University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.

#64 Aurora Blvd., Brgy. Doña Imelda, Sta. Mesa, Quezon City
COLLEGE OF NURSING

NCM 112 Related Learning Experience: Nursing Skills

PADUA, Markell Daniel E. Section: N3A November 14, 2020
Group A1

Nursing Skill: Suctioning (Tracheal)

Definition and Purpose: Suctioning is performed to maintain patient’s patent airway, to provide
adequate level of oxygen and to remove thick copious mucus secretions since the patient is
unable to cough out effectively and remove secretions from the lungs.
Assessment:
• Assess the respiratory status of the patients: RR, depth and breathing pattern
• Use stethoscope and auscultate for patient lung sound
• Monitor the ABG and pulse oximeter level
• Assess the patient’s tracheal secretions and determine amount, odor, and consistency
• Assess the patient’s level of understanding about the need for suctioning
• Assess level of anxiety of the patient

Nursing Diagnosis:
1. Ineffective airway clearance related to increased mucus secretions
2. Impaired gas exchange as manifested by ABG result and oxygen saturation level
3. Risk for aspiration

Planning (SMART Form):

1. Promote airway patency
2. Breathing comfortably
3. Patient should not manifest respiratory distress
4. Verbalize understanding of purpose performing the procedure

Equipment:
• Stethoscope
• Portable suction machine
• Suction catheter tube
• Sterile water
• Clean gloves
• Ambu bag

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
1. Establish rapport and explain the To promote cooperation, collaboration,
procedure to the patient understanding, and reduces level of anxiety
2. Position the patient and provide
privacy
3. Assess the respiratory status of the To provide baseline data and comparison
patient
4. Prepare and assemble all the To promote orderliness of the procedure and
equipment before the procedure prevent unnecessary interruptions
 5. Perform handwashing To promote sterility, prevent contamination
and reduce transient microorganism from the
hand
6. Wear clean gloves Important to maintain sterility of the
procedure because we are going to introduce a
catheter or contagion to the lungs
7. Using ambubag, hyperoxygenate the Necessary to maintain adequate oxygen
patient before suctioning before performing the procedure
8. Open the suction catheter package and
assess the suction tube if it is patent
9. Wrap or coil the suction catheter with To avoid it to get in touch to unsterile objects
dominant hand and make sure that the
tip is neatly coiled to the portal end
10. Connect the suction catheter tube to
the suction machine
11. Turn on the suction machine
12. When inserting the catheter tube, do To minimize irritation and trauma to the
not apply pressure patient’s tracheal mucosa
13. Insert the suction tube gently and Never put pressure to prevent irritation and
straight trauma
14. Gently rotate and apply intermittent Close and open the suction port for
suctioning as you pull up for not more intermittent suctioning; not more than 10
than 10 seconds seconds because longer than 10 seconds can
cause hypoxemia or decreased oxygen level
in the blood of the patient
15. After 10 seconds, remove the suction Remember to do not apply pressure
catheter tube
16. After removing the suction catheter In order to clean the suction catheter tube and
tube from the patient’s trachea, do remove remaining secretions from the
suctioning to sterile water or normal catheter
saline to clean the suction catheter
tube
17. Reassess the patient’s condition To determine whether there is a need to
continue performing more suctioning
18. Evaluate the patient’s condition To determine if the patient does have patent
airway, improved gas exchange, and assess if
the patient is still developing respiratory
distress
19. Remove gloves and perform
handwashing
20. Document the entire procedure Serves as legal document
performed
21. Ask the patient how he/she is and To determine the understanding and feelings
assess the condition of the patient through verbalization

Evaluation
1. Tracheal secretions and note for the amount, odor, and consistency
2. Document for the patient’s reaction towards the procedure
3. If the normal saline was instilled
4. If the sputum samples were sent to the lab
5. Document the oxygen levels every after suctioning suing pulse oximeter
Nursing Skill: Tracheostomy Care
Definition and Purpose: Tracheostomy care is performed to maintain patent airway by
removing mucus and encrusted secretions; promote cleanliness and prevent infection and skin
breakdown at the stoma site; promote comfort and verify if still properly intact
Assessment:
• Assess the respiratory status of the patients: RR, depth and breathing pattern
• Use stethoscope and auscultate for patient lung sound
• Monitor the ABG and pulse oximeter level
• Assess for the stoma site for swollen, redness ad signs of infection
• Assess if clothes and ties are soiled from secretions
• Assess the patient’s level of understanding about the need for suctioning
• Assess level of anxiety of the patient

Nursing Diagnosis:
1. Ineffective airway clearance related to increased mucus secretions
2. Impaired gas exchange as manifested by ABG result and oxygen saturation level
3. Risk for aspiration

Planning (SMART Form):

1. Promote airway patency
2. Breathing comfortably
3. Patient should not manifest respiratory distress
4. Verbalize understanding of purpose performing the procedure

Equipment:
• Stethoscope
• Tracheostomy care kit:
o Sterile cloth
o Sterile pickup forceps
o Sterile cotton applicators
o Sterile brushes
o Sterile tracheostomy ties
o Sterile pre-cut dressing
• Sterile water
• Hydrogen peroxide
• Sterile basin
• Sterile scissors
• Sterile gloves (2 pairs)

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
1. Establish rapport and explain the To promote cooperation, collaboration,
procedure to the patient understanding, and reduces level of anxiety
2. Position the patient and provide
privacy
3. Assess the respiratory status of the To provide baseline data and comparison
patient
4. Prepare and assemble all the To promote orderliness of the procedure and
equipment before the procedure prevent unnecessary interruptions
5. Perform handwashing To promote sterility, prevent contamination
and reduce transient microorganism from the
hand
6. Pour hydrogen peroxide in sterile For removal of encrusted secretions
container
7. Pour sterile water in sterile basin For rinsing
8. Pour hydrogen peroxide in another
sterile basin
9. Open the tracheostomy care set Preparing equipment allows for smooth,
organized performance and prevent
unnecessary interruptions
10. Open the sterile tracheostomy care set To maintain the sterility of the field
using sterile technique
11. Wear the first sterile gloves
12. Remove the inner cannula
13. Soak the inner cannula in hydrogen Hydrogen peroxide loosens and removes
peroxide secretions from the inner cannula
14. Remove the soiled dressing
15. Remove the first gloves and don new To reduce transmission of microorganisms
sterile gloves
16. Place the sterile cloth over the Reduces transmission of microorganism and
patient’s chest protects the linens and bedclothes
17. Dip the cotton applicator in a sterile
water
18. Clean the stoma under faceplate and Aseptically removes secretions from stoma
outer cannula surfaces (inner to outer site
in a circular motion)
19. Repeat until it is well cleaned
20. Wipe it with dry sterile cotton Dry surfaces prohibit formation of moist
applicator environment from growth of microorganisms
21. Dress the stoma with a precut sterile
dressing
22. Brush the inside and outside of inner Hydrogen peroxide loosens secretions from
cannula within the container inner cannula; mechanical force and friction
containing hydrogen peroxide are needed to remove thick or dried secretions
23. Rinse the inner cannula with sterile Rinsing and agitations remove secretions and
water water from the cannula and provide
lubrication for easy reinsertion
24. Wipe the inner cannula with a dry
sterile cotton applicator
25. Replace the inner cannula
26. Insert it gently in a twisting motion
then lock it
27. Remove the old tie
28. Untie it on one side then insert the
new tie
29. Secure the tie properly and Secure tracheostomy tube in place
comfortably
 30. Verify that there is a space for 1 to 2 Prevents skin necrosis
snug finger widths under neck strap
31. Cut the excess strap and tie it securely
32. Remove and discard gloves and Prevents transmission of microorganisms
perform hand hygiene
33. Position the client comfortably Promotes comfort
34. Assess the patient’s respiratory status Reassessment of airway patency and
respiratory status ensures good patient
outcomes and provides clues to whether
further interventions are needed
35. Record amount and consistency of
secretions
36. Document the procedure done Serves as legal document
37. Document condition of the client’s
skin

Evaluation
1. Tracheal secretions and note for the amount, odor, and consistency
2. Document for the patient’s reaction towards the procedure
3. If the normal saline was instilled
4. If the sputum samples were sent to the lab
5. Document the oxygen levels every after suctioning suing pulse oximeter

Documentation
• Record date and time of procedure
• Note size and type of tracheostomy tube in place
• Describe client’s tolerance of the procedure

Nursing Skill: Urinary Catheterization

Definition and Purpose: Catheterization involves passing a rubber or plastic tube into the
bladder via the urethra; to drain urine from the bladder or to obtain a urine specimen.
Assessment:
• Assess the need for catheterization and the type of catheterization ordered
• Assess the need for peritoneal care prior to catheterization
• Assess the client’s ability to assist with the procedure
• Assess the environment
• Assess for an allergy in povidone iodine and/or latex
• Assess urinary meatus for signs of infection or inflammation

