NCM 102.1 Final Checklist

NEUROLOGIC ASSESSMENT

OBJECTIVES: 1. ________________________________________________________________________________2. ________________________________________________________________________________3. ________________________________________________________________________________

EQUIPMENTS:Reading material vials containing aromatic substances

(e.g., vanilla and coffee)Opposite tip of cotton swab or tongue blade broken in half Snellen ChartPenlight vials containing sugar or saltTongue blade two test tubes, one filled with hot waterCotton balls or cotton tipped applicators tuning forkReflex hammer

PERFORMANCE/RATIONALE/FINDINGS CHECKLISTPROCEDURE RATIONALE 1 2 3 4 5

1. See Standard Protocol before starting the procedure.

2. Assess for client’s cultural and educational background, values and beliefs.

3. Assess for sensory loss.

4. To test for client’s ORIENTATION, ask at least 5 questions and give one point for each as follows:What is the (1) year, (2) season, (3) date, (4) day, and (5) month.The perfect score is 5.

PROCEDURE RATIONALE 1 2 3 4 55. To test for client’s REGISTRATION:

a. Ask first if you may test his memory.b. Then say the names of 3 unrelated objects clearly

and slowly about 1 second for each (e.g., hospital, cucumber, school).

c. After you have said all three, ask him to repeat them. First repetition determines his score (0-3) but keep saying them until he can repeat all 3, up to 6 trials.

d. If patient does not eventually learn all three, recall cannot be meaningfully tested.

6. To assess for client’s ATTENTION and CALCULATION:a. Ask the patient to begin with 100 and count

backwards by 7. Stop after 5 substractions (93, 86, 79, 72, 65)

b. Score the total number of correct answers.c. If the patient cannot or will not perform this task,

ask him to spell the word “WORLD” backwards. The score is the number of letters in correct order (e.g., dlrow=5; dlorw=3).

7. To assess for client’s ability to RECALL:a. Ask the patient if he can recall the three words you

previously asked him to remember.b. Score 0-3.

PROCEDURE RATIONALE 1 2 3 4 58. To assess for client’s LANGUAGE thru the following:

a. NAMING: Show the client a wrist watch and ask him what it is. Repeat for Pencil. Score 0-3.

b. REPITITION: Ask the client to repeat the sentence after you. Allow only one trial. Score 0 or 1.

c. 3-STAGE COMMAND: Give the client a piece of plain blank paper and repeat the command.

d. READING: On a blank piece of paper print the sentence “CLOSE YOUR EYES” in letters large enough for the client to see clearly. Ask him to read it and do what it says. Score 1 point only if he actually closes his eyes.

e. WRITING: Give the patient a blank piece of paper and ask him to write a sentence for you. Do not dictate a sentence; it is to be written spontaneously. It must contain a subject and verb and be sensible. Correct grammar and punctuation.

f. COPYING. On a clean sheet of paper, draw intersecting pentagons, each side about 1 inch, and ask him to copy it exactly as it is. All 10 angles must be present and two must intersect to score 1 point. Tremor and rotation are ignored.Estimate the client’s level of sensorium along a continuum, from alert on the left to coma on the right.

9. To assess for client’s consciousness using the Glasgow Coma Scale, familiarize first the standardized table.

PROCEDURE RATIONALE 1 2 3 4 510. To check for EYE OPENING RESPONSE:

a. When you enter the client’s room, try to close the door louder than the usual. If the client spontaneously opens his eyes, the score is 4.

b. If without response, greet the client and ask him a simple question. If there is eye opening upon hearing you speak, the score is 3.

c. If still with no response, elicit pain by pressing at the client’s fingernail bed. Score then is 2 if the client opens his eyes upon feeling the pain. If still without response, the score is 1.

11. To check for the BEST VERBAL RESPONSE:a. Ask the client a simple question like, “What time of

the day it is?”b. Base from his answer, grade him with appropriate

score for his response as follows:ORIENTED: 5CONFUSED: 4INAPPROPRIATE WORDS: 3INCOMPREHENSIBLE SOUNDS:2NONE: 1

12. To test for the last category of GCS, BEST MOTOR RESPONSE to painful stimuli:

a. Press the client’s fingernail bed.b. Record BEST UPPER LIMB RESPONSE with the

appropriate score as follows:OBEYS COMMANDS: 6LOCALIZED PAIN: 5FLEXION WITHDRAWAL: 4ABNORMAL FLEXION: 3ABNORMAL EXTENSION: 2FLACCID: 1

PROCEDURE RATIONALE 1 2 3 4 513. Add the client’s score based from EYE OPENING RESPONSE,

BEST VERBAL RESPONSE, and BEST MOTOR RESPONSE.

14. To test for the client’s DEEP TENDON REFLEXES:a. BICEPS REFLEX: Support the client’s forearm on

yours. Place your thumb on the biceps tendon and strike a blow on your thumb.

b. TRICEPS REFLEX: Tell the client to let the arm “just go dead” as you suspend it by holding the upper arm. Strike the triceps tendon directly just above the elbow. Alternately, hold the client’s write across the chest to flex the arm at the elbow, and tap the tendon.

c. BRACHIORADIALIS REFLEX: Hold the client’s thumb to suspend the forearms in relaxation. Strike the forearm directly about 2 to 3 cm above the radial styloid process.

d. QUADRICEPS REFLEX (Knee jerk): Let the lower legs dangle freely to flex the knee and stretch the tendons. Strike the tendon directly just below the patella.

e. ACHILLES REFLEX (Ankle jerk): Position the client with the knee flexed and the hip externally rotated. Hold the foot in dorsiflexion, and strike the Achilles tendon directly.

f. For the client in the supine position, flex one knee and support that lower leg against the other leg so that it falls open. Dorsiflex the foot and tap the tendon.

PROCEDURE RATIONALE 1 2 3 4 515. To test for SUPERFICIAL REFLEXES:

a. ABDOMINAL REFLEX: Have the client assume a supine position, with the knees slightly bent. Use the handle end of the reflex hammer to stroke the skin. Move from the side of the abdomen toward the midline at both the upper and lower abdominal levels. When the abdominal wall is very obese, pull the skin to the opposite side, and feel it contract toward the stimulus.

b. PLANTAR REFLEX: Position the thigh in slight external rotation. With the rflex hammer, draw a light stroke up the lateral side of ths ole of the foot and inward across the ball of the foot, like an upside down J.

c. CORNEAL REFLEX: Remove any contact lenses. With the client looking forward bring a wisp of cotton in from the side (to minimize defensive blinking) and lightly touch the cornea, not the conjunctiva.

d. ABDOMINAL REFLEX: Have the client assume a supine position. With the knees slightly bent, use the handle end of the reflex hammer, a wood applicator tip, or the end of a split tongue blade to stroke the skin. Move from the side of the abdomen toward the midline at both the upper and lower abdominal levels.

PROCEDURE RATIONALE 1 2 3 4 516. To test for the client’s major muscle tone and strength, the

following scale is used:

MUSCLE FUNCTION LEVEL GRADE

No evidence of contractility 0Slight contractility, no movement 1Full range of motion, gravity eliminated 2Full range of motion with gravity 3Full range of motion against gravity, 4 with some resistanceFull range of motion against gravity, 5

With full resistance

17. To assess for the MUSCLE TONE:a. The client is asked to allow an extremity (e.g., an

arm) to relax or hang limp.b. The extremity is supported and each limb is grasped

moving it through the normal range of motion.c. Do the same on the lower extremity.\

18. To assess for the MUSCLE STREGNTH:a. Let the client assume a stable position and ask him

to first flex the muscle to be examined and then to resist when you apply opposing force against that flexion.

b. Instruct the client not to move the joint.c. To test for the STERNOCLEIDOMASTOID muscle,

place hand firmly against client’s upper jaw. Ask the client to turn head laterally against resistance.

PROCEDURE RATIONALE 1 2 3 4 5d. To test for the shoulder (trapezius), place hand over

midline of client’s shoulder, exerting firm pressure. Have the client raise shoulders against resistance.

e. To test for the ELBOW1) BICEPS: Pull down on forearm as client

attempts to flex arm.2) TRICEPS: As client’s arm is flexed, apply

pressure against forearm. Ask client to straighten arm.

f. To test for the HIP1) QUADRICEPS: When client is sitting, apply

downward pressure to thigh. Ask client to raise leg up from the table.

