Basic Human Needs: Bowel Elimination

Normal Characteristics of Stool

1. Normal color: yellow, brown, green
Golden yellow: BF infants
Black tany stools: melena; UGIB (stomach)
Bright red stool: hematochezia; LGIB
Clay colored: alcohol stool; HB problem
Greasy, bulky, foul smelling = steatorrhea
2. N frequency: Rule of 3
Max: 3x/day
Minimum: 3x/week - q other day
3. N odor: Aromatic (indole and scatole)
Pungent, fishy, foul smelling: intestinal infxn
4. N shape: Cylindrical
Pencil, bullet, pellet, ribbon-like: colorectal cancer
5. N consistency: semi-formed to formed
6. N amount: depends on the bulk of food intake
Average: 150-300 grams

I.

Laxatives medications given orally to induce/promote defecation/BM

Laxatives/enema -> defecation/BM -> Peristalsis analward movement of

food ->soften the stool and lubricate the stool and anal and rectal canal
1. Distention of colon safest, it mimics the natural way of the body
2. Irritation
A. Chemical irritants: provides chemical stimulation in the intestinal wall ->
increase Penstalsis -> BM
Eg. Bisacodyl (Dulcolax), castor oil, senokot (senna)
Note: it may cause abdominal cramping and f and e imbalance
Faster than bulk formers (8-12 hours)
B. Bulk formers: it increase solid, liquid and gaseous
Component -> increase distention -> increase peristalsis -> BM
Eg. Psyllium Hydrophillic Mucilloid (Metamucil), methylcellulose (cetrocil)
Note: safest to use; long-term use
It may take effect in >12 hrs
C. Stool softeners: it softens the stool, delays drying of stool and allows HO and
fat to penetrate the stool
Eg. Docusate Na (colace), Docusate Ca (surfak)
Note: increase fluid intake
It may take several days to effect
AKA: Emolients
D. Stool lubricants: it softens the stool and lubricates the stool and anal and
rectal canal = decrease surface tension b/n the stool and rectal canal
Eg. Mineral oil
laxative: 6-8 hours swallow properly

Enema: - 3 hours
Note: swallow properly (prevent lipid pneumonia)
Without meals
Prolonged use may inhibit the absorption of fat soluble vit. (ADEK) ->
normal coming from animal sources to absorb
E. Osmotic agent: attracts H2O into the colon by osmosis -> increase peristalsis,
distention, softening
Eg. Duphalac (lactulose, lilac), cephulac
II.
Enema Administration
- Soln introduce into the anus and return going to the colon to promote /
induce defecation/BM
Types of enema according to purpose:
1. Cleansing enema: intended to remove feces
a. Low flow/small volume enema: cleans the anus, rectum and signed
colon only
- 500 ml
b. High flow/large volume enema: cleans as much of the colon as possible
(entire colon)
1000 mL
IVP: dye + X-ray KUB -> located retropentoneal
2. Retention oils < softening and lubrication] feces
Medications, antibiotics
3. Carminative intended to remove flatus ->bloated
-60 -80 mL
Conservative: warm, increase intake OFI, increase activity
4. Return flow/colonic irrigation / Harris flush
alternating flow of 100-200 mL of soln is introduced into and out of
the colon
occasionally used (last resort) for flatus
repeated 5-6x or until flatus is relieved
Things to remember:
1. Positon:
Left sims/side lying/lateral posn
a. Low flow: left sims/SL/lateral
b. High flow: left sims/SL/lateral -> dorsal recumbent or supine ->
right sims/SL/lateral
Total: 30 mins.
2. Technique: clean technique
3. Types of soln / amount / time to effect
Types
Amount
Time to effect
a. Hypertonic
90-120 mL
5-10 mins
Eg. Na Phospate
Increase conc: decrease Solute
(Na)

b.

c.

d.
e.

HO: Isotonic (colon)

->osmosis
->plasma to hypertonic soln
Vol. deficit
Na retention, FVD
Isotonic
500-1000mL
15-20 mins
Eg. PNSS
Safest = no fluid shifting
Distention
Hypotonic
500-1000mL
15-20 mins
Eg. Tap HO
Distention
Tap HO: decrease conc
HO colon: increase conc
-> osmosis
Tap HO to plasma blood circulation
Fluid with excess
Oils
90-120 mL
-3 hrs
Eg. Mineral, coffunseed, oil,
olive oil
Soapsuds
500-1000 mL
10-15 mins

