5-1

Fundamentals : Positioning
Purpose
To ensure client comfort and safety, while preventing complications related to the client's condition, treatment, or
procedure.

Fowler's position Lateral Lithotomy

Includes semi fowler's position Can be right or left sided. Most commonly seen in OB.
which is between 30-40 degrees What am i? What am I ?
and high fowler's which is 90 Right lateral means the right Patient is lying flat on their back
degrees. side of the patient is touching with knees elevated and hips
What am i? the bed, left lateral indicates level, often supported by
A position in which the head and the left side of the patient is stirrups.
trunk are raised 40-90 degrees. touching the bed.
Indications
Indications Gynecological procedures and
Indications GI issues, and rectal surgery. childbirth.
Cardiac issues, SOB, or NG tube.
placement.

Sim’s Position
A prone/lateral.
Prone Supine
What AM I?
Prone your on your tummy. You’re on your spine.

A position in which the patient

What am I? Supine is considered the most
The patient lies on his stomach natural “at rest” position.
lies on his side with his upper
leg flexed and drawn in towards
with his back up. The head is What am i?
typically turned to one side. A position where the patient is
the chest, and the upper arm
flexed at the elbow. Indications flat on his back.

Indications Drainage of the mouth after oral Indications

or neck surgery. It also allows Used in surgery for abdominal,
Administering enemas, perineal
for full flexion of knee and hip facial, and extremity procedures.
examinations, and for comfort in
joints.
pregnancy.

Trendelenburg Reverse Trendelenburg

“Upside Down.” What am i?
What AM I? Patient is in the supine position with the head of the
This position involves a supine patient and sharply bed elevated and the foot of the bed down
lowering the head of the bed and raising the foot. Indications.
Indications Indications
Used to treat hypotension, during gynecological Used in surgery to help promote perfusion in obese
and abdominal hernia surgeries, and in the patients. It can also be helpful in treating venous air
placement of central lines. embolism and preventing pulmonary aspiration.

5-1
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5-2 Ambulation: body mechanics & Mobility
Definition
The safe practice of coordinated efforts to maintain balance, posture, and body alignment when ambulating, lifting, and
moving clients.
Body mechanics ergonomics
❖ Arrange for help prior to moving a client.
Variables that lead to back injury ❖
❖
Encourage the client to assist.
Avoid twisting, keep back, neck, pelvis and feet aligned.
❖ Uncoordinated lifts
❖ Flex knees, keep feet wide apart.
❖ Manual lifting
❖ Position yourself close to the client or object.
❖ Lifting when tired
❖ Use your arms and legs to lift, never your back.
❖ Repetitive lifting, transferring, repositioning and
❖ Slide the client towards yourself, use a pull sheet.
moving
❖ Tighten abdomen and glutes before the move.
❖ Prolonged standing
❖ Person bearing the brunt of the load coordinates the team on
❖ Uncooperative patients
the count of three.
❖

Range of motion
Factors that affect mobility The full movement potential of a joint, usually its range of flexion and
extension.
❖ Age ❖ Active: Patients move their limbs by themselves without
❖ Attitudes and family values assistance.
❖ Developmental level ❖ Passive: Therapist or equipment moves the joint through
❖ Neuromuscular disorders and joint the range of motion with no effort from the patient.
disorders
❖ Life style, Stress, environment
❖ Mental health, Medications
❖
Assessment
Trauma to the musculoskeletal system

❖ Daily activity levels: What does your daily activity look like?
❖ Endurance: How much activity makes you tired? what are you doing when you get tired?
❖ Exercise goals: What are your exercise goals?
❖ Mobility problems: Do you have and problems when ambulating such as, pain, SOB, or other discomforts?
❖ Physical or mental alterations: Do you have any physical limitations or mental health limitations affecting your mobility?
❖ External factors: Is there anything else you can think of that may be altering your ability to ambulate?

Component Normal finding Abnormal finding

General ease of movement Body movements should be voluntary, Involuntary movements, tremors, tics,
controlled, purposeful, fluid and chorea, athetosis, dystonia,
coordinated. fasciculations, myoclonus, oral or facial
dyskinesias.

Gait Head should be erect with vertebral Spastic hemiparesis, scissor gait,
straight, knees and feet forward, arms at steppage gait, sensory ataxia, cerebellar
side with elbows flexed, arms swing freely ataxia, parkinsonian gait, gait of old age,
in alternation with leg swings, while one use of assistive devices for ambulation.
leg is in the stance phase the other should
be in the swing phase.