2) GASTROCNEMIUS: Client sits holding shin of flexed leg. Ask him to straighten leg against resistance.

19. To test for the CRANIAL NERVESa. CRANIAL NERVE I: OLFACTORY NERVE

1) Occlude one nostril at a time and ask the client to sniff.

2) Ask the client to close his eyes and occlude one nostril at a time, presenting an aromatic substance.

b. CRANIAL NERVE II: OPTICE NERVE (Central Visual Acuity)

1) If the client is wearing corrective glasses or contact lens, leave them on. Remove only reading glasses.

2) Position the client on a mark exactly 20 feet from the chart. Hand him an opaque card with which to shield one eye at a time.

3) Ask the client to read through the chart to the smallest line of letters possible. Encourage the person to try the next smallest line also. (Use a Snellen Chart “E” for clients who cannot read letter.)

4) Test near vision using a newspaper. Hand the client an opaque card with which to shield one eye at a time. Hold the card in good light about 35 cm from the eye.

c. CRANIAL NERVE III, IV and VI: OCULOMOTOR,

TROCHLEAR, and ABDUCENS NERVES1) Gauge the pupil size in millimeters.2) Darken the room and ask the person to

gaze into the distance. Advance a light from the side and note the response.

3) Gauge the pupil size in millimeters and compare with baseline.

4) Ask the person to focus on a distant object. Then have the person shift the gaze to a near object (e.g., your finger) held about 7 to 8 cm (3 inches) from the nose.

5) Record the normal response as PERRLA DIAGNOSTIC POSITION TEST

1) Ask the client to hold the head steady and to follow the movement of your penlight only with the eyes. Hold the target back about 12 inches so the client can focus on it comfortably, and move it to each of the six position; hold it momentarily, then back to center. Progress clockwise.

d. CRANIAL NERVE V: TRIGEMINAL NERVE1) MOTOR function:

a) Assess the muscles of mastication by palpating the temporal and masseter muscles as the client clenches the teeth. Assess also for pain.

b) Try to separate the jaws by pushing down on the chin.

2) SENSORY function:a) Ask the client to close his eyes then

touch a cotton wisp to designated areas: forehead, cheeks and chin. Ask him to say “now” whenever the touch is felt.

3) CORNEAL REFLEX:a) Let the client remove contact lenses. With the client looking forward, bring a wisp of cotton from the side (to minimize defensive blinking) and lightly touch the cornea, not the conjuctiva.

e. CORNEAL NERVE VII: FACIAL NERVE1) MOTOR fuction:

a) Note mobility and facial symmetry as the client responds to these requests: smile, frown, close eyes tightly (against your attempt to open them), lift eyebrow, show teeth and puff cheeks.

b) Press the client’s puffed cheeks in and note that the air should escape equally from both sides.

2) SENSORY functiona) Apply to the tongue a cotton

applicator covered with a solution of sugar or salt. Ask the client to identify the taste.

f. CRANIAL NERVE VIII: ACOUSTIC (Vestibulocochlear) NERVEVOICE TEST

1) Test on ear at a time while masking hearing in the other ear to prevent sound transmission around the head. With your head 1 to 2 feet from the client’s ear, exhale and whisper slowly some two syllable words (e.g., Monday, candy, peaceful).

2) Shield your lips as you speak. TUNING FORK TEST (Weber Test)

1) Activate the tuning fork, hold it by the stem and strike the tines softly on the back of your hand.

2) Place a vibrating tuning fork in the midline of the client’s skull and ask if the tone sound the same in both ears or better in one.

g. CRANIAL NERVE IX and X: GLOSSOPHARYNGEAL and VAGUS NERVESMOTOR function

1) Depress the tongue with a tongue blade,

and note pharyngeal movements as the client says “ahh” or yawns; the uvula and the soft palate should rise in the midline, and the tonsillar pillars should move medially.

2) Touch the posterior pharyngeal wall with a tongue blade, and note the gag reflex. Also note that the voice sounds smooth and not strained.

h. CRANIAL NERVE XI: SPINAL ACCESSORY NERVE1) Examine the sternocleidomastoid and

trapezius muscles for equal size. Check equal strength by asking the client to rotate the head forcibly against resistance applied to the side of the chin. Then ask the client to shrug the shoulders against resistance.

i. CRANIAL NERVE XII: HYPOGLOSSAL NERVE1) Inspect the tongue. No wasting or tremors

should be present. Note the forward thrust in the midline as the client protrudes the tongue. Also ask the client to say “bright, light, might”

20. See Standard Protocol after the whole procedure.

ENDOTRACHEAL AND TRACHEOSTOMY TUBE SUCTIONING

Definition:

An endotracheal tube is inserted by the physician or nurse with specialized education through either the mouth or the nose and into the trachea with

the guide of a laryngoscope. The tube terminates just superior to the bifurcation of the trachea into the bronchi. Because the tube passes through the

epiglottis and glottis, the client is unable to speak while it is in place.

A tracheostomy is a surgical incision into the trachea to insert a tube through which the patient can breathe more easily and secretions can be

removed. It is performed more commonly as a prophylactic procedure so that secretions in there respiratory tract can be removed more effectively before a

patient’s breathing is severely. Because the tracheostomy opens directly into the trachea, which is highly susceptible to infection, the nurse must have a

thorough knowledge of sterile technique to care for and suction a tracheostomy.

Parts Of A Tracheostomy Tube:

1. Inner cannula - the "sleeve" inside of the tracheostomy tube that can be removed for cleaning.

2. Neck plate (flange) - site for ties; prevents movement and skin-breakdown secondary to pressure points.

3. Obturator - a guide for positioning the actual trach tube.

4. Cuff - inflates with air inside the trachea to seal the trach wall, preventing aspiration and potential air leak around the cannula. Cuffed trach tubes

are used predominately for patients who require mechanical ventilation with high pressures. For patients requiring only nocturnal ventilation, the

cuff can be deflated during the day.

Types of Tracheostomy Tubes:

Composition - The tube material is chosen on desired flexibility. Metal tubes (Jackson tubes) are rigid. Silicone tubes are very flexible. Polyvinyl

chloride (PCV) tubes may be flexible or rigid. Shiley and Portex are plastic tubes.

Double-cannula tube - Contains a removable, inner cannula. Double-cannula tubes are used mostly for children with thick, copious secretions.

Cleaning the inner cannula avoids frequent tracheostomy tube (outer cannula) changes. Can be cuffed or un-cuffed depending on the indication.

Single-cannula tube - Used mostly for infants and small children. Single-tubes are typically plastic and uncuffed.

Fenestrated tube - Contains an opening on the superior portion of the cannula, where air can travel from the vocal cords, into the cannula, and up

through the fenestration to the oropharynx. This allows the patient to vocalize.

Indications:

This procedure is indicated when the client:

1. Has endotracheal or tracheostomy tube in place;

2. Is unable to cough and expectorate secretions effectively (e.g., infants and comatose patients);

3. Makes light bubbling or rattling breath sounds that indicate the accumulation of secretions in the respiratory tract; and

4. Is dyspneic or appears cyanotic.

Purposes:

1. To remove secretions that obstruct the airway;

2. To facilitate respiratory ventilation;

3. To obtain secretions for diagnostic purposes; and

4. To prevent infection that may result from accumulated secretions in the respiratory tract.

Special Considerations:

1. Maintain the sterility of the dominant glove, suction catheter, normal saline, and syringe, if used.

2. Assess the client’s respirations, pulse, color, breath sounds, and behavior before and after the procedure.

3. For clients who do not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning.

4. For clients who have copious secretions, increase the oxygen liter flow before suctioning.

5. Use appropriate suction pressure.

6. Restrict each suction time to 10 seconds and total suctioning time to no more than 5 minutes.

7. Reapply supplementary oxygen as required during and after the procedure.

8. Replenish supplies in readiness for the next suction.

Equipments:

1. Rescuscitation bag (Ambu bag) connected to 100% oxygen

2. Sterile towel (optional)

3. Portable or wall suction machine with tubing and collection

receptacle.

4. Sterile disposable container for fluids

5. Sterile normal saline or water

6. Sterile gloves

7. Goggles and mask if necessary

8. Gown (if necessary)

9. Sterile suction catheter

10. Y-connector

11. Sterile gauzes

12. Moisture-resistant disposable bag

PROCEDURE RATIONALE 1 2 3 4 5Assessment

1. Assess the needs of the patient with a

tracheostomy/endotracheal tube for suctioning.