Eg. 1000 mL of PNSS or

tap HO + 5 mL of
pure soap (castile soap)
4. Length of rectal tube insertion: 3-4 inches (7-10cms)
5. Indwelling time of rectal tube: 10-30 mins
6. Height of soln: 12-18 inches
7. Temperature of soln:
a. Adult (3y.o.): 100-105 F
b. Child (<3y.o.): 100 F /37.8 C
8. Facilitate smooth insertion:
a. Water based lubricant (KY Jelly)
b. Insert the rectal tube in a rotating motion
c. Inhale and hold breath
R anal and rectal sphincters are relaxed
9. Size of rectal tube: F22-30
10.If resistance occurs.
-> withdraw the tube. Inspect and palpate for any stool that can block
the tube
11.If resistance persists.
-> stop the procedure and notify the MD
Never force insertion against resistance to prevent injury
12.How are you going to know that the peristalsis is stimulated already?
Abdominal cramping
13.If abdominal cramping occurs prematurely
Premature abd cramping: 1. cold soln
2 . rapid introduction of soln

Champ/pinch/kink the rectal tube, temporarily stop the

administration (30 seconds) and restart the flow at a slower rate by
lowering the height of soln
14.If the desired / sufficient amount of soln has been instilled and abd.
cramping occurs.
-> expected
-> instruct the pt to go to the CR and defecate
15.C/I:
Hemophilia
1 day post: stimulates vagal nerve
Appendicitis
IBD, imperforate anus

BLADDER ELIMINATION
N Characteristics of urine
1. N UO: 30-60 ml/hr
Most accurate: 1-2 ml/kg/hr
2. N color: yellow, straw, amber, colorless
Red, pink: bleeding
3. N PH: 4.6-8 Average:6
4. Odor: Aromatic
Pungent, fishy, foul smelling, ammoniacal = abn
5. Sterility: Sterile
6. N USG: 1010-1030
-> bigat ng ihi
7. <1.010 = light -> decrease solute, increase solvent -> diluted -> fluid
overload
8. >1.030 = heavy -> increase solute, decrease solvent -> concentrated ->
DHN
I.
1.

2.
3.
4.
5.
6.
II.

Clean catch midstream urine specimen collection

No catheter involved
Clean the urethral meatus
a. Male -> glans penis: circ. Motion from inner to outer
-> penile shaft: downward vertical stroke
b. Female front to back/ant. to posterior
Labia minora
Antiseptic soln: 10% Betadine
Stream of urine needed: Middle flow (morning)
Amount of urine:
a. Routine urinalysis: 30 mL
b. Urine C and S: 5-10 mL
Container used: sterile container
How long you consider the urine expired/contaminated: 30-60 min
24 hours urine specimen collection
Purpose: BUN, creatinine, creatinine clearance, electrolytes
Vanillymandellic acid
-> end product of epinephrine and NE metabolism

III.

2 days before the test: avoid coffee tea, tea, cola, fruits, fruits juices,
vanilla
- On the day: withhold all medications
- Doderleines Bacili: N female flora
Esang container lang (2.5-3L)
Discard the 1st voided urine
Collect all the succeeding specimen thereafter until the same time the
next day
Babad sa ice
Add sign in the CR: collect all urine
Collecting a urine specimen from an indwelling U. catheter -> closed
drainage system
-> not
exposed to external envi
1. do not remove
2. do not disconnect

How to collect?
1. Clean the self-sealing port using an antiseptic (70% Ethyl Alcohol)
2. Clamp the catheter for 30-60 mins. so that urine will accumulate
3. Using a sterile syringe and needle, aspirate (30-45) urine from the selfsealing port or /luer lock port
4. Urinary Catheterization a procedure where in a double lumen/2-way/Foley
catheter is inserted to the urethra going to the bladder to obtain a urine
specimen
5. last resort; invasive; painful; increase risk for UTI
Purposes:
1. To obtain urine
2. To relieve bladder distention
3. To monitor the hourly UO of the pt
Things to Remember:
1. Technique: sterile tech.
UTI
Catheterization
E.Coli
2. Position:
a. male: supine pxn with legs extended and slightly abducted
b. female: dorsal recumbent meatus
3. Location of the urethral meatus
a. Male: tip of the glans penis
b. Female: b/n the ditons and vaginal onfice
4. Length of catheter insertion

