2
2) stethoscope
3) small basin
4) water- soluble lubricant
5) tongue blade
6) syringes 5-50ml
7) flashlight
8) glass of water with straw
9) clamp/spigot
10) bathe towel
11) emesis basin
12) safety pin
13) clean gloves
14) ph paper
Procedure: Nasogastric Tube (NGT) Insertion
Equipment:
Large or small bore nasogastric tube
Solution basin filled with warm water (if using a plastic tube) or ice (if using a rubber tube)
Tape/plaster Safety pin and elastic band
Clean gloves Stethoscope
Water soluble lubricant Tissue/soft
Glass of water 20-50 ml syringe with adapter
Action Rationale
Verify doctor’s orders To ensure the correct treatment is given to the
correct patient
Verify correct patient As above
Perform hand hygiene Hand hygiene prevents the spread of
microorganisms.
Explain the procedure to the patient: It will
not be painful but it is uncomfortable
because the gag reflex is activated
To ensure that the patient understands the
procedure
Arrange a signal by which the patient can
communicate if he wants the nurse to stop
e.g. by raising his hand
The patient is often less frightened if he feels
able to have some control over the procedure
Screen the patient Provides privacy
Assist the patient to a high fowler’s position
if health permits, and support the head on
a pillow
Drape chest with a towel and have emesis
basin and tissue (soft) available
It will be easier to swallow in this position and
gravity helps the passage of the tube
Provides protection if the patient vomits
Passage of the tube may stimulate gagging
and tearing of the eyes
Assess the patient’s nares:
-ask the patient to breathe through one
nostril while occluding the other
-select the nostril that has the greater air
flow
To identify any obstructions that would make
the insertion more difficult
Prepare the tube: if rubber is being used,
place it on ice; if plastic tube is being used,
place it in warm water
Ice will stiffen the tube making it easier to insert
Warm water makes the tube more flexible
making the insertion easier
Measure and mark the tube: mark the
distance from the tip of the patient’s nose
to the tip of the ear lobe and then from the
tip of earlobe to the tip of the sternum and
mark the tube with adhesive or with a pen
To ensure that the appropriate length of tube is
passed into the stomach
Put on clean gloves Universal precautions. Nurse may be exposed
to body fluids
Lubricate the tip of the tube well with
water-soluble lubricant or plain water to
A water-soluble lubricant dissolves if the tube
accidentally enters the lungs. Lubrication

3
make the insertion easier reduces friction and eases the passage of the
tube
Ask the patient to slightly push the head
back against the pillow. Gently insert the
tube sliding it backward and inwards along
the floor of the nose to the nasopharynx. If
an obstruction is felt, withdraw the tube
and start again in a slightly different
direction or use the other nostril
To make it easier for the tube to pass by
following the natural anatomy of the nose
The tube should never be forced against
resistance because of the danger of injury
As the tube passes down into the
nasopharynx, ask the patient to start
swallowing and sipping water
To focus the patient’s attention on something
other than the tube. A swallowing action closes
the glottis, enabling the tube to pass into the
esophagus
If the patient gags, stop passing the tube
for a moment. Have the patient rest, take a
few breaths, and take sips of water
To calm the patient’s gag reflex
When the pharynx is reached instruct the
patient to touch chin to chest. Encourage
the patient to sip water or swallow if fluids
are not allowed. Stop when patient
breathes. If gagging and coughing
increase stop moving the tube and check
placement of the tube with tongue blade
and flashlight. If tube is curled in the back
of the throat, straighten the tube and
attempt to advance again
Bringing the head forward helps close the
trachea and open the esophagus
Excessive coughing and gagging may happen
if the tube has curled in the back of the throat
With each swallow pass the tube 5 - 10 cm
until the indicated length is inserted
To advance to the required length
If the patient shows signs of distress, e.g.
gasping or cyanosis, remove the tube
immediately
The tube may have accidentally been passed
down the trachea instead of the pharynx
Distress may indicate that the tube is in the
bronchus
Stabilize the tube with one piece of tape
while position is being determined
Check the position of the tube using more
than one method to confirm that it is in the
stomach
Method 1: aspirate 2 ml of stomach
contents. If unable to obtain specimen,
reposition the patient and flush the tube
with 30 ml of air
Method 2: Measure the pH of aspirate fluid
using pH paper
Method 3: Visualize aspirate contents,
checking for colour and consistency
Current literature recommends that the nurse
ensures proper placement of the NG tube by
relying on multiple methods and not on one
method alone
The tube is in the stomach if its contents can
be aspirated. This action may be necessary
several times
pH of aspirate can be tested to determine
gastric placement The pH of gastric aspirate is
5.5 If the patient is taking an acid inhibiting
agent, the range may be 4.0-6.0. The pH of
intestinal fluid is 7.0 or higher. The pH of
respiratory fluid is 6.0 or higher. This method
will not differentiate between intestinal fluid and
pleural fluid
Gastric fluid can be green with particles, off-
white, or brown if old blood is present. Intestinal
aspirate is clear or straw coloured, or a deep
golden-yellow color. Intestinal aspirate may be
greenish-brown if stained with bile. Respiratory

4
Method 4: Obtain an X-ray
or tracheobronchial fluid is usually off-white to
tan and may be tinged with mucus
X-ray is considered the most reliable method
for identifying the position of the NG tube
Cut 10cm of tape/plaster and split bottom
5cm. Place un-split end over the bridge of
the patient’s nose. Wrap split ends under
the tubing up and over onto the nose. Be
careful not to pull the tube too tightly
against the nose
To maintain the correct placement of the tape
Clamp tube and cap or attach to suction
according to the doctor’s orders
Suction provides for decompression of stomach
and drainage of gastric contents
Secure the tube to the patient’s gown by
using a rubber band and safety pin or tape.
For additional support, the tube can be
taped onto the patient’s cheek using a
piece of tape
This prevents pulling and tugging on the tube
Assist with or provide mouth care every 2
to 4 hours. Lubricate the lips, clean the
nares
Mouth care keeps the mouth clean and moist,
promotes comfort and reduces thirst
Remove all equipment. Wash hands Hand hygiene decreases the spread of
microorganisms
Student Notes:
Performing gastric lavage
Gastric lavage
-is washing out /irrigating of stomach with a solution
-it is used most frequently as an emergency treatment
Purpose of gastric lavage
o to remove poison which has been swallowed
o to relive congestion, there by stimulating peristalsis e.g. pyloric stenosis
o to clean the stomach of undigested food, mucosa, fermented material
o to relieve extreme nausea, vomiting, & distress in case of
 acute dilatation of stomach
 pyloric stenosis
 intestinal obstruction
o to remove irritant material
o to cleanse the stomach as a preparation of surgery
o to cleanse the stomach post-operatively to prevent dilatation
Indication of gastric lavage
poisoning
drug over dose
gastric / esophageal bleeding
abdominal surgery
chronic nausea, vomiting due to acute dilatation of stomach, pyloric stenosis, intestinal
obstruction
Precautions
 remove false teeth
 never force passage of tube