Planning

2. Wash your hands.

3. Obtain tracheostomy or endotracheal suctioning kit.

Implementation

4. Identify the patient.

Assessment



Planning

6. Wash your hands.


Implementation





Planning

10. Wash your hands.


Implementation


13. Provide privacy.

14. Explain the procedure carefully.

Ask the responsive patient to cough.

An explanation should also be given to the unresponsive

patient.

PROCEDURE RATIONALE 1 2 3 4 515. Establish a way patient can communicate.

16. Test suction apparatus.

a. Turn on either the wall suction or the portable suction

machine.

b. Place your thumb over the end of the unsterile tubing

that is attached to the suction equipment and test for

“pull.”

c. Keep the suction regulated to a range of efficiency,

usually low to medium.

17. Position the patient: Supine or mid-fowler’s with head

slightly toward you if conscious; lateral position facing you

if unconscious.

18. Put on eye protection and mask.

19. Prepare 5 mL sterile saline in a syringe; remove needle.

PROCEDURE RATIONALE 1 2 3 4 520. Open kit and prepare equipment.

a. Place drape or towel over patient’s chest.

b. Put on gloves.

c. Open and pour saline.

d. Attach catheter to suction tubing, and moisten catheter

in normal saline solution.

21. Attach breathing bag to oxygen source.

22. Attach breathing bag to tracheostomy/endotracheal tube

and provide three breaths as the client inhales. If the client

has copious secretion, do not hyperventilate with a

resuscitator. Instead, keep the regular O2 device on and

increase the liter flow or adjust the FiO2 to 100% for

several breaths before suctioning.

23. Instill saline into tracheostomy/endotracheal tube (if this is

the policy).

PROCEDURE RATIONALE 1 2 3 4 524. Quickly but gently insert the catheter without applying any

suction.

Insert the catheter about 12.5 cm (5 inches) for adults with

Tracheostomy tube or until the client coughs or you feel

resistance.

25. Perform suctioning.

A. Apply intermittent suction for 5-10 seconds by placing

the non-dominant thumb over the thumb port.

B. Rotate the catheter by rolling it between you thumb

and forefinger while slowly withdrawing it.

C. Rinse the catheter with sterile water of normal saline

solution.

D. Provide ventilation immediately after the suction

catheter is removed (usually done by an assistant) to

supply needed oxygen.

E. Stop the procedure when there is persistent coughing.

PROCEDURE RATIONALE 1 2 3 4 526. Observe the patient for dyspnea and skin color changes.

27. If these symptoms of hypoxia occur, provide additional

deep breaths of oxygen.

28. Turn off the suction and listen for clear breath sounds.

29. If the breathing sounds are not clear, repeat steps 17a

through d.

30. If the breathing sounds clear, use the breathing bag to

provide three or four deep breaths of oxygen.

31. Disconnect the catheter from the suction tubing.

32. Pull sterile glove over catheter to cover it, and remove eye

protection and mask.

33. Discard disposable equipment, and take nondisposable

equipment to appropriate place for cleaning.

34. Wash your hands.

PROCEDURE RATIONALE 1 2 3 4 535. Perform oral hygiene.

Evaluation

36. Evaluate using the following criteria:

a. Tracheostomy/endotracheal tube securely in place.

b. Respiratory rate and depth normal.

c. Breath sounds clear.

d. Patient resting comfortably.

Documentation

37. Document the procedure and observations. Include the

amount and description of suction returns and any other

relevant assessments.

DEFLATING AND INFLATING A CUFFED TRACHEOSTOMY TUBE

Definition:

A cuffed trachestomy tube compounds the nursing care requirements of the patient in acute respiratory failure. To give intelligent, knowledgeable

care, it is essential to have a thorough understanding of the cuffed tube – its design, purpose, principles of use, and the potential dangers associated with it.

The cuff is so design that when it is properly inflated, it forms a seal between the tracheostomy tube and the trachea, preventing air from entering or

escaping around the tube. The cuff, usually made of soft rubber, encircles the lower portion of the outer cannula of the tracheostomy tube. Once the

tracheostomy tube is in place in the patient’s trachea, the cuff is inflated to form the seal. The only route of effective air exchange; with the cuff inflated, is

the lumen of the tracheostomy tube. The inflated cuff also reduces the possibility of aspiration of secretions into the lower trachea and bronchi. Nothing gets

by the seal created in the trachea by the inflated cuff.

Purposes:

Cuffed tracheastomy tubes are generally inflated:

1. During the first 12 hours after a tracheostomy;

2. When the client is being ventilated or receiving IPPB therapy, to prevent leakage;

3. When the client is eating or receiving oral medications, and for a prescribed period of time following meals or medications (e.g., 30 minutes), to

prevent aspiration; and

4. When the client is comatose, to prevent aspiration of oropharyngeal secretions.

At other times the cuff is deflated. If double-cuffed tubes are used, deflation and inflation must be done at regular intervals according to the

manufacturer’s directions.

Critical Elements:

For cuff deflation:

1. Maintain asepsis when suctioning.

2. Suction the oropharngeal cavity adequately before cuff deflation.

3. Withdraw the correct amount of air while the client inhales and while providing a positive pressure breath if ordered.

4. If the cough reflex is stimulated after deflation, suction the lower airway.

For cuff inflation:

1. Inflate the cuff on inhalation.

2. Follow the minimal leak technique.

3. Make sure the cuff pressure does not excess 15-20 mm Hg or 25 cm H2O.

4. Clamp the inflation tube if required.

5. Document the exact amount of air used to inflate the cuff.

Equipments :

1. Equipment needed for suctioning the oropharyngeal cavity

2. 5- to 10- ml syringe

3. Stethoscope

4. Rubber-tipped hemostat

5. Manual resuscitator (Ambu bag)

6. Manometer specifically designed to measure cuff pressure (if available)

7. Sterile three-way stopcock (optional)

PROCEDURE RATIONALE 1 2 3 4 51. Check the physician’s orders to determine when the cuffed

tube should be inflated.

2. Assist the client to a semi-fowler’s position unless

contraindicated. Clients receiving positive pressure ventilation

should be placed in a supine position so that secretions above

the cuff site are moved up into the mouth.

3. Assess the client’s respiration, pulse, color, breath sounds, and

behavior.

Deflating the Cuff

4. Suction the oropharyngeal cavity before inflating the cuff.

Discard the catheter after use.

5. If a hemostat is clamping the cuff inflation tube, unclamp it.

Some tubes have one-way valves that replace the hemostat.

6. Attach the 5- or 10-ml syringe to the distal end of the inflation

tube, making sure the seal is tight.

7. Suction the lower airway with a sterile catheter, if the cough

reflex is stimulated during cuff deflation.

PROCEDURE RATIONALE 1 2 3 4 58. Assess the client’s respirations, and suction the client as

needed. If the client experiences breathing difficulties,

reinflate the cuff immediately.

Inflating the Tracheal Cuff

9. Add the least amount of air following the manufacturer’s

recommendations, to create a minimal air leak. The minimal

leak technique is designed to prevent tracheal damage and is

performed as follows:

a. Inflate the cuff on inhalation, and place your

stethoscope on the client’s neck adjacent to the

trachea.

b. Listen for squeaking or gurgling sounds, which indicate

a leak.

c. If no leak is present, slowly remove 0.2-0.3 ml more air.

d. Listen again for sounds.

PROCEDURE RATIONALE 1 2 3 4 5e. The cuff is inflated sufficiently when:

You cannot hear the client’s voice.

You cannot feel any air movements from the client’s

mouth, nose, or tracheostomy site.

You hear a slight or no leak from the positive

pressure ventilation when auscultating the neck

adjacent to the trachea during inspiration.

10. Measure the cuff pressure:

a. Attach the cuff’s pillow port to the cuff pressure

manometer.

b. Read the dial on the manometer. The pressure should

not exceed 15-20 mm Hg or 25 cm H2O.

11. Clamp the inflation tube with the hemostat if the tube does not

have a one-way valve.

12. Remove the syringe.

13. Determine the exact amount of air used to inflate the cuff.

14. Document the time of the deflation and/or inflation, the

amount of air withdrawn and/or injected, and your

assessments.