a. Male: 6-9 inches

b. Female: 3-4 inches
5. Size of catheter:
a. Male: F. 16-18
b. Female: F. 14-16
c. Children: F. 8-10
6. Strengthen the male condom
hold penis firmly at a 90angle / perpendicularly/ upright position
7. Prepare accordingly
test the fxning of the balloon of the FC first before using it to the pt
10 mL of Sterile HO
8. Faulitate smooth insertion
a. Use a HO based lubricant
b. Insert the catheter smoothly and slowly
c. Instruct pt to take few deep breaths and insert the catheter as the pt
exhales -> urinary sphincters are open
9. How are you going to know that you are in the bladder already?
there is a flow of urine
10.Once the urine starts to flow, advance the catheter 1-2 inches further before
inflating the balloon -> to make sure it is on the bladder
11.Secure the catheter by taping it:
a. Male: -> upper thigh: to prevent tension in the male urethra
-> lower abdomen: to prevent penoscrotal pressure
b. Female: inner thigh
Les mobile and safest
it will not pull even if the pt moves
it will prevent tension and pressure in the F. urethra
12.Secure urine the bag at the bedframe
Always keep the urine bag below the level of the bladder
13.Freq. of changing
a. Plastic: q / week
b. Rubber: 2-3 wks
c. Silicone: 1-2 mos
d. PVCS: 4-6 wks
14.Restart bladder training 2-3 hrs with removal of indwelling catheter
IV.

Condom catheterization
external catheter
non invasive: decrease risk for UTI
for male clients only
can be used by ambulating clients
Used to manage urinary incontinence
Things to remember:
1. Position: supine, sitting
2. Technique: clean
3. Roll down the condom catheter towards the base of the penile shaft
and make sure to leave a 1 inch (254cm) space b/n the tip of the penis
and the condom catheter
To allow outflow of urine and prevention of irritation of tip of penis

4. Tape the condom catheter firmly -> not too tight nor too loose
-> impaired circulation in the penis
-> potentially permanent damage
5. A. special tape (provided by the manufacturer, a strip of flexible tape
or Velcro tape may be used to secure the CC
Most impt characteristics of tape in CC: flexible/elastic
Ordinary tape is C/1 because it is not flexible and may impair
circulation in the penis Apply the CC first then the tape
Manner of the application of the tape: around the base
6. If a double-sided elastic tape is used
Apply it in an overlapping spiraling motion -> 2-3 turns
If a DS elastic tape is used, apply the tape first the CC
7. Freq. of changing the CC: 24/daily
8. Freq. of emptying urine bag:
8 hrs or if it is -1/2 full
9. Inspect the penis 30 minutes after the application of CC and WOF SSX
of circ. Impairment
Discoloration and swelling
10.Secure the urine bag
a. Bedridden: bedframe
b. Ambulatory: inner aspect of lower thigh or leg
11.Wash the penis with soapy HO
12.Avoid loops and kinks

Basic human needs: Nutrition

I.

Diet:
A. Regular diet: pertains to food and fluids that contain all the
essential nutrients (CHO, CHON, fats, calories, vitamins, elec,
minerals, HO) necessary for tissue growth and repair
B. Clear Liquid Diet
Purposes: 1. To relieve thirst
2. To manage DHN

3. To minimize stimulation of GIT

- it contains HO, CHO, but has no adequate amounts of CHON,
fats and other essential nutients
- it short term use only: 24-36 hours
Eg. HO, coffee, tea, ginger ale, softdrinks, fruit juice without
pulp, honey, gelatin, hard candy, popside
Pertains to food that turns liquid at room temp- nalulusaw
Ind. 1. GIT dysfxn
2. Pts who cannot tolerate solid to semi-solid food
It contains water, CHO, fats but has little amount of Fe, CHON and
other essential nutrients
Can be used for 5-7 days
Eg. All clear liquids

Dairy products ice cream, sherbet, butter, margarine, soya, yakult,

vitamilk, smooth peanut butter, vegetable juice, cream, pudding, soft
boiled eggs
C. Soft diet: pertains to food that is easily chewed and swallowed
Ind: increase for aspiration -> diff. chewing -> diff. swallowing
Reg. and soft diet same nutrient content
Eg. All full liquids
Fresh/canned fruits
Boiled vegetables / mashed
Cheese
Meat products-lean meat, fish fillet
Mealth alternatives EGG
Cereals, oatmeals, bread, applesauce / gerber
Nutritional therapy -> enternal = to the stomach eg. NGT,
OGT, PEG
Parenteral = other than the stomach eg. IV
-> TPN = immediate effect
A. NGT insertion
Purposes:
1. To provide feeding (gavage) = most common
2. To wash the stomach (lavage)
3. To provide gastric decompression (post-op) -> connected to sanctum
machine with a pressure not greater than 25 mmHG
4. To administer medication
Given: simple, compressed tablets, capsules, liquid preparations
Not given: enteric coated, sustained release, time released -> overdosage
5. To aid in laboratory analysis
Things to remember:
1. Position: high-fowlers position: so that the gravity will aid in the
insertion
2. Name of tube: Leviris tube
Miller abott: intestinal tube
Salem sump: with balloon
Sengstaken: control esophageal varices
3. Length of NG tube insertion : NEX method / XEN
4. Preparation of NG tube
a. Rubber tube / soft coiling / too flexible
-> immerse the tube in a vessel of HO with ice
b. Plastic tube / stiff/ rigid / not flexible
-> immerse the tube in a warm HO
5. Determine the best nostril to be used
> instruct the pt to breathe through one nostril while occluding the
other
Select the nostril that has the greater airflow -> patent
6. Insert the NG Tube
a. Instruct the pt to hyperextend the neck until the tube reaches the
nasopharynx (N-E)
R to decrease the curvature of the nasopharyngeal junction

