OXYGENATION Administration of Oxygen Via Nasal Cannula

Administer of Oxygen Via Simple Face Mask Purpose: It is the most common method of
administering oxygen, because it is easy to apply
Purposes: Simple face mask is used for and comfortable to the patient.
emergency situation or at times when patients
need relatively high concentration of oxygen Equipment’s:
promptly. 1. nasal cannula
2. oxygen tank
Equipment’s: 3. flow meter
1. oxygen face mask 4. humidifier bottle
2. flow meter 5. oxygen gauge
3. oxygen tank
4. humidifier bottle
5. oxygen gauge

Procedures:
1. Assess the patient for any signs of
respiratory problems; check doctor’s order.
2. Perform hand hygiene.
Procedures: 3. Prepare the equipment
1. Assess the patient for any signs of 4. Identify the client, introduce self and
respiratory problems; check doctor’s order. explain the procedure.
2. Perform hand hygiene 5. Make sure the humidifier is filled with
3. Prepare the equipment appropriate mark.
4. Identify the client, introduce self and 6. Attach the large-bore tubing from the nasal
explain the procedure. cannula to the humidifier.
5. Make sure the humidifier is filled with 7. Adjust flow rate until the desired mist is
appropriate mark. produced usually 2 – 3 l/min. feel to
6. Attached the large-bore tubing from the determine if oxygen is flowing through the
mask to the humidifier. tips of the cannula.
7. Adjust flow rate until the desired mist is 8. Apply the nasal cannula to the patient’s
produced, (usually 10 -12 l/min.) nose and adjust the straps so that the
8. Apply the mask to the patient’s face and cannula fits snugly around the ears.
adjust the straps so that the mask fits 9. Document any changes / observations and
snugly. refer accordingly
9. Document any changes / observations and
refer accordingly.
Administering oxygen by way of ENDOTRACHEAL SUCTIONING
Endotracheal tube and Tracheostomy tubes
with a T- piece Purpose: Secretions must be removed to facilitate
breathing.
Purpose: it is used when a patient must be
weaned from a mechanical ventilator. Equipment’s:
1. Suction tip of an appropriate size.
Procedures: 2. Gloves
1. Assess the patient for any signs of 3. 2 bottles for lubrication of oral and ET
respiratory problems; check doctor’s order. suction tips
2. Show the T – tube / T – piece to the client 4. Suction machine
and explain the procedure. 5. Oxygen
3. Check the humidifier if filled in the 6. Plain NSS
appropriate mark. Attach large – bore
tubing from the T – piece to the humidifier
bottle.
4. Adjust flow rate until the desired mist is
produced and meets the patient ‘s
respiratory demand
5. Drain the tubing frequently by emptying
condensate into a separate receptacle, not
into the humidifier.
6. Document changes in condition and refer if
necessary.
Procedure:
1. Assess the patient for need in suctioning
2. Perform hand hygiene.
3. Organize equipment
4. Explain procedure to the patient
5. Perform any procedure that will loosen
secretions ( postural drainage, percussion,
nebulization)
6. Wear gloves, goggles, gown and mask
7. Position client on side or back with the head
elevated, opening the airway.
8. Turn suction machine on and place finger
over end of tubing attached to suction
machine
9. Open sterile irrigation solution and pour into
sterile cup.
10. Open sterile gloves and suction catheter
package
11. Place towel under client’s chin
12. Don sterile gloves
13. Pick up suction catheters with dominant
T-tube Tracheostomy Stoma hand and attached suction – control port to
tubing of suction source ( held with non
dominant hand)
14. Slide dominant hand from control port to
suction catheter tubing ( may wrap tubing
around hand)
15. Lubricate 3 – 4 inches of catheter tip with
irrigating solution
 16. Set oxygen on resuscitator bag to 100%
and turn on full flow.
17. Have an assistant on delivering ventilations,
administer 3 – 5 deep ventilations or allow
clients to take three to five breaths if able.
18. Perform suction maneuvers
a. insert catheter into Et tube using
slanted, downward motion. Make sure
fingers is not covering opening of
suction port. Continue insertion until
resistance is met or coughing is
stimulated. If catheter meets resistance
after being inserted the expected
distance, it may be on the carina, if so
pull back 1 cm before advancing further
or suctioning.
b. place thumb over suction port,
encourage client to cough.
c. withdraw catheter in a circular motion,
rotating between thumb and finger.
Suction should not be applied for more
than 10 seconds.
19. Place tip of suction catheter in sterile
solution and apply suction for 1 to 2
seconds.
20. If secretions are thick, place 2 to 3 ml.
saline into ET tube and administer deep
ventilations with resuscitator bag.
21. Repeat steps 17 to 18 once.
22. Suction oral airway with another suction tip
and perform oral care.