CLEANING A DOUBLE-CANNULA TRACHEOSTOMY TUBE

Definition:

The Universal is most commonly used tracheostomy tube. Also known as the "double-luman" or "double-cannula" tube, the Universal consists of three

parts: the outer cannula (with cuff and pilot tube), the inner cannula, and the obturator.

Purposes:

1. To maintain the patency of the tube; and

2. Prevent infection.

Equipments:

1. Sterile bowls for the cleaning solutions

2. Cleaning solutions: hydrogen peroxide and sterile normal saline

3. Sterile nylon brush or pipe cleaners to clean the lumen of the inner cannula

4. Sterile gauze squares or sterile cotton-tipped applicator sticks to clean the flange of the outer cannula

5. Sterile gloves (1 pair and 1 glove or 2 pairs)

6. Clean glove

http://www.answers.com/topic/obturator

http://www.answers.com/topic/cuff

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http://www.kokenmpc.co.jp/english/products/medical_plastics/tracheal_tube/pp_cannula_w/product_l.html

Critical Elements:

1. Suction the inner cannula before its removal.

2. Remove the tracheostomy dressing and inner cannula with your nondominant clean hand.

3. Wear sterile gloves on both hands to clean the tube.

4. Inspect the cannula for cleanliness and remove excess liquid from it before insertion.

5. Suction the outer cannula before insertion the inner cannula.

6. Lock the inner cannula after insertions.

PROCEDURE RATIONALE 1 2 3 4 51. Don an unsterile glove on the nondominant hand and a sterile

glove on your dominant hand.

2. Suction the entire length of the inner cannula prior to its

removal.

3. With your nondominant hand, which is wearing a clean glove,

remove and discard the tracheostomy dressing.

4. With the nondominant hand, unlock the inner cannula by

turning the lock about 900 counterclockwise.

5. With the nondominant hand, remove the inner cannula by

gently pulling it out toward you in line with its curvature.

6. Soak the inner cannula in the hydrogen peroxide solution for

several minutes.

PROCEDURE RATIONALE 1 2 3 4 57. Remove the gloves and replace with sterile gloves on both

hands.

8. Remove the cannula from the soaking solution Clean the

lumen and entire inner cannula thoroughly, using the pipe

cleaners or brush moistened with sterile saline.

9. Agitate the cannula for several seconds in the sterile saline.

10. Inspect the cannula for cleanliness by holding it at eye level

and looking though it into the light. If encrustations are

evident, repeat steps 6, 8, and 9.

11. After rinsing the cannula, gently tap it against the inside edge

of the sterile solution bowl.

12. Dry the inside of the cannula by using two or three pipe

cleaners twisted together. Do not dry the outer surface.

13. Suction the outer cannula.

14. Clean the flange of the outer cannula if necessary, using

cotton-tipped applicators or gauze squares moistened with

sterile saline.

PROCEDURE RATIONALE 1 2 3 4 515. Grasp the outer flange of the inner cannula and insert the

cannula in the direction of its curvation.

16. Lock the inner cannula in place by turning the lock clockwise

about 900 to an upright position.

17. Gently pull on the inner cannula to ensure that the position is

secure.

18. Clean the tracheostomy site, and apply a new tracheostomy

dressing.

19. Document removal, cleaning, and reinsertion of the cannula

and all assessments.

PROVIDING TRACHEOSTOMY CARE

Definition:

The nurse provides tracheostomy care for the client with a new or recent tracheostomy to maintain patency of the tube and reduce the risk of

infection. Initially, a tracheostomy may need to be suctioned and clean as often as every 1 to 2 hours. After the initial inflammation response subsides,

tracheostomy care may only need to be done once or twice a day, depending on the client.

Purposes:

1. To maintain airway patency.

2. To maintain cleanliness and prevent infection at the tracheostomy site

3. To facilitate healing and prevent skin excoriation around the tracheostomy incision

4. To promote comfort.


1. Suction the inner cannula before its removal.

2. Remove the tracheostomy dressing and inner cannula with your non-dominant clean hand.

3. Wear sterile gloves on both hands to clean the tube.

4. Inspect the cannula for cleanliness and remove excess liquid from it before insertion.

5. Lock the inner cannula after insertion.

6. Assess the status of the incision and surrounding skin.

7. Use noncotton-filled gauze square for cleaning and for the dressing.

8. Securely support the tracheostomy tube when cleaning it, and when applying the dressing and tie tapes.

9. Always fasten clean ties before removing soiled ties unless an assistant to hold the tracheostomy tube in place is available.

Equipments:

Scissors

1 pair of clean gloves

1 pair of sterile gloves

Hydrogen peroxide

Normal saline

Tracheostomy kit (4x4-inch gauze, cotton-tipped applicators,

tracheostomy dressing, basin, small bottle brush or pipe

cleaner, twill tape or tracheostomy ties/collar)

Oral care equipment

Bag for soiled dressings


1. Although done routinely after tracheostomy care, assess

the patient’s dressing for drainage or soiling.

Planning

2. Wash your hands.

3. Obtain tracheostomy care kit.

Implementation


5. Provide privacy.

6. Explain what you are going to do.

PROCEDURE RATIONALE 1 2 3 4 57. Put on clean gloves, and remove old dressing and discard.

a. Hold tube while you remove dressing.

b. Place your fingers around tube while you remove

dressing.

8. Remove gloves and wash hands.

9. Put on sterile gloves.

10. With sterile, moistened swabs, clean around edges of

tracheostomy opening.

11. Note any redness or swelling.

12. Prepare the dressing using precut or 4x4 gauze squares:

a. If 4x4 gauze, open first fold.

b. Fold in half lengthwise.

c. Fold each end toward center.

13. Secure the tube by gently holding in place. Cut and remove

soiled tape.

PROCEDURE RATIONALE 1 2 3 4 514. Position new dressing.

a. Thread tape through flange on one side.

b. Bring tape around back of patient’s neck.

c. Pass tape through opposite flange.

d. Tie tape securely at side of neck.

It is helpful for you or the patient to hold a finger under

the tape as it is tightened.

15. Check tube placement.

16. Perform oral care.

17. Dispose of equipment.

PROCEDURE RATIONALE 1 2 3 4 518. Remove gloves, and wash your hands.

Evaluation

19. Evaluate, using the following criteria:

a. Tracheostomy tube securely in place.

b. No redness or swelling present.

c. No secretions present.

d. Dressing and tapes clean and dry.

e. Absence of stale or foul-smelling breath.

Documentation

20. Document procedure and any observations such as status

of surrounding skin and amount of type of drainage.

ASSISTING WITH THE INSERTION AND REMOVAL OF A CHEST TUBE

Definition:

Chest tubes are inserted and removed by the physician with the nurse assisting. Both procedures require sterile technique and must be done without

introducing air or microorganisms into the pleural cavity. After the insertion, an x-ray film is taken to confirm the position of the tube. Chest tubes are

generally removed within 5-7 days. Before removal, the tube is clamped with two large, rubber-tipped clamps for 1-2 days to assess for signs of respiratory

distress and to determine whether air or fluid remains in the pleural space. An x-ray film of the chest is generally taken 2 hours after tube clamping to

determine full lung expansion. If the client develops signs of respiratory distress or the film indicates pneumothorax, the tube clamps are removed, and

chest drainage is maintained. If neither occurs, the tube is removed. Another x-ray film of the chest is often taken after removal to confirm full lung

expansion.

Equipment:

For tube insertion:

- A sterile chest tube tray, which includes

. Drapes

. A 10-ml syringe

. Sponges to clean the insertion area with antiseptic

. A 1-in. #22 gauge needle

. A 5/8-in. #25 gauge needle for the local anesthetic

. A scalpel

. Forceps

. Two rubber-tipped clamps for each tube inserted

. Several 4 x 4 gauze squares

. Split drain gauzes

. A chest tube with a trocar

. Suture materials (eg, 2-0 silk with a needle)

- A pleural drainage system with sterile drainage tubing and

connectors

- A Y-connector, if two tubes will be inserted

- Sterile gloves for the physician and the nurse

- A vial of local anesthetic (eg, 1% lidocaine)

- Alcohol sponges to clean the top of the vial

- Antiseptic (eg, povidone-iodine)

- Tape (nonallergenic is preferable)

- Sterile petrolatum gauze (optional) to place around the

chest tube

For tube removal:

- Clean gloves to remove the dressing

- Sterile gloves to remove the tube

- A sterile suture removal set, with forceps and suture

scissors

- Sterile petrolatum gauze

- Several 4 x 4 gauze squares

- Air-occlusive tape, 2 or 3 in. wide (nonallergenic is

preferred)

- Scissors to cut the tape

- An absorbent linen-saver pad

- A moistureproof bag

- Sterile swabs or applicators in sterile containers to obtain a

specimen (optional)

Intervention:

Assessment

Essential data include

. Vital signs for baseline data and then every 4 hours.