Nursing Diagnosis:
1. Pain
2. Altered urinary elimination
3. Risk for infection

Planning (SMART Form):

1. The catheter will be inserted without pain, trauma, or injury
2. Client’s bladder will be emptied without complication
3. Sterility will be observed during catheter insertion
Equipment:
• Disposable gloves (clean and sterile)
• Drape
 • Indwelling or straight catheter
• Sterile catheterization set
• Urine drainage bag
• Povidone iodine
• Cotton balls
• Forceps

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
CATHETERIZATION (FEMALE)
1. Establish rapport and explain the To promote cooperation, collaboration,
procedure to the patient understanding, and reduces level of anxiety
2. Position the patient and provide
privacy
ASSESSMENT
3. Assess the need for catheterization and
the type of catheterization ordered
4. Assess the need for peritoneal care
prior to catheterization
5. Assess the client’s ability to assist
with the procedure
6. Assess the environment
7. Assess for an allergy in povidone
iodine and/or latex
8. Assess urinary meatus for signs of
infection or inflammation
9. Prepare and assemble all the To promote orderliness of the procedure and
equipment before the procedure prevent unnecessary interruptions
10. Perform handwashing To promote sterility, prevent contamination
and reduce transient microorganism from the
hand
11. Provide safety: raise side rails and set Promotes proper body mechanics and assures
the bed to a comfortable height client safety
12. Assist the client to a supine position Provides good access to and visualization of
with legs slightly flexed and lightly perineum
spread
13. Drape the patient with a blanket or Facilitates proper execution of technique
sheet covering the abdomen and lower
legs. Expose only the
perineum/genitalia
14. Done clean gloves and PPE (if Protects the nurse from the patient’s bodily
possible) fluids. Prevent exposure to pathogens from
the patient’s genitalia and secretions/fluids.
Reduces transfer of microorganisms
15. Gently spread the labia minora using Helps to locate the meatus, so the catheter can
the fingers of your non-dominant hand be placed in the correct spot
and visualize the urinary meatus
16. Using your dominant hand, apply Cleans the area and minimizes the risk of
povidone iodine (soak the forceps to urinary tract infection by removing surface
pick up a cotton ball soaked in it. Use pathogens
one downward stroke for each cotton
ball and dispose. Keep the labia
 separated with your non-dominant
hand until you insert the catheter.
Remember:
• Figure of 7 when cleaning
• Upper to lower
• Least contaminated to most
17. Ask the assisting nurse to put lubricant To facilitate easy insertion of catheter tube
over the non-dominant hand and and prevent trauma because catheter tube can
lubricate the tip of the catheter (at cause irritation, trauma, and injury to urethral
least 1-2 inches) meatus and mucosa
18. Holding the catheter in dominant Provides a visual confirmation that the
hand, steadily insert the catheter into catheter tip is in the bladder. The catheter
the meatus until urine is noted in the needs to be inserted far enough to allow
drainage bag or tubing complete bladder drainage, but not so far as to
possibly irritate the bladder, causing spasms
19. If the catheter will be removed as soon
as the client’s bladder is empty, insert
the catheter another inch and hold the
catheter in place as the bladder drains
20. If the catheter will be indwelling with Ensures adequate catheter insertion before
a retention balloon, continue inserting retention balloon is inflated
another 1 to 3 inches
21. Reattach the water filled syringe (10 Provides a sterile method for inflating the
ml) to the inflation port retention balloon
22. Inflate the retention balloon using Ensures retention of the balloon. Retention
manufacturer’s recommendation or catheters are available with a variety of
according to the physician’s orders balloon sizes. Use a catheter with an
appropriate size balloon
23. Instruct the client to immediately Pain or pressure indicated inflation of the
report discomfort or pressure during balloon in the urethra; further insertion will
balloon insertion. If pain occurs, prevent misplacement and further pain or
discontinue the procedure, deflate the bleeding
balloon, and insert catheter farther into
the bladder. If the client continues to
complain of pain with balloon
inflation, remove the catheter and
notify the physician
24. Once the balloon has been inflated, Maximizes continuous bladder drainage and
gently pull the catheter until the prevents urine leakage around the catheter
retention balloon is resting against the
bladder neck
25. Tape the catheter to the abdomen and Prevents excessive traction from the balloon
secure it in the thigh yet with enough rubbing against the bladder neck, inadvertent
slack so it will not pull the bladder catheter removal, or urethral erosion. Secure
proper placement of foley catheter.
26. Place the drainage bag below the level Maximizes continuous drainage of urine from
of the bladder. Do not rest It on the the bladder (drainage is prevented when the
floor. Make sure tubing lies over, not drainage bag is placed above the abdomen).
under the leg Urine flows with gravity
27. Help the client adjust position. Drape Promotes client comfort, privacy and safety
the patient properly again. Lower the
bed
28. Remove gloves, dispose of equipment, Prevents transfer of microorganisms
and wash hands
 29. Assess and document the amount, Monitors urinary status
odor, color, and quality of the urine
30. Document all the procedures done Serves as a legal document

INTERVENTION RATIONALE
CATHETERIZATION (MALE)
31. Establish rapport and explain the To promote cooperation, collaboration,
procedure to the patient understanding, and reduces level of anxiety
32. Position the patient and provide
privacy
ASSESSMENT
33. Assess the need for catheterization and
the type of catheterization ordered
34. Assess the need for peritoneal care
prior to catheterization
35. Assess the client’s ability to assist
with the procedure
36. Assess the environment
37. Assess for an allergy in povidone
iodine and/or latex
38. Assess urinary meatus for signs of
infection or inflammation
39. Prepare and assemble all the To promote orderliness of the procedure and
equipment before the procedure prevent unnecessary interruptions
40. Perform handwashing To promote sterility, prevent contamination
and reduce transient microorganism from the
hand
41. Provide safety: raise side rails and set Promotes proper body mechanics and assures
the bed to a comfortable height client safety
42. Drape the patient with a blanket or Facilitates proper execution of technique
sheet covering the abdomen and lower
legs. Expose only the
perineum/genitalia
43. Ensure adequate lighting of the penis Facilitates proper execution technique
and perineal area
44. Done clean gloves and PPE (if Protects the nurse from the patient’s bodily
possible) fluids. Prevent exposure to pathogens from
the patient’s genitalia and secretions/fluids.
Reduces transfer of microorganisms
45. Cleanse perineal area with Reduce the presence of microorganisms near
antibacterial solution urethra
Rinse well then dry:
• Hold the penis using 2 fingers with
dominant hand
• From urethral meatus-glans of penis-
shaft-base of penis
46. Remove clean gloves, discard and Reduce transmission of microorganism
wash hands
47. Open the catheterization kit using Provides an area for sterile equipment to be
aseptic technique. Use the wrapper to laid out and assembled. Establish a sterile
establish a sterile field field close to the client or near the client’s leg
48. If the catheter is not included in the Prevents contamination of the sterile
kit, carefully drop the sterile catheter equipment and sterile field
onto the field using aseptic technique.
Add any other items needed
49. Apply sterile gloves Prevent contamination of the sterile
equipment and sterile field
50. Place the fenestrated drape from the Provides a sterile field at the procedural site.
catheterization kit over the client’s Prevents accidental contamination from
perineal area with the penis extending adjacent areas
through the opening
51. If inserting a retention catheter, attach Tests the patency of the retention balloon.
the syringe filled with sterile water to Detaching the syringe prevents accidental
the Luer-Lock tail of the catheter. inflation during catheter insertion
Inflate and deflate the retention
balloon. Detach the water-dilled
syringe
52. Attach the catheter to the urine The catheter and drainage system may be not
drainage bag if it is not preconnected preconnected; otherwise it is connected before
catheterization to avoid exposing the client to
ascending infection from an open-ended
catheter
53. Clean urinary meatus: a. Reduces microorganisms to meatus
a. With a dominant, sterile gloves hand, and moves from least contaminated to
use forceps to pick-up a cotton ball most contaminated area
saturated with antiseptic or betadine b. Prevents contamination after cleaning
solution. Move in a circular motion c. Lubricating the tube will facilitate
b. Discard each cotton ball after use easy insertion
c. Repeat cleaning at least 2 to 3 more
times
d. Discard forceps, and with dominant,
sterile gloved hand, pick-up lubricated
catheter about 3 to 4 inches from the
tip
54. Hold the penis perpendicular to the Facilitates catheter insertion by straightening
body and pull-up gently urethra
55. Put water-soluble lubricant over the Avoids urethral trauma and discomfort during
tip of the catheter (at least 1-2 inches) catheter insertion and facilitates insertion
56. (ask the patient to take a deep breath Provides visual confirmation that the catheter
prior to insertion) Holding the catheter tip is in the bladder. Straightens the urethra
in the dominant hand, steadily insert for easier insertion of the catheter. Also,
the catheter about 7-9 inches in adults further advancement of the catheter ensures
until urine is noted in the drainage proper placement
bag. When there is backflow of urine,
advance the catheter another 1-2
inches. Hold in place
57. A. if the catheter will be removed as The catheter needs to be inserted far enough
soon as the client’s bladder is empty, to allow complete bladder drainage, but not so
insert the catheter another inch, place far as to possibly irritate the bladder. Causing
the penis in a comfortable position and spasms. Ensures adequate catheter insertion
hold the catheter in place as the before the retention balloon is inflated
bladder drains
B. If the catheter will be indwelling
with a retention balloon, continue
inserting until the hub of the catheter
 (bifurcation between drainage port and
retention balloon arm) is met
58. Reattach the water-filled syringe to the Provides a sterile method of inflating the
inflation port retention balloon
59. Inflate the retention balloon with Ensures retention of the balloon. Retention
sterile water (slowly and gradually) as catheters are available with a variety of
per physician’s order balloon sizes. Use catheter with the
appropriate size balloon
60. Instruct the client to immediately Pain or pressure indicated inflation of the
report discomfort or pressure during balloon in the urethra; further insertion will
balloon insertion. If pain occurs, prevent misplacement and further pain or
discontinue the procedure, deflate the bleeding
balloon, and insert catheter farther into
the bladder. If the client continues to
complain of pain with balloon
inflation, remove the catheter and
notify the physician
61. Once the balloon has been inflated, Maximizes continuous bladder drainage and
gently pull the catheter until the prevents urine leakage around the catheter
retention balloon is resting against the
bladder neck
62. Tape the catheter to the abdomen and Prevents excessive traction from the balloon
secure it in the thigh yet with enough rubbing against the bladder neck, inadvertent
slack so it will not pull the bladder catheter removal, or urethral erosion. Secure
proper placement of foley catheter.
63. Place the drainage bag below the level Maximizes continuous drainage of urine from
of the bladder. Do not rest It on the the bladder (drainage is prevented when the
floor. Make sure tubing lies over, not drainage bag is placed above the abdomen).
under the leg Urine flows with gravity
64. Help the client adjust position. Drape Promotes client comfort, privacy and safety
the patient properly again. Lower the
bed
65. Remove gloves, dispose of equipment, Prevents transfer of microorganisms
and wash hands
66. Assess and document the amount, Monitors urinary status
odor, color, and quality of the urine
67. Document all the procedures done Serves as a legal document

