CEBU DOCTORS’ UNIVERSITY

COLLEGE OF NURSING BATCH 2024

Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

SUPPLEMENTAL VIDEO: [Link] CLO #2

CLO #1 Importance of Each Laboratory Results to Client Care
Definition of Terms • D - To immediately discover and diagnose a
Laboratory Test pathological process in the body which will enable
A procedure, usually conducted in a laboratory, medical professionals to promptly perform
that is intended to detect, identify, or quantify one or more preventive measures.
significant substances, evaluate organ functions, or establish • A - To assess if the current treatments are working.
the nature of a condition or disease. • M - To monitor the course of the patient’s
Blood Test condition.
These tests are done on a sample blood to check for • A - To detect adverse reactions of drug therapy
certain diseases and conditions. This also helps in checking • G - To generate a plan of treatment that will fulfill
the function of your organs and shows how well treatments the unique needs of every patient.
are working. ***Characteristics of the Blood • E - To oversee and examine the patient's overall
Complete Blood Count health.
• S - To predict the severity of a patient’s condition.
• This test is one of the most common blood tests.
This is a test that counts the cells that make up your Blood Chemistry
blood: the red blood cells, white blood cells, and Significant information on the health of a person’s
platelets, as well as the hemoglobin and kidneys, liver, and other organs can be seen in blood
hematocrit. chemistry tests. A high level of chemical in the blood might
• Used to evaluate your overall health and detect a be a sign of illness or a side effect of medication. Moreover,
wide range of disorders blood chemistry tests aid in diagnosing and monitoring a
variety of illnesses before, during, and after treatment.
Blood Chemistry
A test done on a sample of blood to measure the Blood Test
amount of certain substances in the body. These substances Blood testing is one of the most reliable methods
include electrolytes (such as sodium, potassium, and for monitoring the general state of physical health. Doctors
chloride), fats, proteins, glucose, and enzymes. Blood are able to discern several diseases and ailments through
chemistry tests give important information about how well blood tests. These tests also aid in determining how
a person’s kidneys, liver, and other organs are working. An efficiently organs function and how effectively the
abnormal amount of a substance in the blood can be a sign treatments are working.
of disease or side effect of a treatment. Blood chemistry Complete Blood Count
tests are used to help diagnose and monitor conditions Complete blood count gives physicians information
before, during, and after treatment. about a patient’s blood and overall health. Physicians are
Urinalysis able to diagnose, monitor, and screen a broad variety of
A urinalysis is a test that measures different diseases, ailments, disorders, and infections through CBCs.
chemicals in the blood, such as electrolytes, fats, proteins, This can identify diseases early, sometimes even before
blood glucose, and enzymes. patients experience symptoms, allowing for immediate
treatment. A CBC only involves taking a blood sample. The
Stool Exam
results are often available in a few days.
This is a basic examination of the stool, including
inspecting the specimen for its consistency, color, and occult Sputum Test
(not visible) blood. This examination also helps diagnose A bacterial sputum culture is significant because it
certain conditions affecting the digestive tract. These can be used to identify and diagnose bacterial lower
conditions can include infection (such as those coming from respiratory tract illnesses like bacterial pneumonia or
parasites, viruses, or bacteria), poor nutrient absorption, or bronchitis. To determine the bacteria that is causing a
cancer. person’s illness, a sputum culture is often done with another
Sputum Exam test called a Gram stain. This enables the doctor to find the
best medication to cure the infection. Additionally, a sputum
Sputum is obtained for analysis to identify
culture is important since it shows if a chronic illness of the
pathogenic organisms and to determine whether malignant
lungs has worsened and if the treatment for infection is
cells are present. This is done to figure out what might be
effective.
causing your illness, whether it is a bacterium, or a virus.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Stool Exam • Diet and Nutritional Status. Fasting contributes to

Stool tests can detect blood in the stool sample and having accurate laboratory results.
assist in the diagnosis of medical disorders such as • Malnutrition. A decrease in ferritin, folate, and
inflammatory bowel disease, stomach or colon cancer, anal Vitamin B12 levels will appear to a person with
fissures, and hemorrhoids. These tests are performed to malnutrition.
know whether or not the intestines have been infected by • Alcohol. The hepatic gluconeogenesis is inhibited
bacteria or other microorganisms. If a positive test result is due to the decrease of serum glucose, and
obtained, the lab will help the doctor identify what type it is increased plasma lactate which appears in the
and what medication will be best to combat it. laboratory results.
Urinalysis
A urinalysis is a series of tests that are used to CLO #4
identify various diseases. It can be used to identify and/or Principles In Collecting and Handling Laboratory Test
assist in the diagnosis of health conditions including urinary Specimens
tract infections, renal disease, liver disease, diabetes, and Anatomy and Physiology
other metabolic disorders Knowledge on the different organ systems regarding their
anatomical sites and functions aid in the understanding of
CLO #3 laboratory results. Nurses should also know the location of
Factors Affecting Laboratory Results puncture sites when extracting samples from the clients to
Diseases are common reasons that affect the laboratory collect the correct and appropriate amount of sample.
results. However, there are several other factors that affect Microbiology
the results as well. The aseptic technique (prevention methods to avoid
contamination) is used when handling collections to prevent
These factors are the following: contamination that can cause inaccuracy in test results. The
• Physiologic Factors. Age, sex, race, and other use of proper personal protective equipment will prevent
physiologic factors are beyond the control of a cross contamination.
nurse, it is important to set reference limits or Physics
intervals in these factors in order to manage the This refers to the use of physics for the sampling techniques
results properly. For example, women after in order to produce accurate results.
menopause has increased plasma concentrations
Chemistry
than women not in the menopausal phase. Before
The mixing of different chemicals to the samples to obtain a
puberty, the data of boys and girls have few
result of whether it’s positive or negative.
differences however as they reached after puberty,
there will be changes in sex hormones. Safety and Security
Certain Component from the CBC that concentrates on The specimen should be sealed and labeled correctly in
Physiologic Factors? order for the specimen not to be mixed and avoiding
Red Blood Cells (Hemoglobin & Hematocrit) confusion over which specimen is the patient’s.
• Specimen and Handling Factors. The collection of Sociology
specimens is the most critical step in laboratory Communication is one of the key principles in having a
testing. It is important to properly identify the successful nurse-patient relationship. It is important to
specimen, have the sufficient amount to perform engage with the patient in a calm, approachable and
the test, have the correct blood-to-coagulant ratio, competent way.
and the quality of the specimen. In the storage of Psychology
the specimen, time and temperature is important. Most of the collection methods are invasive so it is important
• Pregnancy. Women who are pregnant undergo to explain the procedure and its purpose for patient
many physiologic changes that affect the laboratory awareness. Inform the patient as you go along with the
results. The ranges of Blood volume, liver and renal process.
function and hormone levels are not in the general
reference range during the pregnancy of the
woman.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

CLO #4
Guidelines and Types of Each Laboratory Tests
Complete Blood Count (CBC)

General Guidelines in Extracting Blood

• Prepare all needed equipment for the procedure and place it within safe and easy reach on a tray, ensuring that all the
items are clearly visible.
• Approach the patient, introduce yourself and identify the patient by asking them to state their full name.
• Once the patient is properly verified by their name, DOB, and MR number, prepare the patient by explaining the
procedure to be done.
• Position hand, apply tourniquet and ask the patient to make a fist.
• Place the patient's arm down in a straight line from shoulder to wrist.
• Tourniquets must be placed 3-4 inches above the antecubital area.
• Select the site by locating a vein of a good size that is visible, straight and clear.
• Clean the site with an antiseptic such as isopropyl alcohol and air-dry site.
• Re-apply the tourniquet, uncap and inspect needle.
• Ask the patient to remake a fist, anchor vein and insert needle bevel up, then perform venipuncture.
• Then first aid needle entry. Anchoring by grasping the arm just below the elbow supporting the back of it with your
fingers. Place the thumb 1-2 inches below and slight below the vein and pull the skin toward the wrist.
• Establish blood flow, release tourniquets and ask patients to open fist.
• Place gauze, remove needle, apply pressure and inspect the venipuncture site.
• Discard the collection unit and label the tubes.
• Dispose of used and contaminated materials.
Guidelines on the Proper Handling of Specimen
• Prepare samples by packing laboratory samples safely in a plastic leak-proof bag. Placing the requisition on the outside
helps avoid contamination.
• If there are multiple tubes, place them in a rack or padded holder to avoid breakage during transportation.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Urinalysis
Specimen Collection Guideline
• Urine specimens should be delivered within 2 hours of collection or
refrigerated and transported to the lab as soon as possible.
• Identification of the patient must be performed by asking a
conscious patient his or her full name and birthdate. Verify by
checking the identification band if available.
• Specimens submitted for routine urinalysis should be collected in
clean, dry containers. The specimen should be submitted to the lab in
a plastic screw-top transfer tube or specimen cup.
• Specimens submitted in syringes will not be accepted.
• Specimens improperly labeled must be discarded and recollected.
• The specimen containers must be properly labeled with
appropriate patient identification including: name, medical record
number, date of birth/age, the date and time of collection, and initials
of the person collecting (or submitting) the sample
• Specimens should be submitted to the laboratory immediately.
• A specimen for urinalysis should be examined while fresh.
Specimens left at room temperature will begin to decompose
resulting in chemical and microscopic changes.
Types of Urine Collection Method
Randomly Collected Specimen
• Sample which is collected anytime during the day. Usually used only for routine screening because the composition of
urine changes throughout the day.
First Morning Specimen
• This sample is collected the first time the patient urinates in the morning. A first voided specimen is the most
concentrated and is the preferred specimen for pregnancy testing, bacterial cultures and microscopic examinations.
Midstream Clean Catch Specimen
• This is the preferred type of specimen for culture and sensitivity testing because of the reduced incidence of cellular and
microbial contamination.
• A “mid-stream clean catch” urine sample is necessary for culture so that any bacteria present around the urethra and on
the hands do not contaminate the specimen.
Is it okay if you can Randomly Collect/First Morning Specimen this? Yes, you can collect any time of the day. As this entails
the duration of collecting the specimen.

What to Instruct before collecting specimen? Instruct the client to clean their private parts. **Females: Front to Back; **Males:
Urethral opening to shaft (inward to outward)

How to instruct the SO of the babies/elderly clients to collect? (Pediatric) Urine Collector. Make sure that the collector is
secured and pasted. Do not let them wear diapers.
24 hr Urine Specimen
• A 24-hour urine collection is a simple lab test that measures what's in your urine. The test is used to check kidney function.
• A 24-hour urine collection is done by collecting your urine in a special container over a full 24-hour period.
• Discard the First Morning Specimen, start at the second urination
Suprapubic Aspiration
• Suprapubic aspiration of urine is a simple and safe technique for obtaining an uncontaminated specimen of urine in
children. (Can also be for elderly clients or bedridden patients)
• Sterile urine (suprapubic aspiration and catheter)

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Stool Exam
Guidelines in Collecting Stool Sample
• Certain stool collections need that the client adhere to a particular
diet or refrain from taking specified drugs before to the collection.
• Label the stool cup with your full name, date and time of collection.
• Avoiding contact with urine, pass stool directly into the stool cup
OR pass stool into a large clean container (such as a cut out milk jug)
or onto a newspaper placed under the seat of the toilet. Transfer
entire specimen into the stool cup using the tongue depressor
provided or other handy implement (such as a plastic spoon). If your
stools are loose, pass directly into a container, not onto newspaper.
• Place only the quantity that is required.
Guidelines in Storing
• Ensure that the specimen containers are sealed well.
• Depending on the test that needs to be done, the sample should
either be kept cold or warm. If stool needs to be kept in the fridge,
make sure the container is first sealed in a plastic bag. Before you start
collecting the sample, call the lab if you don't know how to handle it.
They will give you detailed instructions on what to do with it.
Fecal Occult Blood Test/Guaiac Test
To check any microscopic blood in the stool (esp. GI problems)
Preparations Done Before the Test
Starting 3 days before you begin collecting your stool samples, avoid:
• Red meat, such as beef, lamb, or liver
• Raw fruits and vegetables
• Vitamin C, such as fruit juices with vitamin C and vitamin C supplements in doses higher than 250 milligrams (mg) per day
• Antacids (medications to relieve heartburn or stomach pain)
• Medications to stop diarrhea (loose or watery bowel movements)
• Iron supplements
• Most people will need to stop taking aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), and vitamin E before
and during the 3-day collection period.
• If you have any of the following during the 3 days, you’re planning to collect your stool samples, talk with your healthcare
provider. They may tell you to wait to collect your samples.
 Menstrual period
 Bleeding hemorrhoids (swollen veins in your anus)
 Blood in your urine (pee)
Sputum Exam
Guidelines in Collecting and Storing Specimen
• Collect specimen in a well-ventilated designated TB DOTS - Tuberculosis Directly Observed Treatment
sputum collection area or outside the facility Short-course
• Obtain the sample early in the morning. It should • Instruct the patient not to use tap water or bottled
be before the patient has drunk or eaten anything. water in rinsing mouth as it may contain non-
• Educate the patient about the difference between tuberculous mycobacteria that may alter the results
sputum and oral secretions. Oral secretions, such as of the test
saliva, is a thin and watery sample that comes from • The container containing the sample should be
the mouth, whereas sputum is usually thick and labeled with the patient’s name, ID number,
cloudy coming from a person’s chest. specimen type and date collected.
• Upon sample collection, instruct the patient to rinse • Store the container at room temperature
mouth sterile, filtered water or normal saline • Avoid freezing and thawing specimens to avoid
before expectorating a deep cough sputum into a diminishing the viability of some pathogens from
sterile screw-cap container. Rinsing the mouth will specimens, which could result to a false-negative
decrease contamination of the sputum sample test result

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

What if the patient cannot cough up? Chest physiotherapy (Chest Tapping or Chest Vibration); if not, do suctioning (you can
suction from endotracheal tube too)
Blood Chemistry and Serum Levels
Specific test preparations done to the client for each blood chemistry and serum levels
Electrolyte (sodium potassium, chloride, magnesium, phosphate and bicarbonate)
• Preparation: Typically, no extra preparation is required on the part of the client. After an eight-hour fast, one should
collect samples for calcium, phosphorus, and magnesium.
Kidney Function Test
• BUN Preparation: If only blood urea nitrogen is being tested, you can eat and drink as usual before the test. If your blood
sample will be used for more tests, you may need to fast for a certain amount of time before the test.
• Creatinine Preparation:
 Not to do any strenuous exercises for 2 days (48 hours) before having the tests.
 Not to eat more than 255 grams of meat, especially beef, or other protein for 24 hours before the blood
creatinine test and during the creatinine clearance test.
 Drink plenty of fluids if you are asked to collect your urine for 24 hours
Which is more accurate? Creatinine, it is not affected by factors such as diet and hydration.
Normal Values of Creatinine 60 - 110 mg/dL
Blood Sugar
• Glucose Preparation: For a fasting blood sugar test, do not eat or drink anything other than water for at least 8 hours
before the blood sample is taken. If you have diabetes, you may be asked to wait until you have had your blood tested
before you take your morning dose of insulin or diabetes medicine.
Liver Function Test
• Alanine aminotransferase (ALT) test preparation: An ALT test doesn't require any special preparation. But you should
tell your doctor if you are taking any prescription or over-the-counter drugs. Some drugs can change how much ALT is in
your blood. Before the test, your doctor might tell you to stop taking some medicines for a while.
• Alkaline phosphatase level preparation: It's usually done with other tests to check the liver and kidneys. You might need
to go without food for 10 to 12 hours before the test. But you probably won't need to do anything else to get ready in
advance.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

CLO #6
Guidelines and Types of Each Laboratory Tests
Complete Blood Count (CBC)
LABORATORY
PURPOSE CONVENTIONAL UNITS SI UNITS CLINICAL SIGNIFICANCE
TEST
COMPLETE BLOOD COUNT
The RBC is a cellular Males: 4,600,000 - 4.6–6.2 X 1012 • Increased in severe
component of blood 6,200,000/ cu mm /L diarrhea and dehydration,
in the transport of polycythemia, acute
oxygen and carbon Females: 4,200,000 - poisoning, pulmonary
Red Blood Cells
dioxide 5,400,000/ cu mm 4.2–5.4 X fibrosis
(Erythrocytes)
1012 /L • Decreased in all anemias, in
leukemia, and after
hemorrhage when blood
volume has been restored
White Blood One of the several Total Count: 4,500 - 4.5–11 X 109 /L • Allergy
Cells components of 11,000/ cu mm • Parasitic Disease
(Leukocytes) blood involved in • Collagen Disease
the defense of the • Necrosis
body

Differential
WBC Count:

A. Neutrophils Essential in 45% - 73% Number • Neutrophils increased with

preventing or Fraction: acute infections,
limiting bacterial 0.45–0.73 neutrophils trauma or
infection via surgery, leukemia,
phagocytosis malignant disease, necrosis;
decreased with viral
infections, bone marrow
suppression, primary bone
marrow disease

B. Eosinophils Involved in allergic 0% - 4% Number • Eosinophils increased in

reactions Fraction: allergy, parasitic disease,
(neutralizes 0.00–0.04 collagen disease, subacute
histamine); digests infections; decreased with
foreign proteins stress, use of some
medications (ACTH,
epinephrine, thyroxine)

C. Basophils Contains histamine; 0% - 1% Number • Basophils increased with

An integral part of Fraction: acute leukemia and
hypersensitivity y 0.00–0.04 following surgery or
reactions trauma; decreased with
allergic reactions, stress,

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

allergy, parasitic disease,

D. Lymphocytes An integral 20% - 40% Number use of corticosteroids
component of the Fraction:
immune system 0.2–0.4 • Lymphocytes increased
with infectious
mononucleosis, viral and
some bacterial infections,
hepatitis; decreased with
aplastic anemia, SLE,
immunodeficiency including
E. Monocytes Enters the tissues as 2% - 8% Number AIDS
a macrophage; Fraction:
highly phagocytic, 0.02–0.08 • Monocytes increased with
especially against viral infections, parasitic
fungus disease, collagen and
hemolytic disorders;
decreased with use of
corticosteroids, RA, HIV
infection
The oxygen-carrying Males: 13-18 gm/dL 2.02–2.79 • Decreased in various
proteins in RBCs to mmol/L anemias, pregnancy, severe
the body’s tissues or prolonged hemorrhage,
Females: 12-16 gm/dL 1.86–2.48 and with excessive fluid
mmol/L intake
Hemoglobin • Increased in polycythemia,
(Hgb) chronic obstructive
pulmonary disease, failure
of oxygenation because of
congestive heart failure,
and normally in people
living at high altitudes
The percentage of Males: 42%-52% Volume • Decreased in severe
total blood volume Fraction: anemias, anemia of
consisting of RBCs 0.42–0.52 pregnancy, acute massive
blood loss
Hematocrit
Females: 35%-47% Volume • Increased in erythrocytosis
(Hct)
Fraction: of any cause, and in
0.35–0.47 dehydration or
hemoconcentration
associated with shock
Mean Shows the average 84 - 96 cu μm 84–96 fL • Increased in macrocytic
Corpuscular size of the RBC anemias; decreased in
Volume (MCV) microcytic anemia
Mean Measures the 28–33 μμg/cell 28–33 pg • Increased in macrocytic
Corpuscular amount of anemias; decreased in
Hemoglobin hemoglobin in an microcytic anemia
(MCH) average RBC
Mean Measures the 33% - 35% Concentration • Decreased in severe
Corpuscular concentration of Fraction: hypochromic anemia
Hemoglobin hemoglobin in an 0.33 - 0.35
Concentration average RBC
(MCHC)
Platelets are cellular 150,000 - 450,000/ cu 0.15–0.45X • Increased in malignancy,
Platelets
components of mm 1012 /L myeloproliferative disease,
(thrombocytes)
blood involved in rheumatoid arthritis, and
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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

blood coagulation postoperatively; about 50%

and maintains of patients with unexpected
homeostasis increase of platelet count
will be found to have a
malignancy
• Decreased in
thrombocytopenic purpura,
acute leukemia, aplastic
anemia, and during cancer
chemotherapy
COAGULATION TESTS
Bleeding Time:
Measures the time it Lower Limit of Normal: • Prolonged in deficiency of
takes for a blood 20-25sec fibrinogen, factors II, V VIII,
PTT clot to form IX, X, XI, and XII, and in
Upper Limit of Normal: heparin therapy
32-39sec
Measures the time it 9-12 seconds • Prolonged by deficiency of
takes for the plasma factors I, II, V, VII, and X, fat
PT of the blood to clot malabsorption, severe liver
disease, coumarin
anticoagulant therapy
Measures how Males under 50 y.o.: • Increased in tissue
quickly RBCs settle < 15 mm/h < 15 mm/h destruction, whether
at the bottom of a inflammatory or
test tube that Males over 50 y.o.: degenerative; during
contains a blood <20 mm/h <20 mm/h menstruation and
ESR sample pregnancy; and in acute
Females under 50 y.o.: febrile diseases
<25 mm/h <25 mm/h

Females over 60 y.o.:

<30 mm/h <30 mm/h

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Urinalysis
LABORATORY CLINICAL SIGNIFICANCE
PURPOSE NORMAL VALUES
TEST INCREASED DECREASED
URINALYSIS
CHEMICAL EXAM
This measures the acid and • Urinary tract • Concentrated
alkaline present in the infections urine
various fluids. This helps • Severe alkalosis • Dehydration
pH determine the chances of 4.6-8 • Reduced renal
formation of kidney stones blood flow
• Increase in ADH
secretion
This measures the kidneys’ • Acidosis • Overhydration
Specific ability to balance water • Emphysema • Renal disease
1.010-2.025
Gravity content and excrete waste • Starvation • Inadequate ADH
• Dehydration secretion
This helps indicate how • Nephritis
well your kidney is • Cardiac failure
functioning. Proteinuria • Mercury poisoning
can be a sign of kidney • Bence-Jones
Protein damage 0 (negative)
• Protein in multiple
myeloma
• Febrile states
Hematuria
Shows if there is a • Diabetes mellitus
presence of glucose in the • Pituitary disorders
Glucose urine. This is used to 0 (negative) • Increased ICP
screen for or monitor • Lesion in floor of
diabetes 4th ventricle
Measures the amount of • Typhoid fever • Muscular
creatinine in the urine. This • Salmonella atrophy
test helps evaluate how infections • Anemia
Creatinine the kidneys are functioning 0-270 mg/ 24h • Tetanus • Advanced
degeneration of
kidneys
• Leukemia
Presence of blood in the • Extensive burns
Blood urine may indicate a • Transfusion of
(Hemoglobin possible health problem incompatible blood
0 (negative)
and • Myoglobin in
Myoglobin) severe crushing
injuries to muscles
This helps determine the • Gout • Complete or
cause of a high uric acid nearly biliary
Uric Acid level in the blood. This 250-750 mg/ 24h obstruction
helps diagnose and/or
monitor people with gout
This helps assess liver Random Urine: • Liver and biliary • Complete biliary
function < 0.25 mg/ dL 24- tract disease obstruction
Urobilinogen hr • Hemolytic anemias
24 hr - Urine:
Up to 4 mg/ 24h

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Stool Exam
CLINICAL SIGNIFICANCE
LABORATORY TEST NORMAL VALUES Possible Cause
ABNORMAL
INCREASED DECREASED
STOOL EXAM
• Black
• Red Blood
Color Brown • White Tapeworms
• Yellow
• Green Gallbladder Issues
• Liquid Diarrhea
Texture Soft and well formed
• Very hard Constipation
Does not contain: Contains:
• Blood • Blood
• Mucus • Mucus
• Pus • Pus
• Undigested • Undigested Soluble and insoluble
Constituents fibers (it can happen)
meat fibers meat fibers
• Harmful • Harmful
bacteria, bacteria,
viruses, fungi viruses, fungi
or parasites or parasites
Narrow and pencil
Shape Tubelike shape
shaped
pH 7.0-7.5 <7.0 or >7.5
• Problems in • Celiac Disease
digesting • Cystic fibrosis
sugars • Malnutrition
• Use of birth
Reducing Factors
<0.25 g/dL >0.25 g/dL control pills
(Sugars)
• Medications
such as
colchicine (for
gout)
• Pancreatitis
Fat Levels 2-7 g/24h >7g/24h • Cystic Fibrosis
• Celiac Disease

Fecal Occult Blood Test

CLINICAL SIGNIFICANCE
LABORATORY TEST NORMAL VALUES
INCREASED DECREASED
Negative (-) = No • Ulcers
color change or Positive (+) = turns blue; presence • Polyps
Hemoccult Test
any color other of occult blood • Hemorrhoids
than blue • Abnormal bleeding may
occur somewhere in the
digestive tract
• Colon cancer
Flushable Reagent Pads (EZ Negative (-) = No Positive (+) changes to blue or
• Benign polyps
Detect or Colocare change in color green color
• Diverticulosis
• Inflammatory bowel
disease
Culture and Sensitivity (Culture: What is the disease? Sensitivity: What kind of medication to take? Sensitive or Resistant?