5
 discontinue treatment for any return flow of blood
 indication of tube in trachea, remove it
 avoid introducing air into the esophagus
 watch pt for pallor, feeble pulse, & other sign of exhaustion
 do not perform a lavage within 3-4hrs after food a meal unless especially ordered in an
emergency
Solution commonly in use
1. plain water—in case of an unknown poison
2. normal saline solution
3. weak solution of sodium bicarbonate/boric acid in poisoning
4. specific antidotes, if the poison is known
-Three types of antidotes
a. physical antidotes
-it mixed with poison & dilute it or
-prevent its absorption
-it protects the m.m
b. chemical antidotes—it reacts with poison & neutralizes it
c. physiologic antidotes—has systemic effects opposite to that of the poison e.g. if the poison
has depressive action, it will stimulate effect on the body
NB. Antidote is substances used to counteract the effect of poison e.g. large quantity of dilute
alkali for acid poisoning
Contraindication of gastric lavage
-pt’s who have ingested a corrosive substance
E.g. lye, ammonia, or mineral acid b/c the NGT may perforate the already compromised
esophagus
Complication of gastric lavage
 Brady arrhythmias
 cardiac arrest due to body temperature lowered
 inadvertent passing of the Nasogastric tube into trachea
 respiratory aspiration of gastric contents resulting aspiration pneumonia
 perforation of the esophagus/stomach
NB- for pt with gastric / esophageal bleeding lavage with tepid/iced water/0.9% sadiumchloride solution may
used to stop bleeding
*action
-iced irragating solution stimulates the vagus nerve
-these leads to increased HCL secretion
-these again stimulate gastric motility, which can irritate the bleeding site
-gastric lavage is usually performed in the emergency department / ICU by a
 a doctor
 gastroenterologist (most)
 nurse
-chart 1) type & amount of solution used
2) Character & amount of returns
3) Condition of the pt
4) Name of the health professional who giving Rx
5) Time to be noted
Procedure: Nasogastric Lavage

6
Equipment:
Large bore stomach tube (approx. 1.25 cm in diameter and 150 cm in length)
Funnel or 50 mL syringe
500 mL jug
Pail, plastic apron, clean gloves
4 liters of appropriate solution at room temperature
Specimen bottle for laboratory (PRN)
Action Rationale
Verify the doctor’s order To ensure that the correct procedure is
performed on the correct patient
Verify the correct patient As above
Perform hand hygiene Hand hygiene prevents the spread of micro-
organisms
Explain the procedure to the patient To ensure that the pt understands the
procedure
Assist the patient to the correct position as in in in
procedure ”Insertion of Nasogastric tube”
If the patient is unconscious, place on a firm
surface, lying in the semi prone position,
with the head down
The head must be kept low so that fluid/
vomitus will runs out of the mouth and not
down into the trachea
Aspirate a specimen of stomach contents
for laboratory analysis
To obtain information on the poison
ingested
Attach the funnel to the tube and insert 400
mL of the appropriate tepid solution
Dilutes the gastric contents
When the solution is in the base of the
funnel clamp the tube by pinching with the
fingers and lower the funnel over the pail
Clamping prevents spillage. Siphoning will
not occur if the funnel has been allowed to
empty
Return the funnel to the upright position and
again add 400 mL of the solution
A lavage to clean the stomach pre-
Operatively needs to be done until the fluid
returns clear
A lavage performed for a poisoning: a total
of 8 liters is to be given
When the procedure is completed, remove
the tube as per the procedure ” Removal of
Nasogastric tube”
Following the correct procedure decreases
the possibility of complications
If the lavage was done because of the
Ingestion of poison, continue to monitor the
patient for signs and symptoms of poisoning
Document: time of the procedure, solution
used, amount given, character of the return
flow, if a specimen was sent to the lab,
condition of the patient before, during and
after the procedure
Student Notes:
Procedure: Nasogastric Gavage
Equipment:
Correct amount of feeding solution (at room temperature); check expiration date
feeding solution to room temperature
Syringe if intermittent feeding or feeding bag with drip chamber
Measuring container

7
Water (60ml unless otherwise specified)
Action Rationale
Verify the doctor’s order To ensure that the correct procedure is
performed on the correct patient.
Verify the correct patient As above
Explain the procedure to the patient: will not
cause discomfort but may prompt a feeling
of fullness
Adult: intermittent feeding should take 20-30
Minutes
To ensure patient understanding of the
procedure
Screen that patient: Provide privacy for the
patient if the patient wants
Nasogastric feedings may be embarrassing for
some people
Assist the patient to a Fowler’s position
or sitting position in a chair. If sitting is
contraindicated, a slightly right side-lying
position is acceptable
These positions allow the gravitational flow of
the solution and prevent aspiration of fluid into
the lungs
Assess tube placement. See insertion of NG
tube and 4 methods of insuring placement
Must insure that feeding solution will not enter
the lungs
Assess residual feeding contents by
Aspirating all the stomach contents.
Measure the amount
 If 50 mL or more of undigested formula
is withdrawn in an adult check with the dr
before giving the feeding
This evaluates absorption of the last feeding.
The feeding may be withheld or the amount
withdrawn is subtracted from the total feeding
and that volume is administered slowly or
re-instill the gastric contents into the stomach
Administer the feeding
Using a bulb syringe: remove the bulb from
the syringe and connect the syringe to a
pinched or clamped NG tube. Add the
feeding solution to the syringe barrel and
permit the feeding to flow in slowly at the
prescribed rate. Raise or lower the syringe
to adjust the flow as needed.
Pinch or clamp the tubing to stop the flow if
the patient experiences discomfort
Using a feeding bag: Hang the bag from an
IV pole about 30cm above the tube’s point of
insertion into the patient. Clamp the tubing & and
add the formula to the bag. Open the clamp, run
add the formula through the tubing, and
re-clamp the tube. Attach the bag to the
NG tube and regulate the drip by adjusting
the clamp to the drop factor on the bag ( e.g. 20
10 drops/mL)
Pinching or clamping prevents excess air from
entering the stomach and causing distention
Giving the feedings too quickly can cause
flatus, cramps or reflux vomiting
Air in the tubing is removed thus preventing air
entering into the stomach and intestines
Rinse the feeding tube before all the formula
has run through the tubing by instilling 60 ml of
water through the feeding tube. Add the
water before the solution has drained
completely
Water cleans the tube, preventing future
blockage by sticky formula
Adding water before the tubing is empty
prevents air from entering the stomach and
intestines
Clamp the feeding tube before all the water is is is
is through
Cover the end of the tube
Prevents leakage and air from entering the tube
Covering the tube prevents leakage
Ensure the patient’s comfort and safety:
Pin the tubing to the patient’s gown.
Ask the patient to remain sitting upright in
This decreases the pulling of the tube and
prevents discomfort and dislodging of the tube.
Upright position facilitates digestion and