b. Once the tube reaches the oropharynx (throat), ask the pt to tilt the
head forward
c. R to facilitate the passage of the tube to the posterior pharynx and
esiophagus rather than the larynx
7. Instruction to the pt during NG tube insertion -> swallow or sip HO
8. Length of tube insertion per swallow
2-4 inches or 5-10 cms
NEX ->18 inches ->18 inches
9. Check NG tube placement
a. Xray = best
b. Check for gastric pH 2nd best
It must be acidic (<4) HCL acid stomach
If >6 = intestinal placement (presence of bile)
c. Auscultate air insufflation 3rd best but the most common bedside
method
1st: place the diaphragm of the stethoscope in the left upper
quadrant or Epigastrium
2nd: introduce 10-30 mL of air
3rd: listen for a swooshing sound (Kozier) or gurgling sound
(Udan/saunders)
d. Assess for gastric content (color) 4th best
-> yellowish/greenish/ previous color of OF -> osterized
10.Secure the NG tube by taping it at the bridge of nose (leucoplast)
11.Instruction to the pt during NG tube removal
-> inhale and hold breath
B. NGT Feeding (gavage) most common purpose
1. Position
a. sitting /upright position in a chair
b. semi-fowlers pxn in bed
c. slightly elevated R side lying pxn
R Pylorus directing toward the right
X left = food will regurgitate
Poison = left side lying
2. Most dreaded / fatal complication of NGT feeding : aspiration
3. Check for NG tube placement esp. before giving feeding (same with #9)
4. Assess for residual volume before each feeding -> it assesses the amount
and rate of absorption of the previous feeding
N 300 mL
Kozier/saunders
Udan
<100 mL = give the next feeding
<500 mL = give the next
feeding
100 mL = withhold the next feeding
50 mL = verify if feeding is to
be given

Notify the ordering MD

100 mL = withhold
a. Decrease amt of feeding
b. Gastro kinetic drugs
Eg. Domperidone
R caloric intake is computed, prevent malnutrition
After measuring the RV return it to the pt to prevent metabolic
alkalosis (acid-base ab.)
5. Assess and maintain the patency of the tube -> instilled / flush the tube
with 30 mL of PNSS before and after giving / feeding or at reg interval (q
4-6 hours) medications -> Kallium Durule, Fe supplement, antibiotics ->
capsule (gel)
6. Height of feeding
-> 12 inches (1 foot) above the point of tube insertion (nose)
>12 inches = rapid feeding ->
abd cramping, flatulence
reflux vomiting aspiration
7. Duration of feeding : 30-40 min
8. Warm feeding at room temp. before giving to pt
Cold feeding -> cramps
Period from unrefrigeration to administration : 30 mins
9. Frequent of changing the NG tube
a. Plastic : q 1-3 days
b. Rubber/ silastic: q 5-7 days (q week)
c. Silicone: q 1-2 mos
10.After feeding the pt, the pt must remain in a semi-fowlers pxn for at least
30 mins
R prevent aspiration
: administration of blood and other blood products into the venous circulation
-

Part of iV therapy
Last resort, immediate effect
Increase risk, irreversible, fatal

Things to remember:
1. First to do: Verify doctors order -> check for the completeness of the
order
1. Patient
2. Medication
3. Dosage
4. Time
5. Route
6. Documentation
7. Assessment
8. Evaluation
9. Education

10.To refuse
11.Approach
2. Do crossmatching
At least 2 RNs are allowed (JCAHO)
a. Blood type: ABO system -> A/ B/ AB/ O
Each letter represents the antigen / agglutinogen
- Present in the surface of the RBC
Antibody/agglutinins: present in the blood plasma

