner will be able to:
1. Define preoperative care

2. Identify preoperative activities
3. Assemble necessary equipments
4. Perform appropriate preoperative care
Definition:preoperative care is a care given for a patient from the time the decision is made for
surgical intervention to the transfer of the patient to the operating room.
Purpose
 To prepare the patient emotionally, mentally for surgery

 To prevent complication before surgery unless it is an emergency operation
 To promote patient and family involvement in care
Equipment:
1. Blood pressure apparatus b. Preoperative checklist

2. Stethoscope c. Container for dentures, glasses
3. Enema equipments and solution as needed d. Appropriate storage for valuables
4. Catheterization equipments and clothes
a. Flashlight
25
e. Information packets regarding g. Intravenous fluids, IV set ,syringe
surgery and needles, and equipment as
f. Informed consent forms needed
h. Preoperative medication
i. Transfer cart
Procedures
1. Explain the procedure

2. Check whether the client has any questions regarding the surgery and understands the
procedure.
3. Wash hands
4. Verify admission orders regarding type of surgery, any risks (including recent changes in vital
signs), and client preparation
5. Verify the client by checking name tag and asking name
6. Make the patient NPO for six to eight hours
7. Complete the preoperative checklist, including history, physical assessment, and check of
valuables.
8. Perform neurological assessment, including checks for orientation, eye coordination, hand-
grips, knee bends, and plantar and dorsi-flexion of the feet
9. Perform vascular assessment including checks of pulse, blood pressure, and apical pulse
rhythm, peripheral pulses, and temperature. Compare with previous information. Clients over
50 may require baseline electrocardiogram
10. Auscultate the lungs bilaterally front and back. If any wheezes, rhonchi, coughs, upper
respiratory infections, or increased temperature, notify physician or qualified practitioner
11. Assess the gastrointestinal system (time of last meal, food allergies, bowel sounds, last bowel
movement, time of last fluids).
12. Assess the genital/urinary system (last menstrual period, last void, state of pregnancy, estrogen
replacement therapy).
13. Assess skin and muscle tone for any skin breakdown, redness, bruises, decreased skin integrity
14. Ascertain any allergies or adverse reactions during previous surgeries or use of anesthesia.
15. Obtain medication history, including the time and date of the last dose of medication
16. Ascertain any history of drugs/alcohol use and when they were last used.
17. .Check weight.
26
18. Check if family is available and who is present
19. .Ascertain if client has signed the surgical consent. Determine if the client has a living will or
has designated resuscitation status.
20. Remove all valuables with the exception of wedding rings if requested. Tape rings in place.
Check and document whether valuables are placed in a locked area, safe storage area, or given
to family.
21. Check if eyeglasses and dentures are removed; place in a labeled container
22. Maintain elimination as needed (catheterization, enema)
23. Administer intravenous fluids according to orders
24. Administer medications according to orders.
25. Ascertain that preoperative checklist is complete.
26. Transport the client to appropriate area.
27. Inform family members where surgical waiting area is and establish a way to contact them
when surgery is completed
14.2. Intra-operative care
Objectives:-At the end of the lesson, the learner will be able to:
1. Define preoperative care

2. Identify intra-operative activities
4. Perform appropriate intra-operative care
Definition: intra-operative care is a care given for a patient from when the patient is transferred to
operation room table to when the patient is admitted to the recovery room or post anesthesia care
unit.
Purpose
• To prevent risk of infection

• To reduce risk of injury related to positioning
• To reduce risk of injury related to chemical hazards
• To reduce risk of injury related to foreign objects left in the body
27
Equipment
1. Gloves (clean for shaving; sterile for 6. Sterile cotton swabs

cleaning surgical site) 7. Sterile cotton sponges
2. Razor and sharp blades 8. Transfer forceps in antiseptic solution
3. Sterile gauze (to clean the razor) 9. Solution for surgical site cleaning, such
4. Warm water as 70% alcohol
5. Antibacterial cleansing agent 10. Solution basins
Procedures
1. Review chart for surgery to be performed and determine the exact area to be prepped.
2. Wash hands.
3. Assess client’s level of consciousness and mobility
4. Explain the procedure to client.
5. Be sure that hairpins, jewelry, nail polish, con-tact lenses, prostheses, and dentures were re-moved
during the preoperative preparation.
6. Assist client with transfer from wheelchair or bed to the surgical table.
7. Position the client for optimal access to the surgical site according to institutional protocol
8. .Cover with blanket
9. Cover hair if required
10. Assemble equipment needed
11. \Remove ring(s) and watch. Wash hands and apply clean gloves.
12. The surgical prep sites follow, depending on the type of surgery to be performed.
 Head and neck: The site extends from above the eyebrows, over the top of the head, and
includes the ears and both anterior and posterior areas of the neck. The face and eyebrows
are not shaved.
 Lateral neck: Clean the external auditory canal with a cotton swab. Anteriorly, prepare the
side of the face, from above the ear to the upper thorax to just below the clavicle.
Posteriorly, prepare from the neck to the spine including the area above the scapula.
 Chest surgery: The site extends from the neck to the bottom of the rib cage and to the
lateral midline. The shoulder and arm of the operative side should be included.
 Abdominal surgery: The preparation site ex-tends from the axilla to the pubis extending
bilaterally to the lateral midline. All visible pubic hair should be shaved.
28
 Perineal surgery: Shave all pubic hair and the inner thighs to the midthigh. The area starts
above the pubic bone anteriorly and extends beyond the anus posteriorly.
 Cervical spine surgery: Posteriorly from the top of the ears to the waist. The area extends
on each side to the midaxillary line.
 Lumbar spine surgery :Posteriorly from the axilla down to the midgluteal level of the but-
tocks. The area extends on each side to the midaxillary line
 Rectal surgery: Shave the buttocks from the iliac crest down to the upper third of the
thighs, including the anal region. The area ex-tends to the midline on each side.
 Flank surgery: Extends anteriorly from the axilla, down to the upper thigh, including the
external genital area. Posteriorly the area ex-tends from the midscapular to the midgluteal
regions
 Hand and forearm surgery: The area includes the full circumference of the affected arm,
from the axilla to the fingertips.
 Lower extremity surgery: The area includes the entire leg, toes, and foot of the affected
leg from the umbilicus anteriorly and the top of the buttocks posteriorly.
 Lower leg surgery: The area to be prepared includes the circumference of the entire region
from midthigh to the distal toes of the affected leg.
13. Arrange for adequate light on the area to be prepared.
14. Using warm water, hold the skin taut and hold the razor at a 45° angle. Shave the area care-fully by
stroking in the direction of hair growth. Rinse the razor carefully to remove ac cumulated hair from
the blade.
15. Dry the client’s skin with a sterile towel.
16. Clear the shaving supplies from the preparation area.
17. Apply sterile gloves and gown.
18. Scrub the surgical site with an antibacterial cleaner. Using a rotary movement to clean the skin,
begin in the center and gradually enlarge the area with each rotation.
19. Continue this process for three to ten minutes as prescribed by institutional policy.
20. Clean any hidden areas in the surgical site (the ear canals, under the fingernails, the umbilicus)
using cotton swabs.
21. Rinse the area with sterile water. Wait for the site to dry or pat dry with a sterile towel.
22. .Cover the area with sterile drapes leaving the surgical site exposed
29
13.3. Postoperative Care
Objective: At the end of the practical session, the students will be able to:
1.Define postoperative care

2.Identify postoperative activities
3.Assemble necessary equipments
4.Perform appropriate postoperative care
Definition: postoperative care is a care given for a patient which begins with the admission of the
patient to the post anesthesia care unit and ends after follow up evaluation in the clinical setting.
Purpose
 To prevent any complication from anesthesia

 To detect sign of post operative complications
 To rehabilitate the patient
 To re-establish physiological equilibrium
 To alleviate pain
Equipment
1. Vital sign equipments 6. Sterile dressings as needed

 Stethoscope 7. Client’s chart with postoperative
 Sphygmomanometer orders
 Thermometer 8. Incentive spirometer (may be optional)
2. Watch 9. Supplemental oxygen, if needed
3. Oximeter 10. Sequential stockings and/or anti
4. Blankets embolic stockings (as ordered)
5. Cardiac monitoring equipment 11. Gloves
Procedures
1. Wash hands and apply gloves.

2. Check the client’s temperature, pulse, respiratory rate, and blood pressure upon the client’s arrival
in the unit.
3. Identify client via armband and verify the client’s identity with the chart.
4. Inform the client that she/he is out of the operating room and in the recovery room.
30
5. If bedside electrocardiogram monitoring is available, attach the leads to the client and run a
baseline electrocardiogram strip.
6. Attach the oximeter to the client and monitor the client’s oxygen saturation
7. Check intravenous (IV) site using gloves. Check IV solution(s), flow rate, and that the IV line is
taped as necessary
8. Check surgical dressing and site, if visible. Assess dressings for amount and type of drainage.
Reinforce the dressings as needed.
9. Complete a total head to toe assessment
10. Encourage the client to deep breathe, cough, and use the incentive spirometer
11. Check and implement postoperative orders.
12. Inform the client’s family or significant other that the client is in the recovery room.
13. Turn the client every hour, maintaining proper alignment.
14. Upon discharge by the postanesthesia care-giver, a full report of the postanesthesia phase and
intraoperative course of events should be given to the nurse assuming care of the client.
Perioperative Nursing Care

When caring for post-surgical patient,
think of the “4 W’s”
Wind: prevent respiratory

complications
Wound: prevent infection
Water: monitor I & O
Walk: prevent thrombophlebitis
By Agezegn A Hawassa University
31
CHAPTER FITEEN
OXYGENATION
General objective: at the end of this chapter the learner will be able to:-
1. Utilize different oxygenation delivery system when necessary
2. Provide suctioning of airway
3. Give Nursing care to patient with tracheostomy
4. Provide CPR for Adult, children and infant
5. Monitor oxygenation level of client
1.1. Monitoring with pulse oximetery

Objectives: At the end of this lesson learner will be able to:
1. Define pulse oximetery
2. Describe indications of pulse oximetery
3. Explain the purpose of pulse oximetery
4. Demonstrate how to measure oxygen concentration using pulse oximetery
Definition
 Monitoring with pulse oximetery refers to the process of determining effectiveness of
pulmonary gas exchange and arterial gas saturation.
Purpose
 To monitor arterial oxygen saturation non-invasively.
 To detect clinical hypoxemia promptly.
 To assess client tolerance to tapering of oxygen therapy or activity.
Indications
 COPD
 Sleep apnea
 monitor oxygenation during sleep apnea ,acute illness perioperativly, pulmonary exercise,
stress testing and while the patient is on mechanical ventilation
Equipment
1. Pulse oximetry apparatus
2. Documentation chart
Procedures
1. Select appropriate type of sensor
2. Explain purpose of procedure to client and family
32
3. Perform hand washing
4. Instruct client to breathe normally.
5. Select appropriate site to place sensor.
6. Avoid using lower extremities that may have compromised circulation, or extremities receiving
infusions or other invasive monitoring
7. If clients has poor tissue perfusion due to peripheral vascular disease or is receiving
vasoconstrictor medications nasal sensor or forehead sensor may be considered.
8. Remove nail polish from digit to be used.
9. Attach sensor probe and connect it to the pulse oximetery. Make sure the photo sensors are
accurately aligned.
10. Watch for pulse sensing bar on face of oximetery to fluctuate with each pulsation and reflect
pulse strength.
11. Double check machine pulsations with client’s radial or apical pulse.
12. If continues pulse oximetery is desired, set the alarm limits on the monitor to reflect the high
and low oxygen saturation and pulse rate.
13. Inspect the sensor site every four hours for tissue irritation or pressure from the sensor.
14. Read saturation on monitor and document as appropriate with all relevant information on
clients chart.
15. Wash your hands
16. Return used equipment
17. Document and report abnormal results to the responsible clinician
1.2. Oxygen Administration
Objectives: At the end of this lessonlearnerwill be able to:

1. Define oxygen administration
2. Identify the indications and contraindications of oxygen administration
3. Describe the precautions of oxygen administration
4. Identify the different methods of oxygen administration
5. Re -demonstrate oxygen administration by using different methods
Definition
 Oxygen administration is provision of oxygen for a patient with a serious respiratory problem by
using oxygen administration methods
33
Purpose
 Used primarily to reverse hypoxemia
 To provide and maintain a normal supply of oxygen for blood, and tissues.
 To provide adequate transport of oxygen in the blood while decreasing the work of breathing
and reducing stress on the myocardium.
 Decrease work of the heart in clients with cardiac disease
 To relieve dyspnea
Indication
 Respiratory failure: • Cystic fibrosis
• Type 1 (hypoxemic): Saturation < • Chest injury
90%. PaO2 <60 mm Hg  Blood disorders such as anemia
• Type 2 (hypercapnic): PCO2>50  Cardiac insufficiency
mmHg, pH<7.35  High metabolic demands
 Lung diseases and injury  Hypoxia
• COPD  Hypoxemia
• Pneumonia  Asphyxia
• Bronchial asthma  Gas poisoning
Precautions
 A “no smoking” sign must be posted in the client’s room to prevent the risk of fire 3 meters
 The catheter tip and the cylinder itself must not be lubricated with Vaseline, oil.
 Never use alcohol on the patient’s skin while the oxygen is run.
 Never use an electrical facial shaver (razor) while the oxygen is in use.
 The cylinder must be handling carefully as the oxygen is under pressure
 The fine adjustment must always be closed when the main tap is turned on.
 Check that if there is obstacle in the patient airway before giving oxygen in order to prevent
patient from suffocation.
 The rate of flow will be ordered by the doctor.
 Protect patient from asphyxiation by inspecting regularly the pressure gauge and flow
 Monitor the vital signs, and mental status.
 Transport oxygen cylinder always by the transport cart.
 Never deliver more than 2-3 liters of oxygen to patients with chronic lung disease, e.g. COPD
Methods of oxygen administration
34
1. Face mask
2. Nasal cannula
3. Nasal catheter
4. Oxygen tent/hood
1.2.1. Oxygen administration via face mask
1. Define Oxygen administration via face mask
2. Describe the specific purposes of Oxygen administration via face mask
4. Demonstrate oxygen administration by using face mask
Definition
 Oxygen administrations via face mask administering oxygen to the patient by means of face
mask according to requirement of patient ( Figur..).
Purpose
 Used to administer higher concentration of oxygen.
Equipment
1. A cylinder of oxygen. 5. Humidifier with distil water
2. Face Mask of appropriate size 6. Gauzes
3. Regulator 7. No smoking sign
• Gauge 8. Equipments for V/S
• Flow meter 9. Receiver
4. Oxygen tube 10. Chart
Procedure
1. Determine need for oxygen therapy
2. Check order for rate, device to be used and concentration.
3. Greet the patient and explain the procedure (if conscious) to the relatives (if unconscious).
4. Wash hands.
5. Assemble equipment to the bedside
6. Perform an assessment of vital signs, level of consciousness, lab. Values etc and record.
7. Assess risk factors for oxygen administration in patient and environment like – hypoxia drive
in patient and faulty electrical connection.
8. Post “No smoking” signs on patient’s door “oxygen in use” sign on the bed
35
9. Place the patient on fowlers position unless contraindicated
10. Check for patency of air ways
11. Set up oxygen equipment and humidifier:
a. Attach regulator to source. Set flow meter in “Off” position.
b. Open main tap while flow meter is closed then turn on fine adjustment to release small
amount of oxygen, to clean the inside of regulators
c. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
d. Fill humidifier with sterile water between the maximum and minimum mark on it.
e. Attach humidifier bottle to base of the flow meter.
f. Check the presence of bubbling in humidifier to confirm the flow of oxygen through.
g. Attach tubing and face mask to humidifier.
h. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube and mask before applying to the patient (feel the
incoming air with your cheek).
13. Clean the mouth if there is visible soiled
14. Apply mask to patient face from nose to down ward
15. Secure elastic band around patient head.
16. Apply gauze behind ears as well as scalp where elastic band passes.
17. Ensure that safety precautions are followed.
18. Inspect patient and equipment frequently for flow rate, clinical condition, level of water in
humidifier etc.
19. Wash hands
20. Remove the mask and dry the skin every 2-3 hours if oxygen is administered continuously
21. Document relevant data in patient record
36
Simple mask Partial rebreather mask
Nonrebreather mask
Figure 40: Oxygen administration via face mask
1.2.2. Nasal Cannula (Nasal Prongs) or nasal catheter

1. Define Oxygen administration via nasal cannula

2. Describe the specific purposes of Oxygen administration via nasal cannula
4. Demonstrate oxygen administration by using nasal cannula
Definition
 A method by which oxygen is administered in low concentration through a cannula which is a
disposable plastic device with two protruding prongs for insertion in to the nostrils (Figur..)
37
Purposes
 To administer low concentration of oxygen to patients
 To allow uninterrupted supply of oxygen during activities like eating, talking
 Light weight, comfortable, continuous use with meals and activity
Equipments
2. Nasal cannula 6. Gauzes
 Gauge 8. Equipments for V/S
 Flow meter 9. Receiver
Procedure
1. Determine need for oxygen therapy
2. Check order for rate, device to be used and concentration.
3. Greet the patient and explain the procedure (if conscious) to the relatives (if unconscious).
4. Wash hands.
8. Post “No smoking” signs on patient’s door “oxygen in use” sign on the bed
10. Check for patency of air ways
i. Attach regulator to source. Set flow meter in “Off” position.
j. Open main tap while flow meter is closed then turn on fine adjustment to release small
k. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
l. Fill humidifier with sterile water between the maximum and minimum mark on it.
m. Attach humidifier bottle to base of the flow meter.
n. Check the presence of bubbling in humidifier to confirm the flow of oxygen.
38
o. Attach tubing to humidifier and then to the nasal cannula
p. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube before applying to the patient (feel the incoming
air).
13. Place tips of cannula to patient’s nares and adjust straps around ear for snug. The elastic band
may be fixed behind head or under chin. If nasal catheter it should be lubricated preferably
with water and passed backward into pharynx till the tip of the catheter is opposite the uvula.
14. Pad tubing with gauze pads over ear and inspect skin behind ear periodically for
irritation/break down.
humidifier etc.
17. Wash hands
18. Remove the mask and dry the skin every 8 hours if oxygen is administered continuously
Figure 41: Oxygen administration via nasal cannula
NB: A patient receiving oxygen by catheter requires special mouth and nose care since the catheter
tends to irritate the mucous membrane.
39
1.2.3.Giving oxygen by tent/hood
Objectives: At the end of this lesson, learner will be able to:
1. Define Oxygen administration via oxygen tent
2. Describe the specific purposes of Oxygen administration via oxygen tent
4. Demonstrate oxygen administration by using oxygen tent
Definition
 Methods of administering oxygen via tent /hood
Purposes
 To administer high concentration of oxygen to patients
 To administer oxygen for infants
Equipments
2. Oxygen tent/hood 6. Gauzes
a. Gauge 8. Equipments for V/S
b. Flow meter 9. Receiver
Procedure
1. Determine need for oxygen therapy, check physicians order for rate, device to be used and
concentration.
2. Identify the patient
3. Explain the procedure to the relatives of the infant.
4. Wash hands.
8. Post “No smoking” signals on patient’s door in view of patient and visitors and explain to
them the danger of smoking when oxygen is on flow.
10. Instruct him/her to clean his nostril to avoid obstruction (if well enough)
40
q. Attach regulator to source. Set flow meter in “Off” position.
r. Open main tap while flow meter is closed then turn on fine adjustment to release small
s. Read the gauges (or check the color in gauges) of the cylinder to determine the amount
of oxygen.
t. Fill humidifier with sterile water between the maximum and minimum mark on it.
u. Attach humidifier bottle to base of the flow meter.
v. Check the presence of bubbling in humidifier to confirm the flow of oxygen.
w. Attach tubing to humidifier and then to the oxygen tent
x. Adjust flow meter to prescribed level
12. Check the flow of oxygen through the tube before applying to the patient (feel the incoming
air).
13. Prepare tent and position over bed attach to oxygen source
14. Place client in tent observe all safety precautions
15. secure tent by folded towels
16. Change cloth and linens as necessary
humidifier etc.
19. Wash hands
20. Oxygen catheter are removed every 8 hrs and a clean catheter is inserted into the other nostril.
41
1.3. Air way suctioning
1.3.1. Performing Nasopharyngeal and Oro pharyngeal Suctioning
Objectives: At the end of this practical session, the students will be able to:
1. Define nasopharyngeal and oropharyngeal suctioning
2. Describe the purposes of nasopharyngeal and oropharyngeal suctioning
3. List the indications and contraindications of suctioning
5. Demonstrate nasopharyngeal and oropharyngeal suctioning
Definition
 The removal of secretion from the nasopharynx and oropharynx by using suction catheter and
suction machine
Purposes
 To clear secretions the client cannot remove by coughing.
 To relief dyspnea caused by secretion accumulation
 To maintain patent air way
 To collect sputum or secretions for diagnostic testing
 To prevent aspiration
Indications
 For nasopharyngeal suctioning
 Post operative patient
 Conscious patients who cannot maintain airway
 Can be used with intact gag reflex
 For oropharyngeal
o Unconscious patients
o Secretion in oral cavity
Precaution
 Limit suctioning to 3 times per day for adult but if needed consult your physician
 Never insert the catheter in to nares or mouth while the suction is on and the port is closed
 Never suction more than 15 seconds for adult and 10 seconds for infant at a time to avoid
hypoxia.
Contraindication
 For oropharyngeal suctioning
42
o Mouth/buccal burn
o Conscious patient
 For nasopharyngeal suctioning
o Head injuries
o Nosebleeds
Equipments
1. Suction machine: Wall suction/portable 5. Normal saline
suction with extension tubing connected 6. Sputum cup(if conscious)
to suction device 7. Sthetescope
2. Sterile glove 8. Pen light (if nasopharyngeal)
3. Sterile suction catheter 9. Gauze/soft tissue
o French of suction catheter 10. Waste receiver
 For infant from 5-8 fr 11. Ambo bag
 For child from 8-10 fr 12. Gown and mask and goggles or face
 For Adult from 12-16 fr shield if indicated
4. Sterile solution container (or sterile 13. Sterile or clean towel/water proof/
kidney dish) 14. Mouth care set
Procedures
1. Determine the need for suctioning, check physicians order.
3. Explain the procedure to the patient if conscious otherwise for his/her relatives. Advice that
suctioning may cause coughing or gagging but emphasize the importance of clearing the airway.
4. Wash hands.
6. Assess the client’s need for suctioning: inability to effectively clear the airway by coughing and
expectoration; coarse bubbling or gurgling noises with respiration.
7. Choose the most appropriate route (nasopharyngeal or oropharyngeal) for your client. If
nasopharyngeal approach is considered, inspect the nares with a penlight to determine patency.
Alternatively, you may assess patency by occluding each nare in turn with finger pressure while
asking the client to breathe through the remaining nare if conscious.
8. Position the client in a high Fowler’s or semi- Fowler’s position and apply clean water proof towel
over the chest of the patient.
43
9. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying
position.
10. Connect extension tubing to suction device if not already in place, and adjust suction control to: If
portable suction unit If wall unit suction machine
 For infant from 2-5 mmHg -For infant from 50-95 mmHg
 For child from 5-10 mmHg -For child from 95-110 mmHg
 For Adult from 10-15 mmHg -For Adult from 100-120 mmHg
11. Open packed sterile instrument and prepare on a sterile field.
12. Pour about 100 ml of solution into the sterile container, unpack sterile suction catheter.
13. Oxygenate the patient with ambo bag 3-5 ventilation
14. Put on gown and mask and goggles or face shield if indicated.
15. Put on the gloves using sterile gloving technique
16. Using your sterilehand (Dominant hand), pick up the suction catheter. Grasp the plastic connector
end between your thumb and forefinger and coil the tip around your remaining fingers.
17. Pick up the extension tubing with your clean hand (Non-dominant). Connect the suction catheter
to the extensiontubing, taking care not to contaminate thecatheter.
18. Position your clean hand on the extension tube.
19. Dip the catheter tip into the sterile solution, and activate the suction with your non-dominant hand.
Observe as the solution is drawn into the catheter. It will also lubricate the catheter
20. For oropharyngeal suctioning, ask the client to open his or her mouth. Without activating the
suction, gently insert the catheter and advance it until you reach the pool of secretions or until the
client coughs or insert 4 inches (12 cm).
21. For nasopharyngeal suctioning, estimate the distance from the tip of the client’s nose to the
earlobe and grasp the catheter between your thumb and forefinger at a point equal to this distance
from the catheter’s tip.
22. Insert the catheter tip into the nare with the suction control port uncovered. Advance the catheter
gently with a slight downward slant. Slight rotation of the catheter may be used to ease insertion.
Advance the catheter to the point marked by your thumb and forefinger
23. If resistance is met, do not force the catheter. Withdraw it and attempt insertion via the opposite
nare.
44
24. Apply suction intermittently by occluding then suction control port with your thumb; at the same
time, slowly rotate the catheter by rolling it between your thumb and fingers while slowly
withdrawing it. Apply suction for no longer than 15 seconds at a time.
25. Repeat step 23 until all secretions has been cleared, allowing 20-30 seconds brief rest periods
between suctioning episodes.
26. Give ambo bag between each single suctioning
27. Instruct the patient to have deep breathing and coughing exercise if conscious. Give sputum cup if
he/she needs to spit secretion then clean with soft tissue/gauze.
28. Withdraw the catheter by looping it around your fingers as you pull it out.
29. Dip the catheter tip into the sterile solution and apply suction after a brief rest.
30. Disconnect the catheter from the extension tubing, holding the coiled catheter in your gloved
hand.
31. Provide the client with oral hygiene if indicated or desired.
32. Return used supplies in the appropriate container.
33. Remove the glove by pulling it over the catheter; discard catheter and gloves in an appropriate
container.
34. Check the effectiveness of the procedure with Sthetescope
35. Wash your hands.
36. Document the procedure, noting the amount, color, and odor of secretions and the client’s
response to the procedure.
1.3.2.Endotracheal tube/tracheal suctioning