8
Fowlers position or in a slightly elevated
right lateral position for at least 10 minutes
movement of the feeding from the stomach
along the digestive tract and prevents potential
aspiration of the feeding into the lungs
Dispose of equipment: If the equipment is to be be
be reused wash it thoroughly with soap and
water. Change the equipment every 24 hrs
or according to hospital policy
Document: amount and kind of feeding/fluids
Duration of the feeding
Assessment of the patient
Record the amt of the feeding and the water given
on the patient’s intake and output record
To have an accurate record of the patient’s
nutritional intake available for all members of
the health care team
Monitor the patient for possible problems:
tolerance of the feedings, regurgitation &
feelings of fullness after feedings, weight
gain or loss, bowel movements (diarrhea,
flatulence, constipation) skin turgor, and
urine output
Student Notes:
URINARY CATHETERISATION
Urinary catheterization is the insertion of a catheter into the bladder to drain urine. This can be done
through the urethra, or through a small supra pubic incision.
Indications for Catheterization
Urinary catheterization may be considered for any of the following reasons:
1. To relieve distension of the bladder when the patient is unable to pass urine
2. For pre or post-operative drainage of urine in patients having abdominal, perineal or pelvic surgery
3. To see if residual urine is present
4. To allow irrigation of the bladder
5. To manage urinary incontinence if other methods fail
6. To monitor urinary output accurately in seriously ill patients
7. To give drugs directly into the bladder
8. To obtain a sterile specimen of urine for laboratory examination
CATHETERS
Urethral catheters are measured in Charriers (Ch). French Gauge (FG) is the same size as Ch.
For women the average catheter size is 12-14 Ch, and for men 14-16 Ch. A larger bore may be required
if there are blood clots or debris in the bladder. A smaller size is used for children. 16-18 Ch is generally used
for supra-pubic catheterization.
Oxygen administration
Oxygen therapy –supplementation of oxygen to relieve hypoxemia & preventing damage to the tissue cells as
results of oxygen lack
Indication
Lung diseases and injury
• COPD
• Pneumonia
• Bronchial asthma
Blood disorders such as anemia
Cardiac insufficiency
Hypoxia
Hypoxemia saturation < 90%
Asphyxia
Gas poisoning
post anesthesia
 post cardio pulmonary arrest
 reduced cardiac out put

9
 hypotension, tachy cardia, central
cyanosis, chest pain, dyspnean, acute
neurological dysfunction
 endotracheal suctioning,
broncoscopy,/thoracenthesis
 severe lower chest wall in drawing
Procedure: Female Urinary Catheterization
Equipment:
Sterile catheterization pack Foley catheter (x2)
Sterile gloves (x2) Drainage bag
10 mL syringe + needle Sterile lubricant (KY jelly)
Sterile water (10 mL) Cleansing solution (normal saline)
Waterproof mackintosh Scissors
Tape (plaster) Specimen container (if needed)
Screen Unsterile K basin
Good light source
Action Rationale
Check the identification of the pt
Explain the procedure to the pt
To ensure the correct pt understands &
consents to the procedure
Screen the bed. Place a garbage container within easy
reach. Assist the pt into the dorsal recumbent
position. Cover the pt with a sheet.
To ensure privacy
For ease of access for the nurse
Do not expose the pt at this stage
Perform hand hygiene To reduce risk of infection
Clean and prepare the trolley, placing all equipment
on the bottom shelf
The top shelf acts as the clean work surface
Take the trolley to the pt’s bedside
Open the outer cover of the catheterization pack &
slide the pack on the top shelf of the trolley
To prepare equipment
Using aseptic technique, open inner pack. Add sterile
supplies: catheter, lubricant, cleaning solutions,
drainage bag, clean gloves, etc
To reduce the risk of introducing infection
Draw up 10 mL sterile water using syringe & needle.
Place in K basin within easy reach of the pt
Place drainage bag where it is easily accessible
Place opened, sterile urine specimen bottle close to
the pt (if urine sample is needed)
For injection into the balloon of the foley
catheter
For ease of access during procedure
Remove sheet that is covering pt. Assist pt to flex her
knees approx. 2 feet apart, with her legs abducted.
Place a waterproof mackintosh under her buttocks
Proper positioning allows visualization of the
urinary meatus
To prevent the linen from becoming wet
Perform hand hygiene To reduce the risk of cross-infection
Put on sterile gloves To reduce the risk of introducing infection to
the urinary tract during the catheterization
Pick up the corners of the sterile drape & unfold it.
Fold back a corner on each side to make a cuff over
gloved hands. Ask pt to lift her buttocks and slide the
sterile drape under her with gloves protected by cuff
The drape provides a sterile field
Covering the gloved hands with a cuff will
keep the gloves sterile while placing the drape
Place the fenestrated drape over the perineal area,
exposing the labia (this drape is optional)
To expand the sterile field
A fenestrated drape may obstruct visualization
of the meatus

10
Arrange supplies on the sterile field, lubricate the end
of the catheter. Place catheter in sterile K basin and
place on sterile drape between pt’s legs
Lubrication facilitates catheter insertion &
reduces tissue trauma
With thumb & 1 finger of the left hand, spread the
labia & identify the meatus. The left hand is now
contaminated and should remain in this position
until the catheter is in-situ
This manoeuver provides better access to the
urethral orifice and help to prevent labial
contamination of the catheter
Use your right hand to pick up the forceps & gauze
soaked in the cleaning solution. Clean one labial fold
in one downward motion. Discard the gauze. Use a
new gauze for each stroke to clean the other labial
fold, then the meatus
Cleaning the urinary meatus last helps reduce
the possibility of introducing micro-organisms
into the bladder
Using your right hand, gently introduce the tip of the
catheter into the urethral orifice in an upward &
backward direction. Advance the catheter until there
is a return of urine (approx 5-6 cm).Do not force the
catheter through the urethra. Ask the pt to breathe
deeply & gently rotate the catheter if resistance is felt
The female urethra is approx. 3.5-6 cm long
Applying force on the catheter can injure the
mucous membranes
Hold the catheter securely at the meatus with your
left hand. Use your right hand to inflate the balloon
with 10 mL of sterile water (from the pre-filled
syringe). Your right hand is now contaminated
The balloon anchors the catheter in place in the
bladder
Pull gently on the catheter after balloon is inflated to
feel resistance
Improper inflation can cause discomfort
Collect urine specimen if needed
Allow the urine to drain into the sterile K basin To empty the bladder
Attach catheter to drainage system; maintaining
aseptic technique
Closed drainage minimizes the risk of micro-
organisms being introduced into the bladder
Measure the amount of urine For accurate record of I&O
Assist the pt into a comfortable position
Remove used supplies & dispose of garbage
properly. Remove gloves. Clean hands
To prevent the spread of infection
Secure the catheter to the pt’s inner thigh. Leave
some slack for leg movement. Position of the
drainage tubing will depend on the pt’s mobility &
comfort of the pt
Proper attachment prevents trauma to the
urethra from tension on the tubing
Secure drainage bag below the level of the bladder.
Teach the pt to keep the bag below the level of the
bladder; to drink at least 2 L of fld per day (unless
contraindicated) & that she may experience a
sensation of needing to void
Facilitates drainage of urine & prevents
backflow of urine into the bladder
To prevent urinary tract infection
Due to pressure of the balloon
Document relevant information (type & size of
catheter, amt of fld used to inflate balloon, amt &
colour of urine drained, any specimen obtained.
(Record amt of urine on I&O record PRN)
To record procedure & relevant information for
other health care professionals
Procedure: Male Urinary Catheterization
Equipment:

11
Sterile catheterization pack Foley catheter (x2)
Sterile gloves (x2) Drainage bag
10 mL syringe + needle Sterile lubricant (KY jelly)
Sterile water (10 mL) Cleansing solution (normal saline)
Waterproof mackintosh Scissors
Tape (plaster) Sterile specimen container (if needed)
Screen Unsterile K basin
Action Rationale
Check the pt’s identification and explain the
procedure to the pt
To ensure the correct pt understands &
consents to the procedure
Screen the pt. Place a garbage container within
easy reach. Assist the pt into the supine position
Cover the pt with a sheet
To ensure privacy
For ease of access for the nurse
Do not expose the pt at this stage
Perform hand hygiene To reduce risk of infection
Clean and prepare the trolley, placing all
equipment on the bottom shelf
The top shelf acts as the clean work surface
Take the trolley to the pt’s bedside
Open the outer cover of the catheterization pack
& slide the pack on the top shelf of the trolley
To prepare equipment
Using aseptic technique, open inner pack. Add
sterile supplies: catheter, lubricant, cleaning
solutions, clean gloves, drainage bag, etc.
To reduce the risk of introducing infection
Draw up 10 mL sterile water using syringe &
needle. Place in K basin within easy reach of the
pt
Place drainage bag where it is easily accessible to
pt
Place opened, sterile urine collection bottle close
to the pt (if necessary)
For injection into the balloon of the foley
catheter
Remove sheet that is covering pt.
Assist pt to a dorsal recumbent position, legs
slightly apart
Place a waterproof mackintosh under his buttocks
and thighs
To prevent the linen from becoming wet
Perform hand hygiene To reduce the risk of cross-infection
Put on sterile gloves To reduce the risk of introducing infection
to the urinary tract during the
catheterization
Place sterile towels across pt’s thighs The drape provides a sterile field
Place the fenestrated drape over the penis To expand the sterile field
Arrange supplies on the sterile field, lubricate the
end of the catheter. Place catheter in sterile K
basin and place on sterile drape between pt’s legs
Lubrication facilitates catheter insertion &
reduces tissue trauma
Wrap a sterile gauze around the penis with the
left hand. Retract the foreskin, if necessary. Be
prepared to keep this hand in this position
until catheter is inserted
The hand touching the penis is now
contaminated
Use your right hand to pick up the forceps &
gauze soaked in the cleansing solution. Using a
Cleaning the urinary meatus last helps
reduce the possibility of introducing micro-

12
circular motion, clean the penis, moving from the
meatus around the glans. Repeat this cleansing
motion x2, using a new gauze each time
organisms into the bladder
Normal saline has been shown to be an
effective cleansing solution
Hold penis with slight upward tension,
perpendicular (or 90 degrees) to the pt’s body.
Use your right hand to gently introduce the tip of
the catheter into the urethra for 15-25 cm until
urine flows
The male urethra is approx. 18 cm long
If resistance is felt, increase the traction on the
penis slightly & apply steady, gently pressure on
the catheter. Ask the pt to strain gently as if
passing urine
Some resistance may be due to spasm of
the external sphincter. Straining gently
helps to relax the external sphincter
Advance the catheter gently almost to its
bifurcation. Hold catheter in place at the meatus
with your left hand. With your right hand, inject
10 mL of sterile water into the balloon with the
prefilled syringe. Once balloon is inflated gently
withdraw the catheter slightly
The balloon anchors the catheter in place in
the bladder.
Improper inflation can cause pt discomfort
and damage to the urethra
Collect a sterile urine specimen if needed
Allow the urine to drain into the sterile K basin To empty the bladder
Attach catheter to drainage system maintaining
aseptic technique
Closed drainage minimizes the risk of
micro-organisms being introduced into the
bladder
Ensure that the glans penis is clean and then
reduce or reposition the foreskin
Retraction & constriction of the foreskin
behind the glans penis may occur if this is
not done
Make the pt comfortable
Ensure that the area is dry
If the area is left wet or moist secondary
infection or skin irritation can occur
Measure the amount of urine For accurate I&O
Remove used supplies & dispose of garbage
properly. Remove gloves. Clean hands
To prevent environmental contamination
To reduce risk of infection to the nurse
Secure the catheter to the pt’s inner thigh. Leave
some slack for leg movement. Position of the
drainage tubing will depend on the pt’s mobility
& comfort of the pt
Proper attachment prevents trauma to the
urethra from tension on the tubing
Assist the pt into a comfortable position
Secure drainage bag below the level of the
bladder. Teach the pt to keep the bag below the
level of his bladder; to drink at least 2 L of fluid
per day (unless contraindicated) and that he may
experience a sensation of needing to void
Facilitates drainage of urine & prevents
backflow of urine into the bladder
Prevents urinary tract infections
Due to pressure of the balloon
Document relevant information (type & size of
catheter, amt of fld used to inflate balloon, amt &
colour of urine drained, any specimen obtained.
Record amt of urine on I&O record PRN)
To record procedure & relevant information
for other health care professionals

13
Oxygen therapy
–supplementation of oxygen to relieve hypoxemia & preventing damage to the tissue cells as
results of oxygen lack
Indication of short term oxygen therapy
documented pao2 less than 60mmhg or sao2 less than90%
post anesthesia
post cardio pulmonary arrest
reduced cardiac out put
hypotension, tachy cardia, central cyanosis, chest pain, dyspnean, acute neurological
dysfunction
endotracheal suctioning, broncoscopy,/thoracenthesis
severe lower chest wall in drawing
Ways of oxygen administration
1. nasal cannula
 most common used
 oxygen flow not exceceed2-4L/min
2. tent or mist tent
 it helps to
o moistens air way
o minimizes fluid loss from the lung
 disadvantage
 make observation of the child difficult b/c of the high humidity
 oxygen concentration also falls quickly when the tent is opened for routine
care & return slowly its previous level
 difficult to maintain specific oxygen concentration
 it increases body temperature thus increasing oxygen requirements
 child is difficult to see & assess
3. mask
o comfortable for child, who is quiet & not struggle
o gas flow should be a minimum of 7L/ min to ensure adequate carbon dioxide removal
o usually delivery inspired oxygen concentration up to 55%
Equipment & accessories for oxygen therapy
pulse oximeter
thermo meter
stethoscope
oxygen source, flow meter, delivery devices
blood pressure monitoring device
extra linen & towels
* Oximeter- is a photo electric cell used to determine the oxygen saturation of blood
* Pulse oximeter- is a non-invasive method for measuring hemoglobin oxygen saturation in the body
Purpose
• To monitor arterial oxygen saturation non-invasively.
• To detect clinical hypoxemia promptly.