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Sputum Exam
CLINICAL SIGNIFICANCE
LABORATORY TEST NORMAL VALUES
INCREASED DECREASED
• Specific identified or an
Sputum Culture and organism is growing in the
Negative (-)
Sensitivity Positive (+) = bacterial growth is sputum
present • Drug resistance
Sputum for Acid-Fast • Presence of AFB for
Negative (-)
Bacillus (AFB) detection of tuberculosis
• Lung cancer
Positive (+) = cancer cells are • Differentiates type of
Sputum for Cytology Negative (-)
detected cancer cells (small cell,
oat cell, large cell)

Blood Chemistry and Serum Levels

LABORATORY NORMAL CLINICAL SIGNIFICANCE
PURPOSE SI UNITS
TEST VALUES INCREASED DECREASED
BLOOD CHEMISTRY AND SERUM LEVELS
LIVER FUNCTION
An enzyme that is found Males: Males: Same conditions as AST (SGOT),
mostly in the liver. It is 10-40 U/mL 0.17– but increase is more marked in
release d into the 0.68 liver disease than AST
bloodstream when liver µkat/L
Alanine
cells are damaged.
Transaminase
Females: Females:
(ALT)
8-35 U/mL 0.14–
0.60
(SGOT),
µkat/L
An enzyme that is found Males: Males: • Myocardial infarction
mostly in the liver, but 10-40 U/mL 0.17– • Skeletal Muscle
also in muscle s. It is 0.68 Disease
release d into the µkat/L • Liver Disease
Aspartate
bloodstream when the
Transaminase
liver is damaged. Females: Females:
(AST)
15-30 U/mL 0.25–
0.51
(SGOT),
µkat/L

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

To evaluate liver Adults:

function
• To aid in the Total: Total:
differential 0.3 - 1.0 5–17 • Hepatitis
diagnosis of mg/dL µmol/L • Pernicious Anemia
jaundice and • Sickle cell anemia
monitor its
progress Direct: Direct:
0.0 - 0.2 1.7– • Choledocholithiasis
mg/dL 3.7µmol • Cancer of the head of
Bilirubin /L the pancreas

Indirect: Indirect:
0.1 - 1.0 3.4–11.2 • Hemolytic anemia
mg/dL µmol/L • Drug toxicity
• Drug transfusion
reaction

Panic Value:
12 mg/dL

KIDNEY FUNCTION
To evaluate kidney • Acute • Severe Hepatic
Blood Urea function and aid in the Glomerulonephritis Failure
10 - 20
Nitrogen diagnosis of renal • Obstructive Uropathy • Pregnancy (2nd
mg/dL
(BUN) disease • Mercury Syndrome to 3rd
• Nephrotic Syndrome Trimester)
To assess glomerular • Nephritis Chronic
filtration 0.7 - 1.4 62–124 renal disease
Creatinine
mg/dL µmol/L

ELECTROLYTES
• Nephrosis • Diabetes
• Nephritis Mellitus
• Urinary Obstruction • Diarrhea
• Cardiac • Vomiting
Decompensation • Pneumonia
• Anemia • Heavy Metal
97 - 107 97–107
Chloride Poisoning
mEq/L mmol/L
• Cushing’s
Syndrome
• Intestinal
Obstruction
• Febrile
Condition s
• Excess ingestion of • Chronic
magnesium containing Alcoholism
0.62– antacids • Severe Renal
1.3 - 2.3
Magnesium 0.95 Disease
mg/L
mmol/L • Diarrhea
• Defective
Growth

13
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Helps control muscle and • Renal Failure • Hyperpara

nerve activity, maintain • Acidosis thyroidism
fluid levels, and perform • Cell Lysis • Vitamin D
other import ant 3.5 - 5 3.5–5
Potassium • Tissue breakdown or Deficiency
functions mEq/L mmol/L
Hemolysis • GI losses
• Diuretic
Administration
Helps keep water (inside • Hemoconcentration • Alkali Deficit
and outside the body) 135 - 145 135–145 • Nephritis • Addison’s
Sodium
and electrolyte balance mEq/L mmol/L • Pyloric Obstruction Disease
• Myxedema
• Tumor or hyperplasia • Hypopara
of parathyroid thyroidism
• Hypervitaminosis D • Diarrhea
• Multiple myeloma • Celiac disease
• Nephritis with uremia • Vitamin D
2.15–
8.6 - 10.2 • Malignant tumors deficiency
Calcium 2.55
mg/dL • Sarcoidosis • Acute
mmol/L
• Hyperthyroidism pancreatitis
Skeletal Nephrosis
immobilization
• Excess calcium intake:
milk alkali syndrome
BLOOD SUGAR
Measures the amount of Fasting: • Diabetes Mellitus • Hyperinsulinism
blood glucose after you 60 - 110 • Nephritis • Hypothyroidism
have not eaten for at mg/dL • Hyperthyroidism • Late
least 8 hours • Early Hyperpituitarism Hyperpiuitarism
Fasting Blood Postprandial • Cerebral Lesions • Pernicious
Sugar -CBS (2h): • Infections Vomiting
65 - 140 • Pregnancy • Addison’s
mg/dL • Uremia Disease
• Extensive
Hepatic Damage
BLOOD FAT (LIPIDS)
• Hypothyroidism • Hyperthyroidism
• Diabetes Mellitus
400 - 800
Lipids, total 4–8 g/L • Nephrosis
mg/dL
• Glomerulonephritis
• Hyperlipoproteinemias
• To assess the • Lipemia • Pernicious
risk of coronary • Obstructive Jaundice Anemia
150 - 200 3.9–5.2
Cholesterol artery disease • Diabetes • Hemolytic
mg/dL mmol/L
• To evaluate fat • Hypothyroidism Anemia
metabolism • Severe infection
• To aid in the No Coronary • Hyperlipoproteinemias
diagnosis of Artery • Patients with
nephrotic Disease: increased risk for
Low Density syndrome, <160 mg/dL coronary heart disease
Lipoproteins pancreatitis,
(LDL) hepatic disease, Coronary
hypothyroidism, Artery
and Disease is
hyperthyroidism Present:
14
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

• To assess the <100 mg/dL

efficacy of lipid Males: • Patients with
lowering drug 35 - 70 increased risk
High Density therapy mg/dL for coronary
Lipoproteins • To measure the heart disease
(HDL) levels of Females:
cholesterol 35 - 85
• To screen for mg/dL
hyperlipidemia • Hypertriglycemia • Low fat diet
or pancreatitis • Increased risk for • Malabsorption
• To help identify atherosclerosis syndrome
nephrotic • Hyperthyroidism
syndrome and 100 - 200 1.13–3.8
Triglycerides
the individual mg/dL mmol/L
with poorly
controlled
diabetes
mellitus
BLOOD PROTEINS
Total Protein 6-8 gm/dL • Hemoconcentration • Malnutrition
Albumin 4-5.5 g/dL • Shock • Hemorrhage
• Multiple Myeloma • Loss of plasma
Globulin 1.7-3.3 g/dL • Chronic Infection from burns
• Liver Disease • Proteinuria

CLO #7 Stool Exam

Sample Documentation Forms
Urinalysis

15
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Sputum Exam Complete Blood Count

Hematology

Cumulative Sample Report of Various Laboratory Tests

Blood Chemistry

16
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Significance of Laboratory Results
Ms. Geniza Fatima V. Lipura

Sample Laboratory Reporting Form

Sample of a Laboratory Results Documented In EMR

Sample Responses from Patients

Before and after the test, the client or patient may ask
questions regarding the lab tests. Some of these include:

Example:
• “When do I get the results?”
• “Are there any dietary restrictions after I take the
test?”
• “What type of sample will be needed and how will
it be collected?”
• “Are there any activity restrictions related to the
test that i need to avoid hours after the test?”

17
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

CLO #1 uses the accessory muscles in the neck and

Definition of Terms shoulders.
o Patient is in a sitting position. As the
Chest Physiotherapy, Postural Drainage and Nebulization:
patient exhales, apply pressure with the
Atelectasis use of a palm or finger tip just below the
• It is the collapse of the entire lung or a section of clavicle
the lung. It happens when the alveoli within the • Basal Expansion
lung deflates or fills with alveolar sacs. o This gives emphasis on the posterior
• It is also one of the common complications post- segments of the lower lobes.
surgery. o This form of segmental breathing is
Emphysema important for post-surgical patients who
Is a lung condition that is characterized by dyspnea. Alveoli, are in a semi-reclining position for an
which are the air sacs, are harmed. Its inner walls deteriorate extended period of time.
and tear over time, resulting in the creation of larger air o Patient is in a sitting position. As the
spaces as opposed to the smaller ones. patient exhales, apply pressure with the
Bronchiectasis use of a palm or finger tip just below the
Is a lung condition characterized by dyspnea. The bronchi are clavicle
the passages in the lungs that allow air to enter. Due to Coughing Exercises
inflammation, this thickens the bronchial surface over time • Quad Coughing - This is used for clients without
and causes scarring. abdominal muscle control e.g. clients with spinal
Auscultatory Points cord injuries. The client or nurse pushes inward and
Are points are the points of placement of the stethoscope upward on the abdominal muscles to the
that will allow you to best hear the inspiratory and expiratory diaphragm while the client breathes with maximal
sounds of the lungs. expiratory efforts, causing the cough.
Chest Physiotherapy • Huff Coughing - In this, the client says the word
Is a method of opening the airways and helps the lungs get "huff" after opening the glottis with an exhale. A
rid of the mucus by gently pounding the chest wall. natural cough response is triggered by the huff
cough. The central airways can be cleared with this
Deep Breathing Exercises
technique. Clients who consistently engage in this
These are exercises that help allow your body to fully greater air inhale, maybe leading to cascade cough
exchange incoming oxygen with outgoing carbon dioxide.
• Cascade Coughing - Ask the client to inhale slowly
• Pursed-lip Breathing - It is a method that gives you and deeply, holding the breath for 2 seconds while
control over your ventilation and oxygenation. It tightening the muscles in the exhalation. Instruct
involves taking calm, controlled breaths in through the client to open their lips and cough repeatedly
the nose and out through the mouth. while exhaling, doing so at a reduced lung volume.
• Diaphragmatic Breathing This promotes airway clearance and keeps a
o There is a large muscle called the significant amount of sputum in patients with
diaphragm that sits at the base of the patent airways.
lungs. It contracts and travels downward
Chest Vibration
during inhalation to provide room for the
Chest vibration is a manual approach that is used by
lungs to expand and fill it with air.
physiotherapists to help with the assistance of airway
o Also known as “belly breathing”
clearance. The mucus is gently shaken to allow it to flow into
o It involves the use of the diaphragm,
the larger airways
stomach, and abdominal muscles to their
full extent. With each inhalation, the • Chest tapping/Percussion
diaphragm must be forcefully pulled o Is a type of chest physiotherapy that's
downward. In this way, diaphragmatic regularly used to help clear the airways of
breathing promotes more effective lung mucus in people with cystic fibrosis,
filling. chronic obstructive pulmonary disease
(COPD), and other diseases. In order to
• Apical Expansion
assist you cough out the heavy mucus in
o This is a pattern of breath that contains
your lungs, a therapist or a close friend will
most movement to the upper chest.
clap on your chest or back.
o This uses fewer muscles than
o Hands are cupped during the procedure
diaphragmatic breathing because it mostly

1
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Postural Drainage • It is also performed to diagnose a condition and

Is the placement of a patient with a compromised lung enables doctors to see, remove a tissue if necessary
segment so that the drainage of broncho-pulmonary or a biopsy.
secretions from the tracheobronchial tree is made as easy as Thoracostomy
possible by gravity. It is based on the idea of mobilizing Thoracostomy involves the insertion of a thin plastic tube
secretions with the help of gravity and moving them to be into the space between the lungs and the chest wall. The
removed. It is a positioning strategy for bronchial secretions tube may be attached to a suction device to remove excess
to be released. fluid or air
Incentive Spirometry
It is a inhalation technique in which the patient is motivated Chest Tube
to perform sustained maximal inhalation by visual cues from Is a surgically implanted hollow plastic tube used to drain
a spirometer. Until they can reach their anticipated fluid or air from the chest cavity. Due to trauma, surgery,
inspiratory reserve volume, patients typically perform 10 to cancer, or infection, various fluids, such as blood, pus, or
20 sustained deep breathing exercises per hour. cancer cells, can amass in the chest.
Nebulization Chest Tube Drainage System
Is the process of giving medicine by inhalation. It makes use Is a sterile, disposable device with one or more chambers
of a nebulizer to deliver medications to the lungs through the and a compartment system with a one-way valve to remove
inhalation of mist. air or fluid and prevent it from returning into the patient.

Care of Clients with Chest Tube Drainage: Blood Transfusion:

Pneumothorax Blood Transfusion
A pneumothorax occurs when air leaks into the space It is an administration of blood with the use of a tiny tube
between your lung and chest wall. This air pushes on the that is inserted into a vein of your arm.
outside of your lung and makes it collapse. Recipient
Hemothorax A person that receives the donated blood.
This occurs when blood builds up between your lungs and Donor
chest wall. The pleural cavity is the name given to this space A person that gives blood for the transfusion.
where blood may collect. As the blood pushes on the outside
Plasma
of the lung, the accumulation of blood in this space may
• Also known as the liquid portion of the blood.
eventually cause your lung to collapse.
• Plasma acts as a transport medium for nutrients to
What is the difference between pneumothorax and
reach the cells of the body's organs and for waste
Hemothorax?
products produced by cellular metabolism to be
• Pnuemo - Air
transported to the kidneys, liver, and lungs for
• Hemo - Blood
elimination.
What is normally in the pleural space (in between the Direct Transfusion
visceral and parietal)? The patient’s vein receives blood directly from a donor’s
Pleural Fluid for Lubrication (10-20 mL) artery. Or it can also be a vein-to-vein transfusion.
Chylothorax Indirect Transfusion
It is a rare illness in which lymphatic fluid leaks into the gap Transfusion into a patient of blood previously obtained from
between the lung and chest wall, and is a disturbance of a donor and stored under suitable conditions.
lymphatic flow. Chest pain, a violent cough, and breathing Blood Typing
difficulties can all be brought on by the accumulation of this Testing of a sample of blood to determine an individual’s
fluid in the lungs. blood group
Thoracotomy Blood Screening
• This involves making a cut between the ribs to The examination of any biological material intended for use
access the lungs or other organs in the chest or in biological products, as well as the examination of blood,
thorax. or plasma, or blood components intended for transfusion.
• It is performed on either the left side or right side Cross Matching
of the chest. Although it is very rare, it is possible to It involves mixing a sample of the donor's red blood cells with
make an incision through the breast bone on the the recipient's plasma and the recipient's red blood cells
front of the chest. with the donor's plasma to check for blood compatibility
before a transfusion to prevent potentially fatal hemolytic

2
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

reactions between the donor's red blood cells and

antibodies in the recipient's plasma, or the other way
around. Red blood cell clumping is a sign of incompatibility
and strongly discourages using the donor's blood.
• Anemia - Is a condition in which you lack enough
healthy red blood cells to carry adequate oxygen to
the body tissues.
CLO #2
Importance, Indications and Contraindications in Chest Physiotherapy, Postural Drainage and Nebulization, Clients with Chest
Tube Drainage Systems and Blood Transfusion.
Chest Physiotherapy
Importance
• It aids in the improvement of lung function by strengthening breathing muscles and loosening and improving the drainage
of thick lung secretions.
• Aids in the treatment of diseases such as cystic fibrosis, chronic obstructive pulmonary disease (COPD), atelectasis, and
other lung infections.
• It keeps the lungs clear after surgery and during periods of immobility, preventing pneumonia.
• To aid in the removal of retained or excessive airway secretions.
• To improve lung compliance and keep it from collapsing.
• To reduce the amount of work required for breathing.
Indications and Contraindications with Rationale
INDICATIONS RATIONALE
Cystic fibrosis is a genetic condition that severely harms the Lung secretions are improved with chest physiotherapy, which
lungs, digestive system, and other body parts. The secretions helps to release the secretions.
thicken and become sticky as a result of a defective gene.
Bronchiectasis is a chronic illness where the bronchial walls To aid in the removal of trapped airway secretions caused by
thicken as a result of infection and inflammation. It makes inflammation and infection.
someone cough up mucus.
Atelectasis is a condition in which the lungs' airways and air Improves lung function by strengthening the breathing
sacs collapse or do not expand properly. muscles.
Lung Abscess is a lung infection characterized by a localized To aid in the removal of pus and destroyed tissue from the
accumulation of pus and tissue destruction. lungs.
Neuromuscular Disease is a rare acquired or genetic disease It aids in the strengthening of the breathing muscles.
that causes nerve and muscle damage. Because of
neuromuscular weakness, you may find it difficult to cough
effectively, which means you are unable to clear mucus from
your lungs.
Pneumonia in dependent lung regions is a bacterial, viral, or To assist with the drainage of accumulated fluid or pus.
fungal infection of the lungs that causes fluid or pus to
accumulate in the alveoli.
CONTRAINDICATIONS RATIONALE
Instability of the head or neck If the procedure is carried out, it may result in further injury.
Active Hemorrhage is any amount of bleeding. Could result in more bleeding.
Bronchopleural Fistula is an abnormal passageway (a sinus Secretions could enter the abnormal passageway and cause
tract) that forms between the large airways in the lungs (the additional complications.
bronchi) and the space between the lungs' membranes (the
pleural cavity).
Empyema is a pus-filled cavity between the lung and the Because the pus has accumulated in the pleural space, it
membrane that surrounds it (pleural space). cannot be drained.
Rib Fracture Could result in additional harm

3
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Postural Drainage
Importance
Postural drainage's primary goal is to move loosened secretions toward the proximal airway for eventual removal. The removal of
secretions reduces the risk of a chest infection.
Indications and Contraindications with Rationale
INDICATIONS RATIONALE
Chronic Obstructive Pulmonary Disease (COPD) refers to a Increases lung volume, strengthens breathing muscles, and
group of diseases that cause airflow obstruction and breathing loosens and improves drainage of thick lung secretions.
problems.
Lung Abscess is caused by microbial infection, necrosis of the Aids in the prevention of pneumonia and other breathing
pulmonary tissue and the formation of cavities containing problems
necrotic debris or fluid.
CONTRAINDICATIONS RATIONALE
Orthopnea is a shortness of breath that some people Because the procedure involves the use of various positions,
experience when lying down and disappears when they return significant oxygen desaturation occurs.
to an upright position.
Recent head trauma/surgery Postural drainage is not recommended until the patient has
been stabilized because it can cause further injury.
Uncontrolled or unprotected airway with aspiration risk Causes oxygen desaturation
Significantly distended abdomen - term used to describe An uncomfortable or even painful swollen abdomen is
distention or swelling of the abdomen rather than the common.
stomach.
Nebulizer
Importance
• Nebulizers deliver medications to areas where they are most needed. Unlike systemic medications, which take time to
enter the bloodstream after passing through the gastrointestinal tract, nebulizers deliver medications directly to the
respiratory tract.
• Nebulizer treatments can both prevent the development of respiratory problems and treat acute breathing emergencies.
• Nebulizers are extremely easy to use. In contrast to inhalers, which require you to breathe in when you release the
medication, the medication in a nebulizer treatment flows continuously.
• When compared to oral administration of the same medications, nebulizer therapy reduces the risk of side effects.
Indications and Contraindications with Rationale
INDICATIONS RATIONALE
Bronchospasms is a tightening of the muscles that line your lungs' airways Reduces inflammation in the lungs and makes
(bronchi). Your airways narrow when these muscles contract. Airways that are breathing easier.
too narrow do not allow as much air to enter or exit your lungs.
Respiratory Congestion is a buildup of mucus in the lungs and lower breathing To help clients breathe easier, nebulizers can
tubes (bronchi). It is usually accompanied by a productive cough with thick help open the airways, reduce inflammation,
mucus. and break up congestion.
Asthma is a condition in which your airways narrow and swell, causing extra relaxes the muscles that constrict your
mucus to form. This can make breathing difficult and cause coughing, a airways. This helps to open them up, allowing
whistling sound (wheezing), and shortness of breath. the client to breathe more easily.
Pneumonia is an infection that inflames the air sacs in your lungs (alveoli). The Nebulizer treatment can help clients breathe
air sacs may become clogged with fluid or pus, resulting in symptoms such as better by loosening mucus in their lungs.
a cough, fever, chills, and difficulty breathing.
Atelectasis is the collapse of the entire lung or a section of the lung (lobe). It is Aid in the liquefaction of secretions and their
when the tiny air sacs (alveoli) within the lung become deflated or possibly easy removal.
filled with alveolar fluid, this condition occurs.
CONTRAINDICATIONS RATIONALE
Patients who are unconscious The therapeutic effect could be minimal.
Individuals suffering from cardiac irritability May cause dysrhythmias
• Increases heart rate

4
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Chest Tube Drainage Systems

Importance
• It is significant because it is used to remove air from the intrathoracic space in the case of pneumothorax or fluid from
the intrathoracic space in the case of pleural effusion, blood, chyle, or pus when empyema occurs.
• Allows for the drainage of air or fluid while preventing air or fluid from entering the pleural space. The system is airtight
to prevent atmospheric pressure from entering.
• Restore negative pressure in the pleural space to allow the lungs to expand again.
Indications and Contraindications with Rationale
INDICATIONS RATIONALE
Pneumothorax is a lung that has collapsed In order to prevent air from returning.
Spontaneous Pneumothorax is a sudden onset of a collapsed In order to keep air from returning to the lung.
lung with no obvious cause
Tension Pneumothorax is when air enters the pleural cavity Allows for the drainage of air or fluid while preventing air or
and becomes trapped during expiration fluid from entering the pleural space.
Hemothorax is when blood accumulates between your chest To remove the blood that has accumulated between your
wall and lungs. chest wall and lungs.
Pleural Effusion Is the accumulation of extra fluid between the To drain the accumulation of excess fluid between the pleura
pleural layers outside the lungs layers.
CONTRAINDICATIONS RATIONALE
Pulmonary, pleural, or thoracic Adhesions This procedure may cause additional damage to the site of the
adhesions
Coagulopathy is a condition in which the ability of the blood to This could lead to additional bleeding complications.
clot is impaired
Skin infection at the site of chest tube insertion It may exacerbate the infection.
Blood Transfusion
Importance
A blood transfusion can save a patient's life and limit the complications that can result from severe blood loss.
Indications and Contraindications with Rationale
INDICATIONS RATIONALE
Acute Sickle Cell Crisis happens when sickle-shaped red blood Transfusions of blood reduce the risk of some complications of
cells clump together and block small blood vessels that sickle cell disease as well as the symptoms of severe anemia.
transport blood to specific organs, muscles, and bones.
Acute blood loss of greater than 30% of blood volume A blood transfusion is a simple procedure that replaces blood
• Blood loss is referred to as bleeding, also known as that has been lost due to injury or surgery.
hemorrhage. It can refer to blood loss within the
body, known as internal bleeding, or blood loss
outside the body, known as external bleeding.
• Hypovolemic shock, hemophilia, brain trauma,
bleeding from cuts, internal bleeding such as in the
gastrointestinal tract, and other causes of blood loss.
Symptomatic Anemia is a condition in which you do not have Red blood cells can provide a source of iron for your body to
enough healthy red blood cells to transport enough oxygen to reuse.
your body's tissues. If your iron deficiency anemia is severe,
you may require a red blood cell transfusion.
CONTRAINDICATIONS RATIONALE
Transfused blood contains microbial contaminants The actual risk of transfusion associated sepsis, as well as infections
such as bacteria. caused by contaminated blood products, is likely to be higher.
Mismatches due to differences between donor and If the recipient develops antibodies against minor antigens on the
recipient blood, blood typing and crossmatching transfused red cells, delayed hemolytic reactions may occur. These
reactions are typically mild and are caused by certain chemicals in the
donor's blood, which can cause fever, hives, rashes, itching, low blood
pressure, and other symptoms.