Objective:At the end of this lesson learner will be able to:
1. Define Endotracheal tube/tracheal suctioning
2. Explain the precautions of Endotracheal tube/tracheal suctioning
3. Prepare equipment for Endotracheal tube/tracheal suctioning
4. Prepare the patient for Endotracheal tube/tracheal suctioning
5. Monitor the patient during and after the Endotracheal tube/tracheal suctioning
6. demonstrate proper suctioning of Endotracheal tube/tracheal suctioning
Definition: Endotracheal tube/tracheal suctioning is the process of applying a negative pressure to the
distal trachea by introducing a catheter to clear excess, or abnormal, secretions.
Purpose:The nurse performs Endotracheal and tracheostomy suctioning to:
1. Maintain a patent airway.
45
2. To improve oxygenation and reduce the work of breathing.
3. To remove accumulated trachea-bronchial secretions using sterile technique.
4. Stimulate the cough reflex.
5. Prevent pulmonary aspiration of blood and gastric fluids.
6. Prevent infection and atelectasis.
Equipment:
1. Sterile normal saline  For infant from 5-8 fr
2. Suction machine: Wall suction/portable  For child from 8-10 fr
suction with extension tubing connected to  For Adult from 12-16 fr
suction device 8. Control port or In-line suction catheter
3. Ambu bag connected to 100% O2 9. Sterile solution container (or sterile kidney
4. Clear protective goggles/mask or face dish)
shield 10. Sthetescope
5. Sterile gloves for open suction 11. Gauze/soft tissue
6. Clean gloves for (in-line) closed suction 12. Waste receiver
7. Sterile catheter with intermittent suction 13. Sterile or clean towel/water proof/
o French/size/ of suction catheter 14. Normal saline
Procedures
1. Explain the procedure to the patient before beginning and offer reassurance during suctioning; the
patient may be apprehensive about choking and about an inability to communicate
3. Begin by carrying out hand hygiene.
4. Assess the client’s need for suctioning: inability to effectively clear the airway by coughing and
expectoration; coarse bubbling or gurgling noises with respiration.
over the chest of the patient.
7. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying
position.
8. Connect extension tubing to suction device if not already in place, and adjust suction control to:
If portable suction unit If wall unit suction machine
 For infant from 2-5 mmHg -For infant from 50-95 mmHg
46
 For child from 5-10 mmHg -For child from 95-110 mmHg
 For Adult from 10-15 mmHg -For Adult from 100-120 mmHg
9. Open packed sterile instrument and prepare on a sterile field.
10. Fill basin with sterile normal saline solution.
11. Ventilate the patient with manual resuscitation bag and high flow oxygen.
12. Put on sterile glove.
13. Pick up sterile suction catheter with gloved hand (Dominant hand) and connect to suction.
14. Hyper oxygenate the patient’s lungs for several deep breaths.
15. Insert suction catheter at least as far as the end of the tube without applying suction, just far
enough to stimulate the cough reflex
16. Apply suction while withdrawing and gently rotating the catheter 360° (no longer than 10 to 15
seconds, because hypoxia and dysrhythmias may develop, leading to cardiac arrest).
17. Re oxygenates and inflates the patient’s lungs for several breaths.
18. Repeat previous three steps until the airway is clear.
19. Rinse catheter in basin with sterile normal saline solution between suction attempts if necessary.
20. Suction oropharyngeal cavity after completing tracheal suctioning.
21. Rinse suction tubing.
22. Discard catheter, gloves, and basin appropriately.
23. Discard catheter, gloves, and basin appropriately.
1.4. Tracheostomy care
Objective: at the end of this practical session, the students will able to:
1. Define tracheostomy care
2. List the indications of tracheostomy care
3. Prepare equipment for tracheostomy care
4. Monitor the patient during and after the tracheostomy care
5. Demonstrate proper tracheostomy care
Definition:
Tracheostomy careis a care given to patient with tracheostomy.
Purpose
 To prevent infection
 To promote respiratory function.
 To bypasses the upper airways
47
 To maintain a patent airway
 Prevent pulmonary aspiration of blood and gastric fluids
 To prevent pneumonia that may result from accumulated secretions
 To allow removal of trachea-bronchial secretions
Indication
 When adventitious breath sounds are detected
 Whenever secretions are obviously present.
Equipment
1. Sterile Tracheal dilator 9. Sterile drapes/water proof pad
2. Sterile cotton-tip applicators 10. Sterile glove
3. Sterile Hydrogen peroxide solution 11. Clean glove
4. Sterile Normal saline (0.9% sodium 12. Suction kit and suction equipment
chloride solution ) 13. Tracheostomy ties
5. Sterile 0.9% sodium chloride solution 14. Ambo bag with 100% oxygen source
containers (2) 15. Mouth care set
a. 1 for suctioning 16. Personal protective devices: gown,
b. 1 for rinsing the inner cannula mask
6. Sterile nylon brush 17. Waste receiver/Plastic bag/
7. Sterile precut 4 × 4 dressing gauze 18. Chart
8. Sterile gauze for drying
Procedure
3. Explain the procedure to the patient if conscious otherwise for his/her relatives.
4. Wash hands.
6. Put on goggles and mask or face shield and gown and don sterile gloves
over the chest of the patient; If the client is unconscious or otherwise unable to protect his or her
airway, place in a side-lying position.
8. Place plastic bag or disposal container within easy reach. Position in an area that does not require
crossing over the sterile field or stoma to discard soiled items.
48
9. Prepare sterile equipments. Loosen the caps on the bottles of sterile saline and hydrogen peroxide
then pour in to each galipot (containers) to 1.25cm
NB: pour hydrogen peroxide in to one galipot/container and normal saline in to the rest two
containers
10. Don clean glove then remove the soiled tracheostomy dressing. Note the amount, color, and odor
of any drainage around the stoma.
11. Gently loosen the inner cannula of the tracheostomy tube by twisting the outer ring
counterclockwise; then withdraw the inner cannula in a smooth motion. Place the inner cannula
into the basin of peroxide.
12. Remove the gloves by pulling them over the discarded dressing, and discard the gloves and
dressing.
13. Put on the gloves using sterile gloving technique
14. Place the sterile drape on the patient’s chest, with its upper edge as near to the tracheostomy tube
as possible.
15. Using your sterile hand, pick up the cannula and pick up the nylon brush then scrub to remove
any visible crusts or secretions from inside and outside the cannula
Figure 42: Cleaning tracheotomy inner cannula
16. Place the cannula into the container of sterile saline. Agitate so that all surfaces are bathed in
saline.
17. Inspect the inner cannula again to be sure it is clean; then remove excess saline from the lumen by
tapping the cannula against a sterile surface then place at dry sterile gauze.
18. Perform suctioning.
NB:
 The pressure of tracheostomy suctioning is similar with nasopharyngeal suctioning
49
 Give 1 full minute rest between each single suctioning
 Oxygenation with ambo bag must be given 3-5 times between each single suctioning
19. Using your sterile hand, pick up a sterile cotton swab and saturate the tip with hydrogen peroxide.
Swab the peristomal skin, including the area under the tracheostomy tube’s faceplate. If you must
touch the tracheostomy tube or the client, do so with your clean hand
Figure 43: structure of tracheostomy
20. Gently replace the inner cannula, following the curve of the tube. When fully inserted, lock the
inner cannula in place by rotating the external ring clockwise until it clicks into place.
21. Place a new precut sterile gauze dressing around the stoma, between the faceplate and the skin.
22. Inspect the ties or strap securing the faceplate. If damp or soiled, carefully cut the ties (or loosen
the Velcro to remove a strap). Remove the ties or strap and inspect the underlying skin for redness
or breakdown. (Now no longer sterile procedure is needed)
23. To replace ties, cut a length of twill tape about as long as the circumference of the client’s neck.
Fold over one end to 1 inch and cut a small (1/2 inch) slit into the folded end.
 Thread the slit end of the tape through the eye of one side of the tracheostomy
faceplate from the underside of the faceplate. Thread the end of the tie through the cut
slit and secure it with a knot.
 Slip the tape under the client’s neck, keeping it smooth and flat against the skin.
 Bring the loose end of the tape around to the other side of the faceplate. Ask the client
to flex his or her neck and slip one of your fingers under the tape as you measure the
desired tightness of the tie.
 Fold the end of the tape and cut a slit as in step then tie the end. Trim off excess tape
from the end and knot the cut ends of the tape.
50
Figure 44: Tracheostomy string
24. To replace a Velcro™ strap:

 Place new strap behind client’s neck and thread ends through faceplate eyelets. Adjust
tightness as above and secure Velcro™.
25. Reconnect the patient to oxygen and reposition for comfort.
26. Discard soiled items in the appropriate container.
27. Remove and discard soiled gloves.
28. Wash hands.
29. Document the procedure, noting the appearance of the stomal site and any exudate.
1.5. Postural drainage
Objective: At the end of this lessonlearnerwill be able to:

1. Define postural drainage
2. Describe the purpose, indication and contraindication of postural drainage
3. Demonstrate postural drainage procedure
Definition: Postural drainage is positioning that allow the force of gravity to assist in the removal of
bronchial secretions.
Purpose
 To remove bronchial secretions
Indications
 Evidence of difficulty with secretion clearance
 Presence of atelectasis caused by mucus plugging diagnosis of diseases such as cystic fibrosis,
bronchiectasis, pneumonia, or cavitating lung disease
 Presence of foreign body in airway
51
Contraindication
All positions are contraindicated for:
 Intracranial pressure (ICP) > 20 mm Hg  Large pleural effusions
 Head and neck injury until stabilized  Pulmonary embolism
 Active hemorrhage with hemodynamic  Aged, confused, or anxious patients
instability who do not tolerate position changes
 Recent spinal surgery  Rib fracture, with or without flail chest
 Acute spinal injury  Surgical wound or healing tissue
 Active hemoptysis  Cyanosis, shortness of breath, difficulty
 Empyema breathing, weakness, or very ill feeling
 Bronchopleural fistula experienced.
 Pulmonary edema associated with  Unstable vital signs.
congestive heart failure
Trendelenburg position is contraindicated for:
 Intracranial pressure (ICP) > 20 mm Hg
 Uncontrolled hypertension
 Distended abdomen
 Esophageal surgery
 Recent gross hemoptysis related to recent lung carcinoma
 Uncontrolled airway at risk for aspiration (tube feeding or recent meal)
Reverse Trendelenburg is contraindicated in the presence of hypotension or vasoactive medication
Precaution
 If sputum is foul-smelling, it is important to perform postural drainage in a room away from
other patients and/or family members.
 Aware on the patient’s diagnosis as well as the lung lobes or segments involved, cardiac status,
and any structural deformities of the chest wall and spine.
 Auscultating the chest before and after the procedure helps to identify the areas needing
drainage and to assess the effectiveness of treatment.
Equipment
1. Pillow 4. Bed block
2. Sputum mug 5. Bronchodilator medications
3. Tissue paper 6. Stethoscope
52
7. Specimen bottle and requisition 9. Hospital bed that can be
if required trenbelenburgs position
8. Mouth care set to clean and
freshen the mouth following the
treatment.
10.
Procedure
1. Great the patient and introduce your self
2. Explain the purpose of the procedure and the disease process to the patient.
3. Schedule the postural drainage treatments in to two or three times daily depending on the degree
of lung congestion especially best time before breakfast, before lunch, and late afternoon and
before bedtime.
4. Wash your hands
5. Clean trolley or tray and assemble the necessary equipments
6. Prepare nebulizer medication if necessary
7. Instruct the patient to inhale bronchodilators and mucolytic agents to improve bronchial tree
drainage
8. Assess the patients’ tolerance for postural drainage by assessing vital sign, respiratory status and
fatigue.
9. Instructs the patient to remain in each position for 10 to 15 minutes and to breathe in slowly
through the nose and then breathe out slowly through pursed lips to help keep the airways open
so that secretions can drain while in each position.
Positions
A. Upper lobes
Apical segment
 Client lies back at 300 angle.
 Percussion/vibration area- b/n the clavicle and above the scapulae.
Posterior segment
 Client sits upright in a chair or in bed with head bent slightly forward.
 Percussion/vibration area – between the clavicle and the scapula.
Inferior segment
 Position-Client lies on a flat bed with pillow under the knees to flex them.
53
 Percussion vibration area –upper chest below the clavicle down to the nipple line
except for women
B. Right middle lobe.
Right lateral and medial segments.
 Client lies on left side and leans back slightly against pillows, extending at the back
from the should to the hip.
 Elevate foot of bed about 150 or 400.
Percussion /vibration area
 For male client: over the right side of the chest at the level of the nipple beween the
fourth and sixth ribs.
 For female client beneath the breast, with the heel of the nurse’s hand positioned
toward her axila, cupped fingers extending for ward beneath breast.
Lower division of left upper lobe ( lingual)
 Position as above for right meddle lobe, but on the right side
 Percussion/vibration area –as above right meddle lobe, but on the left side.
C. Lower lobes
Superior lung segment
 Position lies on the abdomen on a flat bed, and place two pillows under the hips.
 Percussion /vibration area -the middle area of the back (below the scapula) on both
sides of the spine.
Anterior basal segments
 Lies on unaffected side with upper arm over the head and pillow between knees.
Elevated the foot of the bed about 3o0 or 450 or to height tolerate by the client.
 Percussion /vibration area – over the lower ribs inferior to the axila on the affected side
of the chest.
Lateral basal lung segment
 Lies partly on unaffected side and partly on the abdomen. Elevate the foot of bed
about 300 or 45 cm or height tolerated, or elevated client’s hip with pillows.
 Percussion /vibration area – the upper most side of the lower ribs.
Posterior basal lungs segment
 Lies in prone position
 Elevated foot of bed about 45 cm
54
 Elevated client’s hip on two or three pillows.
 Percussion /vibration area –over the lower ribs both sides closed to the spine.
1. The nurse should explain how to cough and remove secretions in each position. If the patient
cannot cough, the nurse may need to suction the secretions mechanically.
2. The nurse notes the amount, color, viscosity, and character of the expelled sputum.
3. Assess the patient’s skin color and pulse in the first few minutes the procedure is performed.
4. Perform mouth care
5. Remove gloves from inside out, and discard them in plastic waste bag.
6. Provide patient comfort measures.
7. Clean and return equipment to proper place.
8. Wash your hands
9. Document the patient status and procedure
1.6. Deep breathing and coughing exercise
Objective: At the end of this lessonlearnerwill be able to:

1. Define deep breathing and coughing exercise
2. Demonstrate deep breathing and coughing exercise
3. Describe rationale for deep breathing and coughing.
Definition: deep breathing exercise is a type of voluntary breathing used to maximize inspiration, to
open air ways, to encourage coughing and to promote removal of respiratory secretions.
Purpose
 Management of excessive respiratory secretions
 All clients undergoing surgery
 Reopens small airways
 To prevent atelectasis and pneumonia
Equipment
1. Tissues 4. Stethoscope
2. Water pitcher and glass 5. Pillows for splinting the client’s chest
3. Emesis basin and abdomen
Procedure
1. Wash hands.
2. Assess the client’s pain status.
3. Explain the purpose and importance of theprocedure.
55
4. Help client tosit in a high-Fowler’s position ifable.
5. Auscultate lungs before procedure
6. Place the palms of your hands on the client’srib cage.
7. Place one hand on abdomen (umbilicalarea) during inhalation.
8. Expand the abdomen and rib cage oninspiration.
9. Inhale slowly and evenly through your noseuntil you achieve maximum chest expansion.Hold
breath for 2–3 seconds.
10. Use pillow or folded towels to splint the abdomenor chest if client has had surgery
11. Practice deep breathing with client:
 Instruct the client to cover the mouth withtissue (use mask, gloves, and gown for staffas
needed).
 Take a deep breath in and exhale slowly andrepeat 2–3 times.
 Repeat 10 times every 1–2 hours as needed
12. Reassess lung fields after procedure.
13. Assist the client to cough as follows:
 Follow the procedure for deep breathingand have the client hold breath for 1–2seconds.
 Contract abdominal muscles, cough forcefully,and expectorate secretions into tissueor
basin as nurse splints incision areas as appropriate
 Splint the client’s abdomen and chest as he coughs by pressing on lower chest wall and
abdomen with your hands.
14. Repeat as necessary to clear lung fields; however, be aware that excessive coughing can irritate
the trachea and bronchial tree
15. Observe for dizziness, shortness of breath, orother respiratory problems
16. Comfort patient
17. Dispose of all tissues and wash hands.
18. Record the procedure
56
1.7. Cardiopulmonary resuscitation (CPR)
Objective: At the end of this lesson, learner will be able to:

1. Define Cardiopulmonary resuscitation
2. Describe indications and contraindications of CPR
3. Explain the purpose of CPR
4. Assemble necessary equipment for CPR ( at hospital)
5. Re-demonstrate Cardiopulmonary resuscitation
Definition
Cardio-Pulmonary Resuscitation is an emergency procedure consisting of external cardiac massage
and artificial respiration
Purpose
 To squeeze blood manually out of the heart for victim’s with cardiac arrest
 To provide oxygenated blood to the brain and heart
 To restore blood circulation
Indications
 Respiratory Arrest: - Respiratory arrest refers to the absence of breathing.
 Cardiac Arrest: When the heart stops, there is no pulse.
Precaution
 The CPR Must begins within 4-6 minutes of collapse if not; the brain is sensitive to hypoxia
and will sustain irreversible damage after 4-6 minutes of no oxygen.
 The cause of cardiac arrest is important BUT do not delay CPR to obtain history
Relative Contraindications
 Ribs fractured
 Burn of sternum( full thickness )
Equipments
 No special equipments are needed at emergency situation- just hands and mouth & step by step
procedure.
 At hospital level ( Ambu bag , firm board, stethoscope , spatula , air way )
Procedure
1.6.1. Adult CPR procedure
57
1. Check the Scene or Assessment of the Situation (Always Present if it is out of Health Centers)
 Make sure it is safe for you to help.
 Don't become another victim and assess the environment to know the cause of the problem
2. Check the Victim or Assessment of unresponsiveness
 Tap or gently shake the victim and shout “Are you ok”.
 To elicit a response a painful stimulus can be applied such as:
 Pinching the earlobe,
 Pressing over the eyelid and observing for grimacing.
 Other associations recommend rubbing on the sternum using the knuckles of the
fingers.
Figure 45: Checking client responsiveness in CPR
3. Call for Help or Activate EMS

 Rescuer who is alone should alter sequence of rescue based on most likely cause.
 Sudden witnessed collapse (likely VF) arrest activates EMS (Emergency medical service), do
CPR.
 Hypoxic arrest (i.e., suffocation give 5 cycles of CPR (about 2 minutes) before alerting EMS.
If there is no response, Call ***** and return to the victim. In most locations the emergency
dispatcher can assist you with CPR instructions
58
Figure 46: Calling 911
4. Positioning the victim
 Place the victim first on His/ Her back on hard surface. If the victim is lying face down, turn or
roll the victim as unit, supporting the head and neck
5. Airway
 Open the airway by the head tilt / chin lift maneuver for all victims and Remove foreign body.
We might also assess the breathing status of the victim
 Health care personnel use:
o Head tilt- chin lift
o Jaw thrust in trauma patient
Figure 47: Positioning the client for giving rescue breathing
6. Breathing
 Assessment of breathlessness and carotid pulse (5-10 seconds)
 Place your ear just one inch above the mouth and the nose of the victim and perform the
following simultaneously: Use LLF methods
o LOOK: for the chest to rise and fall
o LISTEN: for air escaping during exhalation, and
o FEEL: for the flow of air on your cheek
59
NB: Count the number 1001,1002,1003,1004,1005,1006,1007,1008,1009,1010 to be sure you are
checking for 10 seconds because 1001 represents 1 second, and 1002 represents 2, and
continue others like this.
Figure 48: Listening (left) and giving rescue breathing (right) in CPR
 Simultaneously assess the presence of pulses

o Assessment of pulselessness (5-10 secs.): check pulse at carotid artery which is the most
common and most reliable.
o While maintaining the head tilt with one hand, locate the victim’s Adams apple (thyroid
cartilage) with two or three fingers of the other hand. Slide your fingers into the groove
between the Adam’s apple and the muscle on the side nearest you where the carotid pulse
can be felt.
Figure 49: checking returning of pulse in CPR
 If breathing is not present, begin rescue breathing by giving two slow breaths: pinch nose and
cover the mouth with yours and blow until you see the chest rise. Give 2 breaths.
 Time:
 Each breath should take 1.5 sec to 2 sec and watch for chest rise and allow time for exhalation
(3-3.5 sec).
60
 Volume:
o Sufficient volume
o No large volume or forceful breathing.
7. Circulation
 If pulse is not definitely felt within 10 seconds, proceed with chest compression
 Provides 30% (or less) of normal circulation
To locate the landmark for external chest compression
 The technique of costal margin that is as follows:
A. Run your index and middle fingers up the lower margin of the rib cage and locate the sternal
notch with your middle finger. The index finger is place next to the middle finger on the lower
and of the sternum.
Figure 50: Selecting proper site for chest compress in CPR
B. The heel of the other hand (the one nearest the victim’s head) is placed on the lower half of the
sternum, and the other hand is placed on the top of the hand on the sternum so that the hands
are parallel.
C. Your fingers may be either extended or interlaced but must be kept off the chest.
61
D. Lock your elbows into position, the arms are straightened and shoulders directly over the victim’s
sternum. Keep the heel of your hand lightly in contact with the chest during the relaxation
phase of chest compression to maintain correct hand position.
 Push hard- push fast: equal compression and relaxation allowing recoil of chest wall.
 Chest compression – ventilation 30: 2, for 5 cycles (2 minutes rate of 100 per minute.
 Depth of 1.5 to 2 inches for adults
 Count compression in English in the sequence of:
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,1= for 1st cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,2= for 2nd cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,3= for 3rd cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,4= for 4th cycle
o 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, and 1,2,3,4,5,6,7,8,9,5= for 5th cycle
8. Reassessment
 After 5 cycles of compressions and 6 cycle of ventilations (30:2), check for return of carotid
pulse/ and spontaneous breathing
 According to the findings (after 2 minutes):
o There is pulse – place in the recovery position, monitor vital signs until EMS arrives.
o There is pulse but no breathing: continue rescue breathing every 5- 6 seconds (10-12
breaths). Recheck pulse every 2 minutes.
o No pulse or breathing continues CPR 30:2. Until provider arrives
Repeat A – B- C to 5 cycle of compression and 6 cycles of breathing. (150:12)
When to Stop CPR
1. if another trained person takes over CPR for you
2. if more advanced medical personnel take over
3. if you are exhausted and unable to continue
4. if the scene becomes unsafe
5. if the victim's heart starts beating
1.6.2. CPR for child below 8 years old
62
 Tap or gently shake the victim and shout “Are you ok”.
 Pinching the earlobe,
 Pressing over the eyelid and observing for grimacing.
 Other associations recommend rubbing on the sternum using the knuckles of the
fingers.
3. Call for Help or Activate EMS

 Rescuer who is alone should alter sequence of rescue based on most likely cause.
CPR.
4. Positioning the victim
 Place the victim first on His/ Her back on hard surface. If the victim is lying face down, turn or
roll the victim as unit, supporting the head and neck
5. Airway
 Open the airway: perform head-tilt, chin lift maneuver. If liquids turn the victim’s head to side
and let it drain
6. Breathing
1. Assessment of breathlessness and pulse (carotid) together– (5-10 seconds)
2. Place your ear just one inch above the mouth and the nose of the victim and perform the following
simultaneously.
 Look for the chest to rise and fall
 Listen for air escaping during exhalation, and
 Feel for the flow of air on your cheek
3. Assessment of pulselessness (5-10 seconds) check carotid
 If breathing is not present, begin rescue breathing by giving two slow breaths: pinch nose and
cover the mouth with yours and blow until you see the chest rise. Give 2 breaths.
63
4. Time: each breath should take 1.5 sec and watch for chest rise and allow time for exhalation.
5. Volume – sufficient volume. No large volume or forceful breathing.
7. Circulation
 If the pulse is absent begin external chest compressions
 Land mark for compression is not to be used; that is as follows:
o Run your index and middle fingers along the lower rib cage until the middle finger
reaches the notch (xyphoid process). The index finger is placed next to the middle
finger.
o The heel of the same hand is placed next hand is placed next to the point where the
index finger was located. (One hand can be used.)
 Lock your elbows into position, the arms are straightened and shoulders directly over the
victim’s sternum. Keep the heel of your hand lightly in contact with the chest during the
relaxation phase chest compression to maintain correct hand position.
 Push hard- push fast without any interruption