Evaluation
1.
2.

Nursing Skill: Blood Transfusion

Definition: Safe intravenous administration of a component of blood or whole blood
Purpose:
• To increase blood volume after surgery, trauma, or hemorrhage
• To increase the number of RBC in clients with severe anemia
• To provide platelets to clients with low platelet counts caused by treatment with
chemotherapy
• To provide clotting factors in plasma for patients with hemophilia or disseminated
intravascular coagulopathy (DIC)
 • To replace plasma proteins such as albumin
Assessment:
• Assess the client for the indication of the blood product to be given
• Verify the physician’s order for the type of blood product to be given
• Review the client’s transfusion history, especially any reactions or pre-transfusion
medications to be given
• Review the baseline vital signs in the client’s medical record and compare with vital
signs taken during the transfusion
• Assess the type, integrity and patency of the venous access in place
• Very that a large-bore catheter (18 or 19-gauge) is to be used
• Review hospital policy and procedure for the administration of blood productions

Nursing Diagnosis:
1. Impaired gas exchange related to anemia
2. Fluid volume deficit related to hemorrhage
3. Pain related to transfusion reaction

Planning (SMART Form):

1. The client will receive the blood component transfusion without any adverse reactions or
has adverse reactions successfully managed
2. The client will demonstrate desired benefit from transfusion as evidenced by relief of
symptoms or improvement in specific hematologic values
3. The client will be able to describe the purpose and procedure for transfusion of a blood
component
4. The client will describe the possible complications of a blood transfusion
Equipment:
• Blood unit
• Bag of 0.9% sodium chloride IV sodium
• Y-set blood tubing with filter
• Antimicrobial swabs
• Clean gloves
• Infusion pump, if needed
• Blood warmer, if needed
• Protective clothing, if needed
• Tape

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
1. Verify physician’s order for Ensures accurate administration of the
indications for blood transfusions solution
2. Identify patient; explain purpose, Decreases anxiety; meets patient’s right to be
procedure and how patient can assist informed; encourages cooperation and
participation
3. Review side effects (dyspnea, chills, Prompt reporting of a side effect will lead to
headache, chest pain, itching) with earlier continuation of transfusion and
client and ask them to report to the minimize the reaction
nurse
4. Secure informed consent An informed consent is and INS standard- the
patient should be aware of what is involved in
the procedure and his/her role in the
procedure and should be made aware if the
symptoms indicating a reaction to the
transfusion
 5. Establish that the patient has a patent Blood should be transfused via a minimum of
large bore IV catheter a 20-gauge IV catheter to provide adequate
flow rate and prevent lysis of RBCs
6. Prime blood administration tubing IV solutions other than 0.9% sodium chloride
with 0.9% sodium chloride solution may result in damage to RBCs or precipitate
clots
7. Obtain baseline vital signs Allows detection of a reaction by any change
in vital signs during the transfusion
8. Obtain the blood product from the To prevent bacterial growth and destruction
blood bank within 30 minuets of of red blood cells
initiation
9. Verify and record the blood product Strict verification procedures will reduce the
and identify the client with another risk of administering blood products to the
nurse or a physician wrong client. If there is an error during this
• Client’s name, blood group, Rh type procedure, notify the blood bank and do not
• Crossmatch compatibility administer the product
• Unit and hospital number
• Expiration date and time on blood bag
• Type of blood product compare with
• Physician’s or qualified practitioner’s
order
• Presence of clots in blood
10. Instruct the patient to empty the A urine specimen after initiation of the
bladder transfusion will be needed if a transfusion
reaction occurs
11. Wash hands and put on gloves Reduces risk of transmission of HIV, hepatitis
or blood-borne bacteria
12. Open blood administration kit and To prevent accidental spilling of blood
move roller clamps to “off” position
For Y-tubing set: • Spiking the blood container in a straight
• Spike the normal saline bag and open the motion prevents puncture to blood bag
roller clamp on the Y-tubing connected to • The Y-tubing allows the nurse to switch
the bag and the roller clamp on the unused from infusing normal saline to blood.
inlet tube until tubing from the normal • A correctly filled dripped chamber
saline bag is filled enables an accurate drip count
• Close clamp on unused tubing • Removes all air from tubing system
• Squeeze sides of drip chamber and allow • Prevents waste of IV fluid
filter to partially fill • Equal distribution of cells prevents
• Open lower roller clamp and allow tubing clumping, which can lead to clotting of
to fill with normal saline to the hub cells. Fragile blood cells may be damaged
• Close lower clamp if they drop on an uncovered filter
• Invert blood bag once or twice. Spike • Prevents blood from flowing until tubing
blood bag, open clamps on inlet tube to is attached to venous catheter
allow blood to cover the filter completely
• Close lower clamp
For single-tubing set: • Attaches tubing to blood unit
• Spike blood unit • A correctly filled drip chamber enables an
• Squeeze drip chamber and allow filter to accurate drip count
fill with blood • Prevents air from being forced into the
• Open roller clamp and allow tubing to fill vein
with blood to the hub • The blood product should not be
• Prime IV tubing with normal saline and piggybacked into the normal saline line to
piggyback it to the blood administration
 set with a needle and secure all avoid forcing blood cells through both a
connections with tape needle and a venous catheter
13. Attach tubing to venous catheter using Allows the blood product to be infused into
sterile precautions and open lower the client’s vein
clamp
14. Infuse the blood at a rate of 2-5 Packed red blood cells usually run over 11/2-
ml/min according to the physician’s 2 hours; whole blood runs over 2-3 hours
order
15. Remain with client for first 15-30 If a reaction occurs, it generally happens
minutes, monitoring vital signs every during the first 15+30 minutes
5 minutes for 1 hour, then hourly until
1 hour after the infusion is completed
16. Monitor patient for any signs or Diligent monitoring of the patient during
symptoms of an adverse reactions to blood transfusion is necessary to ascertain
the transfusion at a 5 minutes intervals adverse effects of the transfusion and institute
and record on transfusion flow form early intervention
17. If a reaction occurs stop the The client will receive all of the blood that is
transfusion, notify physician, and left in the tubing
change IV tubing and keep vein open
with 0.9% sodium chloride solution
18. After the blood has infused, allow the IV site can be maintained for further use.
tubing to clear with normal saline Blood tubing should be utilized only for
transfusion of blood
19. If no further blood has transfused Blood container should be returned to blood
change tubing or cap IV line with bank if transfusion reaction occurs, otherwise
PRN adaptor can be discarded contaminated waste
20. Appropriately dispose of bag, tubing Reduces transmission of microorganisms
and gloves
21. Wash hands Removes microorganisms