14
• To assess client tolerance to tapering of oxygen therapy or activity.
Norma >90%
Complication of oxygen
1. respiratory depression or oxygen induced apnea
-b/c of carbon dioxide completely washed of due to high concentration of oxygen; so that
respiratory centre is not stimulated sufficiently. Normally a part of the carbon dioxide
remaining in the blood, stimulalates respiratory center
2. retrolental fibro plasia
-noted in pre mature infants who have high concentration of oxygen
3. substernal pain
4. atlectasis
-due to increased oxygen concentration in the inspird air
-due to elimination of nitrogen’; normally the nitrogen is not diffused via alveoli
membrane . it remain in the alveoli to keep the alveoli expanded
5. pulmonary toxicity
6. drying of the mucus membrane of the respiratory tract
-b/c of low humidity
Sign & symptom of oxygen toxicity
 tracheal irritation
 cough
 dryness & irritation of m.m
 substernal pain
 vomiting & nausea
 dyspnea
 restlessness, fatigue, malaise,
 progressive respiratory difficult
Precaution of oxygen therapy
1. oxygen must be ordered by physician
2. post, NO SMOKING
3. don’t allow friction, metal, electrical, or battery operated toys in tent
4. oxygen system should be at least 10 feet away from any fire, including pilot light in stoves, furnaces,
water heaters etc
5. avoid using petroleum jelly, faces creams, lip balms, alcohol, or oils ; since all are flammable &
have potential to explode in oxygen rich environment
6. fire extinguisher should available & visible
Nursing responsibility
 monitor v/s every 4hrs
 observe for changes in RR, notify physician for clinical changes
 auscultate breaths sound for symmetry & advent ion of sound
 review lab data, chest x-ray, etc
 position the pt
- ensure that tubing associated with oxygen therapy is changed daily
 regulate body temperature
Procedure: Oxygen Administration
Equipment:
Oxygen cylinder (or machine) Flowmeter
Oxygen tubing Humidifier with sterile distilled water
Face mask or nasal prongs
Follow the steps outlined in “Principles of Medication Administration”. Then:

15
Action Rationale
Check the pt’s chart for the dr’s order To verify the type of oxygen therapy and
flow rate required
Identify the patient a the bedside To ensure therapy is administered to the
correct patient (O2 is a medication)
Explain what you are going to do and the
reason to the pt.
Explanation relieves anxiety and facilitates
cooperation
Perform hand hygiene To prevent the spread of microorganisms
Connect the oxygen setup (tubing and face
mask) with humidification. Adjust the flow
rate as ordered. Check that oxygen is
flowing.
Humidification helps to prevent drying of the
mucous membranes. Low flow oxygen (via
nasal prongs) does not require humidification
Position the pt comfortably with the airway
open and the tubing over the ears and
cheeks. The mask should fit snugly over the nose
and chin. If nasal prongs are used, insert
prongs into the pt’s nostrils.
Excessive pressure from the tubing will be
uncomfortable and can lead to skin irritation or
breakdown
Use gauze padding between the tubing and the
patient’s ears as necessary
To prevent discomfort and pressure on the
area
Encourage the pt to breathe through his/her
Nose
Nose breathing is best for the delivery of
oxygen – the pt will receive less oxygen if
he breathes through his mouth
Assess and re-assess the pt’s respirations,
colour, chest sounds, etc. every hour
To assess effectiveness of oxygen therapy
and to ensure the oxygen is flowing, the
mask or prongs are in the correct position,
etc
Put on gloves to clean the nasal prongs
once per shift. Check nares for irritation or
skin breakdown
To clear the tubing of secretions which can
prevent the delivery of the ordered flow of
Oxygen
Document procedure and assessment of
the pt in the chart
To communicate pt findings and intervention
Air way suctioning
Definition • The removal of secretion from the nasopharynx and oropharynx by using suction catheter
and suction machine
Purposes
•
To clear secretions the client cannot remove
by coughing.
• To relief dyspnea caused by secretion
accumulation
• To maintain patent air way
• To collect sputum or secretions for
diagnostic testing
• To prevent aspiration
Performing Nasopharyngeal and Oro pharyngeal Suctioning
Definition
The removal of secretion from the nasopharynx and oropharynx by using suction catheter and suction machine
Indications
For nasopharyngeal suctioning
Post operative patient
Conscious patients who cannot maintain airway
For oropharyngeal
Unconscious patients
Secretion in oral cavity
Precaution
Limit suctioning to 3 times per day for adult but if needed consult your physician
Never insert the catheter in to nares or mouth while the suction is on and the port is closed

16
Never suction more than 15 seconds for adult and 10 seconds at a time to avoid hypoxia.
Contraindication
For orophringial suctioning
Mouth/buccal burn Conscious patient
For nasopharyngeal suctioning
Head injuries Nosebleeds
Procedure: Nasopharyngeal & Oral Suctioning
Equipment:
Portable or wall suction unit Sterile water or saline
Suction tubing Sterile dressing set
Sterile gloves Goggles & mask
Stethoscope Waterproof mack
Action Rationale
Check that you have the correct pt
Explain the procedure to the pt
To ensure the pt understands the procedure
& gives his consent
Assist the pt into semi-fowler’s if he is
conscious
Position pt laterally (right or left side) if he is
unconscious, with his head facing you
Sitting position helps pt to cough and makes
breathing easier
Lateral position will prevent the airway from
becoming occluded & improves drainage of
secretions by gravity
Place the waterproof mack under the patient
(if he is lateral) or across his chest if he is
In semi-fowlers position
To prevent the linen from becoming
Soiled
Connect the tubing (if not already attached) and
and adjust the suction to the correct
pressure (normally 100 – 150 mmHg for
adults) – occlude the tubing to check the
amount of pressure
Excessive pressure can cause trauma to the
mucosa
Open sterile dressing pack. Add sterile
normal saline or water. Add the sterile
suction catheter, maintaining sterile
technique
Sterile water or saline is used to lubricate the
tip of the suction catheter to minimize
trauma to the mucosa. It is also used to
rinse the catheter between suctioning
attempts
Put on goggles and mask
Put on sterile gloves
To protect eyes and mouth from splash of
patient’s oral secretions
Handling the sterile suction catheter using a sterile
glove will decrease the risk of introducing
organisms into the respiratory tract
Pick up the connecting tube with the left
hand (this hand is now contaminated) and
with the right hand pick up the sterile suction
catheter. Connect the suction tubing to the
sterile catheter
It is important to maintain the sterility of the
suction catheter
Place the tip of the catheter in the sterile
water and moisten it
To lubricate the end of the catheter
Encourage the patient to take several deep
Breaths
The suctioning procedure will produce
hypoxemia. Hyperventilation can help
prevent this
If the pt has oxygen by nasal cannula or
mask, remove it. Gently insert the catheter