X
X

b. Blood components
1. Whole blood not commonly used unless in extreme cases of
acute hemorrhages
replaces blood volume and contains all the blood products:
RBC, plasmachons, fresh pH, clotting factors
unit of WB: 450/500 mL
2. PRBC: it increase the o carrying capacity of the blood in
anemias, disorders with slow bleeding and surgery
1 unit of PRBC: 250 mL
1 unit of PRBC and 1 unit of WB has the same amount of O
carrying RBC
1 unit of PRBC increase Hgb level by 1 gldl and Hct level by 23% (4-6 hrs.)
Hgb -> male: 13-18 gldl
Female: 12-16 gldl
Hct -> male: 42-52%
Female: -> 35-47%
3. Autologous RBC: done after a planned electives surgery
the client donates blood 4-5 weeks prior to surgery
Safest no incompatibility issues
4. Platelets: replaces platelets in pts with bleeding disorders and
plt deficiencies
1 unit of pH = 50 mL
administered rapidly in about 30 minutes
fresh platelets are most effective
1 unit of platelet increase plt count by microliters (cell/cumm)
NV 150-450 K cells/cumm
100,000 K = should receive pH
5-10 units of pH
5. Fresh frozen plasma replaces blood volume and increase
clotting factors
6. 1 unit : 250/350/400 mL
7. 1 unit of FFP increase all clotting factors by 2-3%
c. RH factor -> (+) and (-)
d. Serial #
e. Expiration date

f. Clients identity
3. Technique: sterile
4. Equipments:
a. Macroset tubings
b. Drip chamber msut have an in-line filter micromesh
c. Y-shaped tubing
5. Only compatible slon: PNSS (isotonic)
6. Never mix blood with other medications and soln specially those that
contains dextrose -> hemolysis of RBC
7. Needle gauge: 18-20
18-green
24-yellow
20-pink
26-violet
22-blue
8. KVO rate: 10 gtts/min -> safest, slowest, acceptable
9. 20-20 rule of BT: for the 1st 15-20 mins, flow rate must be 20 gtts/min
10.Height of blood: 1m/3 ft/34 inches
11.Maximum time of BT: 4 hours
If >4hrs = increase risk for infxn and hemolysis
Minimum time: 2 hours
If <2 hrs: rapid BT -> circulatory overload
12.How long should you stay with the client with the start of BT to monitor
for any BT reaction? 15 minutes
R occurrence of BT reaction rapidly within 10-15 min.
13.Monitor VS q 30 mins until / hour post transfusion
14.After receiving the blood from the blood bank, it must be administered
within 30 minutes
If the BT is unexpectedly delayed, return it to blood bank
15.Warm the blood at room temp. before giving it to pt.
Cold blood may cause chills, hypothermia, and cardiac arrhythmia ->
cardiac arrest
If >30 mins = hemolysis of RBC -> accumulation of potassium in the
blood bag -> hyperkalemia
Penstalsis
Oliguria
Tall T ware
Arrhythmia -> arrest
16.Assess VS before, during, after BT
Temperature = 100 F / 37.8 C STOP
The earliest SSX of BT reaction: fever and chills
The presence of fever at the start of BT will mask any developing BT
reaction settle the fever 1st!
17.If BT reaction occurs
1st: stop
75 mL incomp. Blood = renal
failure
2nd: open NSS line
100 mL
= death
3rd: notify MD
4th: notify blood blank
18.Complications of BT
a. Febrile hemolytic RXN (RBC)

b.
c.
d.
e.
f.

Febrile, non hemolytic Rxn (WBC)

Sepsis
Allergic rxn plasma CHON
Circ. Overload - <2 hours rapid adm.
Iron overload chronic BT, sickle cell anemia, increase of defective
RBC
g. Air embolism
h. Hypovolemic shock -> indication
Basic Human Needs: Oxygenation
I.

Oxygen therapy (Administration)

Most important physiologic need
- Odorless, colorless, tasteness gas
- Dry gas -> dryness of the airway -> irritation -> inflammation
- O supports combustion
- It constitutes 21% of air in the atmosphere

Things to remember:
Position:
1. Semi-fowlers
2. Post No smoking: O in use in the:
a. Clients room
b. Head or foot part of the bed
c. Or equipment
3. Humidity O using sterile HO
Avoid PNSS -> salt -> precipitate in the airway -> irritation -> inflammation
Distilled bottled HO -> resourcefulness
4. Fabric of choice : cotton -> does not generate static electricity (esp. high
flow)
5. Main reason for O therapy
To increase O supply to tissue and cells
Oxygen Delivery System
Nasal cannula
Least anxiety producing
Nasal cannula
Lowest capacity to deliver O
Non-rebreathing FM
Highestcapacity to deliver system
Venturi mask
Most accurate or delivery system
Venturi Mask
Or delivery of choice for COPD
Nasal Cannula
If venturi mask is not available for COPD
Nasal Cannula
Safest O delivery system and flow rate for
any type of pt
Pathophysiologic condition
Primary basis for selecting or delivery system
O delivery system
%
Flow rate
1. Nasal cannula
2. Simple face mask

24-45

2-6 LPM
40-60

5-8 LPM

3. Partial rebreathing FM
4. Non rebreathing FM

II.