5
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

CLO #3 Types of Chest Tube Drainage Systems

Types of Nebulizers, Chest Tube Drainage Systems, Blood One-Bottle System
Products and their Compatibilities
Nebulizer Types
Jet

Is the simplest form of underwater seal drainage systems. It

can drain both fluid and air. The distal end of the drainage
tube must be below the water surface level. There is always
an outlet to the atmosphere that lets air out.
Two-Chamber System

This type of nebulizer uses compressed gas (like air) to make

an aerosol (tiny particles of medication in the air). It is the
most common type of nebulizer.
Ultrasonic Wave

When large quantities are drained from the pleural cavity, a

two-chamber system is preferred over a one-bottle system.
In a two-chamber system, the first bottle collects the
drainage and the second bottle is the water seal. The water
seal remains at 2 cm, in which the degree of water seal does
not increase as fluid accumulates in the drain bottle. The
water seal bottle is very useful for chest drainage, as it
Ultrasonic nebulizer uses high frequency vibrations to make includes a place for drainage to collect and a one-way valve
an aerosol. Ultrasonic nebulizers are commonly used in that stops air or fluid from going back to the chest.
hospitals.
Three-Chamber System
Vibrating Mesh

The mesh of a vibrating mesh nebulizer consists of 1,000 A three-chamber system consists of collection of drainage,
precision formed holes that vibrates at 123,000 times per water-seal, and suction control. The purpose of this system
second to generate aerosol by pumping liquid through the is at the time of suction, it requires to pull air and fluid out
holes. It is also an electronically powered nebulizer. of pleural space and pull the lung up against the parietal
pleura. If suction is needed, a third bottle is added. Level of
fluid in the suction control bottle will determine the amount
of suction provided to the patient.

6
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Wet Suction Control Packed Red Cells

It is an older technology that controls the negative pressure

that will be transmitted to the chest. A wet suction system is
usually controlled by the level of water in the suction control
chamber. For adults, it is mostly set at 20 cm on the suction Packed red cells are what remains of whole blood after
control chamber. removing the plasma and platelets. Packed red cells usually
Dry Suction Control contain sodium, potassium, ammonia, citrate, hydrogen
ions, and antigenic protein than whole blood. Packed red
blood cells are transfused to prevent tissue hypoxia. Packed
red blood cells are made from a unit of whole blood by
centrifugation and removal of most of the plasma, leaving a
unit with hematocrit of about 60%. Indicated for patients
with acute sickle cell crisis, acute blood loss of more than
30% of blood volume, and symptoms of anemia (which
include shortness of breath, wooziness, congestive heart
A dry suction system uses a self-controlled regulator that is failure, and impaired exercise tolerance).
capable of adjusting the amount of suction and responds to Platelet Concentrates
air leaks to deliver consistent suction for the patient.
What is the difference?
Wet system uses water to suction, Dry system uses
suction from the wall suction (-80)
Blood Products
Whole Blood

It contains about 60mL of plasma and a small amount of red

blood cells and leukocytes. It must be kept at room
temperature and agitated during storage. Platelet
concentrates can prevent bleeding and stop bleeding in
patients with low platelet count.
Fresh Frozen Plasma
It consists of red blood cells, white blood cells and platelets,
which are suspended in a liquid called plasma. Whole blood
naturally flows through the body with none of its parts being
separated or being removed. According to the Red Cross, In
medicine, whole blood is an uncommon type of transfusion.
That is used to treat patients that need a large amount of all
the components of blood, such as those who have sustained
significant blood loss from trauma or heart surgery.

It contains all factors of the soluble coagulation system. It is

for patients that have multiple factor deficiencies and are
bleeding. Fresh frozen plasma should never be used as a
plasma expander.
7
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Plasma Derivatives It contains a concentrated subset of fresh frozen plasma

components such as fibrinogen. It is used to control and
prevent bleeding in people that have clotting problems. This
is mostly used by patients with Hemophilia A and von
Willebrand disease.
BLOOD COMPATIBILITY
COMPATIBLE
COMPATIBLE
PLASMA TYPES
PATIENT TYPE RED BLOOD
(FFP &
TYPES
This blood product contains concentrated fractions of CRYOPRECIPITATE)
plasma proteins that have been set apart using A A, O A, AB
chromatographic or other fractionation processes. It is B B, O B, AB
indicated for patients with deficiencies of clotting factors, for O O O, A, B, AB
which specific concentrate is not available. AB AB, A, B, O AB
RhD Positive RhD Positive
Cryoprecipitate RhD Positive
RhD Negative RhD Negative
RhD Positive
RhD Negative RhD Negative
RhD Negative

CLO #4
Proper Storage and Transport of Blood and Blood Products
Blood Cold Chain Technique
BLOOD LENGTH OF
PROPER STORAGE PROPER TRANSPORT PICTURE
PRODUCTS TRANSFUSION
Stored at 4°C • Must be kept at +2°C to Begin transfusion
(39.2°F) +10°C during transport within thirty minutes
• Specifically designed from the refrigerator
42 days shelf life blood transport boxes
Packed RBC’s
before being should be used Complete transfusion
discarded w/in 4 hours.

Immediately frozen • Components that are Transfuse immediately

in plasma freezer at frozen during transit after thawing.
below -30C must be kept at or
Frozen Plasma
below the necessary Begin transfusion
and
1 year shelf life if storage level within 30 minutes
Cryoprecipitate
remained frozen temperature. from the freezer.
Complete transfusion
w/in 20-30minutes.
Stored at 4°C • Must be kept at +2°C to Begin transfusion
(39.2°F) in a blood +10°C during transport within 30 minutes
bank refrigerator. • Specifically designed from the Refrigerator.
Whole Bloods blood transport boxes
should be used Complete transfusion
w/in 4 hours.

8
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Cold Chain Technique

The blood cool chain consists of a number of related processes involving necessary tools, people, and procedures for the
secure transportation and storage and storage of blood from collection to transfusion.
A key component of the plan to increase widespread accessibility to secure blood transfusions is an efficient blood cold
chain. The development of a dependable blood cold chain system necessitates the commitment, support, and continuous funding
of national health authorities. The easiest way to accomplish this is through a blood transfusion service that is organized at various
levels of the national healthcare system.
All parts of the blood supply chain, including blood centers, hospital blood banks, and other establishments that handle
blood, blood products, and blood samples, should adhere to quality principles. For the purpose of managing the blood cold chain
effectively, a quality system that includes employees, procedures, and equipment needs to be designed and put into place.

CLO #5 into the medication cup to create a breathable

Parts of the Nebulizer, Chest Tube Drainage System and mist.
Blood Administration Set 2. Nebulizer cup: The reservoir where the measured
liquid medication goes. It also determines how well
Nebulizer
the system can produce droplets that are the right
size to travel deep into the airways.
3. Mouthpiece/mask: The opening through which
the mist is inhaled. Most nebulizer sets come with
mouthpieces, but masks are available for those who
find them more comfortable or who have trouble
wrapping their lips around the mouthpiece.
Nebulizers can be used to deliver many types of
medicines. The medicines and moisture help
control breathing problems like wheezing and help
loosen lung secretions.
4. Tubing: The tubing delivers air from the compressor
to the medication cup
A nebulizer is an electrically powered machine that turns 5. Tubing connectors: These connect the tubing to the
liquid medication into a mist so that it can be breathed compressor and nebulizer cup
directly into the lungs through a face mask or mouthpiece.
People with asthma can use a nebulizer to take their
medications. It helps you to breathe in medicine as a fine
mist through a mask or a mouthpiece.
Parts of the Nebulizer
1. Nebulizer compressor: Nebulizers can be used to
deliver many types of medicines. The medicines and
moisture help control breathing problems like
wheezing and help loosen lung secretions. A
nebulizer might be used instead of other inhalers.
The compressor is said to be the base system that
plugs into an electrical outlet where it pumps air

9
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Chest Tube Drainage System 3. Wet or dry suction control chamber: Not all
patients require suction. If a patient is ordered
suction, a wet suction system is typically controlled
by the level of water in the suction control chamber
and is typically set at -20 cm on the suction control
chamber for adults. If there is less water, there is
less suction. The amount of suction may vary
depending on the patient and is controlled by the
chest drainage system, not the suction source.
Monitor the fluid level to ensure there is gentle
bubbling in the chamber. A dry suction system uses
a self-controlled regulator that adjusts the amount
of suction and responds to air leaks to deliver
consistent suction for the patient. If suction is
discontinued, the suction port on the chest
drainage system must remain unobstructed and
open to air to allow air to exit and minimize the
development of a tension pneumothorax
4. Air leak monitor: is indicated when negative
pressure in the pleural space is disrupted, as from
thoracic surgery or unanticipated trauma. The tube
helps restore negative pressure, preventing further
A sterile, disposable system that consists of a respiratory com
compartment system that has a one-way valve, with one or Blood Administration Set
multiple chambers, used to remove air or fluid and prevent
return of the air or fluid back into the patient. It allows for
air or fluid to be drained, and prevents air or fluid from
entering the pleural space. The system is airtight to prevent
the inflow of atmospheric pressure.
In general, a traditional drainage system will have
these three chambers. Parts of the Nebulizer (definition and
purpose):
1. Water Seal chamber: The main purpose of the
water seal is to allow air to exit from the pleural
space on exhalation and prevent air from entering
the pleural cavity or mediastinum on inhalation.
As a result of the chamber's pressure, the one-way
valve in this chamber permits air to leave the 1. Drip chamber: a device used to allow gas (such as
pleural cavity during exhale but prevents it from air) to rise out from a fluid so that it is not passed
returning during inhalation. To guarantee effective downstream.
operation, the water-seal chamber should always 2. Blood filter: helps remove clots and small clumps of
be filled with sterile water and kept at the 2 cm platelets and white blood cells that form during
mark. It should also be regularly inspected. Should collection and storage.
it be necessary, add more sterile water. Tidaling, a 3. Roller Clamp: tube clamp particularly for adjusting
sign that the chest tube is patent, is when the water liquid flow through tubes. provides blood or blood
in the water-seal chamber rises with inhale and falls components if you've lost blood due to an injury,
with exhale. Continuous bubbling may be an during surgery or have certain medical conditions
indication of an air leak, and more recent systems that affect blood or its components.
feature a measurement system for leaks; the higher 4. Injection Bulb and Luer Lock with a Needle: a
the number, the worse the breach. medical instrument used to inject the blood to the
2. Collection chamber: collects drainage from the client.
pleural cavity. The chamber is calibrated to
measure the drainage. The outer surface of the
chamber has a “write-on” surface to document the
date, time, and amount of fluid

10
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

CLO #6 Guidelines of Postural Drainage

Guidelines of Chest Physiotherapy, Postural Drainage, • Consult first a physician before doing postural
Nebulizer, Care of Clients with a Chest Tube Drainage and drainage.
Blood Transfusion • Make sure to perform postural drainage on an
Guidelines of Chest Physiotherapy empty stomach
• Assess the patient’s lungs and listen for wheezing • Do postural drainage 30 minutes after using
and crackles and unequal aeration through bronchodilators or inhalers.
auscultations • Before determining the postural drainage position,
• Provide patient education with regards to the it is very important to auscultate the lungs and
procedure identify the lung segments where added sound
(Crepitus, Ronchi) is heard.
• Obtain baseline data such as vital signs and pain
score • Find positions that the client feels comfortable
• Gather needed materials for the procedure • When the client feels or has the urge to cough,
• Do medical hand washing prior to the procedure assist them in sitting up and do controlled coughing.
• Each position should be maintained for a minimum
• Patient should be monitored throughout therapy
of five minutes.
• Provide coughing instruction prior to therapy
• Positions may be done on a bed or on the floor.
• Tracheal suctioning and Oropharyngeal suctioning
may be done as needed. • In every position, the chest should be lower than
the hips to allow mucus to drain.
• During the procedure check the patient’s comfort,
and response to the procedure. • Pillows, foam wedges, and other devices are used
to make the procedure comfortable.
• Check patient's vital signs frequently. If significant
• While maintaining the positions, one must breathe
changes occur, notify the physician after
through the nose and breathe out to the mouth
repositioning the patient.
longer than the time breathing in for maximum
• During chest percussion position the hand so the
effectiveness of the procedure.
fingers and thumb touch and the hands are cupped
• One can do these positions in the morning to clear
the mucus that built up overnight or right before
bed to prevent coughing during the night.
• Postural drainage should be performed 2-4 times a
day before meals as indicated by the physician.
Guidelines of Nebulization
• Washing of hands before using a nebulizer is very
important.
• Clean and disinfect workplace
• Always use a clean nebulizer.
• Perform percussion over a single layer of clothing. • Ensure the correct dose of medication and other
(not over buttons or zippers) solutions prescribed by the physician.
• Do not percuss over the spine, sternum, stomach or • Check all connections of the nebulizer, if it is
lower back as trauma can occur to the spleen, liver, properly attached.
or kidneys. • The nebulizer must be in an upright position to
• Usually, each area is percussed for 30-60 seconds prevent spilling and promote maximum
several times a day. For patients that have effectiveness of the treatment.
tenacious secretions, the area must be percussed • Take slow deep breaths and if possible, hold each
for 3-5 minutes several times a day. breath for 2 or 3 seconds before breathing out. This
• After each vibration during the treatment, will let the medication settle in the airways.
encourage the client to cough and expectorate • Clean all the parts of the nebulizer with liquid dish
secretions into the sputum container. soap and water after using it.
• Observe the changes in sputum production, breath • Make sure that all the washed parts are completely
sounds, vital signs, chest Xray, and peak expiratory dry before storing the nebulizer.
flow rate to determine the effectiveness of the • It is advisable to replace the tubing every two
treatment weeks.
• Document the therapy and the result

11
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Guidelines of Chest Tube Drainage Systems Air Leak (bubbling)

• Chest drains should not be clamped unless ordered • Check the drainage tube and/or water-seal
by a medical staff Underwater sealed drains unit chamber for tidalling (water moving up and down
and tubing with respirations).
• Never lift drain above chest level o Gentle bubbling is normal as the lungs
• To facilitate drainage, the unit and all tubing should expand in wet suction systems.
be below the patient's chest level. o Intermittent bubbling in wet and dry
• Tubing should have no kinks or obstructions that suction systems is normal.
may inhibit drainage. o Assess air leak meter following the chest
• Ensure the tightness and security of all connections drainage unit’s feature. On every shift,
between chest tubes and drainage unit document the level of air leak and if the air
• To prevent the drain from being pulled out, the leak happens at rest or while coughing.
tubing needs to be secured to the patient's skin. o If there is a suspected air leak, observe and
• The unit must be positioned securely or hanging on look for the source of the air leak.
the bed o Air leaks may be found in the tightness of
• The water seal is maintained at 2cm at all times. connection, or in the tubing.
• The severity of the leak will be indicated by
Suction
numerical grading on the UWSD (1- small leak 5-
• Suction may not always be required, and may lead large leak)
to tissue trauma and prolonged air leak in some • If the chamber is bubbling nonstop, it means that
patients there is an air leak happening in the drainage or in
• If suction is required, it must be ordered by a the chest tube. Assess the patient's condition after
medical staff and be written. air leak is indicated.
o Atrium Oasis - The wall suction should be o Check the drainage for disconnections,
set at >80mmHg or higher dislodgments, and loose connections. If
o Atrium Ocean - Suction needs to be the issue cannot be fixed, immediately
titrated so that the fluid in suction notify the medical professionals.
chamber is gently bubbling • Document on Fluid Balance Flowsheet on EMR
• Suction on the Drainage unit should be set to the
Patient Positioning
prescribed level
• Post-operative ambulant patients will experience
Drainage
fewer problems and shorter hospital stays. To make
• Ensure the chest drainage unit is below the level of this easier, consider switching to a transportable
the insertion site, upright, and secured to prevent it flutter valve system like the pneumostat. If a chest
from being accidentally moved or tipped over. drain is going to be needed for a while
• Monitor fluid level to ensure there is gentle • Regular position changes should be recommended
bubbling in the chamber. to encourage drainage if a patient is newborn or on
• Mark the drainage level by writing the time and strict bed rest, unless a clinical condition prevents
date at the drainage level on the drainage collection doing so.
chamber every shift (or more often if there’s a large Guidelines of Blood Transfusion
amount of drainage).
• Collection of the blood sample from the patient into
• Drain output should be monitored no less than
the sample tubes and sample labelling must be a
every 8 hours.
continuous
• Chest drains must only be milked in accordance
• Sample tubes must not be pre-labelled.
with written instructions from medical personnel.
• Identify the right patient. Ask for a full name, date
High negative pressure produced by drain milking
of birth and Identification Card.
can result in pain, tissue damage, and bleeding.
• Check for patient information and consent for
Volume blood transfusion.
• If a drain with an ongoing loss suddenly stops • Read pre-transfusion documents and verify
draining, alert medical personnel. • There must be a transfusion prescription that
• Simply tip the chamber up to allow blood to flow to contains components to be transfused, date of
the original chamber if the chamber tips over and transfusion, volume or number of units to be
spills into the subsequent chamber. transfused and rate or duration of transfusion, and
special requirements.