23. Position client with head of the bed at 45
degrees.
24. Document any observations and refer Procedures:
accordingly. 1. Assess the patient for need in suctioning
2. Perform hand hygiene
TRACHEOSTOMY SUCTIONING 3. Explain the procedure to the patient
4. Prepare equipment
Purpose: Suctioning of secretions in the trachea 5. Perform any procedure that loosen
using suction catheter appropriate to the size of secretions
tracheostomy tube. 6. Wear mask, goggles, gloves and gown
7. Place the client on side or back with the
Equipment’s: head of the bed elevated.
1. Suction tip of an appropriate size 8. Turn suction machine on and place finger
2. Gloves over end of tubing attached to suction
3. Bottles for lubrication of tracheostomy machine.
suction tip 9. Open sterile irrigation solution and pour into
4. Suction machine sterile cup.
5. Oxygen 10. Withdraw 10 ml sterile saline into syringe
6. Plain NSS and place back into sterile holder or either 3
ml. saline container on table.
11. Hyperventilate the patient with oxygen
concentration to tracheostomy collar or
resuscitator bag at 100%.
12. Place towel or drape on client’s chest under TRACHEOSTOMY CLEANING
tracheostomy
13. Wear sterile gloves Purpose: To remove accumulated microorganism
14. Pick up suction catheter with dominant in the tracheostomy parts thus preventing
hand and attach suction – control port infection.
tubing of suction source held with non –
dominant hand. Equipment’s:
15. Turn on the suction machine using non – 1. Tracheostomy care kit
dominant hand. May wrap tubing around 2. Bowl and tray
dominant hand. 3. NSS and peroxide bottle
16. Lubricate 3 -4 inches of catheter tip with 4. Gloves
irrigation solution.
17. Instruct client to take several deep breaths Mixture:
with tracheostomy collar intact or Fill first bowl with equal parts of peroxide and
resuscitator bag at tracheostomy tube saline.
entrance, if necessary, have assistant Fill second bowl with saline
deliver four to five deep breaths with
resuscitator bag. Procedures:
18. Remove tracheostomy collar or resuscitator 1. Assess the patient as well as the need for
bag. tracheostomy cleaning.
19. Insert catheter approximately 6 inches into 2. Perform hand hygiene
inner cannula until resistance is met or 3. Explain the procedure to the client.
cough reflex is stimulated. Be sure finger is 4. Prepare the equipment
not covering opening opening of suction 5. Place four cotton-tipped swabs in peroxide
port. mixture, then place across tracheal care
20. Encourage client to cough tray.
21. Place thumb over suction port. 6. Pick up one sterile gauze with fingers of
22. Withdraw catheter in a circular motion, sterile hand, stabilize neck plate with non –
rotating catheter between thumb and dominant hand (or an assistant will do)
finger, intermittent release and application 7. With sterile hand, use gauze to turn inner
of suction during withdrawal is cannula counter clockwise until catch is
recommended. Apply suction for less than released / unlocked
10 seconds. 8. Gently slide cannula out using an outward
23. Place tip of suction catheter in sterile and downward arch.
solution and apply suction for 1 to 2 9. Place cannula in bowl of half – strength
seconds. peroxide, discard gauze.
24. Allow client to take five breaths while you 10. Unwrap catheter and suction outer cannula
auscultate bronchial breath sounds and of tracheostomy.
assess status of secretions. 11. Have client take deep breaths or use
25. Repeat steps 19 to 24 once or twice if resuscitator bag to deliver 100% oxygen.
secretions are still present 12. Disconnect suction catheter from suction
26. Position client for comfort and place call tubing and discard sterile glove and
light within reach. catheter.
27. Document and refer if necessary. 13. Remove tracheostomy dressing.
14. Using gauze pads, wipe secretions and
crustation from around tracheostomy tube
15. Use moist swabs to clean area under neck
plate at insertion site.
16. Discard gloves
17. Wear sterile gloves
18. Pick up inner cannula and scub gently with
cleaning brush. Use pipe cleaners to clean
lumen of inner cannula thoroughly.
 19. Run inner cannula through peroxide Administration of Enteral (Tube) Feedings
mixture. Rinse cannula in bowl containing
sterile saline. Purpose: To enhance the nutritional status of
20. Place cannula in sterile gauze and dry patients who are unable to take food normally.
thoroughly, use pipe cleaner to remove
residual moisture from lumen. Equipment’s:
21. Slide inner cannula into outer cannula from 1. Dietary formula
side to side with fingers. 2. Medicine glass
22. Hold neck plate stable with other hand and 3. Measuring cup
turn inner cannula clockwise until catch lock 4. Asepto syringe
is felt and dots are aligned. 5. Water
23. Place the client in comfortable position. 6. Towel
24. Discard materials used.