60-90
95-100

6-10 LPM
10-15 LPM

6th VS. O Sat

+ exhalation port -> open -> partial rebreathing -> close -> non
rebreathing
White/blue/green
O saturation and Pulse oximetry
Pulse oximeter
Non- invasive device that measures a clients arterial blood O saturation
level SSx of hypoxemia develops
Oxygen saturation: pertains to the amount of O that is attended to the
Hgb of the RBC
O + Hgb = oxyhemoglobin
Med. Abbreviation: SPO/SaO/OSat
NV : 95-100%
<91% = the pt needs immediate tx
Notify the MD!
MGT.
High flow O delivery via partial or non-rebreathing FM
<85% = tissues of the body hare diff. time becoming oxygenated
Mgt. ET intubation -> mech. Ventilator
Sites for PO:
Theoretically, any parts of the body as long as there is skin
Preferred sites:
1. Fingers and toes
2. Earlobe
3. Forehead
4. Nose
5. Hands
6. Feet
2 types of PO:
1. Spring tension / clip type
2. Adhesive type
2 parts:
1. Light emiting diodes (LEDS)
a. Red light =marller
b. Infrared = detected by photodetector -> directly proportional
with O Hgb
2. Photodetector detects infrared -> directly proportional and the
reading (%)
THINGS TO REMEMBER
1. 2 things that PO can assess
a. O. sat = most impt
b. Pulse

2. Avoiding using extremities for PO (fingers and toes)

a. If the extremities are used for infusions, transfusions and any
other invasive monitoring
Eg. IVF, BT, TPN, CVP reading, Cardiac catheterization, fistulal
shunt -> HD
b. If the circulation in the extremities are impaired
Eg. Phlebitis, infiltration,/extravasation, DVT
3. If the extremities are unavailable for PO
Use earlobe sensor, reflectance, sensor in the forehead or nasal
sensor PO
4. 2 ways in measuring O sat
a. Pulse oximeter most common, convenient, non- invasive,
sometimes not accurate/reliable
CO poisoning - O in the Hgb is displaced by CO

III.

IV.

- O + Hgb = O Hgb
Co poisoning = CO + Hgb = carboxyhemoglobin
b. ABG analysis invasive, increase risk, inconvenient
Accurate
5. Preparation for pulse oximetry
a. Clean the site using CB with alcohol
b. If with nail polish, use acetone instead of alcohol -> interferes
with the reading
6. Freq. in changing the site
a. Spring tension type: 92 hours
b. Adhesive: 94 hours
7. It is impt to immobilize the site with PO because movements are
detected as pulse
8. What are you going to do if the site with PO is being exposed to
sunlight?
cover the site with blanket or dark colored towel (light coming
from the sun increase infrared)
ABG Analysis
measure the dissolved O and CO in the arterial blood to reveal or
status and acid-base balance
a. Allens test
b. Ban suctioning 15-20 mins before extraction
c. Get the specimen using a pre-hepannized syringe
Give pressure on the site 5-10 mins
Incentive Spirometry/ Sustained Maximal Inhalation Device
a device used to measure the amount of air inhaled through the mouth
piece
To promote maximal expansion
Purposes:
Secretions loosening
Promotes maximum lung expansion and gas exchange
Increases alveolar rentilation
Reverses the effects of GA and hypoventilation

Opens / expands collapsed alveoli

Things to remember:
Seal tightly the lips through the mouthpiece
Position: sitting / upright, high fowlers position
Inhale slowly to elevate the ball/disc
Repeat the exercise for 10x/hour
Oral care

V.