12
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

• The request form should be signed by the person Fractured Ribs

collecting the sample. • Encourage patient to do deep breathing exercises
• Before collection of the blood from the blood bank, • Assess the severity and quality of the patient’s pain
ensure the patient is ready to begin transfusion and • Avoid binding the fractured area to prevent
there is good venous access. improper breathing and may cause further
• Only qualified personnel should retrieve blood from complications
satellite refrigerators or transfusion laboratories. • Encourage adequate periods of rest
• Authorized documentation with minimum patient • Provide alternative comfort measure
identifiers must be checked against labels on blood • Cold compress, position changes, diversionary
components. activities such as watching TV or listening to music
• Minimum patient identifiers, date and time of • Assess pain medication
collection and staff member ID must be recorded. • Administer pain relievers that are prescribed.
• Patients should be regularly observed visually, and
Pulmonary Hemorrhage
for each transfused unit, the following minimal
monitoring should be carried out: • At first sign such as coughing up blood, discontinue
o Pre-transfusion pulse (P), blood pressure therapy
(BP), temperature (T) and respiratory rate • Take and monitor vital signs
(RR). • Immediately notify the assigned physician
o 15 minutes after the commencement of
the transfusion, check Pulse, BP, and T. If Possible complications in Clients with Chest Tubes and its
there is a considerable change, check RR as corresponding Nursing Interventions.
well. Respiratory Distress
o Monitor and record P, BP, T, and RR and • Identify and eliminate its cause while providing
take necessary action if there are any supplemental oxygen
symptoms or indications of a potential • Position the patient appropriately, such as in an
reaction. upright or semi-fowler’s position. This allows
o Not more than 60 minutes after the increased thoracic capacity, total descent of the
transfusion was finished, posttransfusion diaphragm, and increased lung expansion
P, BP, and T. preventing the abdominal contents from crowding.
o Outpatients are asked to report late • Monitor respiratory rate, BP, and HR
symptoms and inpatients are examined • If the condition progresses to respiratory failure,
during the following 24 hours (24-hour intubation and mechanical ventilation may be
access to clinical advice). necessary.
Pneumothorax
CLO #7 • Maintain a closed chest drainage system.
Possible Complications when Performing Chest o Be sure to tape all connections, and secure
Physiotherapy, Postural Drainage and Nebulization, Caring the tube carefully at the insertion site with
for Clients with Chest Tube Drainage Systems and Blood adhesive bandages.
Transfusion • Monitor airway, breathing, and circulation
Possible complications when performing Chest Bleeding at the drain site
Physiotherapy and its corresponding Nursing • Apply pressure to insertion
Interventions. • Notify the assigned physician
Increased Intracranial Pressure • Place occlusive dressing over site
• Focus on preventing further ICP and monitoring ICP • Check the drainage chamber to ensure no excessive
• Properly position the patient blood loss
o Position head of bed: 30-to-45-degree, Infection on the insertion site
proper alignment of head (midline) NO • Immediately notify the assigned physician of the
flexion of neck or hips patient
• Monitor blood gases, oxygen level to also prevent • Swab wound site
hypoxemia and hypercapnia
• Consider blood cultures
• Monitor temperature
• Administer antibiotics, if prescribed
• Avoid straining activities
• Monitor vital signs

13
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Accidental Disconnection of System CLO #8

• Assess Chest tube regularly. Nursing Responsibilities Before, During and After Chest
• Before reconnecting, the two ends should be Physiotherapy, Postural Drainage, Nebulization, Care of
cleaned well with an antiseptic, like alcohol pads. Clients with a Chest Tube Drainage and Blood Transfusion
Ensure all connections are cable tied and ensure Nursing Responsibilities (before, during, after) for the
proper function. following procedures:
• If the tube is completely pulled out from the Chest physiotherapy
patients’ chest, immediately apply pressure and
apply a sterile petroleum impregnated gauze over BEFORE
the site and call the physician immediately • Verify the order. This to prevent potential errors.
• Monitoring the patient and the drainage device. • Identify the patient’s identity. Compare the name
• Monitoring the patient’s vital signs, comfort, and on the client’s ID bracelet using two client
response to the procedure. identifiers according to the facility’s policy.
• An important part of monitoring includes recording • Provide Privacy and explain to the client the
the amount and color of chest drainage. procedure.
• Follow up imaging (usually an x-ray) may be ordered • Do handwashing and follow standard precautions.
to determine chest tube location and assess for any • Auscultate the lungs to determine the baseline
residual pneumothorax. respiratory status.
• Position the client as ordered to drain affected and
Possible complications during Blood Transfusion and its other involved areas.
corresponding Nursing Interventions. DURING
Allergic Reactions • Instruct the client to remain in each position for 10-
• When reaction occurs, stop the transfusion 15 minutes. Perform percussion and vibration, this
• Notify the physician helps loosens secretions in target areas.
• Start IV line (0.9% NaCl) • After percussion and vibration, instruct the client to
• Administer antihistamines, steroids and cough to remove loosened secretions. Tell the
epinephrine as indicated by the severity of the client to inhale deeply through the nose and then
reaction exhale in three short huffs. Then, have the client
Infection inhale deeply again and cough through a slightly
• When there are s/s of infection, stop the the open mouth.
transfusion • If the cough is ineffective, suction the client.
o s/s: Fever, chills and sweats, abdominal Secretions that have built up in the trachea are
pain, nausea, vomiting, fatigue removed by suction.
• Notify the physician AFTER
• Start IV line (0.9% NaCl) • Monitor the client's response to the treatment. Be
• Administer antibiotics as ordered. alert for significant color changes, particularly if the
• Notify blood bank & lab client is dusky which may indicate poor
• Draw cultures for testing. oxygenation.
Acute Hemolytic Reaction • Provide oral hygiene.
• Stop transfusion immediately • Auscultate the client's lungs again to evaluate
• Hydrate with normal saline effectiveness of therapy
• Monitor and maintain airway, breathing & • Record the date and time of chest physiotherapy,
circulation. chest segments which were percussion or vibrated,
color, amount, odor and viscosity.
• Do after care. Dispose secretions appropriately.

14
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Postural Drainage AFTER

BEFORE • Turn off the compressor and take off the mask or
mouthpiece once the "misting" has stopped.
• Obtain client data, including a chest evaluation,
client charts for the doctor to review, and client x- • Reassess the patient’s oxygen saturation, pulse rate
rays. and respirations.
• Auscultate the chest to determine the areas of the • Perform medical handwashing and do aftercare.
chest that need drainage. Clean the apparatus with warm water, then let it air
dry. Place the pack inside its container to store it.
• Explain the procedure to the patient.
• Document accurately. medication name,
• To create a positive interpersonal connection with
medication dosage, route of administration, date
the client, develop rapport with them.
and time medication were given, oxygen
• Make sure the patient is comfortable before
saturation, pulse rate and respirations before and
proceeding with the procedure.
after medication administration.
DURING Chest Tube Drainage Systems
• Place the patient in a position that allows for good
postural drainage and/or adjust position as BEFORE
indicated. • Review patient’s charts for the reason of chest tube
• Encourage the client to cough or suction the client’s and location and insertion date.
airways to assist in secretion clearance. • Identify the patient’s identity using two identifiers.
• After the allotted amount of time in each posture, • Perform handwashing. Wash hands thoroughly
encourage the clients to cough and take a deep with soap and warm water and don sterile gloves
breath. before coming in contact with the patient.
• Unless it is contraindicated, the nurse should • Explain the procedure to the patient.
encourage the client to drink more fluids. • The patient should be instructed that he or she may
feel pressure in that area.
AFTER
• The client should sit up slowly after the treatment DURING
to take some deep breaths and cough. • Give the physician the sterile end of the tube.
• Do handwashing and aftercare. • Ensure that unit is securely positioned on its stand
Nebulization or hanging on the bed.
• Make sure there are no kinks or obstructions in the
BEFORE tubes.
• Check the physician’s order for nebulization. • Secure all connections between chest tubes.
• Check the medication and compare it with the
AFTER
ticket three times.
• Check the date and procedure duration, drainage
• Gather all the materials needed.
volume, and a marking on the outside of the
• Identify the patient’s identity using two identifiers.
chamber. Record the drainage's characteristics and
• Explain the purpose and procedure to the client and
amount on the client's chart and the fluid balance
obtain informed consent.
sheet.
• Ensure that the patient is positioned upright as
• To promote drainage, encourage frequent position
possible and in a comfortable position. Allowing
changes.
optimal ventilation.
• Monitor the heart rate, blood pressure, oxygen
• Assess oxygen saturation, pulse rate and
saturation, and respiratory rate of the patient.
respirations.
• Inspect for inflammation and infection signs.
DURING • Perform pain assessment frequently.
• Make sure a thin mist of medication is being • Record the following data accurately:
produced. o Chest tube size
• Teach patient the proper way of inhalation o Date and time tube were inserted
• Ensure the patient inhales through the lips slowly, o Insertion site and practitioner who
deeply, and holds each breath for three to five inserted the chest tube
seconds. o Heart rate, oxygen saturation, blood
• To avoid condensation from forming, ask the pressure, respiratory rate and breath
patient to tap on the nebulizer chamber every few sounds
minutes. o Client’s reaction to procedure
o Amount of drainage and characteristic
15
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Chest Physiotherapy, Postural Drainage, Nebulization,
Chest Tube Drainage Systems, Blood Transfusion
Ms. Kerstine Iza Malang

Blood Transfusion
BEFORE
• Review the chart of the patient and review the
doctor’s order
• Identify the client using two identifiers, such as
name and birthdate. Perform medical
handwashing.
• Let the patient understand the procedure, including
the purpose for blood transfusion, and secure
consent.
• Make sure that the blood unit information is correct
by reviewing it three times. Secure all the materials
to be used.
• Check the client’s vital signs; blood pressure,
respiratory rate, and temperature.
DURING
• Using aseptic technique, open the sterile back.
• Make sure that there are no air bubbles in the
tubing.
• Observe the patient’s vital signs for the first 15
minutes or first 50 mL of blood.
• Look after the patient properly and assess for any
adverse reactions and give appropriate
interventions if required.
• Regulate the blood transfusion to the advised rate.
• Get the patient’s vital signs at the peak of
transfusion.
AFTER
• Do after care.
• Provide comfort to the patient.
• Put back bed to the lowest height with brakes
secured and raise siderails.
• Check the vital signs of the patient 30 minutes
post-transfusion.
• Record the following data accurately:
o Type and volume of blood product infused
o Serial number
o Time and duration of transfusion
o Vital signs prior, during (peak of
transfusion), and after 30 minutes
o Reaction to the therapy
o Adverse reactions if there are any,
including the provided interventions

16
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

CLO #1 Vectorcardiogram
Definition of Terms It is a method of developing two-dimensional (2D) images of
Central Venous Pressure Monitoring cardiac electrical activity by displaying the spatial locations
of ECG waveforms at each sequential time of their duration.
Central Venous Pressure (CVP)
Measurement of the pressure in the vena cava or right
atrium. It shows how much blood pressure is returned to the
right atrium from the superior vena cava.

Echocardiogram
Noninvasive ultrasound test to assess cardiac structure and
mobility. It can also measure the ejection fraction (EF) or the
percentage of end-diastolic blood volume that is ejected
during systolic.

Manometer
An instrument (such as a pressure gauge) for measuring the
pressure of gases and vapors
Electrocardiogram
A graphic representation of the magnitude and direction of
the action currents of the heart, in the form of a vector loop Hypervolemia
A record of a test that graphically measures the electrical • Also known as Fluid Volume Excess (FVE)
activity of the heart, including each phase of the cardiac • Fluid overload
cycle. • Is a condition in which blood has excess fluid
• Refers to an excess of isotonic fluid (water and
sodium) in enterocutaneous fistula (ECF)
Hypovolemia
• Also known as Fluid Volume Deficit (FVD)
• Volume depletion
• Is a critical decrease in blood volume in the body. It
can happen due to blood loss or loss of body fluids,
such as water.
Phlebostatic Axis
• Is used as an external landmark to measure the
level of the left atrium in a supine patient
• Which lies at the 4th intercostal space (ICS) mid-
axillary line

1
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Assisting in Bone Marrow Aspiration Hematoma

Bone Marrow • Localized collection of clotted blood in tissue
• Bone marrow is the spongy tissue inside some of • Most commonly, hematomas are caused by an
the bones in the body, including the hip and thigh injury to the wall of a blood vessel, prompting blood
bones. to seep out of the blood vessel into the surrounding
tissues. A hematoma can result from an injury to
• Bone marrow contains immature cells called stem
any type of blood vessel (artery, vein, or small
cells.
capillary).
Bone Marrow Aspiration • A hematoma usually describes bleeding which has
Is a procedure that involves taking a sample of the semifluid more or less clotted, whereas a hemorrhage
part of the soft tissue from the bone marrow signifies active, ongoing bleeding
Hematopoiesis
• Hemato = blood, Poiesis = making
• Is the process that produces formed elements
• Formed elements are cells (RBC and WBC) and cell
fragments (platelets)
Hemorrhage
• Rupture or leaking of blood from vessels
• Also known as bleeding
• It can refer to blood loss within the body, known as
internal bleeding, or blood loss outside the body,
Biopsy known as external bleeding.
• Sample of tissue taken from a body part (muscle or
Myeloma
bone) to determine the disease state of the tissue.
• Also called as multiple myeloma
• The sample may be taken through a closed (needle)
biopsy or an open (incisional) biopsy • a type of blood cancer that develops from plasma
cells in the bone marrow
• It is done to determine the presence of infection,
cancer, muscular atrophy or inflammation, or Electrocardiogram Analysis, Interpretation, and
presence of mitochondrial disorders. Computation
Electrocardiogram
Is a graphic representation of the electrical currents of the
heart
Electrocardiograph
Is a machine that consist of a set of electrodes connected to
a central unit
Electrophysiology
A test performed to assess the heart's electrical system or
activity and is used to diagnose abnormal heartbeats or
arrhythmia.

Fibrosis
• Is the thickening or scarring of the tissue
• May refer to connective tissue deposition that
occurs during normal healing or excess tissue
deposition that develops as a result of a
pathological process
Hematologist
Is a physician that specializes in the study, diagnosis,
treatment, and prevention of blood and lymphatic system
illnesses (lymph nodes and vessels).

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Electrodes Excitability
• Are devices such as small metal plates or needles Ability to respond to an electrical impulse
that carry electricity from an instrument to a Automaticity
patient for treatment or surgery. Ability to initiate an electrical impulse
• Electrodes can also transport electrical impulses
from muscles, the brain, the heart, the skin, or Depolarization
other bodily regions to recording equipment to • The electrical charge of a cell is altered by a shift of
diagnose specific disorders. electrolytes on either side of the cell membrane.
• This change stimulates muscle fiber to contract
Bradycardia
Heart rate less than 60 bpm
Tachycardia
Heart rate in excess of 100 bpm
Rhythm
A measured movement; the recurrence of an action or
Lead function at regular intervals
An electrical conductor carrying current or intermittent
signals between an organ or tissue and an electrical or
electronic device.

Arrhythmia/Dysrhythmia
• Describes an irregular heartbeat/ abnormal
heartbeat
• Disruption in the normal events of cardiac cycle
• Most common complication and most major cause
SA Node of death among client with myocardial ischemia
Primary pacemaker of the heart, located in the right atrium (MI)
initiates contraction at 60- 100 bpm Cardiac Arrest
Sudden, unexpected, cessation of breathing & adequate
circulation of blood by the heart

3
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

CLO #2
Importance, Indications and Contraindications of the Following Nursing Procedures
Central Venous Pressure Monitoring

Rationale
• To evaluate for circulatory failure
• CVP is used to measure the fluid balance in critically ill patients.
• Estimate a patient's fluid volume status, assess cardiac function, and gauge how well the right ventricle of the heart is
functioning
• To assist in monitoring circulatory failure.
Importance
• To serve as a guide for fluid replacement in seriously ill patients.
• To estimate blood volume deficits.
• To determine pressures in the right atrium and central veins.
• Below 2 mmHg can result to reduced right ventricular preload, this results to hypovolemia
• Above 6 mmHg can result to Hypervolemia
• CVP is most valuable when monitored over time and correlated with the patient’s clinical status.
Indications Rationale
Measurement of right heart filling pressures. This is to assess intravascular volume and right heart
function.
Intravenous insertion for patients with poor peripheral This is to have access for IV insertion of peripheral vascular.
access.
Access for insertion of Pulmonary Artery Catheter (PAC). This is a procedure in which an intravascular catheter is
inserted through a central vein to connect to the right side of
the heart and advance towards the pulmonary artery.
Hypotension refractory to fluid resuscitation and severe In patients with sepsis-induced tissue hypoperfusion, delivery
sepsis. of oxygen and nutrients to tissues is inadequate. Monitoring
CVP provides an indicator of the patient's response to
treatment.
Contraindications Rationale
Distorted local anatomy (such as for trauma, Infection, An infection or trauma at the proposed site would preclude
hemorrhage etc.) the use of the site.
Combative or uncooperative patients. An uncooperative patient may instead promote harm instead
of care of the patient; the patient may be able to refuse the
said procedure

4
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Bone Marrow Aspiration

Importance
• To diagnose and monitor blood and marrow diseases, including some cancers, as well as fevers of unknown origin.
• Diagnose a disease or condition involving the bone marrow or blood cells
• Determine the stage or progression of a disease
• Determine whether iron levels are adequate
• Monitor treatment of a disease
Indications Rationale
Anemia Certain types of Anemia such as Aplastic Anemia prevents
your Bone Marrow to produce more RBC.
Monitor and determine the progression of a disease such as: Bone marrow examination can be a helpful tool in critical
care diagnosis and management of various diseases.

• Lymphoma • Can be used to diagnose or evaluate lymphomas that

originate in the blood producing bone marrow cells.
• Unexplained Anemia • Can be used to confirm anemia and to rule out any
blood related diseases.
• Hematologic Diseases • Can be a valuable tool in diagnosing, assessing and
also in critical care management, in patients both
with and without hematological malignancy or
cancer known on admission.
Cancers of the blood or bone marrow, including leukemias, Bone marrow examination can be an essential tool in
lymphomas and multiple myeloma investigating various suspected disorders of the blood and
bone marrow.
Contraindications Rationale
Severe Osteoporosis Severe Osteoporosis is a condition where the bones in the
body will break easily. Doing this procedure may instead may
cause the bone marrow to be destroyed more easily causing
severe pain to the patient.
Local Site Infection (Osteomyelitis) Distorted local anatomy (e.g., from vascular injury, prior
surgery, or previous irradiation) infection at insertion site.
Severe Coagulopathy The procedure is an invasive procedure that involves the
Bone marrow that have a high risk for bleeding.
Thrombocytopenia or bleeding disorders are not Bone marrow aspiration and biopsy can be safely performed
contraindications as long as the procedure is performed by a even in the setting of extreme thrombocytopenia (low
skilled clinician platelet count). If there is a skin or soft tissue infection over
the hip, a different site should be chosen for bone marrow
examination.

5
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

ECG Analysis

Importance
• ECG is used to visualize the electricity that flows in the patient’s heart.
• interpretation of the cardiac rhythm, conduction system abnormalities, and the detection of myocardial ischemia.
• Nurses are usually the first to conduct an ECG and therefore need to know how to interpret them. failure to detect
abnormalities means that physicians will not be notified which will affect patients' care.
• A 12 lead ECG is used to diagnose arrhythmias, conduction abnormalities, and chamber enlargements (i.e. myocardial
ischemia, injury or infarction).
o 12 lead ECG may suggest cardiac effect of electrolyte disturbances (high or low calcium or potassium levels) and
the effects of antiarrhythmic medications (i.e., Disopyramide, flecainide, mexiletine, propafenone, quinidine and
beta blockers).
• A 15 lead ECG is used for early diagnosis of right ventricular and left posterior(ventricular) infraction.
• An 18 lead ECG is useful for early detection of myocardial ischemia and injury.
Indications Rationale
Diagnosis of disorders related to the cardiovascular system Early detection increases chances for treatment and limits
(such as tachycardia and bradycardia). possible risk of complications by closely monitoring existing
conditions.
• Frequent heart palpitations • Helps detect possible problems concerning the
heartbeat and heart structure that may cause heart
palpitations.
• Frequent and unexplainable chest pains • Used to investigate if chest pains are a result of
reduced blood flow to the heart muscles, such as with
unstable angina.
Patients with a family history of heart disease. Doctors of patients with a family history of heart disease may
suggest an ECG screen test even if the patient does not
manifest any signs and symptoms.
Detection of myocardial injury, ischemia and the presence ECG detects cardiac abnormalities and allows a direct
of prior infarction as well. visualization of scar from previous myocardial injury.
Contraindications Rationale
Uncooperative patients A patient has the right to deny such procedure.
Patient allergic to adhesive (used to be affixed to the leads) To prevent further skin problems, try moving the electrodes to
avoid the skin irritation and consider a different electrode
position.

6
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

CLO #3
Locations of the Commonly Used Veins in CVP Insertion, Bone Marrow Aspiration Landmarks and their Corresponding
Positions and ECG Lead Placement
Common Veins in Central Venous Pressure Insertion
LOCATION ADVANTAGE DISADVANTAGE
The Internal Jugular Vein • Bleeding can be • Risk of Carotid Artery
recognized and can Puncture
be controlled • Pneumothorax is
• Malposition is rare possible
• Less risk of
pneumothorax

• Right side is preferred Lower pleural dome and

thoracic duct on left
• Trendelenburg position (0- 15 degrees)
• Head rotated approximately 15 degrees to the left
• At the cricoid level while palpating the carotid
pulse, introducer needle into the apex of the
sternocleidomastoid clavicular triangle at the 30- 40
degrees angle to the skin. Aim the needed caudally
towards the patient's ipsilateral nipple.
Common Femoral Vein • Vein is easy to locate • Highest risk of
• No risk of infection
Pneumothorax • Risk of deep vein
• Preferred site for thrombosis
emergencies • Not good for
ambulatory patients

• Supine/ Flat position

• Palpate the femoral artery’s pulse just distal to the
inguinal ligament
• The femoral vein lies just medial to this.

7
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Subclavian Vein • Most comfortable for • Highest risk of

conscious patient bleeding
• Vein is non
compressible/ deep
vein
• Highest risk of
pneumothorax

• Right side preferred

• Supine position, head natural, arm abducted
• Trendelenburg position (10 - 15 degrees)
• Shoulders neutral with mild retraction
• Junction of the medial and middle thirds of the
clavicle
• The site of needle insertion lies about 1cm inferior
to the clavicle allowing for the needle to pass under
the clavicle
• Needle should be parallel to skin
• Aim towards the supraclavicular notch
These veins are preferred sites for temporary central venous catheter placement.

Bone Marrow Aspiration Landmarks and Position

LOCATION ADVANTAGE DISADVANTAGE
Posterior Iliac Crest • The biopsy technique • Patients typically feel a
induces elevated pressure sensation as
thromboplastic the needle is advanced
substances, and this leads into position which
to a reduction in the makes the patient feel a
effectiveness of an sharp but brief pain
aspiration sampling. • Advice the patient to
• More Safe take deep breaths or
• Large reservoir of Marrow using relaxation
• Most Preferred Site • Decreased pain techniques often helps
• Because no vital organs or vessels are • No large blood vessels in ease the discomfort
nearby. the area
• The patient is typically placed in the prone • Larger samples can be
or lateral decubitus position to facilitate obtained
access to the posterior iliac spine.
Tibia • Sampled only for infants • Discomfort or pain at the
younger than 1 year old. biopsy site for 1-2 days.
• In rare cases, infection or
bleeding can happen.

• marrow can be aspirated from the medial

aspect of upper end of tibia just beneath
tibial tuberosity.
• Position client in a prone position
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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Sternum • Supposed to be the easiest • Avoided since it causes

site from which to obtain more pain for the
the most cellular marrow patient and present the
risk for injury.
• Some individuals may
develop bleeding
problems at the site or if
an artery is cut.