Tracheostomy Dressing and Tie Change

Equipment’s:
1. Tracheostomy dressing
2. Tracheostomy tie
3. Gloves

Procedures:
1. Assess the patient as well as the need for
tracheostomy dressing and tie change.
2. Perform hand hygiene
3. Explain the procedure to the patient
4. Prepare the equipment
5. Have an assistant hold tracheostomy by
neck plate while you clip old tracheostomy
ties and remove them.
6. Slip end of new tie through tie holder on
neck plate and tie a square knot 2 to 3
inches from neck plate.
7. Place tie around back of client’s neck and
repeat above step with another end of tie
cutting away excess tie.
8. Apply dressing
a. hold ends of tracheostomy dressing (or
open gauze and fold into V shape.
b. gently lifts neck plate and slide end of
dressing under plate and tie.
c. pull other end of dressing under neck Procedures:
plate and tie. 1. Perform hand hygiene
d. d. slide both ends up toward neck using 2. Remove formula from refrigerator and allow
a gentle rocking motion, until middle to come to room temperature.
of dressing (or gauze) rests under neck 3. Explain procedure to patient.
plate. 4. Prepare equipment
9. Place the patient in comfortable position 5. Position the patient, elevate the head of the
10. Discard all materials use. bed 30 – 45 degrees.
6. Lay the towel across the chest.
7. Check the placement of feeding tube, using
the catheter- tipped syringe, inject 20cc –
 30cc of air while listening with a
stethoscope positioned at the epigastric
area (nasogastric tube). Gurgling sounds
will be heard. For nasointestinal tubes 20 cc
of air. But auscultation site maybe displaced
laterally and inferiorly.
8. Aspirate stomach contents, if residual
gastric contents exceed 100cc for
intermittent tube feedings or greater than
1.5 times the hourly rate for continuous
tube feeding, hold feeding and notify
physician. No residual will be obtained with
intestinal placement.
9. If residual is within normal limits, return the
gastric content and continue feeding.
10. The height of the tube from the stomach
should not be more than 12 inches or 1 foot
to delay gastric emptying.
11. After the feeding, maintain the position for
30 mins
12. Document and refer accordingly.

BLADDER IRRIGATION (CYSTOCLYSIS)

Purpose:
1. To clean the bladder of decomposed urine,
bacteria and their products, pus and excess
mucus, blood and blood clots.
2. To apply drugs to the lining of the bladder.
1. Sterile 30cc syringe or asepto syringe SET
Equipment’s:
2. Graduated glass with solution B
1. Bottle of NSS
2. IV Tubing SET A
Procedure:
3. 3-way catheter
1. Perform hand hygiene.
2. Prepare the equipment
3. Identify the patient, introduce self and
explain the procedure.

FOR SET A
1. Connect one end of the catheter to bottle of
NSS through the IV tubing.
2. Connect the other end of the catheter to
the urine bag output bottle.
3. Regulate the flow.

FOR SET B
1. Connect sterile 30cc or asepto syringe to
catheter, introduce about 100 – 150 cc each
time.
2. Let the catheter flow until approximately
the same amount introduced is drained out.
 3. Repeat 1 and 2 until the solution is
consumed.
4. Connect catheter outflow tube if it is
indwelling catheter.
5. Document amount of solution used, kind of
solution, character of return flow-color,
odor, transparency or cloudiness, foreign
washed out with flow reaction, reaction of
patient and time administered. Refer
accordingly.

NASOGASTRIC TUBE INSERTION

(Providing assistance to the physician)