 Rate of compression: 100 per minute
 Depth of compression: 1/2 -1 inch the depth of the chest
 Compression /ventilation ration: 30:2
 Compression / relaxation cycle should be equal
8. Reassessment:-
 After 5 cycles of compressions and 6 cycle of ventilations (30:2), check for return of carotid
pulse and spontaneous breathing
 According to the findings (after 2 minutes):
o There is pulse – place in the recovery position carefully; monitor vital signs until EMS
arrives.
64
o There is pulse but no breathing: continue rescue breathing every 3-5 seconds (12-20
breaths per minute). Recheck pulse every 2 minutes.
o No pulse or breathing continues CPR 30:2. , until provider arrives
1.6.3. One rescuer CPR procedure for infant (to approximate 1 year)
 Tap the infant and shake to elicit a response, or palpate the sole of the feet
o Pinching the earlobe,
o Pressing over the eyelid and observing for grimacing.
 If unresponsive start CPR immediately. If second rescuer or someone is available, have him or
her activate the EMS system.
3. Call for Help or Activate EMS (if second rescuer is available otherwise call after 2 min.)
CPR.
4. Position the victim in supine, firm and flat surface
5. Airway
 Open the airway:
o Apply head tilt- chin lift to ‘sniffing’ or neutral position.
o Jaw thrust maneuver in trauma patient
6. Breathing
 Assessment of breathlessness and brachial pulse (5-10 seconds)
o Place your ear just one inch above the mouth and the nose of the infant and perform
the following.
 Look for the chest to rise and fall
 Listen for air escaping during exhalation
65
 Feel for the flow of air on your check
 Assessment of pulselessness: brachial pulse (5-10 seconds)
o Feel for the brachial pulse while maintaining head tilt with the other hand, Never
use carotid pulse for infants because you may interrupt circulation to brain if
present.
o The brachial pulse is located on the inside of the upper arm, between elbow and
shoulder.
Figure 53: checking pulse in infant in CPR
 If the breathing is not present, make a tight seal over the mouth and the nose of the infant
and begin rescue breathing by giving two slow breaths.
 Time: 1 second per breath and watch chest rises and allows time for exhalation.
 Volume; enough to see the chest of the infant rise during ventilation (cheek)
7. Circulation
 If pulse is absent give 5 cycles of external 30 chest compressions followed by 2 slow
breaths.
Figure 54: Giving chest compression infant in CPR
Land mark for external chest compressions
 Nipple line technique
66
o The area of compression is just below the imaginary line, using the middle and ring
fingers. draw a line between your baby's nipples, and go 1 finger length lower than the
nipple line. hold your index finger up, and use your other 2 fingers to do chest
compressions.
 Rate of compression: 100 per minute
 Depth of compression: 1/3-1/2 the depth for the chest
 Compression / ventilation ratio: 30:2
 Compression / relaxation cycle should be equal
8. Reassessment
 Reassess the infant after every 5 cycles of 30 compressions and 6 cycles of 2 ventilations (2
minutes).
 According to the findings:
o There is pulse and breathing, place the infant in the recovery position, monitors
vital signs until EMS arrives
o There is pulse but no breathing continues rescue breathing one breath every 3-5
seconds (12-20 per minute) and reassess.
o No pulse or breathing continues CPR 30:2. Ratio, assess for pulse and breathing
after 5 cycles (2minutes)
67
CHAPTER SIXTEEN
THERAPEUTIC AND DIAGNOSTIC PROCEDURE
Objective: At the end of this chapter, the learner will be able to:-
1. Prepare patient for the procedure
2. Assemble necessary equipment
3. Monitor client after assistive procedure
4. Apply measures to reduce complication during and after assistive and diagnostic procedure
1.1. Assisting with thoracentesis
Objective: at the end of this lesson, learner will be able to:-
1. Define thoracentesis
2. prepare equipment for thoracentesis
3. prepare the patient for thoracentesis
4. monitor the patient during and after the procedure
Definition: thoracentesis is the procedure in which a puncture is made into the chest wall to withdraw
fluid or air from the pleural cavity for diagnostic or therapeutic purposes.
Figure 55: Site for thoracenthesis
Indication
A. When unexplained fluid or air accumulates in the chest cavity outside lung.
B. Pleural effusions
C. Compromised cardiovascular status due to air fluid or blood outside the lung,
D. Pleural fluid analysis
E. Instillation of Instillation of medicatimedication into the pleural space
Purpose
 Removal of fluid and air from the pleural cavity
 Aspiration of pleural fluid for analysis
 Pleural biopsy
 on into the pleural space
Contraindication
1. Absolute contraindications.
 Uncooperative patient
 Coagulation disorders that cannot be corrected
68
2. Relative contraindications
 the site of insertion has known bullous disease (e.g. emphysema)
 use of positive end-expiratory pressure (PEEP, see mechanical ventilation)
 Only one functioning lung (due to diminished reserve).
Precaution: The aspiration should not exceed 1L as there is a risk of development of
pulmonary edema.
Equipment
Sterile:
1. 2 Gallipots 8. Syringe and needle for local anaesthesia
2. 1 pair of dissecting forceps 9. Rubber tube which fit the opening of the
3. 1 pair of artery forceps two-way tap
4. Swabs and gauze in a receiver 10. 10 or 20 cc aspiration syringe and needle
5. towel with a hole((fenestrated towel) 11. two - way tap
6. hand towel 12. 2 glass tube for specimen
7. Gloves 13. Receiver to collect fluid specimen
Clean
1. Rubber sheet and towel 6. Cleaning lotion such as ether, tincture of
2. Receiver for used instrument iodine
3. Measuring jug 7. Plaster with scissor
4. Trolley 8. Sputum mug
5. Local anaesthesia 9. Lab request-form
Procedure:
1. Check clinical record for order and possible allergy
2. Alert physician if any abnormal lab result
3. Explain the procedure to the patient and inform them to try not to cough, not to breathe
deeply, and not to move suddenly during the procedure to avoid puncture of the visceral
pleura or lung
4. Verify informed written consent
5. Wash hands
6. Collect necessary equipment and bring to patient bedside
7. Take baseline vital sign including pulse oximetry
8. Screen the patient.
9. Remove clothes to expose chest.
10. Position the patient as directed by the physician. The position may be either one of the
following or a similar position, as directed by the physician.
(a) Position the patient to sit on the side of the bed, facing away from the physician, with
feet supported on a chair and the head and arms resting on an over bed table padded
with pillows. The arms are elevated slightly to widen the intercostals spaces.
(b) If the patient is unable to sit, turn him on the unaffected side with the arm of the
affected side raised above his head. Elevate the head of the bed 300 to 450.
11. Place the thoracentesis tray on instrument table. Open sterile wrapper cover to provide a
sterile field.
12. Place other supplies on adjacent bedside stand or over bed table. Open glove wrapper.
69 | P a g e
13. Assist with handling of local anesthetic vial. Hold vial with label uppermost so that the
physician can personally check the label before withdrawing any of the solution. Cleanse
stopper with alcohol swab. Invert vial and hold firmly while the doctor, with gloved
hands, withdraws the required solution.
14. Support and help patient to avoid moving and coughing while the thoracentesis needle is
introduced.
15. Assist as directed with collection of specimens as the physician manipulates the syringe,
the stopcock, and drainage tubing. Use care not to contaminate the end of the tubing, the
cap, or the open end of the specimen tubes. Cap the tubes and place them upright in a
clean glass provided for this purpose. Label each tube as directed by the physician.
16. If drainage of a large amount of accumulated fluid is necessary, assist the doctor by
placing the free end of the tubing in the drainage bottle.
17. Watch the patient's color; check pulse and respiration. Immediately report any sudden
change, as this may indicate damage to the visceral pleura from a nick or puncture by the
needle.
18. After the needle is withdrawn, apply a sterile occlusive dressing over the puncture site.
19. Position patient comfortably (usually Fowler's position).
20. Complete entries on appropriate laboratory request forms as directed.
21. Send properly labeled specimens with completed request forms to laboratory immediately
if required
22. Measure and record amount of fluid withdrawn and discard this fluid unless directed
otherwise.
23. Return used equipment and wash hand
24. Proper documentation
Complications
 Pneumothorax  Infection
 Hemorrhage into the pleural space or  puncture of the spleen or liver,
chest wall,  Re-expansion pulmonary edema due
 Vasovagal syncope (fainting) to rapid removal of more than one
 Air emboli liter of fluid
1.2. Assisting with Water-seal chest drainage system

Objective: at the end of this lesson the learner will able to:-
1. Define water seal chest drainage system

2. Prepare equipment for water seal chest drainage system
3. Prepare the patient for water seal chest drainage system
4. Monitor the patient during and after the procedure
Water-seal chest drainage
Definition:Underwater-seal chest drainage is a closed (airtight) system for drainage of air and
fluid from the chest cavity.
Indication
Pneumothorax
70 | P a g e
 Haemothorax
 Empyema
 Chest trauma
 Flail chest
Purpose
 To re-establish expansion of the pleural space
 To remove the air or bloody fluid from pleural space and allow for expansion of the lung (or
to evacuate fluid & blood).
 To re-establish negative intra pulmonary and intrathoracic pressure or restoration of the

normal negative pressure in the pleural space.
Contraindications for chest tubes:

 Infection over insertion site
 Uncontrolled bleeding
Patient Positioning and Insertion Sites for Chest tubes
Pneumothorax: (AIR)
 The best position is supine or with head elevated anywhere from low to high fowler’s.
 The chest tube will be inserted into the 2nd or 3rd intercostal space anterior chest at the
mid-clavicular line
Effusions: (FLUID)
 If patient able, the best position is sitting on the side of the bed leaning over a pillow
placed on a bedside table.
 The chest tube is inserted between the 7th to 8th intercostal space in the mid-axillary line
Precaution
 To protect occlusion of tube use rolled towels.
 The patient should be encourage to cough and deep breath once hourly to prevent atelectasis
and assist in removing air and fluid.
 Use aseptic technique when preparing equipment and changing the bottle.
 Make sure that the system is air tight at any time
 Keep a clamp with the pt for emergency.
Equipment
1. Sterile gloves 6. Suction machine with tube

2. suture set (or sterile scissors and 7. Dressing material
sterile forceps) 8. Wide tape
3. Sterile Vaseline gauze 9. Local anaesthesia
4. Sterile glass tube 10. Drainage bottle and tube
5. Sterile water/saline 11. Vital sign equipments
Procedures
71 | P a g e
1. Check consent form is signed
2. Identify the patient and explain the procedure
3. Check vital sign
4. Collect equipment after washing your hands
5. Assist patient to the upright position, have the patient sit upright in bed and lean forward resting
on the over bed table.
6. Open the chest tube tray and assist the physician as indicated.
o Pour antiseptic over the cotton ball
o Hold the vial of local anaesthesia
o Apply an occlusive dressing to the tube-inserting site.
o Make sure a chest firm in order to check proper placement.
7. Reassure and observe the patient throughout the procedure.
8. If a specimen needed take specimen, label it and send to the laboratory immediately.
9. Return the patient to comfortable position
10. Check vital signs
Figure 56: three bottle system
Nursing intervention
1. If using a chest drainage system with a water seal, fill the water seal chamber with sterile
water to the level specified by the manufacturer.
2. When using suction in chest drainage systems with a water seal, fill the suction control
chamber with sterile water to the 20-cm level or as prescribed.
 In systems without a water seal, set the regulator dial at the appropriate suction level.
3. Attach the drainage catheter exiting the thoracic cavity to the tubing coming from the
collection chamber. Tape securely with adhesive tape.
4. If suction is used, connect the suction control chamber tubing to the suction unit. If using a
wet suction system, turn on the suction unit and increase pressure until slow but steady
bubbling appears in the suction control chamber.
 If using a chest drainage system with a dry suction control chamber, turn the regulator
dial to 20 cm H2O.
5. Mark the drainage from the collection chamber with tape on the outside of the drainage unit.
Mark hourly/daily increments (date and time) at the drainage level.
72 | P a g e
6. Ensure that the drainage tubing does not kink, loop, or interfere with the patient’s
movements.
7. Encourage the patient to assume a comfortable position with good body alignment. With
the lateral position, make sure that the patient’s body does not compress the tubing. The
patient should be turned and repositioned every 1.5 to 2 hours. Provide adequate analgesia.
8. Assist the patient with range-of-motion exercises for the affected arm and shoulder several
times daily. Provide adequate analgesia.
9. Gently “milk” the tubing in the direction of the drainage chamber as needed.
10. Make sure there is fluctuation (“tidaling”) of the fluid level in the water seal chamber (in
wet systems), or check the air leak indicator for leaks (in dry systems with a one-way valve).
 Fluid fluctuations in the water seal chamber or air leak indicator area will stop when:
a. The lung has re-expanded
b. The tubing is obstructed by blood clots, fibrin, or kinks
c. A loop of tubing hangs below the rest of the tubing
d. Suction motor or wall suction is not working properly
11. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the
water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Also,
assess the chest tube system for correctable external leaks. Notify the physician immediately
of excessive bubbling in the water seal chamber not due to external leaks.
12. When turning down the dry suction, depress the manual high negativity vent, and assess for
a rise in the water level of the water seal chamber.
13. Observe and immediately report rapid and shallow breathing, cyanosis, pressure in the
chest, subcutaneous emphysema, symptoms of hemorrhage, or significant changes in vital
signs.
14. Encourage the patient to breathe deeply and cough at frequent intervals. Provide adequate
analgesia. If needed, request an order for patient-controlled analgesia. Also teach the patient
how to perform incentive spirometry.
15. If the patient is lying on a stretcher and must be transported to another area, place the
drainage system below the chest level. If the tubing disconnects, cut off the contaminated
tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the
drainage system. Do not clamp the chest tube during transport.
16. When assisting in the chest tube’s removal, instruct the patient to perform a gentle Valsalva
maneuver or to breathe quietly.
 The chest tube is then clamped and quickly removed.
 Simultaneously, a small bandage is applied and made airtight with petrolatum gauze
covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous
tape.
1.3. Assisting with Bronchoscopy
Objective: at the end of this lesson the learner will able to:-
1. Define Bronchoscopy
2. Explain the precuations of Bronchoscopy
3. Prepare equipment for Bronchoscopy
4. Prepare the patient for Bronchoscopy
73 | P a g e
5. Monitor the patient during and after the Bronchoscopy
Definition: Bronchoscopyis the direct inspection and examination of the larynx, trachea, and
bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope.
Purposes
A. Diagnostic:
 To examine tissues or collect secretions
 To determine the location and extent of the pathologic process and to obtain a tissue
sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy)
 To determine if a tumor can be resected surgically, and
 To diagnose bleeding sites (source of hemoptysis).
B. Therapeutic:
 Remove foreign bodies from the tracheobronchial tree
 Remove secretions obstructing the tracheobronchial tree when the patient cannot clear
them
 Treat postoperative atelectasis, and
 Destroy and excise lesions.
Indications
 Abnormal chest x-ray: presence of a lesion, persistent atelectasis, infiltrates in the
lung fields.
 Hemoptysis
 Unexplained cough, localized wheeze, or stridor
 Need to obtain lower respiratory tract secretions or tissue for diagnostic purposes
 To assess and/or evaluate airways
 To perform difficult intubations
 To remove a foreign body
Contraindications
 Inability to adequately oxygenate the client during the bronchoscopy
 Clients with severe obstructive lung disease
 Unstable hemodynamic status
 Lack of client consent
 Recent myocardial infarction
 Unstable angina
 Hypoxemia or hypercarbia
 Low platelet count
Precautions
1. Determine whether the client has been NPO for 4 to 8 hours.