17
through the naris and along the floor of the
nostril toward the trachea. Roll the catheter
between your fingers to help advance it
Insert the catheter approximately 12-14 cm
to reach the pharynx
Do not apply suction to the catheter when
introducing it into the airway
If the oropharnyx is being suctioned, insert
the suction catheter through the mouth,
along the side of the mouth, toward the
trachea. Advance the catheter 7 – 8 cm to
reach the pharynx
Using suction while inserting the catheter
can cause trauma to the mucosa and
Removes oxygen from the respiratory tract
Intermittently occlude the Y port on the
suction catheter while gently rotating it as it
is being withdrawn
Maximum suctioning time: 10-15seconds
Occluding the port provides suction
Suctioning for more than 15 seconds results in
hypoxemia. However, suctioning too quickly
may be ineffective in clearing all of the
secretions
Allow the patient to rest and encourage him
to take several deep breaths before
proceeding
Flush the catheter with saline
Assess effectiveness of suctioning and
repeat procedure PRN
Allow at least a 30-60 second break
between each suctioning. Maximum of 3
attempts
Be sure to alternate the nares that is used
Flushing clears the catheter of secretions
and lubricates the tip for future suctioning
Time is required to allow for re-oxygenation
of the tissues
To reduce trauma
When suction is finished, remove the gloves by by
by pulling them over the coiled catheter,
pulling from the inside out
Dispose of the gloves
Remove goggles and mask
Perform hand hygiene
This technique reduces the transmission of
microorgnanisms
To prevent the spread of microorganisms
Turn off the suction
Re-apply oxygen apparatus PRN
Position pt comfortably
Offer oral hygiene
Assess pt’s respiratory status
Document the procedure
To evaluate the effect of the procedure
To communicate with other health
Professionals
Tracheostomy
-is the surgical creation of an opening /stoma into the trachea /windpipe
Purpose of Tracheostomy
 To pass upper air way obstruction
 To remove tracheo-bronchial secretions
 To prevent aspiration
 To replace endotracheal tube
 To provide & maintain air way for
respiratory support
Indication of Tracheostomy
o Air way obstruction at /above larynx
o Inability to remove secretions from the
tracheo-bronchial tree
o Need for long term positive pressure
ventilation
o Broncho pulmonary dysplasia
o Pneumonia

18
o Hyaline membrane diseases o Diaphragm dysfunction
Assessment
 Placement of Tracheostomy
 The reason for placement
 Type & size of the tube
 C
o
n
d
i
t
i
o
n
o
f
t
h
e
s
k
 Child’s color
 v/s, breath sound
 the consistency & amount of secretions
Precaution with tracheostomy
o always have extra tracheostomy
tube
o follow strict aseptic condition
o watch for the f/f signs of obstruction
of the air way & report them to the
doctor immediately ,if they don’t
improve with
a. suction tracheostomy
tube
b. changing the
tracheostomy tube
 restlessness,
labored
breathing,
increased RR,
 NOISY
RESPIRATIO
N
 Retraction (in
drawing of
chest or ribs)
 Mouth
breathing with
no air
passages the
tracheostomy
Suction of the Tracheostomy
-It is used to clear the tracheostomy tube
Indication of tracheostomy suctioning
 noisy respiration
 pulling inward of the chest wall
 pulling inward of the hollow in the
neck
 fast breathing
 difficulty eating/ sucking
 mucus bubbling around the tracheo
opening
 flaring nostrils
 change in color of mouth, lips,(
pale,blue,dusky)
Emergency care pt with tracheostomy
- If the patient stops breathing
Suction the tracheostomy tube immediately

19
If the tracheostomy tube is plugged with mucus & you can’t suction it out, change the tube
If the pt still does not breath when the new tube is inserted, and no pulse begin CPR
Call for help. Continue CPR until help arrives or the child responds by breathing on is own
-if a strong pulse present but child still not breathing, continue with artificial ventilation
breathing
General instructions for a pt with tracheostomy
 Avoid breathing the cold air into tracheostomy b/c it can cause tracheal spasm & form
small ice particles in the mucus if exposed for extended period of time
 Encourage routine food
 Don’t let the pt take showers
 Avoid the f/f environmental irritants
 Pets with fine air
 feathers, dust,
 Aerosol sprays
 Smoke,
 powder
Procedure: Tracheostomy Suctioning
Equipment:
Suction machine Protective eye wear (goggles)
Sterile suction catheters Sterile normal saline + syringe
Sterile gloves Waterproof mackintosh
Sterile dressing pack Mask
Waterproof apron Stethoscope
Action Rationale
Identify the patient To ensure therapy is administered to the
correct patient
Explain what you are going to do and the
reason to the pt. (even if the pt does not
appear to be conscious)
Explanation relieves anxiety and facilitates
cooperation
Position the pt:
Conscious pt – semi fowlers
Unconscious pt – lateral position facing
towards the nurse
Allows pt to breathe easier
Prevents airway from becoming obstructed
and promotes drainage of secretions
Place waterproof pad across the pt’s chest Prevents the linen from becoming soiled
Turn suction on to the appropriate level
(Portable suction machine: 10 – 15 cmHg
Wall suction: 80 – 150 mmHg)
Excessive pressure can damage the
mucosa, cause hypoxemia & atelectasis
Perform hand hygiene To decrease the spread of microorganisms
Select the correct catheter size
(the diameter of the catheter should be half
the tracheostomy tube size)
If secretions are very thick or copious, a
larger bore catheter will be needed
Open the sterile dressing pack to create a
sterile field
Asepsis must be maintained throughout
the procedure
Open the suction catheter package using
aseptic technique & place the catheter on
the sterile field
Pour sterile water (or other antiseptic
solution as ordered) into the gallipot
Sterile water is used to lubricate the suction
tubing and clear the lumen between suction
attempts
Put on goggles, mask & apron To protect the nurse from contamination by
secretions during suctioning

20
Put on sterile gloves To prevent the introduction of organisms into the
the respiratory tract
The right (dominant) hand must remain
sterile
The left hand is considered clean & is used
to manipulate the suction valve of the
catheter
The glove on the left hand is used to protect the
the nurse from the pt’s secretions
Connect the sterile suction catheter to the
suction machine (remember the right hand
must remain sterile)
Lubricate the tip of the suction catheter with
normal saline using the right hand
To minimize mucosal irritation when the
catheter is introduced
Rinse the catheter with sterile Normal
Saline
Assess the need to repeat the suctioning
Flushing clears the catheter of secretions
Suctioning should only be repeated as
necessary due to the potential risks to the pt
Allow at least a 30-60 second interval
between suctioning attempts
To allow for re-oxygenation of the of the
Patient
A maximum of 3 suction passes should be
Made
Excessive suctioning contributes to
Complications
Remove glove from the right hand over the
coiled catheter by pulling it off inside out.
Then remove the glove from the left hand;
dispose of gloves and catheter and used
dressing pack
To prevent contamination and the spread
of microorganisms
Turn off suction
Assist pt into a comfortable position
Reassess pt’s respiratory status: rate,
effort, oxygen saturation & breath sounds
To assess effectiveness of suctioning
procedure and the presence of any
complications
Chart procedure and pt’s condition To have a record of the procedure
Assisting with thoracentesis
Definition: thoracentesis is the procedure in which a puncture is made into the chest wall to withdraw
fluid or air from the pleural cavity for diagnostic or therapeutic purposes.
Indication
A. When unexplained fluid or air accumulates in the chest cavity outside lung.
B. Pleural effusions
C. Compromised cardiovascular status due to air fluid or blood outside the lung,
D. Pleural fluid analysis
E. Instillation of medication into the pleural space
Purpose
Contraindication
 Uncooperative patient