Pulmonary Fxn
- Done to measure the different pulmonary volumes and capacities
1. Tidal volume (TV) amount of air that goes in and out of the lungs
with each N breath
500 mL N
2. Inspiratory Reserve Volume (IRV) maximum amount of air that can
be inhaled after N inhalation
-3,100 mL
3. Expiratory Reserve Volume (ERV) maximum amount of air that can
be exhaled after a N exhalation
1200 mL
4. Residual volume: amount of air that remains in the lungs after a
forceful exhalation; 1200 mL
5. Total lung capacity: amount of air in the lungs at full inflation
Formula: TD + IRV + ERV + RV = 6000
500 + 3100 + 1200 + 1200
6. Vital capacity: total amount of air that can be exhaled after a
maximal inhalation
Formula: TD + IRV + ERV = 4800 mL
500 + 3100 + 1200
7. Inspiratory capacity: amount of air that can be inhaled after a
normal exhalation
Formula: TV + IRV
8. Functional Residual Capacity (FRC) : maximum amount of air that
remains in the lungs after a normal exhalation
Formula: ERV + RV
Chest Physio therapy
Aka PUD, Pulmonary hygiene, pulmonary hygiene toilet
systematic process of removing tenacions secretions from the lungs
using the techniques of positioning, percussing and vibration

A. Positioning / Postural Drainage drainage by gravity of secretions from various

lung segments by assuming different positions
1. Force utilized: gravity
2. Principle used in positioning
3. Duration : 10-15 mins (each)
B. Percussion/ clapping- forceful, striking of the clients chest wall to remove and
dislodge tenacions secretions
1. Position of the hand: cupped (scooping HO)

2. Where should the striking force come from: wrist alternately flexing and
extending it
3. Manner of striking: rapid, short, firm using both hands alternately at a
90angle
4. Pattern: none
5. Duration: 1-2 mins
6. How are you going to know that you are percussing correctly?
Popping /hollow/booming sound = cupped
Slapping = flat
7. To lessen the pain, discomfort and redness in percussion.
Place a layer of towel over the area to be percussed
Do not percuss on bare skin
8. Do not percuss the ff:
breast, slemum, vertebra, kidney area, (lower back)
Ribcage advanced PTB, advanced lung cancer, rib fracture
C. Vibrating vigorous, quirering/shaking of the hand to remove pulmonary
secretions
1. Part of the hand that should vibrate: heel
2. When to apply vibration: exhalation cycle only
3. No. of times applied: 5 exhalation cycles only
Things to remember:
1. Correct sequence: PoPeVi
2. Type of nursing intervention: dependent requires DO before it must be
camed out
It cannot be delegated to family members
3. Freq. of CPT : 2-3x per day and depending on the degree of the lung
congestion
4. Time to perform CPT
Before breakfast, before lunch, late afternoon, before dinner
Before meals; 2-3 hrs after eating = prevent aspiration
5. First and foremost major consideration before CPT
Clients tolerance to the procedure
6. To achieve the maximum benefits of the CPT cough -> promote expectoration
of secretions

VI.

Thoracentesis
Aspiration using a large- bore needle (g. 14-16) fluids/and/ or air from a
cavity
Thora/ thorax pleural space
Pleural space it contains minimal fluid (20-30 mL) that serves as a
cushion/lubricant
Air pressure in the pleural space: negative air pressure -> suction
Fluids in PS pleural effusion presence of excessive fluids (HO, blood,
pus) in the pleural space
Water -> hydrothorax
Blood -> hemothorax
Pus -> pyothorax / empyema

Air -> pneumothorax

Pulmonary edema: presence of fluids in the lungs/alveoli
Thoracentesis: aspiration of excessive fluids (blood, HO, pus) and/or from
the pleural space to ease breathing
Things to remember:
1. Position:
a. Sitting/upright position on an overbed table
Orthopneic position
b. Straddling at the back of the chair
c. Side lying pxn: unaffected side
2. Invasive procedure: informed consent -> right before the procedure
3. Anesthesia used: local anesthesia
Eg. 1% lidocaine (xylocaine), 1% tetracaine
2% procaine
4. Determine the exact site of needle insertion
Best way: CXR
If CXR is unavailable, palpation and percussion on the site may be
performed by an experienced MD
->opex-air-2nd or 3rd ICS
->base-fluids-7th or 8th ICS
5. Instruction to the pt to decrease agitation, anxiety, restlessness
Reassure the pt that he/she will feel pressure sensation as the needle
is being inserted
6. Most important consideration in thoracentesis
a. Patient: remain still; avoid sudden movements such as deep
breathing, coughing and sneezing
b. Nurse: sterile technique
7. Most dreaded/fatal complication
Accidental perforation/puncturing of the lungs
SSX:
a. Expectoration of cough
b. Dyspnea
c. Cough
d. Pallor
8. Remember: remove fluids the pleural space gradually to prevent
hypovolemic shock -> fatal
Do not remove >1000 mL in the 1st 30 minutes
Post-procedure:
1. Position: side pxn: unaffected
a. To promote maximum expansion of the lung on thee affected side
b. To prevent leakage of pleural fluids
2. Apply to the side a fixed, sterile, small, vasocclusive dressing
Prevent bleeding and infxn
3. The MD will re-order CXR
To rule out Pneumothorax

VII.