2. Determine the presence of a current chest x-ray and blood work (especially bleeding
times).
3. Assess where the procedure is to be performed (in a hospital room, or in the
bronchoscopy suite)
4. Identify the drugs ordered: action, purpose, normal dosage, common side affects, time of
onset and peak action, duration of action and implications.
5. Assess the client’s vital signs, including lung sounds and blood oxygen levels,
74 | P a g e
6. Assess the client’s chart for a signed consent form
7. Assess the client’s level of understanding regarding the procedure as well as the client’s
level of anxiety
Equipments
1. Bronchoscope (The scope size will be determined by the physician or qualified
practitioner based on the client and the procedures to be performed.)
2. Light source for the bronchoscope and any related video or photographic equipment
3. Brushes (cytology, protected for microbiology tissue samples)
4. Specimen traps
5. Syringes of various sizes for bronchoalveolar lavage, drug delivery, and needle aspiration
6. Bite block (to protect the scope)
7. Intubation tray
8. Intravenous supplies
9. Resuscitation bag
10. Monitoring devices: pulse oximeter, ECG monitor, sphygmomanometer
11. Oxygen delivery equipment: cannula, masks
12. Suction supplies for scope and/or mouth
13. Fluoroscopy equipment, including personal protection and radiation badge
14. Adequate ventilation, to prevent the spread of infection
15. Ultraviolet light, to prevent transmission of tuberculosis
16. Cleaning, disinfection, and sterilizing equipment
Procedure

2. Wash hands.
3. Set up for the bronchoscopy. Plug the appropriate bronchoscope in a light source and
connect the suction tubing. Set up an emergency oral suction.
4. Draw up medication per physician’s or qualified practitioner’s orders and label each
syringe with drug and dosage per milliliter.
5. Ready syringes of saline for the broncho-alveolar lavage and saline washes.
6. Lay out traps, biopsy forceps, cytology brushes, and protected brushes as needed. Have
everything ready for an IV placement (if an outpatient; an inpatient should already have an
IV).
7. Make sure all the required paperwork is filled out and ready for the client and the
physician or qualified practitioner.
8. Check that emergency medications and supplies are available.
9. Verify client’s identity.
10. Have client put on a gown if she is an outpatient
11. Place monitoring devices for vital signs. Record baseline vital signs and continue to
monitor every 5–15 minutes depending on institution policies.
75 | P a g e
12. For outpatients, confirm the presence of a family member or caregiver to provide
transportation after the procedure.
13. Obtain informed consent from the client prior to the bronchoscopy procedure.
14. Start supplemental oxygen.
15. Have client remove false teeth (if appropriate).
16. Give the anticholinergic agent if the doctors have ordered it. Watch the heart rate closely.
17. The physician or qualified practitioner may also want a nebulizer given with a
bronchodilator diluted with lidocaine.
18. Anesthetize the nares and the throat with topical lidocaine and cocaine.
19. Give first dose of IV sedation; may be required to give PRN prior to and during procedure
depending on client’s tolerance to the drugs and comfort level.
20. Lubricate the distal end of the scope using a water-soluble lubricant.
21. If you are introducing the scope orally, place a mouth guard or airway in client’s mouth.
Secure if possible.
22. As the physician or qualified practitioner passes the scope into the airways the assistant
will inject lidocaine into the scope, numbing the airways as they go. This is usually 2 cc of
2% lidocaine (no preservatives) with 3 cc of air as a push in the syringe.
23. Instruct the client not to talk. If she needs something have her use the prearranged hand
signals.
24. Assist the physician or qualified practitioner in obtaining the type of samples needed:
25. While obtaining the samples, make sure to label all of them immediately with clients
name, ID number, date, time, and location in lung.
26. After the bronchoscopy, rinse the scope by suctioning approximately 240 ml of soapy
water through the working channel of the scope
27. During the recovery period (at least 30 minutes), wean the client off the oxygen (if none
was required prior to the procedure).
28. Remember to keep a close watch on the oxygen saturation and the vital signs.
29. When client is awake and vital signs have returned to baseline, take out the IV, and
instruct the client or the caregiver to withhold food and liquids for at least 2 hours after the
procedure.
30. Instruct the client and/or caregiver about common side effects to expect following the
bronchoscopy.
a. Outpatients should not drive for at least 6 hours after the bronchoscopy.
b. For inpatients, call a report to the floor if the physician or qualified practitioner has not
already done so.
31. Deliver samples to the various laboratories if you have not already done so.
32. Check the scope for any leaks or damage sustained during the procedure.
33. If there are no leaks or damage, clean the scope inside and out with soft brushes. Rinse
well and sterilize.
34. Periodic post procedure follow-up monitoring of client condition is advisable for 24–48
hours for inpatients. Outpatients should be instructed to contact the physician or qualified
practitioner regarding fever, chest pain or discomfort, dyspnea, wheezing, hemoptysis, or
any new findings presenting after the procedure has been completed.
35. Comfort the patient after the procedure
76 | P a g e
36. Return equipment and Wash hands.
Complications
 Hypoxemia  Penumothorax
 Hypercarbia  Hemoptysis
 Hypotension  Adverse effect of medication used
 Laryngospasm before and during the bronchoscopy
 Bradycardia
1.4. Assisting with an abdominal paracentesis

Objective: at the end of this lesson learner will be able to:-
 Prepare equipment for abdominal paracentesis

 Prepare the patient for abdominal paracentesis
 Monitor the patient during and after the abdominal paracentesis
Definition: -Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a
small surgical incision or puncture made through the abdominal wall under sterile conditions.
Purpose:
1. For diagnostic purpose:- to obtain a specimen of fluid
2. For therapeutic purpose: - to relieve pressure on the organs of the abdomen and chest.
Precaution
 During and after the procedure watch patient carefully for signs of shock
 If the puncture is done on the site, lay the patient on the unaffected site at the end of the
procedure
 Make sure the abdomen binder is under the patient before the procedure
Equipment
Sterile set
1. Sterile trochar and cannula—small 6. Syringe and needle for local
pieces of tubing attached to the anaesthesia
cannula with clamp. 7. Dissecting forceps & artery forceps
2. Towel with hole/ fenestrated towel 8. Small scalpel if needed
3. Hand towel 9. 2 Test tubes
4. Gloves, swabs & gauze in a bowel 10. Cotton balls
5. 2 gallipots 11. Knife and small scalpel
Clean
1. Rubber sheet with cover 4. Pail or other receiver to collect fluid
2. Abdominal binder with safety pin 5. adhesive tape
3. Cleansing lotion and local anesthesia 6. Screen
Procedure
1. Explain the procedure to the patient

2. Wash hands
77 | P a g e
3. Assemble equipments
4. Keep patient privacy
5. Empty the bladder immediately before tapping
6. Position the patient (sitting up position) depending on the degree of the ascietes.
 The usual site for the paracentesis is half way between the umbilicus and the symphysis
pubis on mid line of the abdomen.
7. Place the abdomen binder in position so that it can be used during or after the procedure.
8. The nurse opens the set, pours of cleaning lotion in bowel (galipot). The Doctor then will
scrub his hands, put gloves & clean the area. He inserts the trocher and cannula; the nurse
should hold the anesthetic bottle for the doctor.
9. At the end of the procedure, dray the punctured area; adjust the binder & secure it in place
with safety pin ;leave the patient in the comfortable position
10. Check for leakage and report.
11. Measure the liquid with drawn & record the time of the procedure the cloure, amount
&condition of the patient.
12. Comfort patient
13. Return used equipment to its place and wash hand
1.5. Assisting with liver biopsy
Objective: at the end of this lesson learner will be able to:-
 Prepare equipment for Liver biopsy

 Prepare the patient for Liver biopsy
 Monitor the patient during and after the Liver biopsy
Definition: It is sterile procedure performed to aspirate a sample of liver tissue for laboratory diagnosis
Purpose
 To evaluate diffuse disorders of the parenchyma
 To diagnose space-occupying lesions.
 Useful when clinical findings and laboratory tests are not diagnostic.
Site: between 6th and 7th ribs on right lower chest wall patient lay in supine position with right hand over
the head.
Equipment
Sterile
1. Gallipot 6. Syringes for needle for local anaesthesia
2. Fenestrated towel 7. Dressing forceps, scissors and scalpel if
3. Swabs and gauze in a receiver needed
4. Hand towel 8. Liver biopsy needle
5. Gloves 9. Test tubes
Clean
 Rubber sheet and towel
78 | P a g e
 A small bottle containing formalin
for the specimen
 Local anesthesia
 Cleaning solution
 Plaster and scissors
 A laboratory required paper
79 | P a g e
Procedure

2. Wash hands
4. Keep patient privacy
5. Do general assessment
6. Assess the client general appearance and health status.
7. Determine drug allergies (local anesthesia, and antiseptics)
8. Determine the clients understanding of the procedure
9. Give procedural medication as ordered E.gVit.k before hand
10. Ensure the patient fasting for at list 2 hours before the procedure
11. Administer appropriate sedative about 30 minute before hand or at the specified time.
12. Help the client assume a supine position, with the upper right quadrant of the abdomen exposed.
Cover the client with the bed cloths so that only the abdominal areas exposed.
13. Open the sterile set and the sterile gloves for the physician pour antiseptic solution over the
sterile sponges or gauze or in to a container as needed done disposable gloves
14. Support the client in a supine position.
15. Instruct the client to take a few deep inhalation and exhalation and hold the breath after the final
exhalation for up to 10 seconds as the needle is inserted, the biopsy, obtained and the needle
withdrawn.
16. Instruct the patient to resume breathing when the needle is withdrawn
17. Apply pressure to the site of the puncture
18. Apply a small dressing to the site of the puncture.
19. Assist the patient/ client to a right side –lying position with a small pillow or folded towel under
the biopsy site. And instruct the client to remain in this position for several hours
20. Assess the client vital sign every 15 minutes for the first hours following the test or until the
sign are stable.
21. Determine whether the patient experiencing pain, Sever abdominal pain indicate bile peritonitis
22. Check the biopsy site for any leaking if occurs pressure dressing may be needed if bleeding
occurs.
23. Send the labeled specimen immediately to the laboratory along with the completed requisition
24. Comfort patient
25. Return used equipment to its place and wash hand
26. Document the procedure
Complication:
 Bleeding
 Bile peritonitis
80 | P a g e
1.6. Assisting with Bone marrow puncture/biopsy
Objectives: at the end of this lesson the learner will be able:
1. Define bone marrow puncture

2. Assemble the necessary equipments for Bone marrow puncture/biopsy
3. Assist in preparing and positioning the patient for the procedure/biopsy
4. Properly label and send the sample of Bone marrow puncture/biopsy
5. Monitor the patient for possible post-procedure complications
Definitions:
1. Bone marrow aspiration is the removal of a small amount of organic material

from the medulla of certain bones by a large-bore needle.
2. A bone marrow biopsy is the removal of a core of bone marrow cells by a biopsy
needle.
Purpose: The biopsy or aspiration is used to diagnose
 Leukemia
 Anemia
 Thrombocytopenia
 Other malignancies such as non–Hodgkin’s lymphoma or multiple myeloma.
Precaution:
 The client may be at increased risk for bleeding, infection, or other problems
Equipments:
Sterile set
1. Tray 9. Two bone marrow needles with inner

2. Fenestrated towel stylus
3. Hand towel 10. One biopsy needle
4. Gloves 11. Two 10 ml syringe and adaptor if
5. Swabs and gauze (4x4) in a receiver needed
6. Dressing forceps 12. Sterile test tube, water, glass slide
7. Syringe and needle (two 3-ml with 13. Sterile gauze and tape or Band-Aid
23- to 25-gauge) for local anaesthesia
8. Two 10-ml syringes for marrow
aspiration
81 | P a g e
Clean
1. Sodium oxalate solution for preservation