Alignment Standing or sitting a straight line can be Abnormal spinal curvatures as seen in
drawn from the ear to the shoulder and scoliosis, inability to maintain normal
hip. alignment independently.

Absence of joint deformities and full Limitation of full range of motion,

Joint structure range of motion . increased joint mobility, swelling, heat,
tenderness, crepitation, deformities .

Adequate mass, tone and strength to Atrophy, hypertrophy, flaccidity,

Muscle mass and tone complete ADL’s. spasticity, paralysis.

Ability to turn in bed, maintain correct Significantly increased pulse,

Endurance alignment, ambulate, and perform self respirations, BP, SOB, dyspnea,
care activities. weakness, pallor, confusion vertigo,
pain.

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5-2
5-3
Urine specimen collection
24 hr Urine culture from a
Clean catch / culture The test is used to check kidney
function. A 24-hour urine collection urinary catheter.
Most agencies require a clean catch to
is done by collecting your urine in a Always obtain the specimen from the
be obtained mid stream. Meaning the
special container(s) over a full catheter itself using the special port
patient voids to flush away
24-hour period. The container(s)
microorganisms and discards a small made for specimen collection. Do not
must be kept cool until the urine is
amount of urine. Then collects the administer antibiotics until the urine
returned to the lab. Do not
remainder in the sterile collection culture comes back.
administer antibiotics until the urine
container. Do not administer antibiotics
culture comes back.
until the urine culture comes back.

Procedure
Procedure
1) Perform hand hygiene.

Procedure
2) Obtain consent.
3) Provide privacy.
1) Perform hand hygiene.
4) Identify patient.
1) Obtain consent. 2) Obtain consent.
5) Wear clean gloves.
2) Provide privacy. 3) Provide privacy.
6) Separate the labia.
3) Identify patient. 4) Identify patient.
7) Clean the area at the meatus with
4) Don clean gloves. 5) Don clean gloves.
soap and water, or according to
5) Perform hand hygiene. 6) Clamp the tube below the access
policy.
6) Explain to the client they will port briefly.
8) Have the patient void about 30 mL
discard their first void and 24h 7) Clean the port.
into the toilet or bedpan and
collection will begin after. 8) Carefully attach syringe to the
discard this urine.
7) Be sure to place a Hat in the port.
9) Position the sterile specimen
commode or give the client a 9) Aspirate urine into the syringe.
container near, but not touching,
urinal. 10) Release the clamp.
the meatus, and collect at least 10
8) Record I&O’s. 11) Transfer urine into the sterile
mL of urine in the container.
9) Label the specimen container. specimen container.
10) Stop collecting urine before the
10) package it appropriately, and 12) Label the specimen with patient's
patient empties the bladder.
send the specimen to the name, date, and time of
11) Allow patient to continue voiding
laboratory. collection. Package it
into a bedpan or the commode
appropriately, and send the
and discard this urine.
specimen to the laboratory.
12) Remove gloves and perform hand
hygiene.
13) Label the specimen container.
14) package it appropriately, and send
the specimen to the laboratory.

Documentation
❖ Color: Normal freshly voided urine is pale yellow, straw colored, or amber, depending on its
concentration.
❖ Odor: Normal urine usually has no smell. If it sits long enough it will begin to smell like ammonia from
bacterial growth.
❖ Turbidity Fresh urine should be clear, as urine stands it becomes cloudy.
❖ pH: The normal pH of urine is about 6.0 with a range of 4.6-8.
❖ Specific gravity: Normal range is 1.015- 1.025.
❖ Constituents: Normal constituents are; urea, uric acid, creatinine, hippuric acid, indican, ammonia,
sodium, chloride, iron traces, phosphorus, sulfur potassium and calcium.