Chest Thoracostomy Tube

connected to a bottle system
3 way Bottle system
1. 1st chamber: drainage/collection chamber
acts as a reservoir for fluids draining from the chest
N amount in 24 hours: 300-500 mL
N color of drainage: clear, yellowish, dark red
Bright red= bleeding
calibrated in ML
2. 2nd chamber: HO seal chamber
acts as a one-way valve or water seal that prevents air from reentering the pleura as the pt. inhales
3. 3rd chamber: suction control chamber
4. it regulates the amount of (-) pressure applied to the chest
5. N Value: 20-25 cmHO

Bubbling
A. Drainage/collection chamber:
no bubbling
B. Water seal
1. Intermittent expected , N
2. Continuous- abnormal=airleak
Mgt: clamp the tube as close as possible to the client
3. No bubbling- it may mean 2 things:
a. Obstruction abnormal
Mgt: perform modified milking -> press-relax method or hand over
hand method
Require DO
b. Lungs hare re-expanded desired
Confirmation is CXR

D. Suction- control chamber

1. Continuous -
2. No bubbling x suction (off)
Verify DO
Problems with tube connections
1. Disconnection of chest tube from the chest -> apply a vasoeclusive dressing
such as vasillinized gauze, petroleum gauze or the cleanest material available
sucking/suction sound (-) pressure vasocclusive gauze blowing sound (+)
pressure dry sterile gauze blowing

Available: vasocclusive dressing

2. Disconnection of chest tube from an intact bottle -> reconnected the chest
tube and bottle
3. The bottle accidentally breaks
Reconnect the tube in a new sterile bottle immerse the tube in a vessel of
sterile HO clamp the tube
Oscillation/fluctuation rise and fall motion of HO seal chamber
2 main indicators of proper fixing of 2nd bottle
1. Intermittent bubbling
2. Fluctuation/osallation
If O/F is not present in 2nd chamber -> it may mean 2 things = same with
no bubbling in the 2nd chamber
NI:
1. Always maintain strict aseptic tech.
2. Always keep the bottle below the level of the chest
3. Always maintain the close drainage system -> 2nd bottle IB and O/F
4. Minimize or avoid handling, manipulating and clamping of the tube and
bottle to prevent tension pneumothorax
5. Assess and monitor for crepitus -> popping/crackling sensation and
sound surrounding a tube insertion site
Hallmark sign subq emphysema -. Not fatal; it may cause severe pain
and disfigurement
Male: scrotum
Female: labia minora
6. Insertion and removal of chest tube is performed by the physician
7. Immediately before the removal of chest tube, instruct the pt to
perform Valsalva maneuver/strain/inhale/ and hold breath to prevent
the air from re-entering the pleura as the tube is removed.
VIII.

Suctioning: removal of various respiratory secretions using a suction

catheter connected to a negative pressure unit (portable/wall suction)
Last resort
Things to remember:
1. Best time/frequency: PRN / as necessary
2. Indicator: noisy respiration / breathing
3. Position:
a. Conscious: semi-fowlers
b. Unconscious: side-lying
4. Lubricant:
a. Nasal-water-based (KY Jelly)
b. Oral-sterile HO/PNSS
5. Duration: 10-15 seconds
a. Typical (nasal/oral): 10-15 secs.
b. Tube (ET/tracheostomy): 5-10 secs,.
6. Interval b/n suction: 20-30 secs.

3x
7. Hyperoxygenate the pt with 100% O before and after breathing +
ambubag connected to the oxygen tank, if x partial or non-breathing
FM
Ratio for 5-7: To prevent hypoxia/hypoxemia
8. Technique: sterile
9. When to apply suction?
withdrawal, rotating motion, intermittently
To prevent trauma
10.Length of catheter insertion ->type of suctioning
a. Nasopharyngeal: N -> E
b. Nasotracheal: N -> E side of the neck (adams apple)
c. Oropharynx: M -> E
d. Orotracheal: M -> E midstemum
Nasal = 5 inches
oral = 6 inches
11.Suction pressure needed
Portable S.U. <
Wall S.U.
Infant

2-5 mmHg

50-95 mmHg

Child

5-10 mmHg

95-110 mmHg

Adult

10-15 mmHg

100-120 mmHg

12.Most dreaded / fatal complication

vasovagal reflex stimulation 2 to the prolonged and freq. stimulation
of the gag reflex
Vagus nerve: wandering nerve
Decrease HR: STOP
13. After suctioning -> oral care