22. Reposition the patient if needed Promotes comfort

23. Document the procedure Ensures accurate records

Evaluation
• Observe for signs of transfusion reaction
• Observe client and laboratory values to determine response to transfusion

Nursing Skill: CPV Monitoring

Definition: The measurement of right atrial pressure or the pressure of the great begins within
thorax
Purpose:
• To serve as a guide for fluid replacement
• To monitor pressures in the right atrium and central veins
• To administer blood products, total parenteral nutrition, and drug therapy contraindicated
for peripheral infusion
• To obtain venous access when peripheral veins sites are inadequate
• To insert a temporary pacemaker
• To obtain central venous blood samples
Assessment:
Nursing Diagnosis:
1. Risk for injury
2. Risk for fluid volume deficit

Planning (SMART Form):

Equipment:
• Venous pressure tray
• Cutdown tray
• Infusion solution/infusion set with CVP manometer
• IV pole
• Arm board
• Sterile dressing and tape
• Gowns, masks, caps, and sterile gloves
• Heparin flush system and pressure bag
• ECG monitor
• Carpenter’s level

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
Preparatory phase (for the nurse) To assess for coagulopathies or anemia
1. Assemble equipment according to
manufacturer’s directions. Evaluate
the patient’s PT, PTT, and CBC
2. Explain the procedure to the patient Procedure is similar to an IV, and the patient
and ensure that informed consent is may move in bed as desired after passage of
obtained catheter
a. Explain to patient how to perform the a. The Valsalva maneuver performed
Valsalva maneuver during catheter insertion and removal
b. NPO 6 hours before insertion decreases risk of air emboli
3. Position patient appropriately. Provides for maximum visibility of veins
a. Place in supine position • Trendelenburg’s position reduces the risk
b. Arm vein: extend arm and secure on of air emboli. Anatomic access and
arm board clinical status of the patient are considered
c. Neck veins: place the patient in in site selection
Trendelburg’s position. Place a small
rolled towel under shoulders
(subclavian approach)
4. Flush IV infusion set and manometer a. The level of the right atrium is at the
(measuring device) or prepare heparin fourth intercostal space midaxillary
flush for use with transducer. Secure line
all connections to prevent air emboli b. Mark midaxillary line with indelible
and bleeding link for subsequent readings to ensure
a. Attach manometer to IV pole. The consistency of the zero level
zero point of the manometer should be
on a level with the patient’s right
atrium
b. Calibrate/zero transducer and level
port with patient’s right atrium
5. Institute ECG monitoring Dysrhythmias may be noted during insertion
as catheter is advanced
To measure CVP This baseline position is used for subsequent
6. Place the patient in a position of readings
comfort
 7. Position the zero point of the
manometer at the level of the right
atrium
8. Turn the stopcock so the IV solution
flows into the manometer, filling to
about the 20- to 25-cm level. Then
turn stopcock so solution in
manometer flows into patient
9. Observe the fall in the height of the The column of fluid will fall until it meets an
column of fluid in manometer. Record equal pressure. The CVP reading is reflected
the level at which the solution by the height of a column of fluid in the
stabilizes or stops moving downward. manometer when there is open
This is CVP. Record CVP and the communication between the catheter and the
position of the patient manometer. The fluid in the manometer will
fluctuate slightly with the patient’s
respiration. This confirms that the CVP line is
not obstructed by clotted blood.
10. CVP catheter may be connected to a
transducer and an electrical monitor
with either digital or calibrated CVP
wave readout
11. CVP may range from 5 to 12 cm H2O The change in CVP is a more useful
or 2 to 6 mm Hg indication of adequacy of venous blood
volume and alterations of cardiovascular
function. The management of the patient is
not based on one reading, but on repeated
serial readings in correlation with the
patient’s clinical status
12. Assess the patient’s clinical condition. CVP is interpreted by considering the
Frequent changes in measurements patient’s entire clinical picture: hourly urine
will serve as a guide to detect whether output, heart rate, blood pressure, and cardiac
the heart can handle its fluid load and output measurements
whether hypovolemia or hypervolemia a. CVP near zero indicates that the
is present patient is hypovolemic
b. CVP above 15 to 20 cm H2O may be
due to either hypervolemia or poor
cardiac contractility
13. Turn the stopcock again to allow IV • When readings are not being made, IV
solution to flow from solution bottle flow bypasses the manometer but keeps
into the patient’s veins. Use an IV line open flow should be controlled to
pump and monitor the infusion at least prevent fluid overload
hourly
Follow up Phase Patient’s complaints of new or different pain
14. Prevent and observe for complications or shortness of breath must be assessed
a. From catheter insertion: closely; may indicate development of
Pneumothorax, hemothorax, air complications
embolism, hematoma, and cardiac a. Signs and symptoms of air embolism
tamponade include severe shortness of breath,
b. From indwelling catheter: infection, hypotension, hypoxia, rumbling
air embolism, central venous murmur, and cardiac arrest
thrombosis
15. Make sure the cap is secure on the end Prevents air from entering system, thereby
of the CVP monitor and all clamps are reducing risk of air embolus
closed when not in use
 16. If air embolism is suspected, Air bubbles will be prevented from moving
immediately place the patient in left into the lungs and will be absorbed in 10 to 15
lateral Trendelburg’s position and minutes in the right ventricular outflow tract
administer oxygen
17. Carry out ongoing nursing a. Local infection could spread rapidly
surveillance of the insertion site and through systemic circulation
maintain aseptic technique b. Make sure sutures are intact
a. Inspect entry site twice daily for signs c. To detect bacterial colonization
of local inflammation and phlebitis.
Remove the catheter immediately if
there are signs of infection
b. Make sure sutures are intact
c. Change dressings as prescribed
d. Label to show date and time of change
e. Send the catheter tip for bacteriologic
culture when it is removed
18. When discontinued, remove central
line
19. Position patient flat with head down Prevents air from entering blood vessels
20. Remove dressings and sutures
21. Have patient take a deep breath and Prevents air emboli by creating positive chest
hold it while catheter is gently pulled pressure
out
22. Apply pressure at catheter site and To prevent bleeding
apply dressing
23. Monitor site and vital signs for signs
of bleeding or hematoma formation
24. Documentation of the procedure Serves as legal document

Evaluation
• Evaluate client’s response to the procedure
• Assess for any signs of complications

Documentation
• Record patient name, blood component and component number, names of individuals,
verifying blood component, start and end times, volume transfused, and reaction if any
• Record volume of blood component transfused and urine output, if appropriate
• Record date, time, type and amount of the blood administered
• Document the condition of the venous access site and patency of the IV

Nursing Skill: Peritoneal Dialysis

Definition: It is the repeated cycle of instilling dialysate into the peritoneal cavity allowing
exchange of substances and the dialysate
Purpose:
• To relieve symptoms of renal failure temporarily until client regain kidney function
• To sustain life in the client with irreversible kidney disease
• To physically prepare the client to receive a transplanted kidney
• To removed excess fluid and electrolytes and waste products such as urea and creatinine
• To maintain a more stable weight, acid-base balance, and blood pressure in the ESRD
client
Assessment:
 • Assess the client’s cardiovascular and respiratory status
• Measure the client’s abdominal girth
• Assess the client’s abdomen
Nursing Diagnosis:
1. Altered tissue perfusion related to peritoneal dialysis
2. Altered urinary elimination
3. Risk for infection

Planning (SMART Form):

• Client will experience relief of respiratory symptoms related to pressure from fluid on the
diaphragm
• Client will experience relief of symptoms related to nitrogenous waste products
• Client will not suffer from fluid volume overload or deficit
• Client will not exhibit any signs or symptoms of infection following the dialysis
• The skin at the catheter entry site will remain intact without infection or excoriation
• Client will not experience pain or discomfort related to the procedure

Equipment:
• Dialysate
• Sterile drape
• Sterile basin
• Povidone-iodine swabs or sterile dressings (4x4) with povidone-iodine liquid
• Sterile gloves
• Masks if needed
• Biohazard bag
• Clean gloves