5-3
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5-4
Stool specimen collection
Occult Blood Stool culture
Testing for blood in the stool that cannot be seen.
Usually a sign of a GI bleed. They can be caused
by peptic ulcer disease, inflammatory bowel
Indications
disorders, and colon cancers. ❖ Suspected infection
Black stools: Upper GI bleed. ❖ Virus
Bright red stools : Lower GI bleeds. ❖ Fungi
❖ Parasites

Procedure
❖ Instruct the patient about food and drug Procedure
restrictions for at least four days before ❖ Before stool testing, avoid the
the test, if applicable. foods (for 4 days) and drugs (for 7
❖ Review manufacturer’s directions for days) that may alter test results.
collecting the specimen. ❖ Do not use laxatives, enemas, or
❖ Equipment: A specimen card, collection suppositories for three days before
tissues, or test paper. testing.
❖ Avoid mixing the specimen with urine or ❖ Postpone the test until three days
water. after her period has ended if a
❖ Inform the patient that multiple or serial woman is menstruating.
specimens are usually collected from ❖ Postpone the test if hematuria or
different bowel movements to verify bleeding hemorrhoids are present.
results. ❖ Postpone the test if the patient has
❖ Collect the amount recommended for the had a recent nose or throat bleed.
particular test (usually only a small ❖ Caution a person who is
amount is required). color-blind to the color blue not to
❖ Wear gloves and perform hand hygiene if attempt to interpret the test
collecting a specimen from a bedpan, results.
commode, or plastic receptacle.
❖ Use tongue blades to transfer the stool to

Specimens for Pinworms

the test tape or folder.
❖ Follow instructions based on type of test.
Hemoccult slide test requires placing two
drops of developer solution on the back Adult pinworms, parasitic intestinal worms,
side of the specimen paper. live in the cecum. Pinworms migrate to the
❖ Document the test results according to anal area during the night to deposit eggs
facility policy. A blue color is a positive and retreat into the anal canal during the
result and needs to be reported. day. The most common symptom of a
Inform the patient of the test results. pinworm infection is perianal itching.
Collect this specimen in the morning,
immediately after the patient awakens and
before the patient urinates, has a bowel

Some Poop Facts

movement, or a bath. Use clear cellophane
tape to collect a specimen for pinworms.
❖ Stool in an adult should be brown in color,
absence of bile will make the stool white or clay ❖ Apply gloves.
colored. ❖ Press the tape against the anal
❖ Diet has an enormous impact on the color of opening, remove it immediately.
stool. ❖ Place it on a slide.
❖ Stool, will never smell like roses! The odor is ❖ Pinworm eggs can usually be
affected by types of foods eaten. detected on the tape under a
❖ Stool, can be soft, semi solid, and formed. microscope.
❖ Or accurate results, this test may
need to be repeated on
consecutive days.
5-4
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5-5 Sputum collection
Purpose
To diagnose and treat multiple respiratory disorders effectively. These specimens prove to be most accurate in the
morning when the patient has not had anything to eat or drink.

Equipment
What to do ! ❖ Emesis basin.
Patients who can cough and breathe deeply can ❖ A sterile specimen cup with a
produce a sputum specimen and expel it into a tight-fitting cap.
collection container. You can use chest ❖ The appropriate label.
physiotherapy to mobilize the secretions of ❖ Gloves, and goggles and a mask if
patients who cannot produce enough sputum. indicated.
For most tests, the sample should contain 1 to 2
teaspoons of sputum. If less invasive methods do
not result in an adequate sample, suctioning and
transtracheal aspiration (by a physician) may be
used as last resorts.

Procedure Documentation
❖ Check physician order. ❖ Document the procedure time and
❖ Perform hand hygiene. indication.
❖ The color and consistency of the
❖ Provide privacy and ensure consent was sputum.
obtained. ❖ The amount of sputum collected.
❖ Position your patient in a chair or on the ❖ Way in which the specimen was
obtained.
side of the bed or high-Fowler's position. ❖ Patient's tolerance to the procedure.
Remove dentures, if appropriate.
❖ Have the patient rinse their mouth with
plain water so they do not contaminate In the Lab
the sputum.
❖ Don't allow them to brush their teeth or ❖ Different methods of laboratory analysis require
use mouthwash. This could kill bacteria in different transport media. Most cultures, are
the sputum, causing it to be unusable. transported in a labeled sterile container. They
❖ Don gloves and goggles. identify types of bacteria present in the culture.
❖ Uncap the container, but avoid touching ❖ Sensitivity testing completes the process by
determining the correct antibiotic treatment by also
the inside to ensure that it's sterile.
determining which antibiotics the strain of bacteria is
❖ Have the patient perform deep breathing resistant to.
and have them cough as instructed, ❖ Acid-fast bacilli (AFB) testing requires a sterile
expectorating the sputum into the container and is performed on three serial samples
container. to detect tuberculosis.
❖ Once you've collected the specimen, ❖ Cytology testing requires a special preservative and
identifies which form of lung cancer a patient has
securely cap and label the container with
(small cell, oat cell, or large cell).
date, time, patient name, and your initials. ❖ For all, you’ll complete the appropriate laboratory
❖ Remove and discard your gloves and requisition form with pertinent patient data and send
wash your hands thoroughly. Allow the it with the specimen for analysis. ( ATi. 2017 )
patient to rinse out their mouth and
provide a tissue. Send the sample to the
lab immediately, without refrigeration,
5-5
❖ Document the procedure.
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5-6
Finger stick Blood Glucose Testing
Purpose
To monitor blood glucose levels and prevent further complications such as DKA and HHNS.