• Usual Sites:
o Manumbrium
o 1st and 2nd parts of the
Manumbrium
• Patient lies on their back, with a pillow
under the shoulder to raise the chest

ECG Lead Placement

• For a standard 12 Lead ECG, 10 electrodes (6 on the chest and 4 on the limbs) are placed on the body.
• The standard left precordial leads are:
V1 FOURTH INTERCOSTAL SPACE; RIGHT STERNAL BORDER

V2 FOURTH INTERCOSTAL BORDER; LEFT STERNAL BORDER

V3 DIAGONALLY BETWEEN V2 AND V4

V4 FIFTH INTERCOSTAL SPACE; LEFT MIDCLAVICULAR LINE

V5 SAME LEVEL AS V4; ANTERIOR AXILLARY LINE

V6 SAME LEVEL AS V4 AND V5; MID AXILLARY LINE

• The right precordial leads, placed across the right side of the chest, are the mirror opposite of the left leads.
o RA - Right Arm o RL - Right Leg
o LA - Left Arm o LL - Left Leg.
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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

CLO #4
Normal and Abnormal Reading and Implication of CVP Monitoring, Normal and Abnormal Results of Bone Marrow Aspiration,
and ECG waves and Complexes in Relation to the Events that Occur during Electrical Conductions of the Heart
CVP Monitoring
NORMAL FINDINGS ABNORMAL FINDINGS SIGNIFICANCE
A reading between 2-6 mmHg > 6 mmHg • An increase in CVP can be an
Possible causes include: indicator of heart failure due to
• Elevated right ventricular preload decreased contractions,
• Hypervolemia (Excessive fluid dysrhythmias, and abnormalities in
circulation in the body) the valve. Being able to detect
• Right sided Heart Failure these abnormalities will aid the
health team in preventing the
< 2 mmHg exacerbation of a patient’s
Possible causes include: condition.
• Reduced right ventricular preload • Hypovolemia or venodilation are
• Hypovolemia some factors that could cause a
• Dehydration decrease in central venous
• Excessive blood loss pressure. The early detection of the
• Vomiting CVP abnormality would help the
• Diarrhea health team come up with the
• Over diuresis necessary interventions that could
aid the client.
Implications: Central venous pressure monitoring refers to the observance of the pressure of blood located in the thoracic vena
cava of the heart. It is specifically located in the region where the right atrium resides. The CVP is a reflection in regards to the
amount of blood that circulates back to the heart, and the capability of the heart to return blood back to the arterial system. The
acquisition of this reading provides numerous objectives. One would be serving as a guide for fluid replacement among severely
ill patients, another is that it also provides an estimate regarding deficits among blood volumes, it is also able to determine
pressure in the central veins and right atrium, and aids in the evaluation for circulatory failure. It is indicated for individuals who
have cardiovascular complications or disorders. However, despite its many uses, CVP alone is not enough. It should just act as a
supplement to support other clinical data.
Bone Marrow Aspiration
NORMAL FINDINGS ABNORMAL FINDINGS SIGNIFICANCE
Male: 4.7 to 6.1 million cells per • Less than 13.5 gm/dl in a A decrease in the number of cells for both males
microliter (cells/mcL) man or and females could be indicators for potential
• Less than 12.0 gm/dl in a diseases including anemia, myelofibrosis,
Female: 4.2 to 5.4 million cells/mcL woman. tuberculosis, etc.

Normal WBC count • Leukopenia (Low WBC) A deficiency in WBC is an indicator for leukopenia.
• Leukocytosis (High WBC) It is important for the health team to discover this
in order to come up with the necessary
interventions needed to be performed.
Iron levels ranging from 60 to 170 • Women: Below 26 mcg/dL • Low levels of iron in the body could
micrograms per deciliter (mcg/dL) • Men: Below 76 mcg/dL. cause General fatigue, Weakness, Pale
skin, Shortness of breath, Dizziness, A
tingling or crawling feeling in the legs,
Tongue swelling or soreness, and many
more.
• Men: Above 198 mcg/dL • An increase in levels of iron is a condition
• Women: Above 170 called hemochromatosis. This condition
mcg/dL could lead to detriments in regards to an
individual’s liver, brain, blood vessels,
heart, endocrine glands, and digestive
tract.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

ECG Analysis and Interpretation

NORMAL FINDINGS ABNORMAL FINDINGS SIGNIFICANCE
P Wave P Wave P waves that increase in amplitude and
• 2.5 mm or less in height • Greater than 2.5 mm in height duration could be indicators for either
• 0.11 seconds or less in duration • Greater than 0.11 seconds hypokalemia or right atrial enlargement.
QRS QRS Increased QRS waves could be an
• Q wave = less than 0.04 • Q wave = Greater than 0.04 indicator for ventricular hypertrophy.
seconds and less than 25% of R seconds and greater than 25% Prolonged waves present ventricular
wave amplitude. of R wave amplitude. conduction disturbance.
• QRS complex is less than 0.12 • QRS complex is greater than
seconds in duration 0.12 seconds in duration
PR Interval PR Interval • If the PR interval is greater than
0.12- 0.20 seconds in duration. • < 0.12 seconds in duration. 20 seconds it could be an
• > 0.20 seconds in duration. indicator for first degree heart
block.
• If the PR interval is less than 12
seconds it could indicate the
presence of an accessory
pathway between the atria and
ventricles or AV nodal
junctional rhythm.
QT Interval QT Interval • A QT interval that exceeds
0.32-0.40 seconds in duration if heart Less than 0.32 or greater than 0.40 normal ranges could be an
rate is 65-95 bpm. seconds in duration if heart rate is 65-95 indicator for ventricular
bpm. arrhythmia, syncope, and
death.
• A QT interval that goes below
normal ranges could be an
indicator for a congenital heart
defect which may later on lead
to atrial fibrillation.
Absence of U waves Presence of U waves may indicate U waves are normally absent during an
hypokalemia, hypertension, or heart ECG analysis in individuals without
disease. complications. If this wave shows up in a
cardiogram, then it could be an indicator
for other potential diseases such as
hypokalemia.

Complications correlated with the events that occur during Atrial Arrhythmias
the electrical conductions of the heart: • Premature Atrial Complex
• Atrial Fibrillation
Abnormalities or differences in regards to the values of the • Wolf Parkinson White Syndrome
ventricular and atrial rhythm, ventricular and atrial rate, QRS • Atrial Flutter
shape and duration, and the P wave could be indicators for
possible complications associated with the heart. The Junctional Arrhythmias
following complications include the different types of • Premature Junctional Complex
Arrhythmias including sinus, atrial, junctional, and • Junctional Rhythm
ventricular arrhythmias. • Nonparoxysmal Junctional Tachycardia
• Atrioventricular Nodal Rentry Tachycardia
Sinus Node Arrhythmias
• Sinus Bradycardia Ventricular Arrhythmias
• Sinus Tachycardia • Premature Ventricular Complex
• Sinus Arrhythmia • Ventricular Tachycardia
• Ventricular Fibrillation
11
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

• Idioventricular rhythm • The dressing and pressure monitoring system or

water manometer are changed according to
Conduction Abnormalities hospital policy
• First-Degree Atrioventricular Block • The dressing is to be kept dry and air occlusive;
• Second-Degree Atrioventricular Block Type 1 Dressing changes are performed with the use of
(Wenckebach) sterile technique
• Second-Degree Atrioventricular Block Type 2 • CVP catheters can be used for infusing intravenous
• Third-Degree Atrioventricular Block fluids, administering intravenous medications, and
drawing blood specimens in addition to monitoring
CLO #5 pressure.
Guidelines of Central Venous Pressure Monitoring, Bone • To measure the CVP, the transducer (when a
Marrow Aspiration and ECG Computation and pressure monitoring system is used) or the zero
Interpretation mark on the manometer (when a water manometer
is used) must be placed at a standard reference
Central Venous Pressure Monitoring point, called the phlebostatic axis
• The CVP or the pressure in the vena cava or right • After locating this position, the nurse may make an
atrium is used to assess right ventricular function ink mark on the patient’s chest to indicate the
and venous blood return to the right side of the location
heart • If the phlebostatic axis is used, CVP can be
• The CVP can be continuously measured by measured correctly with the patient supine at any
connecting either a catheter positioned in the vena backrest position up to 45 degrees
cava or the proximal port of a pulmonary artery • The range for a normal CVP is 0 to 8 mm Hg with a
catheter to a pressure monitoring system pressure monitoring system or 3 to 8 cm H2O with
• Pressures in the right atrium and right ventricle are a water manometer system
equal at the end of diastole (0 to 8 mm Hg), the CVP
is also an indirect method of determining right
ventricular filling pressure (preload). This makes the
CVP a useful hemodynamic parameter to observe
when managing an unstable patient’s fluid volume
status

Guidelines:
• CVP monitoring is most valuable when pressures
are monitored over time and are correlated with
the patient’s clinical status
• Patients in general medical-surgical units who
require CVP monitoring may have a single-lumen or
multilumen catheter placed into the superior vena
cava. Intermittent measurement of the CVP can The phlebostatic axis and the phlebostatic level. (A) The
then be obtained with the use of a water phlebostatic axis is the crossing of two reference lines: (1) a
manometer. line from the fourth intercostal space at the point where it
• Before insertion of a CVP catheter, the site is joins the sternum, drawn out to the side of the body
prepared by shaving if necessary and by cleansing beneath the axilla; and (2) a line midway between the
with an antiseptic solution. anterior and posterior surfaces of the chest. (B) The
• A local anesthetic may be used phlebostatic level is a horizontal line through the
• The physician threads a singlelumen or multilumen phlebostatic axis. The air–fluid interface of the stopcock of
catheter through the external jugular, antecubital, the transducer, or the zero mark on the manometer, must
or femoral vein into the vena cava just above or be level with this axis for accurate measurements. When
within the right atrium moving from the flat to erect positions, the patient moves
• Once the CVP catheter is inserted, it is secured and the chest and therefore the reference level; the phlebostatic
a dry, sterile dressing is applied level stays horizontal through the same reference point. (C)
• Catheter placement is confirmed by a chest x-ray, Two methods for referencing the pressure system to the
and the site is inspected daily for signs of infection phlebostatic axis. The system can be referenced by placing
the air–fluid interface of either the in-line stopcock or
stopcock on top of the transducer at the phlebostatic level.

12
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Bone Marrow Aspiration marrow aspiration, but the site of a biopsy may
• Normal bone marrow is in a semifluid state and can ache for 1 or 2 days
be aspirated through a special large needle. The • Warm tub baths and use of a mild analgesic (eg,
aspirate provides only a sample of cells. Aspirate acetaminophen) may be useful. Aspirin-containing
alone may be adequate for evaluating certain analgesics should be avoided because they can
conditions, such as anemia. However, when more aggravate or potentiate any bleeding that may
information is required, a biopsy is also performed occur.
• Bone marrow aspiration is crucial when additional ECG Analysis, Interpretation
information is needed to assess how an individual’s • ECG or electrocardiogram assesses the electrical
blood cells are being formed and to assess the conduction system of the heart
quantity and quality of each type of cell produced • The electrical impulse that travels through the
within the marrow. This test is also used to heart can be viewed by means of
document infection or tumor within the marrow electrocardiography, the end product of which is an
electrocardiogram (ECG)
Guidelines: • Each phase of the cardiac cycle is reflected by
• In adults, bone marrow is usually aspirated from the specific waveforms on the screen of a cardiac
iliac crest and occasionally from the sternum monitor or on a strip of ECG graph paper
• Most patients need no more preparation than a • An ECG is obtained by slightly abrading the skin with
careful explanation of the procedure, but for some a clean dry gauze pad and placing electrodes on the
very anxious patients, an antianxiety agent may be body at specific areas.
useful. It is always important for the physician or • The number and placement of the electrodes
nurse to describe and explain to the patient the depend on the type of ECG needed. Most
procedure and the sensations that will be continuous monitors use two to five electrodes,
experienced usually placed on the limbs and the chest. These
• A signed informed consent is needed before the electrodes create an imaginary line, called a lead,
procedure is performed that serves as a reference point from which the
• Before aspiration, the skin is cleansed as for any electrical activity is viewed. A lead is like an eye of a
minor surgery, using aseptic technique camera; it has a narrow peripheral field of vision,
• A small area is anesthetized with a local anesthetic looking only at the electrical activity directly in front
through the skin and subcutaneous tissue to the of it
periosteum of the bone. It is not possible to • The ECG waveforms that appear on the paper or
anesthetize the bone itself cardiac monitor represent the electrical current in
• The bone marrow needle is introduced with a stylet relation to the lead. A change in the waveform can
in place. When the needle is felt to go through the be caused by a change in the electrical current
outer cortex of bone and enter the marrow cavity, (where it originates or how it is conducted) or by a
the stylet is removed, a syringe is attached, and a change in the lead.
small volume (0.5 mL) of blood and marrow is
aspirated Guidelines in Obtaining Electrocardiogram:
• Patients typically feel a pressure sensation as the • Electrodes are attached to cable wires, which are
needle is advanced into position. The actual connected to one of the following:
aspiration always causes sharp but brief pain, o An ECG machine placed at the patient’s
resulting from the suction exerted as the marrow is side for an immediate recording (standard
aspirated into the syringe; the patient should be 12-lead ECG)
forewarned about this. Taking deep breaths or o A cardiac monitor at the patient’s bedside
using relaxation techniques often helps ease the for continuous reading; this kind of
discomfort. monitoring, usually called hardwire
• If a bone marrow biopsy is necessary, it is best monitoring, is associated with intensive
performed after the aspiration and in a slightly care units
different location, because the marrow structure o A small box that the patient carries and
may be altered after aspiration that continuously transmits the ECG
• After the marrow sample is obtained, pressure is information by radio waves to a central
applied to the site for several minutes monitor located elsewhere (called
• The site is then covered with a sterile dressing. telemetry)
Most patients have no discomfort after a bone o A small, lightweight tape recorder-like
machine (called a Holter monitor) that the
13
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

patient wears and that continuously diagnosis can occur if electrodes are incorrectly
records the ECG on a tape, which is later placed
viewed and analyzed with a scanner
• The placement of electrodes for continuous Analysis of the Electrocardiogram:
monitoring, telemetry, or Holter monitoring varies • ECG waveforms are printed on graph paper that is
with the type of technology that is appropriate and divided by light and dark vertical and horizontal
available, the purpose of monitoring, and the lines at standard intervals
standards of the institution. For a standard 12-lead • Time and rate are measured on the horizontal axis
ECG, 10 electrodes (six on the chest and four on the of the graph, and amplitude or voltage is measured
limbs) are placed on the body on the vertical axis
• Ensure that the system is set up correctly and • When an ECG waveform moves toward the top of
maintained properly the paper, it is called a positive deflection. When it
moves toward the bottom of the paper, it is called
a negative deflection
• When reviewing an ECG, each waveform should be
examined and compared with the others.

ECG graph and commonly measured components. Each

small box represents 0.04 seconds on the horizontal axis
and 1 mm or 0.1 millivolt on the vertical axis. The PR
interval is measured from the beginning of the P wave to
the beginning of the QRS complex; the QRS complex is
measured from the beginning of the Q wave to the end of
the S wave; the QT interval is measured from the beginning
of the Q wave to the end of the T wave; and the TP interval
ECG electrode placement. The standard left precordial leads is measured from the end of the T wave to the beginning of
are V1—4th intercostal space, right sternal border; V2—4th the next P wave.
intercostal space, left sternal border; V3—diagonally
between V2 and V4; V4—5th intercostal space, left
midclavicular line; V5—same level as V4, anterior axillary
line; V6 (not illustrated)—same level as V4 and V5,
midaxillary line. The right precordial leads, placed across
the right side of the chest, are the mirror opposite of the left
leads
• To prevent interference from the electrical activity
of skeletal muscle, the limb electrodes are usually
placed on areas that are not bony and that do not
have significant movement. These limb electrodes
provide the first six leads: leads I, II, III, aVR, aVL,
and aVF
• The six chest electrodes are attached to the chest
at very specific areas. The chest electrodes provide
the V or precordial leads, V1 through V6
• Locating the specific intercostal space is critical for
correct chest electrode placement. Errors in

14
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

CLO #6
Possible Complications when Performing Central Venous Pressure Monitoring, Bone Marrow Aspiration and ECG
Computation and Interpretation
Central Venous Pressure Monitoring
COMPLICATIONS NURSING INTERVENTIONS
Infection - occurs when unwanted Independent:
microorganisms enter the patient's central line • All invasive procedures must be carried out with aseptic
and then enter into their bloodstream. techniques such as properly cleaned equipment and careful hand
hygiene.
• Monitor antibiotic toxicity, BUN, creatinine, WBC, hemoglobin,
hematocrit, platelet levels, and coagulation studies.
• Assess the patient’s hemodynamic status, fluid intake and output,
and nutritional status.
Dependent:
• Administer prescribed IV fluids and medications including
antibiotic agents and vasoactive medications, as prescribed.
Interdependent:
• Collaborate with the other members of the healthcare team to
identify the site and source of sepsis and specific organisms
involved.
Pneumothorax (air) - one of the most common Independent
complications, caused by a puncture of the lung at • Check vital signs especially blood pressure.
the time of needle insertion in the large vein. • Maintain strict asepsis for dressing changes, wound care,
intravenous therapy, and catheter handling.
Hemothorax (blood) - caused by puncture and • Auscultate breath sounds and assess respiratory rate.
repeated attempts. It may elevate risk when there • Place patients in high fowler’s for better oxygenation/comfort.
is a low insertion position and when the patient is Dependent:
experiencing hypotension. • Assess oxygenation/Provide supplemental O2 if appropriate.
• Assess for Chest Pain/administer analgesics.
Interdependent:
• Collaborate with the other members of the health care team in
preparing the patient for chest tube insertion/Thoracentesis
procedure.
Arterial Puncture - usually caused by Independent:
misplacement of catheter. • Properly insert catheter at the site to avoid malposition.
• Assess skin and temperature.
• Ask the client if he/she feels any pain or discomfort.
Dependent:
• If the client is in pain, provide pain medications such as
paracetamol and avoid giving aspirin.
Subcutaneous Hematoma - may be caused by a Independent:
puncture. • Apply an ice pack wrapped in a towel to reduce any pain or
swelling.
• Assess the client’s vital signs.
Dependent:
• Provide pain medications but avoid aspirin as prescribed by the
physician.
Interdependent:
• Collaborate with healthcare team members in performing
surgical intervention if needed.

15
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Bone Marrow Aspiration

COMPLICATIONS NURSING INTERVENTIONS
Bleeding - risk in patients who have low platelet count or Independent:
taking medications that alter platelet function (e.g., • Monitor patient’s vital signs.
aspirin). • Check medication history of the patient because they
may be using anticoagulant drugs.
• Clean the biopsy site and apply sterile dressing.
• Instruct the patient to avoid rigorous exercises for at least
2 days.
Dependent:
• Provide pain medications as prescribed by the doctor.
• Interdependent:
• Collaborate with other health care team members in
acquiring blood tests.
Infections - generally at the insertion site especially in Independent:
patients with weakened immune system • Assess the client’s vital signs, especially body
temperature.
• Make sure to clean the site and apply sterile dressing.
• Educate the patient to properly clean dressing.
Dependent:
• Administer prescribed IV fluids and medications including
antibiotic agents and vasoactive medications, as
prescribed.
Interdependent:
• Collaborate with other health care team members in
acquiring blood tests to check signs of infection.

ECG Computation and Interpretation

COMPLICATIONS NURSING INTERVENTIONS
Errors in diagnosis • Make sure to properly place electrodes in the body to attain
accurate results.
• Pay full attention to the client when placing electrodes.
• Properly read and interpret results to recognize errors at first
glance.

CLO #7 • Changing the dressing in accordance to hospital

Nursing Responsibilities Before, During and After Central policies and procedures
Venous Pressure Monitoring, Bone Marrow Aspiration and Bone Marrow Aspiration
ECG Computation and Interpretation BEFORE
Central Venous Pressure Monitoring • Ensuring that a consent for the procedure is
BEFORE obtained
• Assembling needed medical equipment • Ask the client to void
• Explain the procedure to the patient • Check the Vital signs
• Assist patient in a comfortable position • Position the Client
• Check the coagulation Profile
DURING
• Perform hygiene and wear you PPE
• Assist Doctor • Assist in injecting local anesthetic
• Monitor patient’s vital signs
DURING
• Apply sterile dressing
• Help the patient remain in position
AFTER
• Monitor vital signs
• Closely monitor the patient and the catheter site • Assist doctor
• Monitor and record patient’s vital signs

16
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

AFTER • Explain that a vasodilator (amyl nitrate) may be

• Apply sterile dressing on the puncture site given. The patient may be asked to inhale a gas with
• Assist the patient in a comfortable position a slightly sweet odor while changes in heart
• Observe puncture site for any signs of bleeding functions are recorded.
• Monitor vital signs DURING
• Documentation • Inform that a conductive gel is applied to the chest
• Disposal of biomedical waste area. A conductive gel will be applied to his chest
ECG Analysis and that a quarter-sized transducer will be placed
over it. Warn him that he may feel minor discomfort
BEFORE
because pressure is exerted to keep the transducer
• Inform the patient that echocardiography is used to in contact with the skin.
evaluate the size, shape, and motion of various • Position the patient on his left side. Explain that
cardiac structures. Tell who will perform the test, transducer is angled to observe different areas of
where it will take place, and that it’s safe, painless, the heart and that he may be repositioned on his
and is noninvasive. left side during the procedure.
• Advise the patient that he doesn’t need to restrict
AFTER
food and fluids for the test.
• Instruct patient to void prior and to change into a • Remove the conductive gel from the patient’s skin.
gown. When the procedure is completed, remove the gel
• Advise the patient to remain still during the test from the patient’s chest wall.
because movement may distort results. He may • Inform the patient that the study will be interpreted
also be asked to breathe in or out or to briefly hold by the physician. An official report will be sent to
his breath during the exam. the requesting physician, who will discuss the
• The room may be darkened slightly to aid findings with the patient.
visualization on the monitor screen, and that other • Instruct patient to resume regular diet and
procedure (ECG and phonocardiography) may be activities. There is no special type of care given
performed simultaneously to time events in the following the test.
cardiac cycles.
CLO #8
Nursing Process in the Care of Clients Undergoing Central Venous Pressure Monitoring, Bone Marrow Aspiration and ECG
Computation and Interpretation
Central Venous Pressure Monitoring
NURSING NURSING NURSING NURSING
NURSING PLANNING
ASSESSMENT DIAGNOSIS INTERPRETATION EVALUATION
• Obtain health Risk for infection After an hour of • Explain procedure • The client has
history. related to invasive catheter insertion, to the client. normal body
• Assess the procedures. client will be able to: • Make sure that temperature.
client's vital • Provide the CVP site is • There is no
signs. normal blood surgically redness,
• Attach ECG to pressure cleansed before swelling, or
monitor the levels and inserting discomfort in
patient blood volume. catheters. the site.
• Make sure to
cover the site
with sterile
dressing after the
procedure with a
catheter taped in
place.
• Promote sterility
in the area of
procedure.

17
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Bone Marrow Aspiration

NURSING NURSING NURSING NURSING
NURSING PLANNING
ASSESSMENT DIAGNOSIS INTERPRETATION EVALUATION
• Obtain Risk for Bleeding After 10-20 mins of • Explain to the There should be no
medical and r/t low platelet bone marrow client the bleeding, swelling, and
medication count. aspiration, the client procedure. redness in the site
history will be able to: • Review client’s after the procedure
• Assess the • Return to medication and within 24 hrs. or more.
client's vital his/her instruct client to
signs. normal avoid aspirin-
activities containing
without analgesics.
discomfort on • Assess the result
the site. and check for the
patient's platelet
count.
• Make sure to
cover the site
with sterile
dressing after
pressure is
applied.
• Instruct the client
to inform
physician or
nurses if there is
bleeding that
doesn’t stop and
swelling at the
site.