. Breath sounds. Auscultate bilaterally for baseline data. Diminished or absent breath sounds indicate inadequate lung expansion and recurrent

pneumothorax after chest drainage is established.

. Clinical signs of pneumothorax before and after chest tube insertion. Leakage or blockage of a chest tube can seriously impair ventilation. Signs

include sharp pain on the affected side; weak, rapid pulse; pallor; vertigo; faintness; dyspnea; diaphoresis; excessive coughing; and blood-tinged sputum.

. Chest movements. A decrease in chest expansion on the affected side indicates pneumothorax.

. Dressing site. Inspect the dressing for excessive and abnormal drainage, such as bleeding or foul-smelling discharge. Palpate around the dressing

site and listen for a crackling sound indicative of subcutaneous emphysema can result from a poor seal at the chest tube insertion site. It is manifested by a

“crackling” sound that is heard when the area around the insertion site is palpated.

. Level of discomfort. Analgesics often need to be administered before the client moves or does deepbreathing and coughing exercises.

Chest Tube Insertion:

PROCEDURE RATIONALE 1 2 3 4 51. Assist the client to a lateral position with the area to receive

the tube facing upward. Determine from the physician whether

to have the bed in the supine position or semi-Fowler’s

position.

2. Open the chest tube tray and the sterile gloves on the overbed

table. Pour antiseptic solution onto the sponges. Be sure to

maintain sterile technique.

3. Wipe the stopper of the anesthetic vial with an alcohol sponge.

After the physician dons the gloves and cleans the insertion

area with antiseptic solution, invert the vial and hold it for the

physician to withdraw the anesthetic.

4. Support and monitor the client as required, while the physician

anesthetizes the area, makes a small incision, inserts the tube,

either clamps the tube or immediately connects it to the

drainage system, and then sutures the tube to the skin.

5. Optional: Don sterile gloves. Wrap a piece of sterile petrolatum

gauze around the chest tube. Place drain gauzes around the

insertion (one from the top and one from the bottom). Place

several 4 x 4 gauze squares over these.

PROCEDURE RATIONALE 1 2 3 4 56. Remove your gloves, if donned, and tape the dressings,

covering them completely.

7. Tape the chest tube to the client’s skin away from the insertion

site.

8. Tape the connections of the chest tube to the drainage tube

and to the drainage system.

9. Coil the drainage tubing, and secure it to the bed linen,

ensuring enough slack for the person to turn and move.

10. When all drainage connections are completed, ask the client to

a. Take a deep breath and hold it for a few seconds.

b. Slowly exhale.

11. Assess the client’s vital signs every 15 minutes for the first

hour following tube insertion and then as ordered, eg, every

hour for 2 hours, then every 4 hours or as often as health

indicates.

PROCEDURE RATIONALE 1 2 3 4 512. Auscultate the lungs at least every 4 hours for breath sounds

and the adequacy of ventilation in the affected lung.

13. Place rubber-tipped chest tube clamps at the bedside.

14. Assess the client regularly for signs of pneumothorax and

subcutaneous emphysema.

Chest Tube Removal:PROCEDURE RATIONALE 1 2 3 4 5

1. Administer an analgesic, if ordered, 30 minutes before the

tube is removed.

2. Ensure that the chest tube is securely clamped.

3. Assist the client to a semi-Fowler’s position or to a lateral

position on the unaffected side.

4. Put the absorbent pad under the client beneath the chest tube.

5. Open the sterile packages, and prepare a sterile field.

PROCEDURE RATIONALE 1 2 3 4 56. Wearing sterile gloves, place the sterile petrolatum gauze on a

4 x 4 gauze square.

7. Removed the soiled dressings, being careful not to dislodge

the tube. Remove the underlying gauzes, which may contain

drainage. Discard soiled dressings in the moistures-resistant

bag.

8. The physician will

a. Don sterile gloves.

b. Hold the chest tube with forceps.

c. Cut the suture holding the tube in place.

d. Instruct the client to either inhale or exhale fully and

hold the breath while removing the tube.

e. Place the prepared petrolatum gauze dressing over the

insertion site immediately after tube removal.

9. While the physician is removing the tube, remove gloves and

prepare three 15-cm (6 in.) strips of air-occlusive tape.

PROCEDURE RATIONALE 1 2 3 4 510. After the gauze dressing is applied, completely cover it with

the air-occlusive tape.

11. If a specimen is required for culture and sensitivity, use a swab

to obtain drainage from inside the chest tube, while the

physician holds the tube.

12. Monitor the vital signs, and assess the quality of the

respirations as health indicates, eg, every 15 minutes for the

first hour following tube removal and then less often.

13. Auscultate the client’s lungs every hour for the first 4 hours to

assess breath sounds and the adequacy of ventilation in the

affected lung.

14. Assess the client regularly for signs of pneumothorax,

subcutaneous emphysema, and infection.

15. Document the date and time of chest tube insertion or removal and

the name of the physician. For insertion, document the insertion site,

drainage system used, presence of bubbling, vital signs, breath

sounds by auscultation, and any other assessment findings. For

removal, document the amount, color, and consistency of drainage,

vital signs, and the specimen obtained for culture, if taken.

Critical Elements of Assisting With The Insertion and Removal of a Chest Tube:

- Assess the client’s vital signs, bilateral breath sounds and chest movements, skin color, character of sputum, and level of discomfort before and after

chest tube insertion and removal.

- Maintain sterile technique.

For chest tube insertion:

- Apply appropriate dressings to the chest tube site.

- Tape the chest tube to the client appropriately to prevent dislocation.

- Tape all chest and drainage tube connections.

- Place rubber-tipped chest tube clamps at the bedside.

For chest tube removal:

- Administer ordered analgesic before the procedure.

- Clamp the chest tube securely before the procedure.

- Quickly provide an airtight dressing over the insertion site after removal.

ESTABLISHING A CHEST DRAINAGE SYSTEM

Definition:

Before setting up a chest drainage system, determine from the physician’s orders the type of system and whether suction is required. Surgical

aseptic technique is followed strictly when setting up chest drainage to prevent microorganisms from entering the system and subsequently entering the

client’s pleural cavity.

Equipment:

- Sterile distilled water

- Adhesive tape

- Sterile clear plastic tubing

- Sterile tubing connectors

- A drainage rack. Racks are supplied by the manufacturer for

disposable unit systems

- Two rubber-tipped Kelly clamps

- Suction apparatus, if ordered

- The drainage system

If the agency does not supply partially assembled systems, the following equipment is needed:

For a one-bottle system:

- A sterile 2-L bottle

- A sterile short glass tube

- A sterile long glass tube

- A sterile rubber stopper with two holes

For a two-bottle gravity system:

- Two sterile 2-L bottles


- Three sterile short glass tubes

- One sterile long glass tube

- Two sterile rubber stoppers with two holes

For a two-bottle suction system:

- Two sterile 2-L bottles


- Three sterile short glass tubes

- Two sterile long glass tube

- Two sterile rubber stoppers: one with two holes

For a three-bottle system:

- Three sterile 2-L bottles


- Five sterile short glass tubes

- Two sterile long glass tubes

- Three sterile rubber stoppers: with two holes, and one with three

holes

For a Pleur-evac or Argyle system

- Sterile distilled water

- A sterile 50-ml Asepto (bulb) syringe

For a Thora-Drain III system:

- Bottle of sterile distilled water or normal saline.

This system has larger caps through which water can be poured

directly from the bottle.

PROCEDURE RATIONALE 1 2 3 4 5One-Bottle System:

1. Fill the bottle with about 300 ml of sterile distilled water

2. Insert one short glass tube and one long glass tube through

the rubber stopper.

3. Attach the rubber stopper with the glass tubes to the bottle.

Make sure the long glass tube is submerged in the water about

2 cm (0.75 in.)

PROCEDURE RATIONALE 1 2 3 4 54. Place the bottle in the drainage rack on the floor beside the

client’s bed.