Normal blood sugar ranges Hypo and hyperglycemia

❖ Glucose capillary monitoring: 60-110 mg/dl ❖ Hyperglycemia
❖ Fasting: 70-100 mg/dl Can be caused by stress, injury, infection, food, too
❖ Random blood sugar test: Under 200 mg/dl little insulin
❖ Fasting blood sugar test: Less than 100 mg/dL Thirst, decreased BP, Loc changes, hot dry skin, poor
(5.6 mmol/L) is normal, If it's 126 mg/dL (7 mmol/L) turgor, fruity breath, potential ketoacidosis ( severe)
or higher on two separate tests, you have diabetes.
❖ Hypoglycemia
❖ Oral glucose tolerance test: A reading of more
Excess insulin, lack of food, alcohol, over exertion.
than 200 mg/dL (11.1 mmol/L) after two hours increased respirations, decreased bp, increased HR,
indicates diabetes. hunger, anxiety, confusion, cold and clammy skin,
❖ Postprandial sugar: Taken two hours after meals weakness, blurred vision seizures ( severe).
should be less than 140 mg/dl.

Factors that affect blood glucose levels

❖ Genetic
❖ Autoimmune disorders

Mixing & Administering insulin

❖ Lifestyle and dietary choices
❖ Infection and surgery
R.N regular than NPH.
❖
Procedure
Infection

1. Check physician's Administration

order. ❖ Before use agitate insulin vial.
2. Obtain consent. ❖ Inject air into the insulin bottle equal to the
3. Perform hand hygiene. amount of units to be administered.
4. Provide privacy. ❖ Administer insulin at a 45 or 90 degree
5. Ensure glucose monitor angle in subcutaneous tissue.
is calibrated and strips
are not expired. Mixing
6. Cleanse the finger with 1. Wash hands.
an antiseptic wipe. 2. Agitate the NPH bottle.
7. Wipe away the first drop 3. Wipe the top of both insulin vials with an
of blood. alcohol swab.
8. Allow drop of blood to 4. Draw back the amount of air that is equal to
slide onto test strip. the total dose to be administered.
9. Insert test strip into 5. Inject air equal to the amount of NPH to be
glucometer and obtain administered, Remove syringe.
reading. 6. Inject the Regular insulin with air equal to
10. Throw away supplies in the amount to be administered.
proper bin. 7. Invert and withdrawal regular insulin.
11. Perform hand hygiene 8. Invert and withdraw NPH, do not add more
12. Document. air.

Documentation NCLEX TIP !

❖ Document date and time.
❖ How many attempts.
❖ Any complications. Avoid exposing insulin to extreme temperatures. Never
❖ Blood glucose level . freeze them or leave them in a hot car. Insulin should be
❖ Site the specimen was room temperature before administration.
tested from. Refrigerate vial if it's going to take longer than a month to
use its contents.
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5-7
Vitals
Vital normal Location s Cause for classification
sign alteration

Pulse 60-100 Radial, carotid, Exercise, increased or Absent, weak,

BPM brachial, femoral, decreased cardiac normal, increased,
popliteal, femoral output, fluid volume bounding.
, dorsalis pedis, alterations.
posterior tibialis.

Vital sign normal Location Cause for alteration Classification

Respirations 12-20 BPM Anterior and Acid base balance, Normal,

posterior chest. activity, fluid volume adventitious,
alterations. absent,
diminished.

Vital sign normal Location Cause for alteration Classification

BP Below 120 and Below 80 Brachial, radial, popliteal, Acid base balance, activity, fluid Systole: Max
ankle. volume alterations. contraction of the left
Acid base balance, activity, fluid ventricle.
volume alterations. infection, Diastole: pressure of
alterations in cardiac output. resting ventricles.