ECG Procedure
NURSING NURSING
NURSING ASSESSMENT NURSING PLANNING NURSING INTERPRETATION
DIAGNOSIS EVALUATION
• Assess Risk for skin After 10 mins of taking • Explain procedure to Observe the client’s
patient’s vital irritation the Electrocardiogram client. skin for any
signs to related to the test, the client will be • Ensure patient to breakdown or
determine any prolonged able to: empty bladder irritation that might
abnormalities removal of • Return back • Encourage patient have occurred due to
or alarming electrode to his/her cooperation the application of the
information patches. daily activities • Clean and dry the electrodes.
that could be without any skin prior to the
vital to the complications. application of the
overall electrodes. If
treatment of instances where
the individual. shaving is done,
• Monitor for allow the skin to
any recover for some
uncomfortable time.
feelings or • Remove the
sensations conductive gel from
that the client the client right away
is once the procedure
experiencing. is finished to avoid

18
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

• Check the irritation from

client's skin occurring.
for the
presence of
skin rashes or
breakdown.

CLO #8 First step is to find the R wave. Then count the boxes
Beginning Skills when Analyzing and Interpreting Central between the 2 R waves.
Venous Pressure Monitoring, Bone Marrow Aspiration and In this case, there are 25 small boxes or 5 large boxes. To
ECG Results calculate for the ventricular rate, remember that there are
1,500 small boxes or 300 large boxes in a 1 minute strip.
ECG Analysis and Interpretation
Hence, 1,500 small boxes are divided by 25 small boxes or
1.1 Compute for the arterial and ventricular rate using the: 300 large boxes divided by 5 large boxes which is equivalent
1.1.1 Cycle method to 60 beats per minute in a regular rhythm.
Simply identify two consecutive R waves and count the
number of large squares between them. By dividing this 2. Calculate for the Atrial rate
number into 300 (remember, this number represents one
minute) we are able to calculate a person's heart rate. Rate
= 300/number of large squares between consecutive R
waves.

1.1.2 Box Method

In a regular rhythm, 1 minute is = 300 large boxes or 1,500
small boxes.

Formula:
• 1, 500 / #of small boxes = ventricular/arterial rate
(bpm) OR
• 300 / #of large boxes = ventricular/arterial rate a. First step is to find the wave which determines the
(bpm) atrial rate, which is the wave. Then count the boxes
between the 2 P waves. In this case, there are 25
Steps: small boxes or 5 large boxes.
1. Count how many small boxes or large boxes are b. To calculate for the Atrial rate, remember that
between a RR interval for the ventricular rate and there are 1, 500 small boxes or 300 large boxes in a
PP interval for the atrial rate. 1-minute strip. In this case, 1,500 small boxes will
2. To calculate the heart rate; Divide 1,500 by the be divided by 25 small boxes or 300 large boxes
number of SMALL boxes between RR intervals or divided by 5 large boxes which is equivalent to 60
300 divided by the number of LARGE boxes. beats per minute in a regular rhythm.
Examples:
1. Calculate for the ventricular rate

19
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

1.1.3 Triplicate Method 1.3 Interpret the following:

Also known as the 6 second rule, is used when rhythm is 1.3.1 Normal Heart Rhythm
irregular. This method will be based on how many R waves Adults typically have a resting heart rate between 60 and 100
or P waves is in 6 seconds. Because the rhythm is irregular, beats per minute. A lower resting heart rate typically
calculation will be based on a time span of 6 seconds. indicates improved cardiovascular fitness and more effective
P wave is for the atrial rate, and R wave for the cardiac function. A well-trained athlete, for instance, might
ventricular rate. have a typical resting heart rate that is closer to 40 beats per
minute.
Formula:
# of P wave or R wave in 6 seconds multiplied by 10 = atrial 1.3.2 Common Abnormal Heart Rhythm
or ventricular rate [Link] Sinus Tachycardia
(bpm)

Steps:
1. Remember that 1 second = 5 large boxes therefore;
6 seconds = 30 large boxes
2. Count how many R waves in 6 seconds and multiply
by 10. In this case, there are 7 R waves.

When your body sends electrical signals to your heart to

speed up, this condition is known as sinus tachycardia. It can
be triggered by strenuous exercise, anxiety, some medicines,
3. The photo above shows that there are 7 R waves in
or a fever. Inappropriate sinus tachycardia is what it is called
6 seconds which are highlighted by the circles. (7 R
when it occurs for an unclear reason (IST). With only a slight
waves x 10 = 70) Ventricular rate is 90 beats
amount of tension or movement, your heart rate may
per minute. To calculate the atrial rate, do the same
increase.
but it will now be based on the number of P waves
multiplied by 10. • Rate: Can be over 100 beats per minute
• Rhythm: Regular
• P-wave: upright and regular
1.2 Compute the following duration of:
• QRS: narrow (0.4 sec)
1.2.1 PR Interval - From start of P wave to first deflection of • PR interval: Consistent interval between 0.12 and
QRS Complex 0.20
• Normal PR interval is around 120-200ms and ranges [Link] Sinus Bradycardia
from 0.12s to 0.20s in duration; around 3-5 small
squares (1 small square=0.04s).

1.2.2 QRS Duration - From first deflection of QRS complex to

end of QRS complex (1 square= 0.04s).
• Ranges up to 120 ms or 3 small squares and 0.06-
0.12s in duration

1.2.3 ST Segment - Is the flat, isoelectric section of the ECG

between the end of the S wave (the J point) and the Having a slow heartbeat is known as sinus bradycardia. The
beginning of the T wave (1 small square= signal to start your heartbeat is started by a certain set of
0.04s) cells. In the sinoatrial (SA) node are these cells. At rest, the
SA node typically emits the signal 60 to 100 times per
1.2.4 QT Interval - from start of QRS deflection to T wave (1 minute. The node emits fewer than 60 times per minute
small square= when there is sinus bradycardia.
0.04s). • Rate: Less than 60 beats per minute
• Normal range up to 440 ms • Rhythm: Regular
• P-wave: Upright and regular
• QRS: Narrow (0.08)
• PR Interval: normal and each P wave are followed
by normal QRS complex
20
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

[Link] Atrial Tachycardia [Link] Atrial Flutter

Another example of an abnormal heart rhythm, or

arrhythmia, is atrial flutter. The top chambers (atria) of the
A rapid heartbeat is called atrial tachycardia (arrhythmia).
heart experience extremely rapid pumping as a result of a
Supraventricular tachycardia is the condition. The heart rate
short circuit. In addition to its symptoms, atrial flutter is
can reach over 100 beats per minute during an atrial
significant because it can result in a stroke that can leave a
tachycardia episode before dropping to the normal range of
person permanently disabled or even kill them.
60 to 80 beats per minute.
• Rate: Beats extra fast, about 250 - 400 beats per
• Rate: more or less regular heart rate > 100 bpm
minute
• Rhythm: irregular heart rhythm
• Rhythm: Irregular heart rhythm due to a short
• P-wave: P-waves is irregular and do not originate
circuit in the heart causes the upper chambers
from the sinus node but from another site in the
(atria) to pump very rapidly.
atria
• P-wave: P waves are absent
• QRS: Narrow
• QRS: Narrow complex (0.12 sec)
• PR interval: Varies on multiple atrial sites
• PR interval: No PR interval
[Link] Ventricular Bradycardia
[Link] Ventricular Flutter
Ventricular bradycardia may be caused by a lack of electrical
impulse or atrial stimulation. Bradycardia can be brought on
by cardiac or noncardiac causes. The noncardiac health
conditions include drug addiction, neurologic conditions,
electrolyte imbalance, and metabolic problems.

[Link] Ventricular Tachycardia

Tachycardia in the ventricles with a rate of more than 250-

350 beats per minute. This is Monomorphic since wave is at
>200bpm. ECG looks identical when turned upside down.
• Rate: 250 - 350 beats per minute
A heart rhythm problem known as ventricular tachycardia is • Rhythm: Regular or slightly irregular
brought on by irregular electrical signals in the lower • P-wave: AV dissociation
chambers of the heart (ventricles). A healthy heart normally • QRS: Wide sine wave
beats between 60 and 100 times per minute while at rest, • PR Interval: No PR interval
and the condition may also go by the names V-tach or VT.
• Rate: Usually 120 - 250 bpm
• Rhythm: Usually regular
• P-wave: P-waves are normal but they do not have
any relation to the QRS complexes
• QRS: Wide QRS complex ( > 0.12 seconds)
• PR Interval: Very irregular, if P waves are seen

21
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

[Link] Ventricular Fibrillation [Link] Premature Ventricular Contractions (PVCs)

This is the early “premature” conduction of a QRS complex.

This may be caused by: Heart failure, Myocardial ischemia,
drug toxicity, caffeine, tobacco, or alcohol, stress/pain, and
increased workload on the heart. The patient may be
asymptomatic and may have chest pains.
The rapid, disorganized pattern of electrical activity in the • Rate: Depends on underlying rhythm
ventricle in which electrical impulses arise from many • Rhythm: Regular but interrupted due to early P
different foci. This may be caused by the following: Cardiac waves
injury, Medication toxicity, Electrolyte imbalances, and • P Wave: Visible but depends on timing of PVC (may
Untreated ventricular tachycardia. The patient may either be
lose consciousness, may have an absence of pulse or blood • hidden)
pressure, cessation of respirations, and/or cardiac arrest and • PR Interval: Slower than normal but still 0.12 - 0.20
death. Treatments may include CPR, Oxygen therapy, seconds
Defibrillation, Drug therapy (Epinephrine, Amiodarone, • QRS Complex: Sharp, bizarre, and abnormal during
lidocaine, Magnesium) the PVC
• Rate: Chaotic
• Rhythm: Chaotic [Link] Heart Blocks
• P-wave: Absent
• QRS: absent
• PR Interval: No PR interval present

[Link] Premature Atrial Contractions (PAC)

• Ventricular and atrial rhythm is irregular - it may

vary. P-P interval is short. 1st Degree
• QRS shape and duration: The QRS that follows the • Regular P and R wave
early P wave is usually normal, but it may be • QRS complex is normal
abnormal (aberrantly conducted PAC). It may even • PR interval is longer than 0.20 seconds
be absent (blocked PAC). 2nd Degree
• P wave: An early and different P wave may be seen Type 1: Wencheback or Mobitz 1
or may be hidden in the T wave; other P waves in • P and R waves are irregular
the strip are consistent. • PR intervals are abnormal
• PR interval: The early P wave has a shorter-than- • Abnormal QRS complex
normal PR interval, but still between 0.12 and 0.20 • Cyclic/ presence of pattern
seconds. Type 2: Mobitz 2
• P:QRS ratio: usually 1:1 • P-waves will be regular, however R-waves is
irregular
• PR interval will measure normal (most of the time)
• NO Pattern
• Missing QRS Complexes after p-waves randomly
22
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

3rd Degree Beginning Skills:

• P-waves will be Regular AND R-waves will be Bone Marrow Aspiration
Regular 1. Check the physician’s order for Bone Marrow
• P-waves will not accompany QRS complexes and Aspiration
vice versa, hence no relationship between the 2. Explain the purpose of the procedure to the client.
atriums and ventricles. 3. Ascertain that the patient had signed the informed
• More P waves than QRS complex consent form.
• You can’t measure a PR interval because the 4. Gather all the materials needed.
atriums and ventricles are independent 5. Perform medical hand washing.
6. Prepare hypoallergenic tape at the bedside table.
1.3.3 Other Abnormalities Open the stock tray of the BMA aseptically. Open
[Link] Electrolyte Imbalance the sterile individual materials and drop them in the
sterile stock tray.
Hypocalcemia - when calcium levels below normal range or 7. Position the patient according to the selected site.
< mg/dL 8. Expose the site and drape the patient.
• Prolonged ST interval 9. Using a sterile technique, cleanse the site with
• Prolonged QT interval Betadine cleanser three times, then with Betadine
paint three times.
Hypercalcemia - when calcium levels in the body exceed 10. Don gloves. Arrange materials in the sterile set-up
normal range or > 11 mg/dL according to use. Loose the top part of the
• Shortened ST segment specimen bottles.
• Widened T wave 11. Hand the eye sheet to the physician. The smooth
side should be facing him.
Hypokalemia - when potassium level in the body is lower 12. Using your dominant hand, give the 3cc sterile
than normal range or < 3.5 mEq/L syringe to the physician. Using your non-dominant
• ST depression hand, offer the anesthetic agent. Your non-
• Prominent U wave dominant hand becomes unsterile but clean. After
• T wave is flat, shallow, or inverted the physician withdraws the anesthesia, with your
non-dominant hand, place the anesthetic agent at
Hyperkalemia - when potassium level in the body is higher the bedside table then place your non- dominant
than normal range or > 5 mEq/L hand at your back.
• Tall peaked T wave 13. Using your dominant hand, give the syringe with a
• Prolonged PR interval large bore needle to the physician. Prepare the
• P waves are flat specimen bottles for the specimens being
withdrawn.
• QRS complex is wide
14. Before the physician withdraws the trochar from
Hypomagnesemia- Magnesium levels are lower than normal the site, offer the sterile gauze.
range or < 1.5 mg/dL 15. Place the withdrawn trochar back into the stock
tray. Apply pressure to the site for 5-15 minutes and
• Tall T wave
secure it with a hypoallergenic plaster.
• Depressed ST segment
16. Remove the drape.
17. Label the specimen bottles appropriately.
Hypermagnesemia - Magnesium levels are higher than
18. Do after care.
normal range or > 2.5 mg/dL
19. Send the specimen bottles to the laboratory.
• Abnormal or prolonged PR interval
20. Document accurately.
• Widened QRS complex

[Link] Angina - Myocardial Infarction

• ST segment depression
• T wave inversion or tall, upright, and pointed

23
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Central Venous Pressure, Bone Marrow
Aspiration, ECG Computation and Interpretation
Ms. Janelyn L. Ortiz

Beginning Skills:
Central Venous Pressure Monitoring
1. Assemble equipment according to manufacturer’s
directions.
2. Explain that the procedure is similar to an IV and
that the patient may move in bed as desired after
passage of the CVP catheter.
3. Place the patient in a position of comfort. This is the
baseline used for subsequent readings.
4. Attached manometer to the IV pole. The zero point
of the manometer should be on a level with the
patient’s right atrium.
5. Mark the midaxillary line on the patient with an
indelible pencil.
6. The CVP catheter is connected to a 3-way stopcock
that communicates to an open IV and to a
manometer.
7. Start the IV flow and fill the manometer 10 cm
above anticipated reading (or until the level of
20cm, HOH is reached). Turn the stopcock and fill
the rubbing with flu
8. The CVP site is surgically cleansed. The physician
introduces the CVP catheter percutaneously or by
direct venous cutdown and threaded through an
antecubital, subclavian, or internal or external
jugular vein into the superior vena cava just before
it enters the right atrium.
9. When the catheter enters the thorax an inspiratory
fall and expiratory rise in venous pressure are
observed.
10. The patient may be monitored by ECG during
catheter insertion.
11. The catheter may be sutured and taped in place. A
sterile dressing is applied.
12. The infusion is adjusted to flow into the patient’s
vein by a slow continuous drip.

24
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

CLO #1 cartilage. The anterior nares (nostrils) are the

Review of the Basic Normal Anatomy and Physiology of external openings of the nasal cavities.
the Respiratory System • Paranasal Sinuses - include 4 pairs of bony cavities
that are lined with nasal mucosa and ciliated
Respiratory System
pseudostratified columnar epithelium. These
Is composed of the upper and lower respiratory tracts. airspaces are connected by a series of ducts that
Together, the two tracts are responsible for ventilation drain into the nasal cavity. The sinuses are named
(movement of air in and out of the airways). The upper by their location: frontal, ethmoid, sphenoid, and
respiratory tract, known as the upper airway, warms and maxillary. A prominent1 function of the sinuses is to
filters inspired air so that the lower respiratory tract (the serve as a resonating chamber in speech. The
lungs) can accomplish gas exchange or diffusion. Gas sinuses are a common site for infection.
exchange involves delivering oxygen to the tissues through • Pharynx, Tonsils and Adenoids - The pharynx is a
the bloodstream and expelling waste gasses such as carbon tubelike structure that connects the nasal and oral
dioxide, during expiration. cavities to the larynx. It is divided into 3 regions:
Upper Respiratory Tract nasal, oral, and laryngeal. The nasopharynx is
Upper airway structures consist of the: located posterior to the nose and above the soft
• Nose palate. The oropharynx houses the faucial, or
• Paranasal sinuses palatine, tonsils. The laryngopharynx extends from
• Pharynx the hyoid bone to the cricoid cartilage. The
• Tonsils and adenoids adenoids or pharyngeal tonsils are located in the
• Larynx roof of the nasopharynx. The tonsils, adenoids and
• Trachea other lymphoid tissue encircle the throat. These
structures are important links in the chain of lymph
modes guarding the body from invasion by
organisms entering the nose and throat.
• Larynx - or voice box, is a cartilaginous epithelium-
lined organ that connects the pharynx and the
trachea and consists of the following:
o Epiglottis - a valve flap of cartilage that
covers the opening to the larynx during
swallowing.
o Glottis - the opening between the vocal
cords in the larynx.
o Thyroid Cartilage - the largest of the
cartilage structures; part of it forms the
Adam’s apple.
o Cricoid Cartilage - the only complete
cartilaginous ring in the larynx
o Arytenoid Cartilages - used in vocal cord
movement with the thyroid cartilage.
The upper respiratory tract is lined with a mucous o Vocal Cords - ligaments controlled by
membrane. Mucus helps to trap smoke, dust and other small muscular movements that produce
particles. Mucus aids in the capture of smoke, dust, and sounds; located in the lumen of the larynx.
other small particles. The membrane is covered in cilia (hair- • Trachea - or windpipe is composed of smooth
like structures that move the mucous upwards only the muscle with C-shaped rings of cartilage at regular
upper respiratory tract). The lining of the tract and the close intervals. The trachea serves as the passage
laying blood vessels (especially in the nose) assist in warming between the larynx and the right and left main stem
and moistening the air as it passes. bronchi which enter the lungs through the opening
• Nose - serves as the passageway for air to pass to called the hilus.
and from the lungs. It filters impurities and
humidifies and warms the air as it is inhaled. The
nose is composed of an external and internal
portion. The external portion protrudes from the
face and is supported by the nasal bones and

1
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

Lower Respiratory Tract this area but are responsible for producing type I
cells and surfactant. Surfactant reduces surface
tension, thereby improving overall lung function
Alveolar macrophages, the third type, are
phagocytic cells that ingest foreign matter and as a
result provide an important defense mechanism.
• Gas Exchange - Gas exchange entails both the
transport of oxygen from the lungs to the
bloodstream as well as the carbon dioxide removal
from the circulation to the lungs. It takes place in
the lungs between the alveoli and a network of tiny
blood vessels called capillaries that are located in
the alveolar walls.

The lower respiratory tract consists of the lungs which CLO #2

contain the bronchial and alveolar structures needed for gas Definition of Terms
exchange
Suctioning
• Lungs - are paired elastic structures enclosed in the
thoracic cage, which is an airtight chamber with Aspiration
distensible walls. Each lung is divided into lobes. Inhalation of either oropharyngeal or gastric contents into
The right lung has upper, middle, and lower lobes, the lower airways.
whereas the left lung consists of upper and lower Asphyxia
lobes. Each lobe is further subdivided into 2 to 5
A breathing impairment or a lack of oxygen due to
segments separated by fissures which are
interrupted breathing.
extensions of the pleura.2
• Pleura - the lungs and the wall of the thoracic cavity Cough Reflex
are lined with a serous membrane called the pleura. A reflex process by which the body expels any irritant or
The visceral and parietal pleura and the small foreign objects that enters the lower respiratory tract
amount of pleural fluid between these 2 through air.
membranes serve to lubricate the thorax and the Hypoxemia
lungs and permit smooth motion of the lungs within Decrease partial pressure of oxygen in the arterial blood.
the thoracic cavity during inspiration and
Hypoxia
expiration.
It is the decrease in oxygen supply to the tissues and cells.
• Mediastinum - is in the middle of the thorax,
between the pleural sacs that contain the 2 lungs. It Suctioning
contains all of the thoracic tissue outside the lungs The aspiration of secretions through a catheter connected to
(heart, thymus, the aorta and vena cava, and a suction machine or wall suction outlet.
esophagus). Tracheostomy Care
• Bronchi and Bronchioles - There are several
Ostomate
divisions of the bronchi within each lobe of the lung.
First are the lobar bronchi (3 in the right lung and 2 An individual who has had an ostomy, a surgical procedure
in the left lung). Lobar bronchi is divided into that creates an opening in the body for the expulsion of
segmental bronchi (10 on the right and 9 on the bodily wastes.
left). These structures facilitate effective postural Tracheotomy
drainage in the patient. Segmental bronchi then A surgical incision in the anterior of the neck on the trachea
divide into subsegmental bronchi. These bronchi to open a direct airway or relieve breathing obstruction.2
are surrounded by connective tissue that contains Tracheostomy
arteries, lymphatics and nerves.
Is an opening made by the tracheotomy in the front of the
• Alveoli - The lung is made up of about 300 million neck to allow a tube to be put into the trachea to aid in
alveoli, constituting a total surface area between 50 breathing.
and 100m². There are 3 types of alveolar cells. Type
I and Type II cells make up the alveolar epithelium.
Type I cells account for 95% of the alveolar surface
area and serve as a barrier between the air and the
alveolar surface; type II cells account for only 5% of
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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