21
 that cannot be corrected
Precaution: The aspiration should not exceed 1L as there is a risk of development of pulmonary edema.
Equipment
Sterile:
1
. 2 Gallipots
2. 1 pair of dissecting forceps
3. 1 pair of artery forceps
4. Swabs and gauze in a receiver
5. towel with a hole((fenestrated towel)
6. hand towel
7. Gloves
8. Syringe and needle for local anaesthesia
9. Rubber tube which fit the opening of the two-way
tap
10. 10 or 20 cc aspiration syringe and needle
11. two - way tap
12. 2 glass tube for specimen
13. Receiver to collect fluid specimen
Clean
1
. Rubber sheet and towel
2. Receiver for used instrument
3. Measuring jug
4. Trolley
5. Local anaesthesia
6. Cleaning lotion such as ether, tincture of iodine
7. Plaster with scissor
8. Sputum mug
9. Lab request-form
Procedure:
1. Check clinical record for order and possible allergy
2. Alert physician if any abnormal lab result
3. Explain the procedure to the patient and inform them to try not to cough, not to breathe deeply, and not to
move suddenly during the procedure to avoid puncture of the visceral pleura or lung
4. Verify informed written consent
5. Wash hands
6. Collect necessary equipment and bring to patient bedside
7. Take baseline vital sign including pulse oximetry
8. Screen the patient.
9. Remove clothes to expose chest.
10. Position the patient as directed by the physician. The position may be either one of the
following or a similar position, as directed by the physician.
(a) Position the patient to sit on the side of the bed, facing away from the physician, with feet supported on a
chair and the head and arms resting on an over bed table padded with pillows. The arms are elevated slightly to
widen the intercostals spaces.
(b) If the patient is unable to sit, turn him on the unaffected side with the arm of the affected side raised above
his head. Elevate the head of the bed
11. Place the thoracentesis tray on instrument table. Open sterile wrapper cover to provide a
sterile field.
12. Place other supplies on adjacent bedside stand or over bed table. Open glove wrapper.
13. Assist with handling of local anesthetic vial. Hold vial with label uppermost so that the physician can
personally check the label before withdrawing any of the solution. Cleanse stopper with alcohol swab. Invert
vial and hold firmly while the doctor, with gloved hands, withdraws the required solution.
14. Support and help patient to avoid moving and coughing while the thoracentesis needle is
introduced.
15. Assist as directed with collection of specimens as the physician manipulates the syringe, the stopcock, and
drainage tubing. Use care not to contaminate the end of the tubing, the cap, or the open end of the specimen
tubes. Cap the tubes and place them upright in a clean glass provided for this purpose. Label each tube as
directed by the physician.
16. If drainage of a large amount of accumulated fluid is necessary, assist the doctor by placing the free end of
the tubing in the drainage bottle.

22
17. Watch the patient's color; check pulse and respiration. Immediately report any sudden change, as this may
indicate damage to the visceral pleura from a nick or puncture by the needle.
18. After the needle is withdrawn, apply a sterile occlusive dressing over the puncture site.
19. Position patient comfortably (usually Fowler's position).
20. Complete entries on appropriate laboratory request forms as directed.
21. Send properly labeled specimens with completed request forms to laboratory immediately if required
22. Measure and record amount of fluid withdrawn and discard this fluid unless directed
otherwise.
23. Return used equipment and wash hand
24. Proper documentation
Complications
Pneumothorax
Hemorrhage into the pleural space or chest wall,
Vasovagal syncope (fainting)
Air emboli
Infection
puncture of the spleen or liver,
Patient assessment
Before the procedure
1. patient patient preparation
 getting informed consent from the patient
 chest x-ray
 small dressing
 local anesthesia
2. assessment of the patient
vital sign
compliant of chest pain
respiratory depth& movement of both chest during inspiration
breath sounds
dyspnea,
type& frequency of cough if present
character& amount of sputum
During the procedure
1. positioning
I. sitting up right position
 arm in the affected above the head
 leaning forward over bedside, table, chair
II. lie on the unaffected side if unable to sit
 arm in the affected above the head
2. observation
 vital sign
 skin color
 difficulty breath
After the procedure
 apply dressing
 observe for vital sign & skin color
 report for change of respiratory, bloody sputum, severe cough & shock
CHEST WATER SEAL DRAINAGE SYSTYM

23
- Is the process in which allow air & fluid to escape from pleural space with each exhalation & prevent their
return flow with each inhalation
-is the process of permitting unidirectional flow of air & fluid out of pleural space but, permitting none to
enter from the drainage system
- It is called closed chest drainage
-it acts as a one way valve
NB a water seal means
Water in the bottle seal off the atmospheric air, preventing the atmospheric pressure from entering the
chest drainage tube & thus from entering the pleural space.
Purpose
 To remove air & fluid from the pleural space
 To re-establish the normal negative pressure in the pleural space
 To restore the normal pulmonary ventilation
 To prevent reflex(return flow) of fluid & air back into the pleural space from the drainage
apparatus
 To prevent shifting of the mediastinum & collapse of the lung tissue by equalizing pressure
on both side
 To promote re-expansion of lung
Indication of water seal drainage system
After thoracic & thoraco-abdominal surgery
After chest injuries
Following chest surgery to re-expand the involved lung
Trouma,pneumothorax&hemothorax
Excessive fluid & air in the pleural space
Working of a water seal drainage apparatus
-it has the following basic parts
a) A sterile bottle which contain
 About 100ml of sterile normal saline or sterile water
 Closed tight rubber stopper
 Two holes at stopper
b) Two hollow tubes which are
o One short—acts as a air vent
o One long—acts as a water seal
NB two tubes are inserted via the holes in the stopper
Long tube
 One end kept below the fluid level 3-5cm in the which seal off atmospheric air
 Other end is attached to the patient’s chest drainage tubing
c) drainage tubing connected to the chest catheter
-the drainage should be placed below the level of chest
Types of chest drainage
One bottle gravity system
Two bottle gravity system
Two bottle suction system
Three bottle suction system