5. Connect the clear plastic tubing to the long glass tube and to

the client’s chest tube.

6. Securely tape all tubing connections.

7. Place a strip of adhesive tape vertically on the drainage bottle

to mark and assess the fluid level at prescribed periods.

8. Two-Bottle Gravity System

9. Follow steps 1-3 to set up the water-seal bottle.

10. Insert two short glass tubes through the second rubber

stopper, attach the stopper securely to the collection bottle,

and place both bottles in the drainage rack on the floor.

11. Connect clear plastic tubing to the long glass tube in the

water- seal bottle, and attach it to the nearer short glass tube

in the collection bottle.

PROCEDURE RATIONALE 1 2 3 4 512. Connect clear plastic tubing to the remaining short glass tube

in the collection bottle and to the client’s chest tube.

13. Follow steps 6-7.

Two Bottle Suction System:

14. Follow steps 1-3 to set up the water-seal (and collection)

bottle.

15. Fill the suction-control bottle with sterile distilled water to the

level for the required suction.

16. Insert one long glass tube and two short glass tubes through

the second stopper, attach the stopper securely to the suction-

control bottle, and place both bottles in the drainage rack on

the floor.

PROCEDURE RATIONALE 1 2 3 4 517. Connect the clear plastic tubing:

a. Between the short glass tube in the water-seal bottle

and one of the short glass tubes in the suction-control

bottle.

b. Between the long glass tube in the water-seal bottle

and the client’s chest tube.

c. Between the remaining short glass tube of the suction-

control bottle and the suction source.


Three Bottle System:

19. Follow steps 1-3 to set up the water-seal bottle.

20. Insert two short glass tubes through the remaining two-hole

stopper, and attach the stopper securely to the collection

bottle.

21. Insert two short glass tubes and one long glass tube through

the three-hole rubber stopper.

PROCEDURE RATIONALE 1 2 3 4 522. Add sterile distilled water to the sucton-control bottle. Make

sure the long glass tube will be submerge to the ordered

length; then attach the stopper securely to this bottle.

23. Place the bottles on a drainage rack on the floor, with the

water-seal bottle in the middle.

24. Connect the clear plastic tubing:

a. Between the long glass tube of the water-seal bottle

and the nearer short glass tube of the collection bottle.

b. Between the remaining short glass tube of the

collection bottle and the client’s chest tube.

c. Between the short glass tube of the water-seal bottle

and the nearer short glass tube of the suction-control

bottle.

d. Between the remaining short glass tube of the suction-

control bottle and the suction source.


26. Pleur-evac, Argyle, or Thoro-Drain III System

PROCEDURE RATIONALE 1 2 3 4 527. Open the package unit.

28. Remove the plastic connector or cap from the tube attached to

the water-seal chamber. (The Argyle system has two water-

seal chambers; do both.)

29. Using a 50-ml Asepto syringe with the bulb removed, fill the

water-seal chamber with sterile distilled water up to the 2-cm

mark. The Thoro-Drain III System has a line indicating the

amount of water required. Use of an Asepto syringe is not

necessary for this system. Then reattach the plastic connector

or cap.

30. If the physician has ordered suction, remove the diaphragm

(cap) on the suction-control chamber.

31. Using the 50-ml syringe if required, fill the suction-control

chamber with distilled water to the ordered level or 20-25 cm,

and replace the cap.

32. Place the system in the rack supplied, or attach it to the bed

frame.

33. Attach the longer tube from the collection chamber to the

client’s chest tube.

PROCEDURE RATIONALE 1 2 3 4 534. If suction is ordered, attach the remaining shorter tube to the

suction source, and return it on. Inspect the suction chamber

for bubbling. Gentle bubbling indicates an appropriate suction

level.

35. If suction has not been ordered, keep the shorter rubber tube

unclamped.

36. Tape all tubing connections, but do not completely cover the

entire tubing connectors with tape.

37. Unclamp the client’s chest tube and inspect the system for air

leaks.

38. Document the establishment of the chest drainage system and

the nursing assessments.

Critical Elements of Establishing A Chest Drainage System:Maintain sterility of the distilled water, the inside of collection bottles, rubber stoppers, and the ends of tubing, tubing connectors, and glass rods.

Set up the prescribed system correctly:

Securely tape all tubing connections, allowing visibility of drainage through tubing connectors. If suction is used, inspect the suction chamber for

continuous gentle bubbling to ensure appropriate suction level.

MONITORING A CLIENT WITH CHEST DRAINAGE

Definition:

Policies and procedures vary considerably from agency to agency in regard to chest drainage interventions. Certain interventions, such as milking a

chest tube to maintain patency, may be prohibited. The nurse must therefore review agency policies before intervening.

Equipment:

- Two rubber-tipped Kelly clamps

- A sterile petrolatum gauze

- A sterile drainage system

- Antiseptic swabs

- Sterile 4 x 4 gauzes

- Air-occlusive tape

- A mechanical chest tubing stripper, if ordered

- Specimen supplies, if needed:

. A povidone-iodine swab

. A sterile #18 or #20 gauge needle

. A 3-or 5-ml syringe

. A needle protector

. A label for the syringe

. A laboratory requisition

Intervention:

Essential data include

. Vital signs for baseline data and then every 4 hours.

. Breath sounds. Auscultate bilaterally for baseline data. Diminished or absent breath sounds indicate inadequate lung expansion and recurrent

pneumothorax after chest drainage is established.

. Clinical signs of pneumothorax before and after chest tube insertion. Leakage or blockage of a chest tube can seriously impair ventilation. Signs

include sharp pain on the affected side; weak, rapid pulse; pallor; vertigo; faintness; dyspnea; diaphoresis; excessive coughing; and blood-tinged sputum.

. Chest movements. A decrease in chest expansion on the affected side indicates pneumothorax.

. Dressing site. Inspect the dressing for excessive and abnormal drainage, such as bleeding or foul-smelling discharge. Palpate around the dressing

site and listen for a crackling sound indicative of subcutaneous emphysema can result from a poor seal at the chest tube insertion site. It is manifested by a

“crackling” sound that is heard when the area around the insertion site is palpated.

. Level of discomfort. Analgesics often need to be administered before the client moves or does deepbreathing and coughing exercises.

PROCEDURE RATIONALE 1 2 3 4 5Safety Precautions:

1. Keep two 15- to 18-cm (6-7-in.) rubber-tipped Kelly clamps

within reach at the bedside, to clamp the chest tube in an

emergency, eg, if leakage occurs in the tubing.

2. Keep one sterile petrolatum gauze within reach at the bedside

to use with an air-occlusive material if the chest tube becomes

dislodged.

3. Keep an extra drainage system unit available in the client’s

room. In most agencies the physician is responsible for

changing the drainage system except in emergency situations,

such as malfunction or breakage. In these situations:

a. Clamp the chest tubes

b. Reestablish a water-sealed drainage system.

c. Remove the clamps, and notify the physician.

4. Keep the drainage system below chest level and upright at all

times, unless the chest tubes are clamped.

PROCEDURE RATIONALE 1 2 3 4 55. If the chest tube becomes disconnected from the drainage

system:

a. Have the client exhale fully.

b. Clamp the chest tube close to the insertion site with

two rubber-tipped clamps placed in opposite directions.

c. Quickly clean the ends of the tubing with an antiseptic,

reconnect them, and tape them securely.

d. Unclamp the tube as soon as possible.

e. Assess the client closely for respiratory distress.

6. If the chest tube becomes dislodged from the insertion site:

a. Remove the dressing, and immediately apply pressure

with the petrolatum gauze, your hand, or a towel.

b. Cover the site with sterile 4 x 4 gauze squares.

c. Tape the dressing with air-occlusive tape.

d. Notify the physician immediately

e. Assess the client for respiratory distress every 15

minutes or as health indicates.

PROCEDURE RATIONALE 1 2 3 4 57. Do not empty a drainage bottle unless there is an order to do

so. Commercial systems cannot be emptied.

8. If the drainage system is accidentally tipped over:

a. Immediately return it to the upright position.

b. Ask the client to take several deep breaths.

c. Notify the nurse in charge and the physician.

d. Assess the client for respiratory distress.

MONITORING AND MAINTAINING THE DRAINAGE SYSTEM

PROCEDURE RATIONALE 1 2 3 4 51. Check that all connections are secured with tape.