Tracheostomy Tube • Sputum retention

It is an indwelling tube that is inserted into the trachea and Occurs when patients are unable to clear
is properly secured in place with a strap around the neck. secretions from their respiratory tract by themselves or
with assistance.
• Suspicion of a blocked or partially blocked tube
• Vomiting
• Desaturation on pulse oximetry
• Changes in ventilation pressures (in ventilated
children)
• Request by the child for suction (older children)
Contraindications
• Irritable airway
• AND (Allow Natural Death) – with specifics: do not
perform tracheal suctioning
Tracheostomy Care • Epiglottitis - because it may precipitate total
Involves cleaning of the tracheostomy tube to remove occlusion of the airway.
secretions and mucus. • Severe hemodynamic instability
Tracheoesophageal Fistula • Tracheoarterial fistula
Is an abnormal connection between the esophagus and • Oral/Nasal Injury
trachea. • Bronchospasm
• Head Injuries
CLO #3 Complication(s)
Purpose, Indication, Contraindication and Complications • Respiratory
Suctioning o Hypoxia - Vagus nerve can be stimulated
due to prolonged suctioning which can
Purpose result to hypoxia
• To remove secretions in order to secure or maintain o Introduction of infection and trauma to
a patent airway. the trachea - infection may develop if
• To prevent infection that may result from suctioning equipment used is not clean3
accumulated secretions • Cardiovascular
• To reduce the risk of aspiration where patients are o Bradycardia - prolonged suctioning
unable to protect their own airway (neurological, stimulates vagus nerve triggering a
unconscious) vasovagal reaction that causes
• To collect specimen for diagnostic purposes bradycardia
• To provide comfort o Hypotension/Hypotension - When
Indications suctioning stimulates the vagus nerve,
• Audible or visual signs of secretions in the tube patients may experience bradycardia,
Suctioning clears mucus from the hypoxia, and hypotension.
tracheostomy tube and is essential for proper breathing. o Hypertension - Routine suctioning
Also, secretions left in the tube could become stimulates the nociceptors which triggers
contaminated and a chest infection could develop. the cough reflex and leads to sympathetic
activity resulting in blood pressure and
• Signs of respiratory distress
heart rate increase
Signs of respiratory distress may include
o Cardiac dysrhythmias - In some patients,
increased respiratory rate, tachycardia, gasping and
aggressive tracheal suctioning triggers a
difficulty talking. Increased resistance, decreased SPO2,
vasovagal reflex, which may cause both
increased PEEP, cyanosis, and pallor and an increasing
bradycardia, hypotension, and cardiac
FiO2 are indications that suctioning may be required in
dysrhythmia.
the intubated patient in order to deliver high
concentrations of oxygen. • Neurological
o Increase in intracranial pressure - in
• Terminal care patient who is distressed by upper
severe head-injured patients it can result
respiratory secretions and is unable to self-
in a sudden increase in intracranial
expectorate
pressure (ICP) and may put the patient at
risk for further cerebral damage
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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

o Reduction in cerebral blood flow - CLO #4

Increased intracranial pressure (ICP) Types of Suction Catheter and Types of Suctioning
causes decreased blood perfusion of brain According to Depth
Tracheostomy Care
Types of Suction Catheters
Purpose
Closed System Suctioning Catheter
• To maintain patency of airway
• In mechanically ventilated patients, either an open
• To prevent the breakdown of the skin surrounding or closed tracheal suction system (CTSS) is utilized
the site to remove tracheal secretions through the
• To prevent infection endotracheal tube. Without having to turn off the
• To promote comfort ventilator, the catheter is connected to the
• To prevent displacement ventilator circuit in CTSS. It appears that the CTSS
Indications reduces the soiling and spraying of respiratory
• For patient who underwent tracheostomy secretions into the ICU. Closed system suction
• Acute respiratory failure necessitating mechanical catheters, which are frequently included in kits,
ventilation for an extended period of time lessen the risk of infection during the draining
• Severe or catastrophic brain injury necessitating procedure. They reduce catheter contamination
airway management, mechanical ventilation, or and allow the user to ventilate more effectively
both while clearing secretions.
• Upper airway obstruction • The ventilator machine's closed circuit is connected
• Difficult airway to the breathing tube, endotracheal tube, or
• Copious secretions tracheostomy tube by the closed suction catheters
(CTSS), also known as inline suction catheters.
Contraindications Suction catheters that may be used several times
• Reddened or swollen areas around the only need to be replaced every 24 to 48 hours. Since
tracheostomy tube they are not disconnected from the ventilator, the
• Pneumothorax fundamental benefit of closed suction catheter is
• Tracheal granulations that the ventilator support is maintained. Most
• Tracheal stenosis often, closed suction catheters are used because
• Tracheoarterial fistula they reduce the risk of infection.
• Posterior tracheal wall perforation • Ex. ReliaMed Coil Packed Suction Catheter Kit
Complication(s)
• Infection - The stoma could cause skin irritation or
infection if not cleaned properly
• Blocked tube (occluded cannula / mucous plugging
• Bleeding from the airway/tracheostomy tube4
• Stomal erosion
• Air leak including Pneumothorax, pneumo-
mediastinum or subcutaneous emphysema
• Respiratory and/or cardiovascular collapse
• Dislodged tube or accidental decannulation
• Granulation tissue in the trachea or at the stoma
site
• Tracheo-oesophageal fistula

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

Suction Catheter Yankauers Latex-Free Suction Catheter

• Yankauers are suction points with a bulbous head • Suction catheters that are latex-free are totally free
to prevent any harm to the surrounding tissue of latex. They are ideal for those who are allergic or
when catheterization is being done. Aspiration is sensitive to latex. To compensate for the lack of
avoided using these catheters when performing elasticity caused by the absence of latex, they utilize
suction operations. Their tip enables effective chest a variety of materials.
secretion and debris drainage. • These sterile suction catheters are designed for
• These stiff catheters are used to suction the mouth persons who are allergic to latex. They are devoid
without injuring the surrounding tissues. of latex and BPA.
• Ex. Conmed Bulb Tip Yankauer with On and Off • Ex. Carefusion Tri-Flo No-Touch Single Catheter
Control Switch

Latex Suction Catheter

• In comparison to any other material used to make
a catheter, latex suction catheters are built entirely
of red rubber and offer the greatest degree of
flexibility. Since they are intended to be
radiopaque, scanners can easily see them.
• These radiopaque flexible suction catheters are
used for x-rays.
• Ex. Bard Tracheal Suction Latex Red Rubber
Catheter

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

Types of Suctioning According to Depth Tracheostomy Suction

Nasal Suction Tracheostomy suctioning removes heavy mucus and
secretions from the trachea and lower airway that coughing
Nasal suctioning is used to remove mucus from your child's
cannot remove. Suctioning is performed in the morning and
nose, throat, and mouth, allowing them to breathe more
before going to bed in the evening. Suctioning is also
freely. A catheter or tiny tip catheter is inserted into the nose
performed following any respiratory therapy.
during nasal suctioning. This is useful when fluids are evident
in the nose or when secretions are suspected of clogging the
nasal canal.

Deep Suction
Oral
Mucus from your patient's airway can be removed by deep
By eliminating mucous fluids and foreign material (vomit or suctioning. This approach is typically used in conjunction
gastric secretions) from the mouth and throat, oral with an artificial airway, such as a tracheostomy tube. It
suctioning helps to maintain a patent airway and increase eliminates mucus between the tube's end and the carina
oxygenation (oropharynx). To suction secretions in the (the part where the trachea splits into the bronchi, the tubes
mouth, a hard-plastic tip with a handle known as a Yankauer that go into the lungs). Deep suctioning is frequently used in
is typically used. emergency settings when other procedures have failed to
remove secretions and the patient is in distress

Nasopharyngeal and Oropharyngeal Suction

If a patient is unable to cough or swallow secretions (mucus),
nasopharyngeal (through the nose) and oropharyngeal
(through the mouth) suctioning is used to remove them. A
suction catheter (a thin, transparent, soft plastic tube with
depth markings) is introduced to a preset depth into the
back of the throat through the nose (nasopharyngeal) or
mouth (oropharyngeal). This form of suctioning is effective
when secretions accumulate at the back of the throat and
your kid is unable to cough or swallow them.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

CLO #5 Outer Cannula

Parts and Types of Tracheostomy Tube This serves as the main component of the tube. It holds the
Parts of the Tracheostomy Tube tracheostomy open.
Tracheal Plate (Flanges)
Flanges can be connected to the trach ties which helps the
trach tube hold in place
Tracheostomy Ties
This is worn around the neck which keeps the tracheal
cannula in place.
Cuff
Cuffs are only attached to patients using a mechanical
ventilator. This is in order to ease effective ventilation while
preventing aspiration at the same time.
Inner Cannula
It is a removal tube that is positioned inside the outer
cannula. It can be detached for cleaning which also prevents
mucus build up inside the trach tube.
Obturator
This is used in insertion of the trach tube. It also provides
structure and appears to have a blunted tip that smooths off
the outer cannula's rough distal end to reduce trauma during
insertion.
Speaking Valve
It is a removable one-way valve that allows the patient to
breathe in through the tracheostomy tube while exhalation
passes through the mouth and nose.7

Types of Tracheostomy Tubes

Types Indications Recommendations
• Inner cannula used should be
disposable
• There are minimal air leaks so cuff
should be inflated just enough
• Cuff pressure should be checked
twice a day
• When using this type of tube, cuff
should be inflated
• Cuff should be deflated if the
patient is using a speaking valve
Cuffed Tube with Disposable Inner
Cannula This is used in order to secure a
closed circuit for ventilation • When the patient is using
ventilators, cuff should be inflated
• There are minimal air leaks so cuff
should be inflated just enough
• Cuff pressure should be checked
twice a day
• Cuff should be deflated if the
patient is using a speaking valve
• Inner cannula is not disposable and
Cuffed Tube with Reusable Inner can be reused after a thorough
Cannula cleaning

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

• Prevents damage or • If obstruction occurred inside the

contamination of the single lumen tube, the entire
healthy lung tracheostomy tube is required to
• Consists of the outer be changed to a new one
cannula only • Patency of the single lumen tubes
• This type is commonly used should be checked regularly
as pediatric tracheostomy
tubes

Single Lumen Tracheostomy Tubes

• Provides individual In preparing the double lumen tube, both
ventilation for each lung the trachea and bronchial cuffs should be
• Contains an inner cannula inflated to check for leaks and symmetrical
which increases airway cuff inflation.
resistance
• Commonly used
tracheostomy tube

Double Lumen Tracheostomy Tubes

This type of tube is used for patients There is a high risk for granuloma formation
who have difficulty in using a at the site of the fenestration (hole)8
speaking valve

Fenestrated Cuffed Tracheostomy

Tube

CLO #6 did not promote secretion clearance and could cause side
Principles and Nursing Responsibilities effects such as hypoxemia and increased risk of pneumonia.
Principles In Suctioning Microbiology
Maintaining proper hand hygiene and antiseptic equipment
Anatomy and Physiology
can help prevent bacterial and fungal colonization. Observe
Knowledge of the physiology of suction is essential for proper infection control measures such as wearing gloves
nurses. This helps indicate where the suction technique and masks.
should be applied properly.
Time and Energy
Psychology
Aspiration must be done carefully and efficiently, neither too
During the procedure, the client may feel uneasy. It is fast nor too slow, to ensure patient safety. You can store
essential to explain and direct the course of the procedure. more energy by expending a reasonable amount of it.
This reduces patient anxiety. Performing this procedure for an extended period of time
Physics can jeopardize the customer's overall security.
This procedure places the patient in a semi-Fowler position Safety and Security
to encourage deep breathing, maximal lung expansion, and Personal protective equipment such as gowns, goggles,
a productive cough. masks, and sterile gloves should be worn for handling
Chemistry hazardous secretions. Patients should also be asked if they
Nurses need to understand how certain substances affect have any allergies for safety.
patients. For example, do not inject saline. A study by
Ntoumenopoulos and Pierson showed that saline infusion

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

Body Mechanics need it. This builds a relationship with the patient as well as
Adhering to the correct posture will allow you to perform the encourages them to participate in the surgery
procedure correctly without any problems. For example, Sterility
place the patient in the semi-Fowler position for catheter Make sure all materials are sterile to prevent bacterial
placement. colonization. A sterile field must be set up to perform this
Sociology procedure.
Social skills and communication are necessary for both
patients and caregivers. Nurses must have good Nursing Responsibilities in Suctioning
communication skills to talk and build relationships with Before
patients. This also encourages patient participation in the
• Check the doctor's orders in the patient file. Note
procedure.
any important instructions.
Sterility • Prepare all materials and equipment required for
Nurses should adhere to the aseptic technique when the procedure.
performing this procedure. Tracheal aspiration can lead to • Introduce yourself to the client to establish rapport
infection of the lower respiratory tract. and ease the client’s anxiety.
Principles In Tracheostomy Care • Explain the procedure thoroughly to the client and
Anatomy and Physiology the family
• Monitor or check the patient’s vital signs for
A tracheostomy is a temporary or permanent medical
baseline data
procedure that requires opening the neck to place a tube.
Nurses need a solid base of knowledge in respiratory • Perform medical handwashing
physiology. This includes gas flow and proper customer • Wear appropriate personal protective equipment
monitoring. During
Psychology • Keep the client hyperoxygenated
Before performing the procedure, nurses should introduce • Position the client with an intact gag reflex in a
themselves and explain to the client what they are doing, semi-Fowler’s position
why it is necessary, how they can participate, and what will • Place a towel on the client’s chest
happen. Also, tell the client that this procedure may cause • Make sure that the materials are sterile
coughing. • Encourage the client to cough
Physics • Switch on the aspirator and set the pressure.
(Child/infant: 50-75mmHg, adult: 100-120mmHg).
This procedure supports the client in a semi-Fowler or
• The suction tube size should be less than half the
Fowler position to facilitate lung expansion.
inner diameter of the tracheal tube
Chemistry • Suction should not be applied while inserting a
Use sterile saline for this procedure. Caregivers need to catheter
know why sterile solutions are used. Observe the sterile field • Apply suction for no longer than 5 to 10 seconds
and flush the internal cannula and lumen using sterile saline. • Assist the client to be in a comfortable position to
Microbiology maximize client comfort
Tracheostomy instruments should be disinfected to avoid After
bacterial colonization. This is aimed at reducing the • Do medical handwashing.
incidence of nosocomial infections. Also, medical hand • Do proper documentation of the findings. Indicate
washing and gloves should be integrated for hygiene. improvement of lung sounds, removal of
Time and Energy secretions, and decreased work of breathing.
In tracheostomy care, nurses must be patient, precise, and • Perform aftercare.
not too hasty or too late in performing the procedure to • Observe proper disposal to avoid cross-
ensure patient safety. Effective time management is contamination.
essential to achieve better/higher work quality and • Recheck the client’s vital signs and note any
efficiency and helps save energy. changes in the values.
Sociology
Nurses must have good communication skills to be able to
converse. For example, introduce yourself to your clients,
listen when they have a problem, and offer help when they

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

Nursing Responsibilities in Tracheostomy Care 2. Check for history of clotting disorders which
increases risk for bleeding during suctioning. For
Before
nasopharyngeal suctioning, check patient history
• Monitor and check the client’s vital signs for for a deviated septum, nasal polyps, nasal
baseline data obstruction, traumatic injury, epistaxis, or mucosal
• Perform medical handwashing swelling.
• Explain the procedure thoroughly to the client and 3. If no contraindications exist, gather and place the
the family suction equipment on the patient’s overbed table
• Introduce yourself to the client to establish rapport or bedside stand. Position the table or stand on
• Wear appropriate PPE such as sterile gloves to your preferred side of the bed to facilitate
avoid cross-contamination suctioning.
During 4. Attach the collection bottle to the suctioning unit,
• For optimal lung expansion, position the client in a and attach the connecting tubing to it. Date and
semi-Fowler’s position. then open the bottle of normal saline solution or
• Drape the client to promote client privacy sterile water.
5. Explain the procedure to the patient even if he’s
• Observe the skin of the client and note any
unresponsive. Inform him that suctioning may
abnormalities
stimulate transient coughing or gaging, but tell
• Use your fingers to ensure that the tracheostomy
him/her that coughing helps to mobilize secretions.
straps are well secured.
If he/she has been suctioned before, just
• Secure the tube with two sutures of 2-0 nylon on
summarize the reasons for the procedure. Reassure
each side of the flange. A tracheostomy tape.
him throughout the procedure to minimize anxiety
After and fear, which can increase oxygen consumption.
• Do medical handwashing Also, ask which nostril is more patent
• Perform aftercare 6. Perform hand hygiene. Put on personal protective
• Do proper documentation of the findings equipment as appropriate.
• Check the client’s vital signs and note any changes 7. Place the patient in Semi-Fowler’s if tolerated, to
in the values. promote lung expansion and effective coughing.
Unconscious clients may be positioned side-lying or
CLO #7 lateral recumbent.
8. Hyperoxygenate patient prior to suctioning by
Beginning Skills
increasing supplemental oxygen or ventilating
Suctioning patient with a bag-valve-mask resuscitator, as per
A. Performing Nasopharyngeal & Oropharyngeal facility protocol. Hyperoxygenation is also done in
Suctioning and Tracheal Suctioning through Artificial between suction passes and after suctioning.
Airway 9. Turn on the suction from the wall or portable unit
1. Review the patient’s blood gas and oxygen and set adequate pressure. Higher pressures cause
saturation values, and check vital signs. Evaluate excessive trauma without enhancing secretion
the patient’s ability to cough and deep-breathe to removal. Occlude the end of the connecting tubing
determine his/her ability to move secretions up the to check suction pressure.
tracheobronchial tree. Auscultate lung fields to 10. Using strict sterile technique, open the suction
evaluate airway and determine need for suctioning. catheter enough to10 expose but not touch its
a. Instances in which suctioning may be proximal end.
needed: (1) raised respiratory rate, (2) 11. Don sterile gloves; consider your dominant hand
inability of client to clear secretions sterile and your nondominant hand non sterile.
effectively, (3) diminished breath sounds, 12. Using your nondominant hand, pour the sterile
(4) audible secretions, (5) spontaneous but water or saline into a sterile bottle/container.
ineffective cough, (5) reduced oxygen 13. With your nondominant hand, place a small
saturation levels. amount of water-soluble lubricant on the sterile
b. The need for suction should be assessed area (if you’re not doing nasopharyngeal
on an individual basis rather than as a suctioning). The lubricant is used to facilitate
‘ritualized’ activity, meaning that patients passage of the catheter during nasopharyngeal
should only receive suctioning when they suctioning
need it, not because a certain length of 14. Pick up the catheter with your dominant (sterile)
time has elapsed since it was last hand, and secure it to the connecting tubing
performed
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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

attached to the suction machine. To activate until you reach the pool of secretions or
suction, use the thumb of your nondominant hand the patient begins to cough.
to cover the hand to cover the suction valve while 17. For oral insertion:
your dominant hand manipulates the catheter. a. Without applying suction, gently insert the
catheter into the patient’s mouth.
Advance it 3 to 4 inches along the side of
the patient’s mouth until you reach the
pool of secretions or the patient begins to
cough. Suction both sides of the patient’s
mouth and pharyngeal area
18. For tracheal insertion via artificial airway
(endotracheal tube or tracheostomy):
a. Insert catheter into trachea without
suction (thumb not covering suction
valve).

b. When resistance is felt upon insertion, this

indicates that the catheter has reached the
carina. Slightly withdraw the catheter
about 1 inch (2.5cm) and then, activate
suction (thumb covering suction valve).

15. Instruct the patient to cough and breathe slowly

and deeply several times before beginning suction.
Coughing helps loosen secretions and may decrease
the amount of suctioning necessary while deep
breathing helps minimize or prevent hypoxia.
16. For nasal insertion:
a. Raise the tip of the patient’s nose with
your nondominant hand to straighten the
passageway and facilitate insertion of the 19. Using intermittent suction, withdraw the catheter
catheter. from the mouth, nose or trachea with a continuous
b. Coat distal 2 to 3 inches (6 to 8 cm) of rotating motion to minimize invagination of the
catheter with water-soluble lubricant mucosa into the catheter’s tip and side ports. Apply
c. Without applying suction, gently insert the suction for only 10-15 seconds at a time to minimize
suction catheter into the patient’s nares. tissue trauma (for tracheal suctioning, suction
d. Roll the catheter between your fingers to should NEVER be applied for more than 10
help it advance through the turbinates. seconds).
e. Continue to advance the catheter 20. Allow 20-30 seconds interval between each suction
approximately 5 to 6 inches (12.5 to 15 cm) pass to bring up mucous secretions and prevent
hypoxia. Between passes, wrap the catheter around
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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

your dominant hand to prevent contamination. This 11. Assemble tracheostomy care equipment. Place
will also be the opportune time to hyperoxygenate hydrogen peroxide solution on one sterile basin and
the client (using your nondominant hand). sterile water or saline on the other. Put on personal
21. If secretions are thick, clear the lumen of the protective equipment and don gloves. Open and
catheter by dipping it in sterile water or saline and moisten cotton-tip applicators (some will be
applying suction. moistened with sterile water/saline, some with
hydrogen peroxide and some are kept dry)
12. Remove soiled dressing and discard.
13. Change a disposable inner cannula, touching only
the external portion, and lock it securely into place.
14. If inner cannula is reusable, remove it with your
contaminated hand.
15. While holding external portion with your
contaminated hand, immerse inner portion of
reusable cannula in the basin with H2O2 solution
briefly.
16. Using a tracheostomy brush or cotton applicator,
clean cannula with your sterile hand.
17. While clean, still holding external portion with
contaminated hand, immerse inner portion of
cannula into basin of sterile water or saline
solution. Agitate it to rinse thoroughly.
18. Tap inner cannula gently unto inner rim of sterile
22. For an artificial airway, 5 to 10 mL of sterile normal container to remove excess water but not dry
saline may be instilled before tracheal suctioning if enough to facilitate reinsertion.
secretions are thick, per agency protocol. 19. Reinsert reusable cannula and lock it securely into
23. Repeat the suctioning procedure until gurgling or place.
bubbling sounds stop and respirations are quiet. 20. Cleanse external end & neck plate of tracheostomy
24. After completing suctioning, pull off your sterile tube with cotton12 applicator moistened with
glove over the coiled catheter and discard it. H2O2.
25. Flush the connecting tubing with normal saline 21. Rinse external end & neck plate of tube/stoma with
solution or water and turn off suction afterwards. cotton applicator moistened with H2O2.
26. Replace the used items so they’re ready for the next 22. Wipe with dry cotton applicator.
suctioning and12 perform hand hygiene. 23. Cleanse skin under neck plate of tube/stoma with
27. Assess patient after the procedure and compare cotton applicator moistened with H2O2. Make only
findings with baseline. a single sweep with each applicator before
28. Monitor secretions for amount, color, consistence, discarding.
& odor to assess for evidence of bleeding or signs of 24. Rinse with cotton applicator moistened with sterile
infection. water or saline. Make only a single sweep with each
applicator before discarding.
Tracheostomy 25. Wipe with dry cotton applicator. Make only a single
A. Performing Tracheostomy Care sweep with each applicator before discarding.
1. Assess respirations for rate, rhythm, & depth. 26. Change tracheostomy ties. Secure ties at the side of
2. Auscultate lung fields. the neck in a square know (ties should be tight
3. Check ABG and pulse oximetry values. enough to keep tube securely in the stoma, but
4. Assess passage of air through tracheostomy tube. loose enough to permit two fingers to fit between
5. Assess anxiety and restlessness. the tapes and the neck)
6. Assess condition of stoma before tracheostomy • It is important to obtain assistance from
care (note redness, swelling, character of another nurse or a respiratory therapist
secretions, and presence of purulence of bleeding). because of the risk of accidental tube
7. Examine neck for subcutaneous emphysema. expulsion during this procedure. Patient
8. Explain procedure to the client. movement or coughing can dislodge the
9. Perform hand hygiene. tube.
10. Suction trachea & pharynx thoroughly before • If changing tracheostomy ties alone or
tracheostomy care. without assistance, remove soiled ties one

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Suctioning and Tracheostomy
Mrs. Francis S. Cañezo

side at a time as you attach the new tie on

each eye of the flange. You may also ask
the client to place his/her fingers over the
flange to secure tube as you change the
tie.
• In removing the soiled ties, DON’T cut it.
Simply untie the square knot during
removal.
27. Change tracheostomy dressing. Place a gauze pad
between the stoma site and the tracheostomy tube
to absorb secretions and prevent irritation of the
stoma.