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
1. Gather equipment needed at the Smooths the performance of the procedure
bedside
2. Warm the dialysate to body b. Warming the dialysate prevents shock
temperature and bring it to the bedside in the client from infusing cold fluid
directly into the abdomen
3. Wash hands and apply clean gloves Reduces the transmission of microorganism
4. Position the client in a semi-Fowler’s Positioning for comfort allows the patient to
position tolerate the dialysis for longer periods of time
Semi-Fowler’s position ensures that there is
room for peritoneal expansion
5. Weigh the dialysate Establishes a baseline to compare with
returned fluid weight
6. Spike the dialysate bag with the Prepares the equipment for use as soon as the
tubing, hang the bag from an IV pole connector has been cleaned
and prime the tubing. Clamp the
tubing once it is primed
7. Establish a sterile field under the end Provides a sterile surface for cleaning the
of the peritoneal catheter, using the catheter and reducing the transmission of
sterile drape microorganisms
8. Open the povidone-iodine swabs using Provides a sterile bactericide to cleanse the
aseptic technique and drop them onto catheter
the sterile filed. If using sterile 4x4,
 open the sterile basin and, using
aseptic technique, pour povidone-
iodine into the basin. Taking care not
to contaminate the 4x4s, drop them
into the povidone-iodine in the basin
9. Apply sterile gloves Prevents contamination of the sterile materials
10. Using the povidone-iodine swabs or Povidone-iodine must be allowed to dry to
the soaked 4x4s, cleanse the proximal provide a bactericidal action
end of the catheter. Allow the
povidone-iodine to dry prior to
connecting the tubing
11. Attach the infusion tubing and Since peritoneal dialysis is a process of
dialysate to the dialysis catheter. The osmosis, concentrations of dialysate are
dialysate is hanged on a pole and determined by the amount of waste products
administered by gravity. The type and and amount of fluid desired to be removed by
amount of dialysate of each bag will the process of gradients
be determined by the client’s
laboratory results, purpose of the
dialysis and physician’s order
12. Unclamp the tubing and allow Dialysate must remain in the abdomen for
dialysate to enter the abdomen and osmosis to occur and for waste products to be
stay the appropriate time as ordered. pulled out of the system
Dialysate takes approximately 5-15
minutes to infuse
13. Assess the client for pain or If the pain is accompanied by signs of
discomfort peritonitis or bleeding, follow-up immediately
14. When the ordered amount of dialysate Allows the dialysate to remain in contact with
has been infused, clamp the dialysis peritoneum. If the dwell time of dialysate will
tubing for the ordered amount of dwell be hours, the client can fold the empty bag
time and carry it along, tucked into clothing, until
it is time to drain the dialysate
15. Wash hands after infusing the Reduces the transmission of the
dialysate and prior to draining the microorganisms
effluent
16. After the dialysate has remained in the The level of bag must be placed well below
abdomen a specified time (usually 20 the abdomen to facilitate drainage by gravity
minutes for intermittent dialysis, 4-8
hours for continuous dialysis) and is
ready to be drained, remove the empty
bag from the pole and place it below
the level of the peritoneum
17. Unclamp the tubing leading to the bag Allow drainage
and allow drainage of the effluent into
the empty bag
18. Periodically weigh the bag of effluent When the weight of the bag no longer
as the abdomen drains. When the changes, the abdomen should be fully
weight of the effluent bag has been drained. At this point the bag of effluent
stable for 10-15 minutes, clamp the should weigh more than it did prior to
drainage tubing. This usually takes instillation as it will also contain waste
approximately 30 minutes products and wastewater. If the stable weight
of the effluent bag is less than the pre-
infusion weight, unclamp the tubing and
reposition the client from side to side to allow
any trapped effluent to drain
 19. Hold the full bag up to the light and Red-tinged, dark, or cloudy effluent could
inspect the fluid. The color should be indicate bleeding, infection, or perforation
light to medium yellow or amber and
clear. If it is red-tinged, dark, or
cloudy, consult the physician or
qualified practitioner ad report
findings
20. Compare the weight of the returned The amount of drainage generally exceeds the
fluid with the pre-infusion weight. If amount of fluid entering the abdominal cavity
there is substantially less fluid since the process of dialysis also removes
returned than was administered, report excess fluid. If less amount of returned fluid
findings to physician or qualified happened, this could indicate that the client is
practitioner retaining dialysate fluid related to dehydration
or occlusion of the catheter by tissue or
kinking
21. Ensure that any laboratory tests Determines how much dialysis is required and
ordered are performed to track the what concentrations of dialysate are required
client’s fluid and electrolyte balance.
Notify the physician or qualified
practitioner of any drastic changes in
the laboratory results
22. Wash hands after disconnecting the Reduces the transmission of microorganisms
effluent and prior to connecting a new
bag of dialysate
23. Warm and connect the next bag of Ensures the procedure continues as ordered
dialysate to be exchanged, if ordered,
and repeat the process. Use new
tubing for each bag of dialysate
24. Documentation of the procedure Serves as legal document

Evaluation:
• Client experienced relief of respiratory symptoms related to pressure from fluid on the
diaphragm
• Client experienced relief of symptoms related to nitrogenous waste products
• Client did not suffer from fluid volume overload or deficit
• Client has not exhibited any signs or symptoms of infection following the dialysis
• The skin at the catheter entry site remained intact without infection
• Client did not experience pain or discomfort related to the procedure

Documentation
• Document the client’s response to dialysis
• Document the color and clarity of effluent
• Document any symptoms that may be associated with peritonitis or internal bleeding,
including rebound tenderness, cloudy outflow, blood in the outflow, fever or abdominal
rigidity.
• Document the time the procedure was started ang how long it took

Nursing Skill: Hemodialysis

Definition: It is a procedure to remove toxic age nts and excess fluids and electrolytes to clients
with acute or irreversible renal failure and fluid and electrolytes imbalances.
Purpose:
 • To relieve symptoms of renal failure temporarily until client regain kidney function
• To sustain life in the client with irreversible kidney disease
• To physically prepare the client to receive a transplanted kidney
• To removed excess fluid and electrolytes and waste products such as urea and creatinine
• To maintain a more stable weight, acid-base balance, and blood pressure in the ESRD
client
Assessment:
• Identify the cause of the client’s renal failure and other chronic diseases
• Assess the venous access site for redness or swelling and dressing for bleeding or other
drainage
• Assess the viral signs
• Check for the presence of pain or numbness in the extremity where the access is located
• Check for the presence of audible bruit and palpable thrill in the fistula/graft
• Assess client’s knowledge of access are and hemodialysis

Nursing Diagnosis:
1. Altered tissue perfusion related to alterations in blood flow due to fistula or graft
2. Risk for infection
3. Risk for fluid volume deficit related to possible bleeding

Planning (SMART Form):

• Access is patent for dialysis without evidence of any redness, drainage, or swelling
• Client is able to state rationale for access and selfcare principles and practices

Equipment:
• Povidone-iodine swabs
• Sterile and non-sterile gloves
• Mask
• Alcohol swabs
• Transparent dressing or gauze dressing supplies
• Heparin (concentration depends on hospital policy for flushing)

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
A. Arteriovenous Fistula: Shunt or Graft Prevents the spread of microorganisms
1. Wash hands
2. Position extremity so that you can Prevents trauma to fistula
easily palpate the fistula
3. Palpate gently over the area with Test for adequate blood flow through fistula
fingertips or palm of your hand to feel
for thrill (vibration)
4. Auscultate over the area with a Tests for adequate blood flow through the
stethoscope to detect a bruit (swishing fistula. Notify the physician if bruit and thrill
noise) are absent. Surgical interventions may be
necessary to restore flow
5. Palpate pulses distal to the fistula and Checks for adequate blood flow and perfusion
observe capillary refill in the to the fistula extremity
extremity
6. Assess for symptoms of infection, Monitors for potential complications
bleeding, or sensation impairment in
 the area around the fistula and the
entire extremity
7. Post signs in the client’s room to let Prevents restriction of flow and possible
all caregivers know to avoid clotting or rupture of fistula. Reduces chances
venipuncture and blood pressure in the for infection
fistula extremity
8. Inform client to avoid any activities Prevents unnecessary loss of access site due
that will restrict flow or cause injury to occlusion or infection
to the affected extremity
9. Once the surgical incision is healed, Prevents infection at the puncture sites
the skin over the fistula or graft
requires only routine care with soap
and water
B. Double-Lumen Catheter Prevents the spread of microorganisms
10. Wash hands
11. Fill two 5-cc syringes with heparin Use to fill both lumens of catheter at end of
and saline per agency policy site care
12. If changing caps, prime with heparin Prevents air from entering the system
and saline
13. Open central line care kit or assemble Maintains sterile technique
needed supplies and place on sterile
field
14. Cleanse site with alcohol and assess Removes any remaining iodine, skin, oils, and
site for any redness, swelling, or drainage to allow clear visualization of site
drainage
15. Cleanse area surrounding the catheter Removes pathogens from the skin and
site with povidone-iodine swabs prepares for a new dressing
beginning at insertion site and going
out in a circular motion. Repeat for a
total of three times
16. Let air dry and apply transparent Allows the iodine solution to complete the
dressing disinfectant process and ensures that the
dressing will adhere tightly to the skin
17. Close clamp to both lumens and Clamping prevents air from entering the
removes and discard old male adapters system when the client inspires and
(caps) creates a negative pressure
18. Cleanse ends of catheter with alcohol Removes any old blood or drainage
swabs and then attach new primed
male adapters
19. Unclamp lumens and flush with Creates a positive pressure within the
heparin and saline per agency catheter, thereby preventing backup of blood
protocol. Close clamp as the least 0.5 into the catheter
cc is being injected
20. Some institutional policies will Aspirating the heparin solution before
include aspirating the heparin solution flushing prevents over anticoagulating the
in the catheter before flushing. The client, who may already have bleeding
permanent catheters may also require tendencies
flushing with normal saline before the
heparin depending on the frequency of
dialysis
21. Normal saline is never used without Heparin maintains patency of dialysis
heparin unless the client has an allergy catheters
to heparin
22. Wash hands Reduces the transmission of microorganisms
 23. Documentation of the procedure Serves as legal document