Purpose: This is done for the purpose of feeding

Procedures:
and instilling medications (gavage), irrigating the
1. Perform hand hygiene
stomach or initiating gastric suction (lavage).
2. Prepare the equipment
3. Identify the client, introduce self and
Equipment’s:
explain procedure to client. Check for
1. Nasogastric tube / levin tube
informed consent.
2. Water soluble lubricant
4. Place patient in semi – fowler’s position.
3. Sterile gloves
5. Check nasal tubing
4. plaster
6. Measure length tubing needed by using
tube itself as a tape measure from tip of
nose to earlobe, placing rounded end of
tubing at earlobe to sternal notch to xiphoid
process, mark location of the xiphoid
process with small strip of tape. Place tube
in ice-water bath (optional)
7. Wear gloves and dip feeding tube in water
to lubricate tip.
8. Instruct client to tilt head backward, insert
tube into cleanest naris. Tip the client’s
head forward once tube reaches the
nasopharynx, if the patient continues to
gag, stop a moment.
9. When tube is seen in the mouth and client
can feel tube in pharynx, instruct client to
swallow (offer ice chips and sips of water)
10. Withdraw the tube immediately if there are
signs of respiratory distress.
11. Advance the tube until the taped mark is
reached.
12. Check the placement of tube; inject 10cc of
air and auscultate for borborygmi. Aspirate
gastric contents and measure pH. Prepare
for x-ray checkup if prescribed.
13. Split 4 – inch strip of tape lengthwise 2
inches. Secure the tube with the tape. Tape
to cheek or bridge of nose.
14. If Lavage, connect the distal end to suction,
draining bag or adapter. If Gavage, secure
the tube with a rubber band and safety pin
 to client’s gown or bed sheet. Make sure 7. Observed for the color respiration, pulse
that the distal end is covered. rate and refer for any untoward s/s.
15. Put the patient in a comfortable position 8. Place patient flat on bed usually no pillow
16. Document and refer accordingly. for 8 hours to prevent spinal headache.
Headache is due to a tear in the dura
matter made by the needle, which allows
small amount of CSF to flow.

LUMBAR/SPINAL TAP

Introduction:
Lumbar tap is the insertion of a needle into the sub
arachnoid space in the spinal canal usually in the
4th and 5th lumbar space.

Purposes:
1. To obtain specimen of CSF for analysis and
culture.
2. To relieve intracranial pressure.

Equipment’s:
1. Spinal set and spinal manometer (spinal
needle g.20 or 22)
2. Povidone iodine
3. Sterile vials for the specimen
4. Disposable needle ( pedia g. 23, adult g 21)
5. Gloves, sterile gauze and plaster
6. Local anesthesia

Procedures:
1. Make sure that the consent is signed.
2. Position the patient. Put him at the edge of
the bed or examining table and lie on the
side. Assist patient to flex his knees and
bring his head and shoulders down as close
as possible to the knees with his back
arched.
3. Paint the area to be punctured with
povidone iodine.
4. Note the time, the physician who did the
procedure, color, amount and pressure of
the specimen taken by the use of spinal
manometer
5. Label the vials with specimen properly and
cover them and send to laboratory
6. Cover the punctured site with sterile gauze.
 1. Make sure that the consent is signed.
2. Weigh patient before and after.
3. Measure abdominal circumference / girth
before and after.
4. Encourage patient to void or catheterized so
as not to hit the bladder.

PARACENTESIS Site for Paracentesis

Introduction:
It is the withdrawal of fluid from any body cavity
usually from the abdomen. The punctured site is 1-
2 inch below the umbilicus.

Purposes:
1. To secure abdominal fluid for analysis and for
therapeutic value.
2. To remove excess fluid (ascites)
3. For diagnostic purposes.
4. To help relieve symptoms caused by the
accumulation of fluid in the peritoneal cavity which
cause pressure.

Equipment’s:
1. Paracentesis set
2. Sterile gloves, IV catheter
3. Syringe
4. Skin prep tray and plaster
5. Local anesthesia
5. Put patient in sitting position.
Procedures:
 6. Paint the area to be punctured with 4. Note the time, physician who did the
povidone iodine. procedure, color and amount of the
7. Measure the fluid taken, chart the amount, specimen. Label the bottle of specimen
color and the physician who did the properly.
procedure. 5. During the procedure, observe the vital
8. During and after the procedure observed for signs.
any untoward signs and symptoms and 6. Cover the punctured site with heavy
refer if necessary. dressing or change when necessary.
9. Note his vital signs 7. Place patient in a comfortable position.
10. Cover the site with heavy dressing or and
change when necessary.
11. Label the specimen properly and bring to
laboratory for examination.

THORACENTESIS

Introduction:
Thoracentesis is the aspiration of fluid from the
pleural cavity.

Purposes:
1. To identify the cause of effusion
2. To assist in the diagnosis, if it is malignant
or not.
3. If the difficulty of breathing is due to the
accumulation of fluid, this is done for
therapeutic reasons to remove excess
fluids.

Equipment’s:
1. Thoracentesis set
2. Gloves, sterile gauze, IV catheter
3. Plaster, syringe
4. Skin prep tray
5. Sterile vials for specimen
6. Local anesthesia

Procedures:
1. Make sure that there is a consent signed.
2. Place patient in sitting position on a chair or
at an edge of a treatment table or on the
bed with the feet supported on the chair. If
unable to sit, he may lie on his head. He is
placed on the affected side with the hand of
that side resting on the opposite shoulder.
3. Paint the area to be punctured with
povidone iodine. The exact puncture will
depend on the area where fluid is present
and where the physician can best aspirate
it. The needle will be inserted between the
ribs thru intercostal muscle in the pleura. X-
ray plate must be at the bedside.