2. Rubber sheet and towel for bed protection
3. Antiseptic solution as tincture of iodine, ether or alcohol
4. Local anaesthetic
5. Receiver for used instruments
6. Masks and goggles
7. Pain medication or sedative as ordered
8. Plaster and scissors.
Procedure:
1. Do general assessment
2. Explain the procedure.
3. Have the client void.
4. Administer medication for sedation or pain
5. Wash hands and assemble the necessary equipments
6. Help the client assume a supine position (with one pillow if desired) for biopsy of the
sternum (sternal puncture) or prone position for a biopsy of either iliac crest; fold the
bed clothes back to expose the area.
7. Open the bone marrow set and pass sterile gloves to the physician, pour the antiseptic
solution into a container in the set or over sterile gauze squares.
8. Open and hold the ampoule or vial of local anaesthetic if it is not in the set.
9. Wear disposable gloves.
10. Describe the steps of the procedure and provide verbal support, observe the client for
pallor, diaphoresis, and faintness.
11. Nurse may assist with applying pressure to the site and applying the ointment and
dressing to the site of the puncture after the needle is withdrawn.
12. Assess for discomfort and bleeding from the site.
13. Provide analgesia as needed and ordered.
14. Arrange for the specimen with the completed request and label to be transported to the
laboratory.
15. Assist client into a comfortable position.
16. Put on gloves and discard supplies appropriately.
17. Wash hands
18. Document the procedure.
19. Regularly assess for discomfort and bleeding for several days.
82 | P a g e
1.7. Assisting with Cast application and removal
Objectives: at the end of this lesson, the learner will be able to:
1. Define cast
2. Assemble equipments for application and removal of cast
3. Identify the preventive and health teaching needs of the patient with a cast
4. Demonstrate the Nursing care for a patient with cast.
1.7.1. Cast application
Definition:- A cast is a rigid external immobilizing device that is molded to the contours
of the body.
Purpose:
 To immobilize a body part in a  To immobilize a reduced fracture
speciﬁc position  To correct a deformity
 To apply uniform pressure on  To support and stabilize
encased soft tissue weakened joints
Contraindications (relative)
 Skin diseases  Open or draining wounds
 Peripheral vascular disease  Susceptibility to skin irritations
 Diabetes mellitus
Equipment
1. Drape for patient 5. Water and basin
2. Knitted material (eg, stockinette) 6. Cast knife or cutter
3. Nonwoven roll padding 7. Trolly
4. Casting material (POP)
Procedure
1. Perform neurovascular assessment
3. Wash hands
5. Support extremity or body part to be casted.
6. Position and maintain part to be casted in position indicated by physician during
casting procedure.
7. Drape patient.
8. Wash and dry part to be casted.
9. Place at least three layers of knitted material (eg, stockinette) over part to be
casted.
 Apply in smooth and non constrictive manner.
 Allow additional material.
10. Wrap soft, nonwoven roll padding smoothly and evenly around part.
83 | P a g e
 Use additional padding around bony prominences to protect superficial nerves
(eg, head of fibula, olecranon process).
11. Apply plaster or fiberglass casting material evenly on body part.
 Choose appropriate-width bandage.
 Overlap preceding turn by half the width of the bandage.
 Use continuous motion, maintaining constant contact with body part.
 Use additional casting material (splints) at joints and at points of anticipated
cast stress.
12. “Finish” cast.
 Smooth edges.
 Trim and reshape with cast knife or cutter.
13. Remove particles of casting materials from skin.
14. Support cast during hardening.
 Handle hardening casts with palms of hands.
 Support cast on firm, smooth surface.
 Do not rest cast on hard surfaces or on sharp edges.
 Avoid pressure on cast.
15. Promote drying of cast.
 Leave cast uncovered and exposed to air.
 Turn patient every 2 hours, supporting major joints.
 Fans may be used to increase air flow and speed drying.
1.7.2. Care of patient with cast

Nursing intervention:
1. Wash hands.
2. Check circulation, movement, and sensation
 Note color and temperature of skin.
 Pinch finger or toe and watch for capillary refill within 2 to 4 seconds.
 Ask client to twist fingers or toes.
 Ask client to tell you if s/he feels you touching the extremity
3. Assess skin.
 Tell client not to put objects under the cast.
 Use powders or creams only outside the cast.
4. Assess pain or soreness.
 Reposition the extremity q2h.
 Elevate the extremity and apply ice.
5. Assess cast for intact cotton padding. Pad or add additional padding to areas of
redness or irritation
6. Assess cast for intact edges.
84 | P a g e
 If edges are crumbling or peeling, or if the cast has been bivalved or windowed,
use tape to petal the edges
 Do not allow the cast to get wet. Teach the client how to cover the cast when
bathing or showering.
7. Assess safety. If client is to ambulate provide cast boot for traction
8. Instruct client and caregiver about symptoms to report to the physician or qualified
practitioner:
 An increase in swelling.
 A tingling or burning sensation.
 An inability to move muscles around the cast.
 A foul odor around the edges of the cast.
 Any drainage, which may show through the cast.
 Any cracks or breaks in the cast.
9. Support the cast.
 Use pillows for arms and legs.
 Use a bed board under the mattress for a spica cast.
10. Assess for infection.
 Check for foul odor under cast.
 Check for drainage on cast.
 Mark drainage and date on cast.
11. Synthetic casts should be kept dry. If the physician or qualified practitioner does
permit bathing or swimming, the wet cast should be dried quickly and thoroughly.
Dry the cast with a towel and then a hair dryer set on low. Dry until the padding
underneath does not feel cold or damp to the skin.
12. Wash hands.
1.7.3. Cast Removal

Indication
 When a fracture heals

 If it requires further manipulation.
Less common indications include:
 Cast damage
 Pressure ulcer under the cast
 Excessive drainage or bleeding
 Constrictive cast
Equipment
 Cast cutter
 cast splitter
85 | P a g e
 Bandage scissors
 Surgical or plaster knife
Figure 57: Material for cast removal
Procedure
1.Introduce yourself to client and explain the planned procedure.
2.Wash hands.
3.Assess vascular status.
4.Prepare equipment and have it at bedside.
5.Assess client’s ability to communicate during cast removal.
6.Prepare environment and client.
7.Wear protective clothing as needed.
8.Prepare client for how extremity will look after reduction.
 Extremity will look thinner than non fractured site.
 Mobility will be less than non fractured site.
9.Client may need to continue to use crutches or immobilizer until full mobility of
extremity is regained
10. The cast removal technician will cut the cast with the saw. Support the limb in the
proper position as requested.
11. The cast technician will split the cast with a cast splitter, and cut the padding
underneath
12. The cast technician will then pull the cast apart and remove it. Support the limb,
and reassure the client, as this step can be anxiety producing and sometimes
uncomfortable
13. Assess the skin underneath the cast. Gently clean the skin with warm water. Do
not rub or use friction on the skin.
14. May need to apply Ace wrap after cast removal.
15. Document the extremity where the cast was removed and how the extremity looks
16. Wash hands.
86 | P a g e
1.8. Assisting with Traction Application
1.8.1. Skin Traction

Objective: at the end of this lesson, the learner will be able to:
1. Define skin traction

2. Describe Nursing responsibilities for patient with skin traction
3. Demonstrate care of patient with skin traction
Definition: Skin traction is immobilizing body part intermittently over an extended time
through direct application of a pulling force on the skin.
Purpose
 To control muscle spasms
 To immobilize an area before surgery.
 To reduce fracture
 To treat dislocation
 To correct/prevent deformity
 To improve or correct contractures
Equipment
 Pain medication, if necessary

 Overhead traction bars if needed
 Weights in various pounds
 Traction line and pulleys
 Skin traction device as ordered by the physician or qualified practitioner
 Adhesive traction tape and elastic bandage if appropriate
 Razor, if needed
 Benzoin solution, if needed
Procedure:
1. Explain the procedure to client

2. wash hands
4. Assessing the site of traction application.
5. Clean the skin area to which the traction will be applied
For adhesive Traction
6. Shave the area if there is a large amount of hair.

87 | P a g e
7. Apply tincture of benzoin to the area to be taped.
8. Place the adhesive traction tape on the body part to provide the appropriate direction of pull.
9. Add spreader bars or hooks needed to attach the tape to the traction rope and weights.
10. Wrap the body part and adhesive tape with the elastic bandage.
For Non-adhesive Traction
11. Apply the traction appliance to the appropriate body part

12. Secure it with the fasteners provided (Velcro, straps and buckles, ties) If no fastener is provided,
an elastic bandage may be wrapped around the appliance or adhesive tape
13. Asses for pain, shifting, or slipping of the traction.
14. Comfort the patient
15. Return equipments
16. Wash hand
17. Document the procedure with patient reaction
1.8.2. Skeletal traction

Objective: At the end of this lesson, the learner will be able to:
1. Define skeletal traction

2. Describe Nursing responsibilities for patient with skeletal traction
3. Verbalize traction regimen
4. Provide care of patient with skeletal traction
Definition: Skeletal traction is procedure of immobilizing body part intermittently over

an extended time through direct application of a pulling force on the bone.
Purpose
 To control muscle spasms
 To immobilize an area before surgery.
 To reduce fracture
 To treat dislocation
 To correct/prevent deformity
 To improve or correct contractures
Equipment
1. Pain medication
2. Sterile pins
3. Sterile pin insertion kit
4. Local anesthetic
5. A topical cleanser such as povidone-iodine for cleaning the insertion site
88 | P a g e
Procedure:
1. Explain procedure to patient

2. Wash hands
3. Assemble all the needed equipment at the bedside.
4. Assess the client’s skin and circulation, sensation, and movement (CSM) of
extremity
5. Check orders for pain medications and local anesthetics needed for the procedure.
6. Check for drug allergies.
7. Administer systemic pain medications.
8. Wash hands. If there is risk for contact with body fluids, gloves should be worn.
9. Adjust the bed to a comfortable working height. If applicable, support extremity
on pillows.
10. Physician or qualified practitioner will open pin insertion kit, administer local
analgesic
11. Assist during the pin insertion procedure.
12. Reassure the client.
13. The physician or qualified practitioner will attach the pins to traction, if
appropriate. Provide help in connecting the traction line through the pulley and
secure appropriate weights
14. Place the patient on a comfortable position
15. Assess the patient as necessary
16. Return equipments and wash hands
17. Properly document the procedure
1.9. Assisting with lumbar puncture

Objectives: at the end of this lesson, the learner will be able to:
1. Define lumbar puncture
2. Assemble the necessary equipments for lumbar puncture
3. Assist in preparing and positioning the patient for the procedure
4. Properly label and send the sample of CSF to the laboratory
5. Monitor the patient for possible post-procedure complications
Definition:-Lumbar puncture is the introduction of a needle into the subarachnoid space

of the spinal column.
Purpose:
 To collect specimen of cerebrospinal fluid for diagnostic purpose
 To measure and reduce CSF pressure
89 | P a g e
 To determine the presence or absence of blood in CSF
 To detect the spinal subarachnoid block
 To administer antibiotics intrathecally in certain cases of infection.
Indications
 Infection of CNS such as suspected meningitis, encephalitis
 Brain or spinal cord tumors
 subarachnoid hemorrhage, hydrocephalus, benign intracranial hypertension
 to inject medications into the cerebrospinal fluid ("intrathecally"),
Contraindications
 Present or suspected epidural infection,
 Topical infections or dermatological conditions at the puncture site
 Patients with severe psychosis or neurosis with back pain
Precaution
 Patient anxiety during the procedure can lead to increased CSF pressure.
Equipment:
Sterile:
1. Gallipots
2. Sterile towel with hole
3. Hand towel
4. Sterile gloves
5. Dissecting forceps and artery forceps
6. Two lumbar puncture needle with different size (Barker's needle) (5 to 12.5 cm long)
7. A measure for fluid to be collected
8. A short length of rubber tubing to be attached to the needle.
9. Needle (5⁄8 to 11⁄2 inches, 21 to 25 gauge) and syringe for local anaesthesia (3 to 5
ml).
10. Four test tubes for specimen.
11. Ten gauze sponges (4 x 4) (dressing and tape)
Clean
1. Tray
2. Monometer with three-way stopcock
3. local anaesthetic (lidocaine)
4. Skin cleansing lotion (ether, povidone-iodine, saline, etc.)
5. Rubber sheet and towel.
6. Plaster and scissors,
7. Receiver for used instruments
8. Alcohol swabs
9. Straight chair
90 | P a g e
10. Pillow for placing between client’s knees
11. Masks and goggles (optional)
Procedure:-
2. Have the client void before the procedure.
3. Wash hands
4. Assemble the necessary equipments
5. Maintain privacy of the client
6. Position the patient: lying on the side with the knee flexed and the head bent forward
with the chin touching the chest or sitting up with knees and spine flexed.
7. Have client grasp knees with hands if it helps maintain the position.
 Place pillow between knees.
 Expose the spine.
8. Put the rubber sheet and towel under the patient.
9. Open the sterile set and pour antiseptic solution into the gallipots.
10. Wear glove.
11. Hold anaesthetic bottle for the doctor.
12. During the procedure, the nurse/assistant might be asked to press the internal jugular
veins in order to see the pressure of the fluid.
13. Observe the patient for signs of shock, nausea and vomiting.
14. The procedure is ended by withdrawing the needle while placing pressure on the
puncture site & applying sterile dressing.
15. After the procedure place the patient comfortably flat (can be raised if needed) and
watched for headache.
16. Label the specimen and send to the laboratory.
17. Return equipments to proper place.
18. Record time of procedure, amount, colour and consistency of the fluid withdrawn
19. Observe client after the procedure for neurologic changes:
 Change in level of consciousness, pupil size, or reaction.
 Vital signs, respiratory status.
 Numbness, tingling, or pain in legs.
91 | P a g e
CHAPTER SEVENTEEN
CARE OF THE TERMINALLY ILL AND POST MORTEM CARE
General objective: - At the end of this chapter leaner will be able to
1. give appropriate Nursing care for the terminally ill
2. meet need of terminally ill client
3. give care for dead body
17.1. Care of the terminally ill patient
Objectives: At the end of this lessonlearner will be able to:
1. Define terminally ill care

2. List purposes of assisting the dying client
3. Assemble the necessary equipment for care of dying patient
4. Practice the care of terminally ill patients
Definition: A patient needs intensive physical and emotional support as he approaches death.
Purpose
 To provide personal hygiene  To support the family

 To provide spiritual support
Equipment
1. Clean bed linens, clean gowns, gloves 6. Petroleum jelly

2. Water-filled basin 7. Suction and resuscitation equipment, as
3. Soap and washcloth necessary
4. Towels, lotion, linen-saver pads 8. Optional: indwelling urinary catheter.
5. Lemon-glycerin swabs
Procedures
1. Introduce self and verify client’s identity.