Evaluation
• Assess catheter site for signs of infection
• Determine if catheter or fistula is patent and provides adequate blood flow for dialysis
• Determine the client’s understanding of rationale for fistula/catheter and related care

Nursing Skill: Continuous Bladder Irrigation (Cystoclysis)

Definition: It is a procedure to remove toxic age nts and excess fluids and electrolytes to clients
with acute or irreversible renal failure and fluid and electrolytes imbalances.
Purpose:
• To maintain or restore catheter patency
Assessment:
• Assess the client for bladder distention or complaints of fullness or discomfort
• Assess the drainage system for equal or larger amounts of drainage versus infused
irrigant
• Assess the color, consistency, and clarity of the bladder drainage as well as noting any
clots or debris present
Nursing Diagnosis:
1. Pain
2. Altered urinary elimination
3. Risk for infection

Planning (SMART Form):

• All irrigation solution and debris from bladder drains into catheter drainage bag
• Continuous: flow rate if irrigant remains constant at prescribed rate, and bags of irrigation
solution are added as needed
• Catheter and drainage bag tubing remain patent
• Urinary output is accurately assessed
• Patient experiences no discomfort during or following procedure

Equipment:
• Clean gloves
• Three-way Foley catheter with drainage bag in place
• Warmed or room temperature sterile irrigation solution
• Sterile infusion tubing
• IV pole

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
1. Review prescriber’s orders and obtain Determines type, strength and amount of
prescribed irrigation solution from irrigation solution, as well as frequency and
pharmacy timing of procedure
2. Place label on irrigation bag if not Provides safety ad continuity of care
labeled; include patient’s initials, date,
time, room number, type of solution,
and any additives
3. Gather all equipment Enhances efficiency and patient safety
 4. Check patient’s identification band Ensure patient safety
5. Explain procedure and its purpose Clear explanations reduce patient’s anxiety
and increase cooperation with procedure
6. Provide privacy Maintains patient’s dignity
7. Organize equipment within easy reach Enhances efficiency and patient safety
and drape patient, exposing access to
irrigation port on catheter only
8. Don clean gloves, and empty and Decreases transmission of microorganisms,
measure urine present in drainage bag; provides pertinent data regarding patient’s
discard urine and gloves in appropriate urine output and provides empty drainage bag
receptacles for accurate measurements following
procedure
9. Wash hands Prevents transmission of microorganisms
10. Hang irrigation solution bag on IV Ensures correct height for effective flow
pole 24 to 36 inches above bladder
11. Connect infusion tubing to irrigation Flushing infusion tubing with irrigation
solution, prime drip chamber, and solution prevents air from entering patient’s
flush tubing with solution bladder and causing discomfort
12. Close infusion tube clamp and connect Closing infusion clamp allows only
infusion tubing to irrigation port on prescribed amount of irrigation to infused
three-way Foley
13. Open flow clamp on urinary drainage Opening drainage bag flow clamp allows
bag instilled irrigation solution to flow form
bladder into drainage bag
14. Open flow clamp on infusion tubing Ensures continuous flow of solution. Ensures
and adjust the prescribed hourly rate. continuous irrigation and change in solution
Change or add irrigation solution as when prescribed
needed, maintaining aseptic technique
15. Change infusion tubing every 24 to 48 Reduces incidence of urinary tract infection
hours or per facility protocol
16. Monitor urine output hourly or as Provides pertinent information about bladder
ordered, subtracting the amount of and kidney function and need for additional or
irrigant from the total output from change in plan of care
drainage bag
17. Assess drainage bag frequently and Bag can fill more quickly with irrigation and
empty as needed often needs more frequent emptying
18. Assess color, clarity, odor, and other Provides pertinent information about bladder
characteristics of urinary output and kidney function and need for intervention
during irrigation process and each
time drainage bag is emptied
19. Discard gloves and urine in Reduces transmission of organisms
appropriate receptacles
20. Wash hands Decreases transmission of microorganisms
21. Normal saline is never used without Heparin maintains patency of dialysis
heparin unless the client has an allergy catheters
to heparin
22. Wash hands Reduces the transmission of microorganisms

23. Documentation of the procedure Serves as legal document

Evaluation
 • Assess the amount, color, clarity, odor, and character of fluid in drainage bag, noting
clots, tissue prior to and following irrigation
• Assess accurately urine volume and irrigant volume
• Assess patient’s comfort level during and after procedure

Nursing Skill: Managing Chest Tube and Drainage System

Definition: The chest drainage system is a closed system designed to drain air or fluid from the
pleural cavity while restoring or maintaining the negative intrapleural pressure needed to keep
the lung properly expanded. The drainage system uses a water seal to prevent air return into the
pleural cavity.
Purpose:
• To remove air, blood, or fluid from the intrapleural space
• To facilitate removal of air and fluids while reestablishing normal intrapleural pressure
and lung expansion
• To remove air, chest tubes are placed through the second intercostals space
• To remove blood or fluid, chest tubes are placed posteriorly through the eighth or ninth
ICS
Assessment:
• Assess:
o That the chest tube is set to the appropriate amount of suction as ordered by the
physician
o That the water level in the water seal chamber is maintained at the marked line
• Assess for any air leak in the water seal chamber
• Assess the chest tube dressing and change every 24-48 hours
• Assess the drainage system and note the amount and color of the drainage
• Assess that the tubing is free of kinks and dependent loops and is not pinned to the bed
• Identify the risk factors for a tension pneumothorax in the client with a chest tube
• Assess the patient’s respiratory status, including respiratory rate and oxygen saturation
• Assess the patient’s lung sounds
• Assess the patient for pain
Nursing Diagnosis:
1. Impaired gas exchange
2. Acute pain
3. Risk for infection

Planning (SMART Form):

Equipment:
• 36 French chest tube
• Chest drainage system
• Sterile water
• 5 in 1 connector or Y connector (for 2 chest tubes)
• Sterile gloves and masks
• Disposable gloves
• Dressing (Vaseline gauze, split drain sponge, 4x4s, 3-inch tape)
• Rubber shod Kelly clamps
• Chest tube-insertion tray (povidone-iodine, local anesthetic, syringe, needles, drapes, scalpel,
suture)