Vital sign normal Location Cause for alteration Classification

Temperature 98.6 Temporal, rectal, oral, Infection, alterations in Febrile, afebrile

axillary fluid balance,
hyper/hypothermia,
metabolism, thyroid
disease.

Adventitious breath Sounds Description

Crackles Crackles can sound like salt dropped
onto a hot pan or like cellophane being
crumpled or like velcro being torn open.

Ronchi Rhonchi are continuous low pitched,

www.Simplenursing.com rattling lung sounds that often resemble
snoring.
O2 Level of hypoxia
Wheeze Wheezes are continuous, coarse,
whistling sound produced in the
95-100% Normal respiratory airways during breathing. For
Wheezes to occur, some part of the
respiratory tree must be narrowed or
91-94% Mild hypoxia obstructed, or airflow velocity within the
respiratory tree must be heightened.
86-90% Moderate hypoxia
Diminished/Absent Absent or decreased sounds can mean:
Air or fluid in or around the lungs (such
<85% Severe hypoxia as pneumonia, heart failure, and pleural
5-7 effusion.
5-8
Sterile Technique
Purpose
Sterile technique is performed to drastically reduce and hopefully eliminate the threat of bacteria being introduced into a
wound, or catheter site. Thus reducing the risk for post procedure or post care infections, also called Nosocomial
infections, “meaning hospitals acquired.”

Education
Assessment Risks
❖ Educate the client to practice
good hygiene.
❖ Asses the need to perform ❖ Educate the client to ask for
❖ Risk for infection.
the procedure. analgesia before the pain
❖ Risk for impaired.
❖ Assess the site you will be becomes unbearable.
tissue integrity.
working on for presence of ❖ Educate the client on the signs
❖ Risk for pain.
current infection. and symptoms of infection and
❖ Risk for
❖ Assess for latex allergies, when to notify the HCP.
hypersensitivity
iodine or adhesive allergies.
reaction.
❖
Supplies
Assess pain level, and
administer analgesia
30-45mins prior to the ❖ Sterile kit
procedure for client comfort. ❖ Running water and soap
❖ Gloves (sometimes these are in your
kit)

Procedure
❖ A clean, dry surface
❖ Clean paper towels
❖ Check expiration date on package and perform hand hygiene.
❖ Open the kit with the special flap so that you are opening your kit away
from you.
❖ Pinch the other sections on the outside, and pull them back gently. DO
NOT touch the inside. Everything inside the pad or kit is sterile except
for the 1-inch border around it.
❖ Throw the wrapper away.
❖ Get sterile gloves ready
❖ Wash your hands again the same way you did the first time. Dry with a
clean paper towel.
❖ If the gloves are in your kit, pinch the glove wrapper to pick it up, and
place it on a clean, dry surface next to the pad.
Documentation
❖ If the gloves are in a separate package, open the outer wrapper and ❖ Date and time of procedure.
❖ Type of procedure.
place the open package on a clean, dry surface next to the pad.
❖ Any fluids or exudate on the site
❖ Put your gloves on carefully. you are working with. Also note
❖ Wash your hands again the same way you did the first time. Dry with a color of exudate or fluids, amount,
clean paper towel. and if there is any odor.
❖ Open the wrapper so that the gloves are laying out in front of you. But ❖ Follow hospital policy on dating,
timing and initialing dressing,
DO NOT touch them.
specimen, or catheter site.
❖ With your writing hand, grab the other glove by the folded wrist cuff. ❖ Document the client's tolerance to
❖ Slide the glove onto your hand. the procedure.
❖ Leave the cuff folded. Be careful not to touch the outside of the glove.
❖ Pick up the other glove by sliding your fingers into the cuff.
❖ Slip the glove over the fingers of this hand. Keep your hand flat and do
not let your thumb touch your skin.
❖ Both gloves will have a folded-over cuff. Reach under the cuffs and pull
back towards your elbow.
❖ Once your gloves are on, do not touch anything except your sterile
supplies. If you do touch something else, remove the gloves, wash your
hands again, and go through the steps to open and put on a new pair of www.simplenursing.com 5-8
gloves.
5-9
Wound care: wet to dry dressing change
Purpose
To maintain skin integrity, to prevent infection,provide comfort, maintain a moist environment, remove necrotic tissue if
appropriate, and prevention of complications associated with injury or surgery.