2. Milk or strip the chest tubing as ordered and only in

accordance with agency protocol. Too vigorous milking can

create excessive negative pressure that can harm the pleural

membranes and/ or surrounding tissues. Always verify the

physician’s orders before milking the tube; milking of only

short segments of the tube may be specified. To milk a chest

tube, use a mechanical stripper, or follow these steps:

a. Lubricate about 10-20 cm (4-8 in.) of the drainage

tubing with lubricating gel, soap, or hand lotion, or hold

an alcohol sponge between your fingers and the tube.

b. With one hand, securely stabilize and pinch the tube at

the insertion site.

c. Compress the tube with the thumb and forefinger of

your other hand and milk it by sliding them down the

tube, moving away from the insertion site.

d. If the entire tube is to be milked, reposition your hands

farther along the tubing, and repeat steps a-c in

progressive overlapping steps, until you reach the end

of the tubing.

PROCEDURE RATIONALE 1 2 3 4 53. Inspect the drainage in the collection container at least every

30 minutes during the first 2 hours after chest tube insertion

and every 2 hours thereafter. Every 8 hours mark the time,

date, and drainage level on a piece of adhesive tape affixed to

the container, or mark it directly on a disposable container.

Note any sudden change in the amount or color of the

drainage. If drainage exceeds 100 ml/hour or if a color changes

indicates hemorrhage, notify the physician immediately.

4. In gravity drainage systems, check for fluctuation (tidaling) of

the fluid level in the water-seal glass tube of a bottle system or

the water-seal chamber of a commercial system as the client

breathes. Normally, fluctuations of 5-10 cm occur until the

lungs has reexpanded. In suction drainage systems, the fluid

line remains constant.

5. To check for fluctuation in suction systems, temporarily

disconnect the system. Then observe the fluctuation.

PROCEDURE RATIONALE 1 2 3 4 56. Check for intermittent bubbling in the water of the water-seal

bottle or chamber.

7. Check for gentle bubbling in the suction-control bottle or

chamber.

8. Inspect the air vent in the system periodically to make sure it

is not occluded. A vent must be present to allow air to escape.

9. Inspect the drainage tubing for kinks or loops dangling below

the entry level of the drainage system.

Detecting Air Leaks:

Continuous bubbling in the water-seal collection chamber normally occurs for only a few minutes after a chest tube is attached to drainage, since

fluid and air initially rush out from the intrapleural space under high pressure. Continuous bubbling that persists indicates an air leak.

PROCEDURE RATIONALE 1 2 3 4 51. To determine the source of an air leak follow the next steps

sequentially.

a. Check the tubing connection sites. Tighten and retape

any connection that seems loose.

b. If bubbling continues, clamp the chest tube near the

insertion site and see if the bubbling stops while the

client takes several deep breaths. Chest tube clamping

must be done only for a few seconds at a time.

c. If bubbling stops, follow step 20. The source of the air

leak is above the clamp, ie, between the clamp and the

client. It may be either at the insertion site or inside the

client.

d. If bubbling continues, follow step 21. The source of the

air leak is below the clamp, ie, in the drainage system

below the clamp.

PROCEDURE RATIONALE 1 2 3 4 52. To determine whether the air leak is at the insertion site or

inside the client:

a. Unclamp the tube and palpate gently around the insertion

site. If the bubbling stops, the leak is at the insertion site.

To remedy this situation, apply a petrolatum gauze and a 4

x 4 gauze around the insertion site and secure these

dressings with adhesive tape.

b. If the leak is not at the insertion site, it is inside the client

and may indicate a dislodged tube or a new pneumothorax,

a new disruption of the pleural space. In this instance leave

the tube unclamped, notify the physician, and monitor the

client for signs of respiratory distress.

3. To locate an air leak below the chest tube clamp:

a. Move the clamp a few inches farther down and keep

moving it downward a few inches at a time. Each time the

clamp is moved, check the water-seal collection chamber

for bubbling. The bubbling will stop as soon as the clamp is

placed between the air leak and the water-seal drainage.

b. Seal the leak when you locate it by applying tape to that

portion of the drainage tube.

c. If tubing continues after the entire length of the tube is

clamped, the air leak is in the drainage device. To remedy

this situation the drainage system must be replaced and

the physician notified.

Client Care:

4. Encourage deep-breathing and coughing exercises every 2

hours. Have the client sit upright to perform the exercises, and

splint the tube insertion site with a pillow or with a hand to

minimize discomfort.

5. While the client takes deep breaths, palpate the chest for

thoracic expansion. Place your hands together at the base of

the sternum so that your thumbs meet. As the client inhales,

your thumbs should separate at least 2.5-5 cm (1-2 in.). Note

whether chest expansion is symmetric.

6. Reposition the client every 2 hours. When the client is lying on

the affected side, place rolled towels beside the tubing.

7. Assist the client with range-of-motion exercises of the affected

shoulder three times per day to maintain joint mobility.

PROCEDURE RATIONALE 1 2 3 4 58. When transporting and ambulating the client:

a. Attach rubber-tipped forceps to the client’s gown for

emergency use.

b. Keep the water-seal unit below chest level and upright.

c. If it is necessary to clamp the tube, remove the clamp as

soon as possible.

d. Disconnect the drainage system from the suction

apparatus before moving the client, and make sure the air

vent is open.

Take a Specimen of Chest Drainage:

9. Specimens of chest drainage may be taken from a disposable

chest drainage system, since these systems are equipped

with-sealing ports. If a specimen is required:

a. Use a povidone-iodine swab to wipe the self-sealing

diaphragm on the back of the drainage collection chamber.

Allow it to dry.

b. Attach a sterile #18 or #20 gauge needle to a 3- or 5-ml

syringe, and insert the needle into the diaphragm.

c. Aspirate the specimen, attach the needle protector, label

the syringe, and send it to the laboratory with the

appropriate requisition form.

Critical Elements of Monitoring A Client With Chest Drainage:

Assess the client for signs of pneumothorax.

Keep two rubber-tipped Kelly clamps, one sterile petrolatum gauze, and an extra drainage system available for emergency situations.

Always keep the drainage system below chest level.

Empty drainage systems only if ordered.

Make sure the system is airtight.

Make sure there is fluctuation or bubbling in the appropriate bottle or chambers.

Keep air vents open.

Prevent tubing obstruction.

Know what to do if the chest tube becomes disconnected or dislodged or if the drainage system tips over.

ASSISTING WITH A CAST APPLICATION

Purpose:

To support and protect injured bones and soft tissue, reducing pain, swelling, and muscle spasm, maintains alignment and prevents movement of the

bones while it heals.


Before and after cast application:

1. Assess for signs of restricted circulation

2. Take the client’s pulse rate, respiratory rate, and blood pressure

Administer ordered analgesics before cast application

Before cast is applied, remove clothing from the body area and rings from fingers of the affected limb

Ensure safe storage of the client’s valuables

Wash the skin area to receive the cast and dry it thoroughly if ordered

Stabilize and support the limb appropriately during cast application.

Remove excess cast material from client’s skin after application.

Document assessment and interventions.

Equipment:

Rolls of cast materials

Plastic –lined bucket of water at the prescribed temperature:

1. Tepid water for Plaster of Paris and water activated

2. Cool water at 26 C (80 F) for polyester and cotton cast or

A thermostatically controlled hydro collator or a boiler or

cooking pot with a temperature- regulating thermometer for

a thermoplastic cast.

Stockinet

Cotton sheet wadding or padding

Felt padding (optional)

Plaster Splints (optional)

Moisture- resistant drapes

Rubber gloves

Plastic aprons

Water- soluble lubricant

Plaster knife

Large bandage scissors

Pillows

Damp cloth

PROCEDURE RATIONALE 1 2 3 4 51. Explain the procedure to the client, including the length of

time the cast material requires for drying. Explain that the cast

may feel warm during and after the application

2. Provide an analgesic as ordered

3. Assist the client into a comfortable sitting or lying position

4. Remove clothing from the body area and rings from fingers of

the affected limb and give them to a family member or store

safely in a locked safe.

5. Support the part to receive the cast

PROCEDURE RATIONALE 1 2 3 4 56. Wash the skin area, and dry it thoroughly, if ordered. If there is

no open wound, powder may be applied.

7. Provide stockinet of the correct size if used, and cut it several

inches longer than the length of the extremity so that it will

extend beyond the plaster edges. Then roll the stockinet to

facilitate application.