24
ONE BOTTLE WATER SEAL CHEST DRAINAGE APPARATUS
 Operates by gravity only(gravity+positive pressure
 Single bottle serves as both water seal& collection container
 Air from chest—goes to bottle & bubbles in fluid—escape out via air vent
 The water seal system affected by the volume of drainage i.e. the fluid level in the bottle
-i.e. as the fluid level in bottle increases, it becomes progressively difficult for air &
fluid to exit from the chest
 The fluid in the water seal bottle is not drawn up into the chest tube because the fluid is
heavier than the air
Two bottle water seal chest drainage apparatus
 Consists of
-One collection chamber (bottle)—collects the drainage from the patients
-One water seal chamber (bottle)—function as the water seal bottle
 Not affected by the volume of the drainage
 Use gravity &positive expiratory for drainage
 Effective drainage depends on gravity & the amount of suction added to the
system
 The pressure is constant b/c no mixing of fluid in the water seal bottle
 Empty drainage is placed b/n the patient & the water seal bottle
 It makes easy—to observe the amount and character of the drainage from the
patient’s chest, since it does not mix with saline/ water in the bottle
---to control pressure with in the system & for fluid& air to leave
the pleural space
The three bottle water seal drainage system---it has
 One collection bottle (chamber)(1)
 Water seal bottle(2)
 Suction control bottle
 The suction machine creates a negative pressure throughout the entire closed drainage system
Nursing responsibility of the patient with water seal chest drainage
 Assisting with the insertion and removal of the tube
 Maintain the water seal and potency of the drainage system
 Keeping chest forceps & rubber –tipped clamps near to the client . the chest tube will
need to be clamped quickly to the insertion site ,if air leak develops in the drainage
system
 Insertion site should be protected with sterile dressing
 Tubing b/n the pt & water seal bottle should be long enough to allow the pt to move turn
 Assessing the client’s v/s, cv status & resp status, shallow breathing, cyanosis

26
Procedure: Chest Tubes – Assessment & Care
Equipment:
Padded Kelly clamps – kept at the bedside at all times
Stethoscope
Action Rationale
Observe the pt for any change in
respiratory status by assessing:
Colour, RR & pattern, unequal chest
movement, capillary refill, breath
sounds
A change can indicate a worsening in
the pt’s condition that may be due to
malfunctioning
of the closed drainage system
Observe the chest tube is well secured
with
the suture and covered with a dressing
To prevent movement of the drain and
ensure safety of the patient
Ensure the drain is well positioned with
no
kinks or loops; do not allow the pt to lie
on
the tubing
To prevent occlusion of the drain
Ensure drainage tubing is long enough
for
to allow the pt to turn freely in the bed
To prevent the drainage tube from
pulling,
causing trauma to the pt or risk pulling
the
tube out
Do not use pins to secure the tubing to
the
linen (use a rubber band or a strip of
plaster)
Pins can puncture the rubber chest tube,
allowing air to enter the pleural cavity
Ensure a 2 padded Kelly clamps are
kept
at the bedside at all times
In case of accidental disconnection the
chest tube can be clamped
Never clamp the tubing without a dr’s
order
unless specifically indicated (ie: when
changing the drainage bottle, for
emergencies such as disconnection of
the
tube from the set-up, etc)
Prolonged clamping of the tube can
cause
air to accumulate in the pleural space, a
tension pneumothorax or mediastinal
shift
Ensure the drainage set-up remains
below
the level of the pt’s chest at all times
To prevent backflow of fluid into the
pleural
Space
Use plaster at all connection sites
between
tubing and bottles
To prevent inadvertent disconnection or
leakage which will allow air to enter
the
pleural space (the entire system must
remain airtight at all times)
Check the patency of the drainage A blocked tube will prevent air and

27
tubing frequently. ‘Milk” the tubes if
they become
blocked with blood clots or secretions
blood
from draining out of the pleural cavity
and
into the drainage bottle
Ensure the chest tube is always
connected
to the tube that is immersed under
water
If connected to the tube that act as an
air
vent, the air will be sucked into the
pleural
cavity causing collapse of the lungs
Observe for the following in the
drainage
set-up: (several times each shift)
- fluctuations of the fluid in the water
seal tube
- intermittent bubbling in the water
seal bottle
- 1 glass rod in the drainage bottle
should be always immersed in
2.5
cm of water, another short glass
rod
should be open to the air or
attached to suction
- the colour and amt of drainage
in the drainage bottle
This indicates the chest tube is patent
and
will drain properly
This should be present during
expiration if
air is being removed from the pleural
cavity
This acts to create pressure so that air
and fluid will drain from the pleural
cavity to
the drainage bottle; if the tube is more
than
2.5 cm below the water the air or fluid
attempting to leave the pleural space
must
exert more pressure and proper
drainage
may not occur ; the short glass rod
vents
air from the set-up to create a negative
pressure
This information is needed to assess the
pt’s
on-going condition
Maintain strict aseptic technique with
the
closed drainage system
To prevent the introduction of infection
into
the pleural cavity
Change the position of the patient while
he
Is in bed; encourage semi-fowler’s
position
To reduce the risk of skin breakdown
Semi fowlers position promotes
drainage by
Gravity
Encourage the pt to do deep breathing
and coughing q2h while awake
To clear the bronchi of secretions, to
facilitate the re-expansion of the lungs,
and prevent pneumonia
Student Notes:

28
Procedure: Care of a Chest Drainage System
Changing the Drainage Bottle
Equipment:
2 padded Kelly clamps Measuring beaker
Clean gloves Sterile drainage bottle
Action Rationale
Identify the patient To ensure therapy is administered to
the
correct patient
Explain what you are going to do and
the
reason to the pt.
Explanation relieves anxiety and
facilitates cooperation
Perform hand hygiene To prevent the spread of
microorganisms
Double clamp the chest catheter close
to the pt’s chest using the padded Kelly
clamps (approximately 3.5 – 5 cm from
insertion
site, 2.5 cm apart)
To prevent air from entering the pleural
space through the chest tube
Put on clean gloves To prevent contamination with body
fluids
Disconnect the bottle to be replaced
along
with the drainage tubing and the glass
connections and attach the new set,
ensuring aseptic technique is
maintained
To prevent contamination with
microorganisms
Make certain that the connections are
air
tight and the long glass tube in the
bottle is
below the fluid level & the chest
catheter is attached to this tube
Use plaster to secure all connections
To prevent the inadvertent separation
which could can lead to air entering
into the pt’s chest
cavity
Place bottles on a chair or stool,
below the level of the pt’s chest
To prevent the bottles from accidentally
being knocked over if they are on the
floor
Unclamp the Kelly clamps from the
chest
catheter and make certain the system is
functioning properly
To allow the air & secretions to drain
freely
Remove gloves & perform hand
hygiene
To prevent the spread of
microorganisms
Observe the pt’s vital signs and general
condition
Leave the pt in a comfortable position
Any changes in the pt’s condition could
indicate malfunctioning of the system
Put on clean gloves
Note the colour of the fluid and
To protect the nurse from body
secretions

29
measure
the amount in the drainage bottle
Empty the bottle and send for
sterilization
Document procedure & amount of fluid
in
the drainage bottle on the pt’s chart
To communicate the intervention and
monitor the amount of fluid drained
which indicates pt’s progress
Student Notes:

Nasogastric Tube Care and Placement

Recommended

Recommended

More Related Content

Similar to Nasogastric Tube Care and Placement

Similar to Nasogastric Tube Care and Placement (20)

More from IbsaUsmail1

More from IbsaUsmail1 (15)

Recently uploaded

Recently uploaded (20)

Nasogastric Tube Care and Placement