2. Explain the procedure to the client
3. Gather appropriate equipment.
Meeting physical needs
92 | P a g e
4. Take vital signs often, and observe for pallor, diaphoresis, and decreased LOC
5. Reposition the patient in bed at least every 2 hours because sensation, reflexes, and mobility diminish
first in the legs and gradually in the arms. Make sure the bed sheets cover him loosely to reduce
discomfort caused by pressure on arms and legs.
6. When the patient's vision and hearing start to fail, turn his head toward the light and speak to him from
near the head of the bed. Because hearing may be acute despite loss of consciousness, avoid whispering
or speaking inappropriately about the patient in his presence.
7. Change the bed linens and the patient's gown as needed. Provide skin care during gown changes, and
adjust the room temperature for patient comfort if necessary.
8. Observe for incontinence or anuria, the result of diminished neuromuscular control or decreased renal
function. If necessary, obtain an order to catheterize the patient, or place linen saver pads beneath the
patient's buttocks. Put on gloves and provide perineal care with soap, a washcloth, and towels to prevent
irritation.
9. With suction equipment, suction the patient's mouth and upper airway to remove secretions. Elevate the
head of the bed to decrease respiratory resistance. As the patient's condition deteriorates, he may breathe
mostly through his mouth.
10. Offer fluids frequently, and lubricate the patient's lips and mouth with petroleum jelly or lemon-glycerin
swabs to counteract dryness.
11. If the comatose patient's eyes are open, provide eye care to prevent corneal ulceration. Such ulceration
can cause blindness and prevent the use of these tissues for transplantation should the patient die.
12. Provide ordered pain medication as needed. Keep in mind that, as circulation diminishes, medications
given I.M. will be poorly absorbed. Medications should be given I.V., if possible, for optimum results.
Some medications can be given sublingually or rectally if the patient can't swallow or has no I.V. access.
Meeting emotional needs
13. Fully explain all care and treatments to the patient even if he's unconscious because he may still be able
to hear. Answer any questions as candidly as possible without sounding callous.
14. Allow the patient to express his feelings, which may range from anger to loneliness. Take time to talk
with the patient. Sit near the head of the bed, and avoid looking rushed or unconcerned.
15. Notify family members, if they're absent, when the patient wishes to see them. Let the patient and his
families discuss death at their own pace.
93 | P a g e
16. Offer to contact a member of the clergy or social services department, if appropriate.
17. Record changes in the patient's vital signs, intake and output, and LOC. Note the times of cardiac arrest
and the end of respiration, and notify the physician when these occur.
Special considerations
 If the patient has signed a living will, the physician will write a Do-not-resuscitate (DNR) • order on his
progress notes and order sheets. Know your state's policy regarding the living will. If it's legal, transfer
the DNR order to the patient's chart or Kardex and, at the end of your shift, inform the incoming staff of
this order.
 If family members remain with the patient, show them the location of bathrooms, lounges, and
cafeterias. Explain the patient's needs, treatments, and care plan to them. If appropriate, offer to teach
them specific skills so they can take part in Nursing care. Emphasize that their efforts are important and
effective. As the patient's death approaches, give them emotional support.
 At an appropriate time, ask the family whether they have considered organ and tissue donation. Check
the patient's records to determine whether he completed an organ donor card.
17.2.Postmortem care/Care after Death
Objectives: At the end of this lessonlearner will be able to:
1. Define postmortem care

2. List the purposes of postmortem care
3. Assemble the necessary equipment for thepostmortem care
4. Give postmortem care correctly
Definition: Postmortem care involves the physical caring for the body after death, respecting as much as
possible the wishes of the deceased and family.
Purpose
 To show respect for the dead

 To prepare the body for morgue
 To prevent spread of infection
 To show kindness to the family
 To preserve the natural appearance of the body for the family and relatives
94 | P a g e
Equipment
1. Gauze or soft string ties, gloves 4. Adhesive bandages to cover wounds or

2. Chin straps, ABD pads, cotton balls, plastic punctures
shroud or body wrap 5. Plastic bag for patient's belongings
3. Three identification tags 6. Water-filled basin, soap, towels, washcloths,
stretcher
Procedure
1. Note the exact time of death and chart it

2. If the doctor is present call him to pronounce death
3. Document any auxiliary equipment, such as a mechanical ventilator, still present. Put on gloves.
4. Place the body in the supine position, arms at sides and head on a pillow. Then elevate the head
of the bed 30 degrees to prevent discoloration from blood settling in the face.
5. If the patient wore dentures and your facility's policy permits, gently insert them; then close the
mouth. Close the eyes by gently pressing on the lids with your fingertips. If they don't stay
closed, place moist cotton balls on the eyelids for a few minutes, and then try again to close
them. Place a folded towel under the chin to keep the jaw closed.
6. Remove all indwelling urinary catheters, tubes, and tape, and apply adhesive bandages to
puncture sites. Replace soiled dressings.
7. Collect all the patient's valuables to prevent loss. If you're unable to remove a ring, cover it with
gauze, tape it in place, and tie the gauze to the wrist to prevent slippage and subsequent loss.
8. Clean the body thoroughly, using soap, a basin, and washcloths. Place one or more ABD pads
between the buttocks to absorb rectal discharge or drainage.
9. Cover the body up to the chin with a clean sheet.
10. Offer comfort and emotional support to the family and intimate friends. Ask if they wish to see
the patient. If they do, allow them to do so in privacy. Ask if they would prefer to leave the
patient's jewelry on the body.
11. After the family leaves, remove the towel from under the chin of the deceased patient. Pad the
chin, and wrap chin straps under the chin and tie them loosely on top of the head. Then pad the
wrists and ankles to prevent bruises, and tie them together with gauze or soft string ties.
95 | P a g e
12. Fill out the three identification tags. Each tag should include the deceased patient's name, room
and bed numbers, date and time of death, and physician's name. Tie one tag to the deceased
patient's hand or foot, but don't remove his identification bracelet to ensure correct
identification.
13. Place the shroud or body wrap on the morgue stretcher and, after obtaining assistance, transfer
the body to the stretcher. Wrap the body, and tie the shroud or wrap with the string provided.
Then attach another identification tag to the front of the shroud or wrap, and cover the shroud or
wrap with a clean sheet. If a shroud or wrap isn't available, dress the deceased patient in a clean
gown and cover the body with a sheet.
14. Place the deceased patient's personal belongings, including valuables, in a bag and attach the
third identification tag to it.
15. If the patient died of an infectious disease, label the body according to your facility's policy.
16. Close the doors of adjoining rooms if possible. Then take the body to the morgue. Use corridors
that aren't crowded and, if possible, use a service elevator.
17. Although the extent of documentation varies among facilities, always record the disposition of
the patient's possessions, especially jewelry and money. Also note the date and time the patient
was transported to the morgue.
96 | P a g e
References
1. AbebawEredie. 2008. Operating Room Technique Lecture note for Nursing Students
2. Abraham Alano. 2002. Lecture note on basic clinical Nursingskills:Hawassa University.
3. Altman, BG,BuchselP&Coxon V. 2000. Dalmar's Fundamental and advanced Nursing skills.
4. Berman ,Snyder ,KozierErbrb’s. 2008. Fundamental of Nursing concepts process and practice.
8th :Pearson international edition,
5. Clement I. 2007. Basic concepts on Nursing procedures 1st edition: Jaypee Brothers ,
6. Craven .R and Hirnle .C.2009. Fundamentals of Nursing Procedure check list .6th Edition:
Lippinicott Williams &wilkins:
7. Craven .R and Hirnle .C.2000. Fundamentals of Nursing Procedure check list .2nd Edition:
Lippinicott Williams &wilkins:
8. DeLaune S C & Ladner P K. 2002. Fundamentals of Nursing: standard and practice. 2nd:
Delmar/Thomson learning. Also available on http://delaune.DelmarNursing.com.
9. Federal Democratic Republic of Ethiopia Ministry of Health Ethiopian Hospital Reform
Implementation Guidelines Volume 1 Ethiopian Hospital Management Initiative March
2010,Version 1.0
10. Joyce, M.B.&Jane, H.2005.Medical-Surgical Nursing. A Clinical Management.
11. Khadka S., Kisi D., Raya P., and shresta S.2008.Fundamentals of Nursing procedure manual
for PLC nurse. 1st edition. Japan international cooperative agency.
12. koziar&Erb’s. 2008. Fundamental of Nursing: concepts process and practice. Pearson
international 8th Ed.
13. Mills and Jacqeline E. 2004. Nursing procedure. 4th edition
14. Nicol M, Bavin C, Turner SB, Croni P & Anderson KR.2004.Essential Nursing skills.
2ndEdition;Elsevier Mosby. Australia.
15. Perry AG & Potter PA. 2006. Fundamental of Nursing. 6th Edition: Elsevier Mosby .
16. Rosdahl& Kowalski’s. 2003. Textbook of Basic Nursing, Procedure Checklists 8th Ed:
Lippincott Williams & Wilkins.
17. Ruth F.cravan&Hirnle J. 2007. Fundamental of Nursing: Human health and function:5th
Edition: Lippincotwillams&wilkins.
18. Suzanne C. O’Connell Smeltzer, & Brenda G. Bare. (2004). Brunner and Suddarth’s Text
Book of Medical-Surgical Nursing. 10th Edition: Lippincott Williams and Wilkins. Pp 249-
282.
97 | P a g e

Fundam Nursing Skill Lab Manual

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Fundam Nursing Skill Lab Manual

Diunggah oleh

Hak Cipta:

Format Tersedia

Prepared By

1.1. Urinary elimination

1. Straight or Robinson catheter a single lumen tube

1.1.1. Urinary catheterization

1. Define urinary catheterization

 To empty the bladder in case of retention of urine, occurring as a post operative

1.1.1.1.1. Catheterization using a straight or plain catheter for female

1. 2 Sterile plain catheter rubber or plastic

1. Rubber and draw sheet 5. Flash light

Figure 39: Male catheterization

1.1.1.2.1. Insertions of indwelling catheter for male patient

1. Explain procedure to client and Provide for privacy

1. define condom catheter

1. Condom catheter kit with 3. Clean gloves

 Irrigation solution e.g. normal saline or  clamp

Procedure for open method

1. Insert catheter as in catheterization

1. Prepare solution bag with IV set

1.1.3. Suprapubic catheter care

 Is an injection of a liquid in to the rectum, to be returned or retained.

 To cleanse the lower bowel,

1.2.1.1.Cleansing enema/evacuating enema/

 To relieve gas, constipation or fecal impaction

1. Tape water = 5000 to 1000 cc

 Rectal surgery  for a patient with appendicitis

1.Container for solution 8.Bed pan and toilet tissue

1. Check physician's order patient

1. To define retention enema

 To supply the body with fluid

1. Enema can 6. Small enema tube

1. To define rectal wash out

 To prepare the patient for x-ray examination and sigmoidoscopy

1. Explain the purposes of the procedure to patient

1. describe fecal impaction

 It can be used to alleviate abdominal distention.

1. Rectal tube or catheter, 22 to 30 French

1.2.3. Colostomy care and irrigation

1. Tape, if gauze is used 3. Ostomy odor eliminator

1.2.4. Digital removal of fecal impaction

1. define manual fecal impaction

 to make client’s rectum free of feces

 This procedure can be uncomfortable and embarrassing for the client.

1. Disposable absorbent pads 4. Water-soluble lubricant

1. Explain the procedure to the client

1. Define preoperative care

 To prepare the patient emotionally, mentally for surgery

1. Blood pressure apparatus b. Preoperative checklist

1. Explain the procedure

14.2. Intra-operative care

1. Define preoperative care

• To prevent risk of infection

1. Gloves (clean for shaving; sterile for 6. Sterile cotton swabs

1.Define postoperative care

 To prevent any complication from anesthesia

1. Vital sign equipments 6. Sterile dressings as needed

1. Wash hands and apply gloves.

Perioperative Nursing Care

Wind: prevent respiratory

By Agezegn A Hawassa University

1.1. Monitoring with pulse oximetery

Objectives: At the end of this lessonlearnerwill be able to:

1.2.2. Nasal Cannula (Nasal Prongs) or nasal catheter

1. Define Oxygen administration via nasal cannula