8. Provide sheet wadding and felt pads as needed. Usually 2- 3

layers are applied.

9. Provide gloves for the physician prior to application of the cast

material

10. Hand the physician the casting material or place the material

within the physicians reach. Preparation of cast material varies

depending on the type of casting material used

11. Squeeze a generous amount of water-soluble lubricant on the

physicians gloves as requested

PROCEDURE RATIONALE 1 2 3 4 512. Support the limb while the physician applies the stockinet,

padding, and cast material. With one hand, grasp the client’s

toes for a leg cast or fingers for an arm cast, and with the

other hand support beneath the limb areas on which the

physician is not working.

13. After the cast is applied, pull the stockinet out over the

proximal and distal cast opening edges, while the physician

secures it in place with one or two layers of cast material.

14. Remove any excess cast material deposited accidentally on

the client’s skin.

15. Assess the client with special reference to the cast.

16. Provide firm support for the cast.

17. Gather and dispose the used materials appropriately

18. Document

CLIENT CARE IMMEDIATELY AFTER A CAST APPLICATION

Equipment:

Soft, pliable pillows

PROCEDURE RATIONALE 1 2 3 4 51. Assess the toes and fingers for nerve or circulatory

impairments every 30 mins for several hours following

application and then every 3 hours for the first 24-48 hours or

until all signs and symptoms of impairment are negative

2. Immediately after the cast is applied, place it on pillows. Avoid

using plastic or rubber pillows.

3. Support the cast in the palms of your hands rather than your

fingertips

4. Control swelling by elevating arms or legs on pillows or, for leg

fracture, by elevating the foot of the bed

5. Report excessive swelling and indications of neurovascular

impairments to the physician or nurse in charge.

6. Apply ice packs to a hip spica cast

PROCEDURE RATIONALE 1 2 3 4 57. Expose the cast to the circulating air

8. Check agency policy about the recommended turning

frequency for clients with different kinds of cast

9. Avoid the use of artificial means to facilitate drying. This

means including fans, hairdryers, infrared lamps, and electric

heaters

10. Monitor drainage for 24-72 hours after surgery. Outline the

stained area every 8 hours.

11. Never ignore any complaints of pain, burning or pressure. If

patient is unable to communicate, be alert to changes in

temperament, restlessness, or fussiness.

12. Give pain medications selectively

13. Do not disregard the cessation of persistent pain or discomfort

complaints

14. Document

CONTINUING CARE FOR CLIENT’S WITH CASTS


Remove crumbs of plaster from the skin, “petal” rough cast edges.

For bed- confined patients, provide skin care over all bony prominences and turn the clients at least every 4 hours

Keep the cast clean and dry

Encourage clients to move toes or fingers of the casted extremity frequently

Provide necessary instructions about cast care, ways to move safely, activity allowed, exercises, elevating the involved extremity, signs of

neurovascular problems, ways to handle itching

Equipment:

Rubbing alcohol

Mineral, olive, or baby oil to apply to the skin after cast removal

Adhesive tape

Scissors

Damp washcloth for Plaster of Paris

Warm water and a mild soap for synthetic casts

Pillows

Fracture pan

PROCEDURE RATIONALE 1 2 3 4 51. Wash crumbs of plaster from the skin with a damp cloth and

feel along the cast edges or areas that press into the client’s

skin. It may be necessary to use a duck billed cast bender to

bend cast edges that may irritate the skin

2. Cover rough edges of the cast when it is dry. If the stockinet

has not been used to line the cast, “petal” the edge with small

strips of adhesive tape.

PROCEDURE RATIONALE 1 2 3 4 53. Check the cast daily for foul odors

4. Discourage the patient from using long sharp objects to

scratch under the cast

5. When cast is removed, dry, flaky and encrusted skin is

observed, remove this debris gently and gradually by:

a. Apply oil (mineral, olive, or baby)

b. Soak the skin with warm water and dry it

c. Caution the client not to rub the area too vigorously

d. repeat steps a and b for several days

Keeping the Cast Clean and Dry

6. Tub baths and showers are contraindicated. POP cast is kept

clean by wiping it with a damp cloth. Place a bib or towel over

a body cast to catch spills. If a spill does wet the cast, allow

the area to air dry.

7. Use a fracture bedpan for people with long leg, hip spica, or

body casts.

PROCEDURE RATIONALE 1 2 3 4 58. Before placing the client on the bed pan, tuck plastic or other

waterproof material around the top of a long leg cast or in

around the perineal cutout. Remove plastic when elimination is

completed

9. For people with long leg casts, keep the cast supported on

pillows while the client is on bed pan.

10. For clients with hip spica casts, support both extremities and

the back on pillows so that they are as high as the buttocks

11. When removing the bedpan, hold it securely while the client is

turning or lifting the buttocks. After removing the bedpan,

thoroughly clean and dry the perineal area

PROCEDURE RATIONALE 1 2 3 4 512. Synthetic casts: Synthetic casts can be cleaned readily and

may, with the physician’s permission, be immersed in water if

polypropylene stockinet and padding were applied.

a. Wash the soiled area with warm water and a mild soap

b. Thoroughly rinse the soap from the cast

c. Dry thoroughly to prevent skin maceration and

ulceration under the cast.

d. If the cast is immersed in water, the cast and

underlying padding and stockinet must be dried

thoroughly. First blot excess water from the cast with a

towel. Then use a handheld blow-dryer on the cool or

warm setting, directing the air stream in a sweeping

motion over the exterior of the cast for about 1 hour or

until the client no longer feels a cold clammy sensation

like that produced by a wet bathing suit.

PROCEDURE RATIONALE 1 2 3 4 5Turning and Positioning Clients

13. Place pillows in such a way that:

a. Body parts press against the cast edges as little as

possible.

b. Toes, heels, elbows, etc., are protected from pressure

against bed surface.

c. Body alignment is maintained

14. Plan and implement a turning schedule incorporating all

possible positions.

Exercise

15. Unless contraindicated, encourage active ROM exercises for all

joints on the affected extremities, as well as on the joints

proximal and distal to the cast

16. Encourage the client to move the toes and/or fingers of the

casted extremity as frequently as possible.

PROCEDURE RATIONALE 1 2 3 4 517. With the physician’s approval, teach isometric (muscle setting)

exercises.

18. Teach isometric exercises on the client’s unaffected limb

before the person applies it to the affected limb. Demonstrate

muscle palpation while the client is carrying out the exercise.

19. Document assessments and nursing implementations on the

appropriate records.

TRACTION CARE

Purpose:

To apply a continuous pulling force to an extremity or body part, maintain its alignment, and prevent infection

Guidelines:

All traction should have a counter traction to prevent the client from being pulled by the force of traction against the pulleys or the bed, thus

negating the traction

To apply and maintain the correct amount of traction, all traction weights should be hanging freely and the ropes should not touch any part of the

bed.

The traction force should follow an established line of pull. The line of pull determines the position and alignment of the body as prescribed by the

physician

Traction should always be applied while the client is in proper body alignment in a supine position

Equipment:

Protective skin devices, e.g. heel protectors

Trapeze

Rubbing alcohol

Antiseptic agent

Sterile gauze dressing

Picking forceps

PROCEDURE RATIONALE 1 2 3 4 51. Inspect the traction apparatus regularly, whenever you are at

the bedside or at prescribed intervals, such as every 2 hours

2. Provide protective devices and measures to safeguard the

skin. E.g. heel protectors, pillows, etc) massage the skin.

PROCEDURE RATIONALE 1 2 3 4 53. Maintain the client in supine position unless there are other

orders

4. Provide a trapeze to assist the client to move and lift the body

for back care if the person is unable to turn, e.g., if the client

has balanced suspension traction

5. Do not remove skeletal and adhesive skin traction.

6. Non adhesive skin traction is intermittent and can be removed;

check agency policy about any orders required. Remove

weights first; then unwrap the bandage and provide skin care.

Rewrap the limb and slowly reattach the weights

7. Provide pin site care and this varies with different hospital

protocols.

Carefully inspect the site

Use sterile technique

Remove crusts with a rolling technique

Cover sites with a sterile barrier

Determine the frequency of care by the amount of

drainage

PROCEDURE RATIONALE 1 2 3 4 58. Teach client deep breathing and coughing.

9. Teach the client appropriate exercises

10. Document

NCM 102.1 Final Checklist

Documents

Transcript of NCM 102.1 Final Checklist