Assessment Risks Education

❖ Assess the wound for color, ❖ Educate the client to
excoriation, order, exudate or ❖ Risk for infection.
practice good hygiene.
drainage, sinus tracts to tunneling. ❖ Risk for impaired
❖ Educate the client to ask for
❖ Assess client's pain level and tissue integrity.
analgesia before the pain
administer analgesia 30-45 minutes ❖ Risk for pain.
prior to dressing change. becomes unbearable.
❖ Risk for
❖ Assess for allergies to latex, ❖ Educate the client on the
hypersensitivity
adhesive and iodine. signs and symptoms of
reaction.
infection and when to notify
the HCP.

Procedure Documentation
Dressing removal
❖ Date and time dressing change was
performed.
❖ Perform hand hygiene.
❖ Why you changed the dressing.
❖ Put on a pair of non-sterile gloves.
❖ Carefully remove the tape. ❖ Document dressing assessment
❖ Remove the old dressing. If it is sticking to your skin, wet it with warm and wound location.
water to loosen it. ❖ Color, odor, exudate, drainage.
❖ Remove the gauze pads or packing tape from inside the wound. ❖ Document size of the wound, any
❖ Measure the wound in diameter and depth, also note any tunneling and tunneling, or sinus tracts, and
sinus tracts. Document these findings. approximation.
❖ Put the old dressing, packing material, and your gloves in a plastic bag.
❖ Document pain assessment before
and after dressing change.
Wound irrigation

❖ Put on a new pair of clean gloves.

❖ Use a clean, sterile gauze to gently clean the wound with warm water
and soap. From the top of the wound to the bottom of the wound and
outward from the incision in lines parallel. Wipe from the clean area to
less clean area.

Debridement
❖ Gently irrigate wound from top to bottom.
❖ Check the wound for increased redness, swelling, or a bad odor.
❖ Pay attention to the color and amount of drainage from your wound. Look ❖ Mechanical: Done during hydrotherapy,
for drainage that has become darker or thicker. with washcloths or sponges to remove
❖ After cleaning your wound, remove your gloves and put them in the eschar. May include wet to dry dressing
plastic bag with the old dressing and gloves. changes. Painful and may cause bleeding.
❖ Wash your hands again. ❖ Enzymatic: Application of a topical enzyme
ointment such as santyl directly on the
wound to remove necrotic tissue.
Dressing replacement ❖ Surgical: Excision/ removal of eschar and
necrotic tissue, via surgery in a sterile OR.
❖ Tangential: Excising very thin layers of
❖ Put on a new pair of non-sterile gloves. necrotic skin until bleeding occurs.
❖ Pour saline into sterile container.. Place gauze pads and any packing ❖ Fascial: Necrotic tissue is removed down
tape you will use in the container. to the superficial fascia, usually reserved
❖ Apply barrier cream. for very deep and severe burns.
❖ Squeeze the saline from the gauze pads or packing tape until it is no
longer dripping.
❖ Place the gauze pads or packing tape in the wound. Carefully fill in the
wound and any spaces under the skin.
❖ Cover the wet gauze or packing tape with a large dry dressing pad. Use
tape or rolled gauze to hold this dressing in place.
❖ Put all used supplies in the plastic bag. Close it securely, then put it in a
second plastic bag, and close that bag securely. Put it in the trash.
❖ Time, date and initial new dressing.
❖ Wash your hands again when you are finished. 5-9
❖ Document. www.Simplenursing.com
5-10 Chest tube
Purpose
To return negative pressure to the intrapleural space. Removes abnormal accumulation of air and fluids from the pleural
space.

Assessment
Parts ❖ Monitor for fluctuation in fluid in the water seal
Drainage collection chamber: Connects the client chamber.
to the chest tube. Drainage from the tube falls into ❖ Obtain a chest x-ray to confirm insertion.
and collects into calibrated columns in this chamber. ❖ This could indicate an obstruction, a loop, or a
Water seal chamber: The tip of the tube is under re-expanded lung.
water which allows air to drain from the pleural and ❖ In a client with a pneumothorax intermittent
stops air from entering the pleural space. Water bubbling is normal in the water seal chamber.
moved up as the client inhales and down as the Continuous bubbling is not. If continuous
client exhales. Continuous bubbling indicates an air bubbling is noted contact the HCP.
leak in the chest tube system. ❖ Notify the HCP if drainage is more than 70-100
Suction control chamber: Controllable changes mL/ H, if it is bright red or increases suddenly.
allows the suction to be adjusted to provide negative ❖ Mark the chamber at 1-4 Hr. intervals using
pressure. Filled with various levels of water to tape.
control suction. Gentle bubbling in this chamber is a ❖ Monitor for crepitus.
good sign of suction, it does not indicate a leaky ❖ Monitor insertion site.
chamber. ❖ Assess respiratory status and lung sounds.
❖ Encourage coughing and deep breathing.
❖ Keep the drainage system below the bed level
and free of kinks.
❖ Ensure connections are secure.