28. Discard all used materials & perform hand hygiene.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

CLO #1 and are accessible as prescriptions and over-the-counter

Definition of Terms medications. Salicylate is a popular rubefacient.
Wound Dressing Topical Application
Topical applications are those applied to a circumscribed
Wound Dressing
surface area of the body. They affect only the area to which
A wound dressing refers to anything that comes into close they are applied.1
touch with a wound to aid in healing and to avoid future
Topical Medication
problems or complications
A topical medication is applied locally to the skin or to
Dressing
mucous membranes in areas such as the eye, external ear
A dressing is a sterile patch or compress that is put to a canal, nose, vagina, and rectum. Most topical applications
wound to assist in healing and safeguard it from further used therapeutically are not absorbed well, completely, or
injury. A dressing is intended to come into direct touch with predictably when applied to intact skin because the skin’s
the wound, as opposed to a bandage, which is typically used thick outer layer serves as a natural barrier to drug diffusion.
to keep a dressing in place.1 This route of absorption through the skin (percutaneous),
Abrasion can be increased if the skin is altered by a laceration, burn,
When superficial layers of the skin are scraped or rubbed or some other problem.
away. The area is reddened and may have localized bleeding
or serious weeping. CLO #2
Puncture Purpose of Wound Dressing and Topical Medication
It refers to the penetration of the skin and often the Application
underlying tissues by a sharp instrument, either intentional Wound Dressing
or unintentional. Wound dressings are applied for the following purposes:
Laceration • To protect the wound from mechanical injury.
A wound caused by the ripping of delicate bodily tissue. This • To protect the wound from microbial
kind of wound is frequently uneven and jagged. Tissues torn contamination.
apart, often from accidents (e.g., with machinery). • To provide or maintain moist wound healing.
Contusion • To provide thermal insulation.
• To absorb drainage or debride a wound or both.
Contusion is defined as a closed wound in which the skin
appears ecchymotic (bruised) because of damaged blood • To prevent hemorrhage (when applied as a
vessels. It is usually caused by a blow from a blunt object. pressure dressing or with elastic bandages).
• To splint or immobilize the wound site and thereby
Incision facilitate healing and prevent injury.
Incision is an open wound and can be deep or shallow. Once Topical Medication Application
the edges have been sealed together as a part of treatment
The purpose of the application of topical medication are
or healing, the incision1 becomes a closed wound. It is
the following:
usually caused by a sharp instrument, such as a knife or
• To apply medicine directly to irritated, inflamed,
scalpel.
itchy, or infected skin regions.
Topical Application
• For quick alleviation of symptoms, topical
Inunction medications are frequently administered directly to
It refers to the process of applying and rubbing in an a rash or irritated region of the skin.
ointment. • To nourish skin and as a protection from harmful
Emollient agents.
Emollients are utilized since they have a moisturizing effect,
providing an occlusive film on the skin surface so that normal
water loss through the skin is halted and allowing the
trapped water to hydrate the stratum corneum. Moreover,
emollients can comfort sore and scaling skin.
Rubefacient
Rubefacients are medications that produce skin irritation
and reddening owing to increased blood flow. They are
thought to treat pain in a variety of musculoskeletal diseases

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

CLO #3 CLO #4
Factors Affecting Wound Healing Indications and Contraindications
Lifestyle Wound Dressing
People who exercise regularly tend to have good circulation Indications
and because blood brings oxygen and nourishment to the
• Pressure Ulcers - promotes the development of
wound, they are more likely to heal quickly. Smoking reduces
new skin cells in the ulcer while maintaining the
the amount of functional hemoglobin in the blood, thus
moisture level of the surrounding healthy skin.
limiting the oxygen-carrying capacity of the blood
• Traumatic Wounds - The wound is covered with a
Age sterile dressing to keep it clean and safe.
The body’s ability to repair skin deteriorates with age. Age- • Superficial Burns - aims to protect the wound
related variations in how well wounds heal have been amply surface, and prevent the spread of burns while
observed. Elderly people are more likely to have diseases causing the patient the least amount of pain.
that affect wound healing, and these diseases have a greater • Skin Tears - this will reduce pain and prevent the
negative impact on healing than they do on young adults. wound from bacterial invasion.
Poor Oxygenation • Surgical Wounds - this will provide physical
Lack of oxygen can cause the wound to take longer to heal, support, protection and absorb exudate
cause new problems, and make it more vulnerable to • Skin Flaps and skin Grafts - to speed up recovery,
infection. Microcirculation is essential for maintaining a increase patient comfort, and lessen pain
steady supply of oxygen to the tissue, which is2 necessary • Venous Stasis Ulcers - They can offer symptom
for both the healing process and infection resistance. management and improve the environment around
Poor Nutrition the wound to aid in healing.
A wound can take longer to heal and become weaker due to Contraindications
inadequate nutrition before or during the healing process.
• Highly Exudative Wounds - excessive exudate can
Nutrition is crucial to the care and healing of wounds, and
strip the skin, resulting in painful excoriation and
nutritional support should be viewed as an integral
maceration.
component of wound management.
• Infected Wounds Allergy to Adhesive - Most
Medications dressings contain adhesive, and if an allergic
Anti-inflammatory drugs (e.g., steroids and aspirin) and reaction develops, the infected wounds may
antineoplastic agents interfere with healing. Prolonged use experience an effect and become painful.
of antibiotics may make a person susceptible to wound • Dry Wounds - Too much dryness in the wound
infection by resistant organisms inhibits cell migration, which leads to inadequate
Infection wound healing.
Local wound-specific factors may cause the healing of a Topical Medication Application
wound to take longer. A defect or excavation of the skin or
Indications
underlying soft tissue that is infected which causes an
invasion of pathogenic organisms into the healthy tissue that • Minor Burns
surrounds the wound may trigger an infection. This could • Pressure Ulcers - Topical medication is possibly
cause tissue damage that also leads to slowing the healing necessary to shield skin that incontinence-related
process. damage or irritation has irritated.
Chronic Diseases • Pediatric Wounds - reduce morbidity and infection
rates from wounds in burn wounds
Past diagnoses conditions may greatly impede, or delay
typical wound healing. This most frequently occurs • Diabetic Foot Ulcers - works by preventing the
secondary to aging and substance abuse but is also seen with growth of fungi that cause infections.
chronic diseases like diabetes and renal failure. Less often, • Partial-Thickness Burns - to promote wound
inflammatory or genetic disorders are also responsible for healing and to prevent or clear microbial invasion
slow wound healing. and colonization
• Leg Ulcers - This prevents the possibility of hair
follicles becoming blocked by keeping the wound
moist.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

Contraindications Impregnated Nonadherent

• Acute/Chronic Wounds Healing - This can slow
down wound healing and also triggers the wound
ang may lead to infection
• Allergic to the Topical Medication Used - variety of
reactions may result from an allergy to a topical
medication. Localized burning, tingling, and itching
can appear as a result of contact urticaria minutes
to one hour after skin contact.
• On Exposed Joint Surfaces/Cartilage - due to the
potential for excessive absorption into the Description
bloodstream, which would delay healing and also • Woven or nonwoven cotton or synthetic materials
infection might occur. are impregnated with petrolatum, saline, zinc-
• Full Thickness Burns - as these increase the risk of saline, antimicrobials, or other agents.
infection and can hold heat in the skin, causing • This requires secondary dressings to secure them in
further damage. place, retain moisture, and provide wound
protection.
CLO #5 Purpose
Types of Dressing Used in Wounds, Types of Wound • To cover, soothe, and protect partial- and full-
Exudate and Types of Topical Medication Preparation thickness wounds without exudate.
Indications
Dressing used in Wounds
• Postoperative dressing over staple/sutures3
Transparent Film • Superficial burns
Example
• Adaptic
• Aquaphor gauze
• Carassyn
• Xeroform dressings

Hydrocolloids

Description
• Adhesive plastic, semipermeable, nonabsorbent
dressings allow an exchange of oxygen between the
atmosphere and wound bed.
• These are impermeable to bacteria and water.
Purpose
• To provide protection against contamination and
friction. Description
• To maintain a clean moist surface that facilitates
• Waterproof adhesive wafers, pastes, or powders.
cellular migration.
Wafers, designed to be worn for up to 7 days,
• To provide insulation by preventing fluid consist of two layers.
evaporation.
• The inner adhesive layer has particles that absorb
• To facilitate wound assessment. exudates and form a hydrated gel over the wound;
Indications the other film provides an occlusive seal.
• IV dressing Purpose
• Central line dressing • To absorb exudate
• Superficial wounds3 • To produce a moist environment that facilitates
• Pressure ulcers stage I healing but does not cause maceration of the
Examples surrounding skin
• Bioclusive • To protect the wound from bacterial
• Op-site contamination, foreign debris, and urine or feces
• Polyskin • To prevent shearing
• Tegaderm
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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

Indications Hydrogels
• Pressure ulcers stage II-IV
• Autolytic debridement of eschar
• Partial-thickness wounds
Examples
• Comfeel
• DuoDERM
• RepliCare
• Restore, Tegasorb

Clear Absorbent Acrylic

Description
• Glycerin or water-based nonadhesive jelly-like
sheets, granules, or gels are oxygen permeable
unless covered by a plastic film.
• It requires secondary occlusive dressing.
Purpose
• To liquefy necrotic tissue or slough
• Rehydrate the wound bed
Description • Fill in dead space4
• Transparent absorbent wafer designed to be worn Indications
for 5 to 7 days. • Pressure ulcers
• The acrylic layer absorbs exudates and evaporates • Skin tears
the excess off the transparent membrane. • Partial-thickness wounds
Purpose Examples
• Maintains a transparent membrane for easy wound • Carrasyn
bed assessment, provides bacterial and shearing • Elasto-Gel
protection • Nu-Gel
• Maintains moist wound healing • Purilon
• Used with alginates to provide packing to deeper • Tegaderm
wound beds4
• Vigilon
Indications
• Pressure ulcers
• Skin tears Polyurethane Foams
• Venous stasis ulcers
• Surgical wounds
• Wounds undergoing chemical debridement agents
Examples
• Tegaderm
• Absorbent

Description
• Nonadherent hydrocolloid dressings; these need to
have their edges taped down or sealed.
• It requires secondary dressings to obtain an
occlusive environment.
• Surrounding skin must be protected to prevent
maceration.
• Easy to cut and fit to wound.4
Purpose
• To absorb up to heavy amounts of exudate
• To provide and maintain moist wound healing
• To provide thermal insulation
4
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

Indications Collagen
• Light to highly exudating wounds
• Pressure ulcers
• Skin tears
• Venous stasis ulcers
• Surgical wounds
• Wounds undergoing chemical agents
Examples
• Allevyn
• Curafoam
• Flexzan
• Lyofoam Description
• VigiFOAM • Gels, pastes, powders, granules, sheets, sponges
derived from animal sources, often cow or pig.
Alginates (exudate absorbers)5 Purpose
• Assists with stopping bleeding
• Helps recruit cells into the wound and stimulates
their proliferation to facilitate healing.
Indications
• Clean, moist wounds
Examples
• Biostep
• Cellerate
• RX - NU-GEL
• Promogran

Description Types of Exudates

• Nonadherent dressings of powder, beads or Exudate is a material (e.g., fluid and cells) that has escaped
granules, ropes, sheets, or paste conform to the from blood vessels during the inflammatory process and is
wound surface and absorb up to 20 times their deposited in tissue or on tissue surfaces.
weight in exudate.
• It requires a secondary dressing. Three Major Types of Exudates
Purpose
Serous Exudate
• To provide a moist wound surface by interacting
with the exudate to form a gelatinous mass
• To absorb exudate
• To eliminate dead space or pack wounds
• To support debridement
Indications
• Pressure ulcers • It consists chiefly of serum (the clear portion of the
• Skin tears blood) derived from blood and the serous
• Venous stasis ulcers membranes of the body, such as the peritoneum.
• Surgical wounds • It looks watery and has few cells.
• Wounds undergoing chemical debridement agents • Example: The fluid in a blister from a burn.
Examples
Purulent Exudate
• AlgiDerm
• Curasorb
• Debrisan
• Kaltostat
• Sorbsan
• It is thicker than serous exudate because of the
presence of pus, which consists of leukocytes,

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

liquefied dead tissue debris, and dead and living Gels

bacteria. • A clear or translucent semisolid that liquefies when
• Vary in color, some acquiring tinges of blue, green, applied to the skin.
or yellow.6 • They become a liquid almost immediately upon
Sanguineous Exudate contact with your skin, leaving a faint film of
medication on the surface after the majority of the
formula evaporates.
Liniments
• A medication mixed with alcohol, oil, or soapy
emollient and applied to the skin.
Lotions
• A medication in a liquid suspension applied to the
skin.
• It consists of large amounts of red blood cells, • This is applied externally on the skin with bare
indicating damage to capillaries that is severe hands, a clean cloth, cotton wool, or gauze to
enough to allow the escape of red blood cells from provide cooling effects through solvent
plasma. evaporation.6
• This is frequently seen in open wounds.
Pastes
• A preparation like an ointment, but thicker and stiff,
Mixed Types of Exudates that penetrates the skin less than an ointment.
• It contains a mixture of various ointments and
Serosanguineous Exudate
powder which makes them extremely thick and
difficult to rub in.
Powders
• A finely ground drug or drugs; some are used
internally, others externally.
• Have a drying effect and form a protective film on
the skin.

• It consists of both clear and blood-tinged drainage

CLO #6
and is commonly seen in surgical incisions.
Complications of Wound Healing
Purosanguineous Discharge
Millions of people experience the financial and
• Consisting of pus and blood and is often seen in a physical costs of healing wounds every year. Early detection
new wound that is infected.6 of risk factors and potential issues can make the difference
between a successful outcome and failure. Some of the more
Topical Medication Preparation common complications include infection, dehiscence with
Creams possible evisceration, and hemorrhage.
• A nongreasy, semisolid preparation used on the Infection
skin. Infection is the contamination of the wound surface
• It is composed of Fat and water mixtures that are with microorganisms. This is an inevitable result because the
easily spreadable. Since fat and water do not surface cannot be permanently protected from contact with
normally mix well, an emulsifying agent is used to unsterile objects. Colonizing organisms compete with new
combine and stabilize these two ingredients. cells for oxygen and nutrition, and since their by-products
interfere with a healthy surface condition, the presence of
Emollients
contamination can impair would healing and lead to
• Used as a moisturizer to treat or prevent dry, rough, infection. Infections occurs when microorganisms multiply
scaly, itchy skin and minor skin irritations. excessively or invade tissues. Severe infections may cause
• Substances that soften and moisturize the skin and fever and an elevated white blood cell count. Wounds are
decrease itching and flaking.6 usually infected when they change in color, has pain, has an
odor, and has drainage and this is confirmed by performing
a wound culture.

6
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

Dehiscence with possible evisceration removing debris and bacteria from the wound or periwound
area and are present in commercial wound cleansers.
Sodium Hypochlorite
To lower the risk of infection, it is used before
surgical procedures or for minor wound care. There are
additional uses for this medication.7
Hydrogen Peroxide
A moderate antiseptic used topically to treat minor
burns, scrapes, and cuts is hydrogen peroxide. As a mouth
rinse, it can be used to assist clear mucus or soothe minor
oral irritation (caused, for example, by canker/cold sores,
gingivitis).
Dehiscence is the partial or total rupturing of a
sutured wound. It usually involves an abdominal wound in Materials Used in Applying Topical Medications
which the layers below the skin also separate. Evisceration is
the protrusion of the internal viscera through an incision. Non-sterile/Sterile Gloves
Factors such as obesity, poor nutrition, multiple trauma, This is to create a barrier between the care provider
failure of suturing, excessive coughing, vomiting, and and the patient. This is to prevent cross-contamination and
dehydration would make the client more prone to and at risk infection.
for dehiscence. Wound dehiscence likely occurs 4 to 5 days Antiseptic Solution
postoperatively before extensive collagen is deposited in the This is to make sure that the surface to be
wound. medicated is clean and free of harmful microorganisms.
Hemorrhage Topical Medications
Hemorrhage is the massive bleeding of a wound. A topical drug is one that is applied directly to the
This can be caused by a dislodged clot, a slipped stitch, or skin or to an area of the body. Topical administration, which
erosion of a blood vessel. Internal hemorrhage may be includes a wide range of classes such as creams, foams, gels,
detected by swelling or distention in the area of the wound lotions, and ointments, most frequently refers to application
and possibly, by sanguineous drainage from a surgical drain. to bodily surfaces like the skin or mucous membranes to
Some clients would have hematoma which is a localized treat illnesses.
collection of blood underneath the skin that may appear as
a reddish blue swelling. The risk of hemorrhage is greatest
during the first 48 hours post-surgery
CLO #8
Guidelines in Would Dressing and the Application Topical
Medications
CLO #7
Common Solutions Used in Would Dressing and the Guidelines in Wound Dressing
Materials Used in Applying Topical Medications 1. Obtain assistance for changing a dressing on a
restless or confused client.
Common Solution Used in Wound Dressing
2. Assist the client to a comfortable position in which
Chlorhexidine the wound can be readily exposed.
Chlorhexidine is a disinfectant and antiseptic. It aids 3. Make a cuff on the moisture-proof bag for disposal
in lowering the quantity of bacteria or germs on your skin or of the soiled dressings, and place the bag within
in your mouth. Gum disease, mouth ulcers, and oral reach.
infections can all be treated with it.7 4. Prior to performing the procedure, introduce self
Povidone-Iodine and verify the client’s identity using agency
protocol.
Iodopovidone, sometimes referred to as povidone-
5. Explain to the client the procedure, why it is
iodine, is an antiseptic used to clean the skin before and after
necessary, and how to participate. Discuss how the
surgery. Both the skin of the patient being cared for and the
results will be used in planning further care or
hands of the healthcare providers may be cleaned with it.
treatments.
Minor wounds can also be treated with it.
6. Perform hand hygiene and observe other
Sterile Normal Saline appropriate prevention control procedures.
The irrigating solution that is most frequently used 7. Provide for client privacy.
is sterile normal saline. It is always safe to use it in wounds 8. Remove and dispose of soiled dressings
because of its physiologic nature. It does not, however, appropriately.
contain any surfactants, which are more efficient at
7
 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

• Apply clean gloves and remove the outer AEROSOL SPRAY

abdominal dressing or surgipad. • Shake the container well to mix the contents. Hold
• If adhesive tape was used, remove it by the spray container at the recommended distance
holding down the skin and pulling the tape from the area (usually about 15 to 30 cm) but check
gently but firmly toward the wound. the label.
• Lift the outer dressing so that the • Cover the client’s face with a towel if the upper
underside is way from the client’s face. chest or neck is to be sprayed.
• Place the soiled dressing in the moisture- • Spray the medication over the specified area.
proof bag without touching the outside of
the bag. CLO #9
• Assess the location, type (color, Nursing Responsibilities
consistency), and odor of wound
Wound Dressing
drainage, and the number of gauzes
saturated or the diameter of drainage Before
collected on the dressings. • Perform hand hygiene and observe other
• Discard the soiled dressings in the bag as appropriate infection prevention procedures.
before. • Introduce yourself to the client and explain the
• Remove and discard gloves in the procedure and why is it necessary.
moisture-proof bag. • Assess the location, type, and odor of the wound.
• Perform hand hygiene. • Place the patient in a comfortable position.
9. Set up the sterile supplies. • Provide for client privacy.
10. Clean the wound if indicated. • Prepare the equipment.
• Clean the wound, using your gloved hands During
or forceps and gauze swabs moistened
• Clean the wound from center to periphery,
with cleaning solution.
discarding the used swabs after each stroke.
• If using forceps, keep the forceps tips
• Cleanse around the drain (if present).
lower than the handles at all times.
• After cleaning the wound, dry the wound with dry
• Use a separate swab for each stroke and
swabs.
discard each swab after use.
• Apply medications if ordered.
11. Apply dressings to the drain site and the incision.
12. Document the procedure and all nursing • Apply inner dressing with forceps to incision, then
assessments. drain site.
• Apply outer dressing, keeping the inside of the
POWDER sterile dressing touching the wound.
• Make sure skin surface is dry. • Secure the dressings with bandage or adhesive
• Spread apart aby skinfolds, and sprinkle the site tapes.
until the area is covered with a fine, thin layer of After
powder. • Assist the client to dress and to sit in a comfortable
• Cover the site with a dressing if ordered. position.
• Replace the bed linen.
CREAM, OINTMENTS, PASTES, and OIL-BASED LOTIONS • Dispose soiled linens into a covered container and
• Warm and soften the preparation in gloved hands send for incineration.
to make it easier to apply and to prevent chilling. • Remove the instruments and other articles and
• Smear it evenly over the skin using long strokes that clean them thoroughly.
follow the direction of the hair growth. • Record and document the procedure
• Explain that the skin may feel somewhat greasy
after application.
• Apply a sterile dressing if ordered by the primary
care provider.

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 CEBU DOCTORS’ UNIVERSITY
COLLEGE OF NURSING BATCH 2024
Wound Dressing and Topical Application
Ms. Geniza Fatima Lipura

Topical Medication Application (TOPICAL CREAMS,

LOTIONS, OINTMENTS
Before
• Perform hand hygiene.
• Introduce yourself to the client.
• Verify the client's name and birthday.
• Check the client's allergy band for any allergies.
• Provide patient education as necessary.
• Prepare the medication
During
• Check the medication administration record against
the doctor's orders.
• Apply non-sterile gloves unless the skin is broken;
then apply sterile gloves.
• Wash, rinse, and dry the affected area with water
and a clean cloth.
• If the skin is very dry and flaking, apply topical while
skin is still damp.
• Perform hand hygiene, change gloves in between.
• Let the client know the initial application may feel
cold and may feel greasy after the procedure.
After
• Document the procedure.
• Perform hand hygiene.
Topical Medication Application (TOPICAL POWDER)
Before
• Perform hand hygiene.
• Introduce yourself to the client.
• Verify the client's name and birthday.
• Check the client's allergy band for any allergies.
• Provide patient education as necessary.
• Prepare the medication.
During
• Check the medication administration record against
doctor’s orders.
• Ensure that skin is completely dry and clean before
application.
• Dust skin with a light layer of powder using tap
motion.
• If ordered, cover the affected site with the
prescribed dressing.
After
• Document the procedure.
• Perform hand hygiene.