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
 1. Assess patient; vital signs, respiratory Enhances efficiency and patient safety.
and cardiac status, anxiety and pain Obtain baseline data
2. Explain the procedure Reduce anxiety
3. Wash hands Reduce transmission of microorganisms
4. Organize equipment Enhance efficiency and patient safety
5. Prepare a chest drainage system, per Facilitate rapid attachment of chest tube to
physician preference, using sterile water seal and suction. Maintain sterility of
technique to open packages, handle system and connections
contents, and pour solutions. Don
sterile gloves; recap connectors when • Maintain water seal and fluid collection in
finished one bottle
• One-bottle system: add sterile water to • Provide separate bottles for fluid
submerge water seal tube collection and water seal
• Two-bottle system: add sterile water to • Depth of long-tube submersion
submerge water-seal tube connect water- determines amount of negative pressure
seal bottle to collection bottle • System is ready to provide water seal,
• Three-bottle system: add sterile water to suction, and fluid collection. Water seal
submerge water-seal tube, connect water- prevents room air from entering pleural
seal bottle to collection bottle, add sterile cavity
water to the suction bottle, ensure that
long tube is submerged, connect suction
bottle to water seal bottle then to suction
regulator
• Disposable system: swivel base of unit to
stand upright, remove cap on suction
control chamber and add sterile water to
20-cm level, replace cap, remove cap on
water-seal chamber tubing and use
catheter tip syringe to add sterile water to
2-cm level, replace cap on tubing, and
inspect system for leaks or cracks
6. Assist physician as needed with chest Assessment facilitates prompt interventions
tube insertion, maintain sterile
technique, don sterile gloves and
mask. Monitor patient’s physical and
emotional response to procedure
7. Once chest tube is inserted, connect it Rubber-shod Kelly clamp prevents or reduces
to the long tube of collection chamber air entering chest during insertion
of chest drainage system and remove
rubber-shod Kelly. If suction is
ordered, attach short water-seal tubing
to suction tubing and regulator. Keep
unclamped if no suction has been
ordered
8. Apply dressing: Vaseline gauze, drain Reduces risk for air leak at insertion site and
sponge, 4x4s, and tape. Tape all all connections
connections
9. Adjust suction until gentle bubbling Unit is functioning properly
occurs in suction control chamber
10. Ensure tubing is free of kinks and is Prevents obstruction and pooling of fluids in
loosely coiled or forms a straight line dependent loops
to drainage system
11. Observe air bubbles in water-seal Continuous, constant bubbling in water-seal
chamber and fluctuations, tidaling, chamber indicates an air leak; intermittent
with respiration bubbling is normal. Fluctuations, tidaling
 with respiration are normal-absence indicates
lung reexpanded or a blockage
12. Position chest drainage system upright Prevents fluid from draining back into chest
and below level of chest
13. Secure bottles in stand or disposable Secure position prevents overturning and loss
system to bed frame of water seal
14. Order chest x-ray Confirms chest tube placement and lung
expansion
15. Mark fluid level on collection Accuracy of output
chamber and time of measurement.
Use tape if needed to write on
16. Encourage patient to breathe deeply, Facilitate drainage and lung expansion
cough, and change positions
17. Assess drainage and vital signs, notify Identify and intervene based on changes in
physician for changes in drainage patient status
quantity or character, especially
change from serous to bloody
18. Keep rubber-shod Kelly clamps at Rapid availability in event of disconnection or
bedside break of drainage system
19. Document the procedure and findings Validates procedure and patient response
Chest tube care (after insertion) Reduce anxiety
20. Explain the procedure
21. Perform hand hygiene and don gloves Reduce transmission of microorganisms
22. Move gown to expose chest tube If dressing is not occlusive, air can leak into
insertion site and ensure that it is the space, causing displacement of the lung
occlusive. All connections should be tissue. Subcutaneous emphysema will be
properly taped. Gently palpate around absorbed by the body after the chest tube is
insertion site, feeling for any removed. At times, subcutaneous emphysema
subcutaneous emphysema can cause discomfort to the patient
23. Check drainage tubing for loops or Dependent loops or kinks can prevent the tube
kinks and its position. It should be from draining appropriately. The drainage
positioned below the tube insertion collection device must be positioned below
site the tube insertion site so that drainage can
move out oof the tubing going into the
collection device
24. Ensure that a bottle of sterile water or Chest tubes should never be clamped except
normal saline is at the bedside at all to change the drainage system. If the chest
times tube becomes accidentally disconnected from
the drainage system, place the end of the chest
tube into the sterile solutions. This prevents
more air from entering the pleural space
through the chest tube but allows for any air
that does not enter the pleural space, through
respirations, to escape once pressure builds up
25. If suction is indicated, assess the Gentle bubbling in the suction chamber
amount of suction set. Look for any indicates that suction is being applied to assist
bubbling or tidaling in the suction drainage. Continuous bubbling may indicate a
chamber leak in the system. Tidaling is normal
26. Measure drainage output at the end of The drainage system is never emptied unless
each shift. Mark the level on the the system has been filled and needs to be
container or place a small piece of
 tape at the drainage level to indicate replaced, as it loses its negative pressure
time and date when opened frequently
Clamping the drainage system This provides for an organized approach
27. Obtain 2 pairs of padded Kelly
clamps, new drainage system and
bottle of sterile water
28. Apply Kelly clamps 1.5” to 2.5” from This prevents air from entering the pleural
insertion site and 1” apart, going space through the chest tube
opposite directions
29. Prepare new drainage system. Don Prevents exposure to microorganisms
disposable gloves
30. Remove the suction from the drainage Removing suction permits application to new
system. Using a slight twisting system. Due to negative pressure, a slight
motion, remove the drainage system. twisting motion may be needed to separate the
Do not pull the chest tube tubes. The chest tube is sutured in place, so
make sure you don’t tug on the chest tube and
dislodge it
31. Keeping the end of the chest tube Chest tube is sterile. Tube must be
sterile, insert the end of the new reconnected to suction to form a negative
drainage system into the chest tube. pressure. If Kelly clamps remain in place,
Reconnect suction if ordered. Remove another pneumothorax may form
Kelly clamps
32. Assess drainage system for continuous Continuous bubbling may indicate a leak in
bubbling, tidaling, and amount of the system. Tidaling is a normal function of
suction applied the chest tube. Make sure that the suction has
not been changed
33. Remove gloves. Performed hand Deters the spread of microorganisms
hygiene
34. Document the procedure Ensures continuity of care and ongoing
assessment record

Evaluation
• Assess the patient’s respiratory and cardiac status, vital signs, skin color, and compare to
baseline
• Assess for symmetric chest wall movement and subcutaneous emphysema
• Monitor water level in water seal and suction chambers; replace sterile water as needed
• Rule out suspected air leaks by first retaping connections, checking dressings, and/or
momentarily clamping tubing with rubber-shod
• Kelly clamp, starting nearest patient and moving distal until bubbling ceases
• Report bleeding or drainage greater than 100 mL/hr

Documentation
• Document chest tube to suction at ordered amount
• Note presence or absence of air leak
• Note state of the dressing and when it was changed

Nursing Skill: Surgical Asepsis

Definition: Surgical asepsis, or sterile technique, consists of those practices that eliminate all
microorganisms and spores from an object or area
Purpose:
Assessment:
• Assess the environment to establish if facilities are adequate for cleansing the hands
 • Assess your hands to determine if they have open cuts, hangnails, broken skin, or heavily
soiled areas
Nursing Diagnosis:
1. Risk for infection
Planning (SMART Form):
• To promote asepsis
• To prevent the transmission of endogenous and exogenous microflora
• To remove transient organisms
• To eliminate the risk for infection during operative procedures
Equipment:
• Deep sink with foot or knee controls for dispensing water or soap
• Antiseptic detergent
• Surgical scrub brush with plastic nail pick
• Paper mask and cap
• Sterile towel
• Proper scrub attire
• Protective eyewear

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE
1. Consult institutional policy regarding Guidelines vary regarding ideal time needed
required length time for hand washing for surgical scrub
2. Be sure that fingernails are short, Long nails and chapped or old polish increase
clean and healthy. Artificial nails number of bacteria residing on nails. Long
should be removed. fingernails can puncture gloves, causing
contamination. Artificial nails are known to
harbor gram negative microorganisms and
fungi
3. Inspect hands for presence of These conditions increase likelihood of more
abrasions, cuts or open lesions microorganism residing on skin surfaces
4. Apply surgical shoe covers, caps or Mask prevents escape into air of
hood, face mask and protective microorganism that can contaminate the
eyewear hands. Other protective wear prevents
exposure to blood and body fluid splashes
during the procedure
5. Turn on water using knee or foot pedal Water runs by gravity from fingertips to
and adjust to comfortable temperature elbows. Hands become cleanest part upper
extremities. Keeping hands elevated
allows water to flow least to contaminated
areas. Washing wide area reduces risk of
contaminating overlying gown that the
nurse later applies
6. Wet hands and arms under running Rinsing removes transient bacteria from
lukewarm water and lather with finger, hands and forearms
detergent to 5cm above elbows at all
times
7. Wash hands and arms thoroughly Removes dirt and organic material that harbor
under running water. Remember to large numbers of microorganism
keep above elbows
8. Under running water, clean under Removes dirt and organic material that harbor
nails of both hands with nail pick. large numbers of microorganisms
Discard after use
 9. Wet clean brush and apply Scrubbing loosens resident bacteria that
antimicrobial detergent. Scrub nails of adhere to the skin surfaces. Ensure coverage
one hand with 15 strokes. Holding of all surfaces-scrubbing is performed from
brush perpendicular, scrub palm, each cleanest area to marginal area
side of the thumb and fingers and
posterior side of hand with 10 strokes
each. The arm is mentally divided into
thirds and each third is scrubbed 10
times. The entire scrub should last 5-
10 minutes. Rinse brush and repeat
sequence for the other arm. A two-
brushed method may be substituted.
Check agency policy
10. Discard brush and rinse hands and After touching the skin, brush considered
arms thoroughly. Turn off water with contaminated. Rinsing removes resident
foot or knee control and back into bacteria. Prevents accidental contamination
room entrance with hands elevated in
front of and away from the body
11. Bending slightly forward at the waist, Drying prevents chapping and facilitates
use sterile towel to dry hand donning of gloves. Leaning forward prevents
thoroughly, moving from fingers to accidental contact of warms with scrub attire
elbow. Dry in a rotating motion. Dry
cleanest to least clean area
12. Repeat drying method for other hand Prevents accidental contamination indicates
by reversing towel or using a new complication from excessive hand washing.
sterile towel Signs of infection include redness, heat,
swelling, pain and drainage
13. Discard towel
14. Proceed with sterile gowning