Risks
❖ Pain during insertion
❖ Infection
❖ Bleeding

Serious complications

❖ Bleeding into the pleural space

❖ injury to the lung, diaphragm, or
stomach.

Documentation Indications ❖ Collapsed lung during tube

removal.
❖ Pneumothorax
❖ Side the tube is inserted. ❖ Tension
❖ Wound site, if there is any
pneumothorax
drainage, color of drainage and
❖ Hemothorax
exudate, excoriation, crepitus,
❖ Empyma
or, odor.
❖ Document the time checked. ❖ Pleural effusion
❖ How the client is tolerating the ❖ Drainage after
thoracic surgery.
chest tube.
❖ A lung infection
❖ Pain level, intervention for pain,
and post intervention evaluation

Nclex tip!!
of pain.

❖ If the dressing comes loose, quickly retape it and contact the HCP.
❖ If the dressing falls off the tube completely and the tube is out replace the
vaseline gauze and 4x4’s. Notify the HCP and assess the client for
respiratory distress.
❖ If the chest tube becomes disconnected from the drainage system, place
the end of the chest tube in a container of sterile water.
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5-11 Pain management
Patho Factors that influence pain
Nociceptors: Pain receptors on nerve endings
❖ Past experience.
that respond selectively to painful stimuli.
❖ Anxiety: decreases pain threshold.
Nociception: The transmission of pain.
❖ Depression: decreases pain threshold.
Chemical substances: some increase pain
❖ Age.
sensitivity some decrease pain sensitivity.
❖ Gender.
Cox 1: Mediates prostaglandin formation, platelet
❖ Culture: different cultures respond to pain differently
formation, provides gut protection from ulcers.
based on what they were taught to be appropriate.
Cox 2: Present in inflammation, pain and fever.
Inhibition will reduce symptoms of fever
inflammation and pain. Inhibits substance P.
Decrease pain sensation: Endorphins and
enkephalins, act as endogenous opioids. Effects of pain
Acute: Increased cardiac output, impaired insulin response, immune
supression, increased cortisol production, and increased fluid
Types of pain retention.
Chronic : Persistent malignant pain that
Chronic: Immune suppression, depression, disability, fatigue,
lasts longer than six months.
anger, inability to perform ADL’s.
Acute pain: Sudden onset of pain, specific
to injury. Lasts from seconds to six months.

Pharmacologic treatments
Non opioids
❖ NSAIDS: Mild pain. Ketorolac, sprix,
calador, ibuprofen.
❖ Acetaminophen: Can cause hepatotoxicity
can be given with NSAIDs.
Non pharmacologic treatments
❖ Ofirmev: IV acetaminophen, newly ❖ Cutaneous stimulation: TENS machine
approved for short term use IV piggyback. ❖ Massage
❖ Thermal therapies: Heat and cold
Opioids ❖ Distraction
❖ Tramadol ❖ Relaxation
❖ Tylenol 3 ❖ Guided imagery
❖ Meperidine ❖ Hypnosis
❖ Propoxyphene with tylenol ❖ Music therapy
❖ Oxycodone ❖ Alternative therapy: Acupuncture
❖ Fetanyl
❖
❖
Morphine
Dauladid Focused pain assessment
❖ Scale: 0-10
Other ❖ Timing: When did the pain start, what was happening
❖ PCA pump when it started?
❖ PRN medications ❖ Location: Where is the pain? Is it radiating?
❖ Multi modal: use of one or more drug ❖ Duration: How long have you had the pain?
❖ Routine admin: admin around the clock ❖ Quality: Is it dull, sharp, or stabbing?
❖ Topical ❖ Aggravating and alleviating factors: What makes it
❖ Local anesthesia worse? What makes it better?
❖ Intraspinal

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