Preparing a sterile field

Indications:
• All invasive procedures, either intentional perforation of the skin (injections, insertion of
intravenous needles or catheters) or entry into a bodily orifice (tracheobronchial
suctioning, insertion of a urinary catheter)
• Nursing measures for clients with disruption of skin surfaces or destruction of skin layers
Equipment:
• Sterile drape
• Sterile supplies

INTERVENTION RATIONALE
1. Prepare sterile field just before Prevents exposure of sterile field and supplies
planned procedure. Supplies are be to air and contamination
used immediately
2. Select clean work surface above waist Sterile object held below waist area are
level considered contaminated
3. Assemble necessary equipment Preparation of equipment in advance prevents
break in technique
4. Check dates/labels on supplies for Equipment stored beyond expiration date is
sterility of equipment considered unsterile
5. Wash hands thoroughly Prevents transmission of infection
6. Place pack containing sterile drape on Ensures sterility of packaged drape
work surface and open
 7. With fingertips of one hand, puck up One-inch border around drape is unsterile and
folded top edge of sterile drape may be touched
8. Gently lift drape up from its outer If sterile object touches any other non-sterile
cover and let it unfold by itself object, it is considered contaminated
without touching any object. Discard
outer cover with your other hand
9. With other hand, grasp adjacent corner Drape can now be properly placed while
of drape and hold it straight up and using two hands. Drape must be held away
away from your body from unsterile surfaces
10. Golding drape, first position and lay Prevents nurse from reaching over sterile field
bottom half over intended work
surface
11. Allow top half drape to be placed over Creates flat, sterile workplace
work surface last. Grasp one-inch
border around edge to position as
needed
12. Open sterile item while holding Frees dominant hand for unwrapping outer
outside wrapper in non-dominant hand wrapper
13. Carefully peel off wrapper unto non- Item remains sterile. Inner surface of wrapper
dominant hand covers hand, making it sterile
14. Be sure that the wrapper does not fall Preventing reaching over the field and
down on the sterile field. Place them contaminating its surfaces
unto field at an angle. Do not hold arm
over sterile field
15. Dispose outer wrapper Prevents accidental contamination of sterile
field
16. Perform procedure using sterile Prevents transmission of infection
technique

Applying a sterile gown and performing closed gloving

Equipment:
• Surgical cap
• Surgical mask
• Eye wear
• Foot covers
• Sterile gown
• Sterile gloves

INTERVENTION RATIONALE
1. Before entering operating room or to Prevents hair and air droplet nuclei from
treatment area, apply cap, facemask contaminating sterile work areas. Eyewear
and eyewear. Feet covers are also protects mucus membranes of eye. Foot
required inside the operating room covers are paper or cloth fit over work shoes
2. Perform thorough hand washing Removes transient and resident bacteria from
fingers, hands and forearms
3. Ask circulating nurse by opening Gown’s outer surface remains sterile
sterile pack containing sterile gown
4. Have circulating nurse prepare glove Keeps gloves sterile and allows nurse who has
package by peeling outer wrapper scrubbed to handle sterile items
open while keeping inner contents
sterile. Inner glove package is then
 placed on sterile field created by
sterile outer wrapper
5. Wash hands thoroughly Prevents transmission of infection
6. Place pack containing sterile drape on Ensures sterility of packaged drape
work surface and open
7. With fingertips of one hand, puck up One-inch border around drape is unsterile and
folded top edge of sterile drape may be touched
8. Gently lift drape up from its outer If sterile object touches any other non-sterile
cover and let it unfold by itself object, it is considered contaminated
without touching any object. Discard
outer cover with your other hand
9. With other hand, grasp adjacent corner Drape can now be properly placed while
of drape and hold it straight up and using two hands. Drape must be held away
away from your body from unsterile surfaces
10. Golding drape, first position and lay Prevents nurse from reaching over sterile field
bottom half over intended work
surface
11. Allow top half drape to be placed over Creates flat, sterile workplace
work surface last. Grasp one-inch
border around edge to position as
needed
12. Open sterile item while holding Frees dominant hand for unwrapping outer
outside wrapper in non-dominant hand wrapper
13. Carefully peel off wrapper unto non- Item remains sterile. Inner surface of wrapper
dominant hand covers hand, making it sterile
14. Be sure that the wrapper does not fall Preventing reaching over the field and
down on the sterile field. Place them contaminating its surfaces
unto field at an angle. Do not hold arm
over sterile field
15. Dispose outer wrapper Prevents accidental contamination of sterile
field
16. Perform procedure using sterile Prevents transmission of infection
technique

Nursing Skill: Wound care

Definition: Wound care includes cleaning of the wound and the use of a dressing as a protective
covering over the wound. Wound cleansing is performed to remove debris, contaminants, and
excess exudate. Sterile normal saline is the preferred cleansing solution

Purpose: The goal of wound care is to promote tissue repair and regeneration to restore skin
integrity
Assessment:

• Assess the situation to determine the need for wound cleaning and a dressing change.
Confirm any medical orders relevant to wound care and any wound care included in the
nursing plan of care.
• Assess the patient’s level of comfort and the need for analgesics before wound care.
• Assess if the patient experienced any pain related to prior dressing changes and the
effectiveness of interventions employed to minimize the patient’s pain.
• Assess the current dressing to determine if it is intact
• Assess for excess drainage, bleeding, or saturation of the dressing. Inspect the wound and
the surrounding tissue.
 • Assess the appearance of the wound for the approximation of wound edges, the color of
the wound and surrounding area, and signs of dehiscence.
• Assess for the presence of sutures, staples, or adhesive closure strips. Note the stage of
the healing process and characteristics of any drainage.
• Also assess the surrounding skin for color, temperature, and edema, ecchymosis, or
maceration.

Nursing Diagnosis:

• Acute Pain
• Impaired Skin Integrity
• Risk for Infection

Planning (SMART Form):

1. Removal of necrotic tissue by promoting mechanical debridement and supporting
autolytic debridement
2. Prevention of infection
3. Wound healing

Equipment:
• Sterile or nonsterile gloves
• Gauzes sponges
• Rolled cotton gauze and scissors (for wet-to-dry)
• 0.9% of saline solution, unless physician order specifies a different solution
• Secondary dressing supplies: surgipad, additional gauze, and tape or island dressing with
tape border
• Specialty dressing as ordered/indicated: hydrogel, transparent film, or hydrocolloid

Implementation (Step by step procedure of the nursing skill with rationale):

INTERVENTION RATIONALE

1. Review prescriber’s order Determines appropriate treatment and dressing

for patient

2. Apply and secure secondary dressing if Protects wound and decreases transmission of
indicated. Use Montgomery straps, if microorganisms
indicated, depending on type and
location of wound, and frequency of
dressing changes. Remove gloves and
discard according to institutional
policy.
3. Wash hands Reduces transmission of microorganisms

For hydrogel dressing Absorbs exudates, eliminates dead space,

4. Follow initial steps for applying a promotes moist healing, and prevents epidural
wetto-dry dressing up to and including stripping. Reduces spread of infection
drying the periwound edge: apply
dressing in size appropriate to cover
the wound. If using amorphous
hydrogel, apply to wound and cover
with gauze or composite dressing,
loosely packing if necessary. Remove
gloves and discard according to
institutional policy
5. Perform handwashing Reduces transmission of microorganisms
 For Transparent Dressing Provides a moist environment, facilitates
6. Follow initial steps for applying a autolytic debridement, protects wound from
wetto-dry dressing up to and including bacterial invasion, and protects periwound
drying the periwound edge. Apply margins from exudates
dressing with adhesive side towards
patient taking care to avoid any
creases or skin folds beneath the
dressing. Tape edges of transparent
film if dressing is in a highly mobile
area. Remove gloves and discard
according to institutional policy
7. Wash hands Reduces transmission of microorganisms

For Hydrocolloid Dressing Provides a moist environment, facilitates

8. Follow initial steps for applying a autolytic debridement, absorbs a small-
wetto-dry dressing up to and including tomoderate number of exudates, protects
drying periwound edge: Apply wound from bacterial invasion, protects
adhesive side toward patient, taking periwound margins from exudates, protects
care to avoid forming any creases or vulnerable skin from friction, and prevents
skin folds beneath the dressing. Warm edges from rolling up
the dressing by placing palm of hand
directly over dressing for 30 to 60
seconds. May apply tape to all edges if
in sacral region. Removes gloves and
discard according to institutional
policy
9. Wash hands Reduces transmission of microorganisms

Evaluation
• Assess the patient’s response and tolerance of dressing change
• Assess wound at each dressing change

Documentation:
• Assessment of wound: location, extent of tissue damage, wound appearance including
periwound, dimensions, characteristics of exudates
• Patient’s tolerance of dressing changes
• Changes in the wound

Reference:
UERMMMCI: College of Nursing Compilation of Holistic Nursing Interventions