I.

Specimens and Reference Values

A. Blood specimens
1. Most blood specimens are obtained through venipuncture
2. Arterial puncture is used to obtained blood for arterial
blood gases
3. Venipuncture and arterial puncture are invasive techniques
requiring a doctor order
4. Sterile technique is required for both procedures
5. Standard precautions are necessary
6. Apply pressure to puncture site after specimen has been
obtained to reduce likelihood of bleeding
7. Types of blood test
a. complete blood count (CBC) - measures the
number of red and white blood cells per cubic
millimeter of blood
b. blood chemistry - varies by agency generally
includes electrolytes, AST, ALT, and other values
8. Blood, plasma or serum values
a. normal plasma values
b. normal blood values

INDICATIONS FOR USING STERILE TECHNIQUE

1. Procedures requiring intentional perforation of the client's skin

2. When skin integrity is broken due to trauma, surgical incision or burns
3. Procedures involving insertion of catheters or surgical instruments into
body cavities

COMPLETE BLOOD COUNT

1. Red blood cell count
a. Men 4.7-6.1 million/mm3
b. Women 4.2-5.4 million/mm3
c. Infants and children 3.8-5.5 million/mm3
d. Newborns 4.8-7.1 million/mm3
2. White blood cell count
a. Adults and children greater than two years of age 5,000-
10,000/cm3
b. Children less than two years 6,200-17,000/mm3
c. Newborns 9000-30,000/mm3
3. Hematocrit
a. Men 42-52%
b. Women 37-47% (pregnancy>33%)
c. Children 31-43%
 d. Infants 30-40%
e. Newborns 44-64%
4. Hemoglobin
a. Men 13.5-18.0 g/dl
b. Women 12-16 g/dl (pregnancy >11 g/dl)
c. Children 11-16 g/dl
d. Infants 10-15 g/dl
e. Newborns 14-24 g/dl
5. Erythrocyte indices
a. Mean corpuscular volume (MCV) 86-98 (m3/cell)
b. Mean corpuscular hemoglobin (MCH) 27-32 pg/RBC
c. Mean corpuscular hemoglobin concentrate. (MCHC) 32-36%
6. Differential white cell count
a. Neutrophils 55-70%
b. Lymphocytes 20-40%
c. Monocytes 2-8%
d. Eosinophils 1-4%
e. Basophils 0.5-1.0%
7. Examination of peripheral blood cells: examination of size and shape of
individual RBCs and platelets

Blood chemistry consists of at least the following:

PLASMA VALUES
A. Albumin: 3.6-5.0 g/dl (see also Proteins, below)
B. Alcohol: negative
C. Alkaline phosphatase
adults 30-85 ImU/ml
 children greater than two years 85-235 ImU/ml
o two to eight years 65-210 ImU/ml
o nine to 15 years 60-300 ImU/ml
D. Ammonia
adults 9-33 mol/liter
children 40-80 g/dl
newborns 90-150 g/dl
E. Alpha fetoprotein (AFP) <25 ng/ml
F. Bilirubin, direct - up to 0.3 mg/dl
G. Bilirubin, indirect - 0.1-1.0 mg/dl
H. Bilirubin total
adults and children 0.3-1.1 mg/dl
newborns 1-21 mg/dl
I. Bleeding time one to nine minutes
J. Calcium 8.6-10.3 mg/dl
K. Chloride 97-110 mmol/liter
L. Creatinine 0.5-1.7 mg/dl
M. Creatinine clearance 107-139 ml/min - can vary by age
norms: 20 years .84 to 100 years .132
N. Fibrinogen 150-360 mg/dl
O. Gamma globulin 0.8-1.6 g/dl
P. Glucose fasting
adults 65-110 mg/dl
children 51-85 mg/dl
newborns 30-80 mg/dl; >24 hrs. 42-68 mg/dl
Q. Glucose (two hour postprandial) < 140 mg/dl
R. Glucose Tolerance Test
fasting 70-105 mg/dl; 30 minute < 200 mg/dl
one hour < 200 mg/dl
two hours < 140 mg/dl
three hours 70-105 mg/dl
four hours 70-105 mg/dl
S. Iron
male: 45-160 g/dl
female: 30-160 g/dl
T. Lead 120 (g/dl or less) <25 g/dl
U. Lipids (total) 400- 800 mg/dl
V. Cholesterol <200 mg/dl
W. HD
females: 30-85 mg/dl
males: 30-65 mg/dl
X. ldl< 190 mg/dl
Y. Triglycerides <250
Z. Phospholipids 180-320 mg/dl
AA. Free fatty Acids 9.0-15.0 mM/L
 BB. Partial thromboplastin time, activated (APTT) 21-32 seconds tow
to three times when anticogulated)
CC. Phosphorus
adults 2.5-4.5 mg/dl
children 3.5-5.8 mg/dl
DD. Potassium 3.8-5.0 mEq/L
EE.Protein (total) 6.2-8.2 g/dl
albumin 3.6-5.0 g/dl
globulin 2.3-3.4 g/dl
FF.Prothrombin Time (PT) 11.3-18.5 seconds (tow to three times when
anticogulated)
GG. Rheumatoid factor negative
HH. Sodium 135-145 mEq/L
II. Thyroid tests
JJ. Thyroxine T4 4.5-12.0 g/dl
KK. TSH 0.35-6.20 U/ml
LL. Urea Nitrogen 8-25 mg/L
MM. Uric acid 3-8 mg/dl

NORMAL BLOOD VALUES

1. Red cell volume 25-35ml/kg body weight
2. Platelets: 200,00-300,000/ml3
3. Erythrocyte Sedimentation Rate (ESR)
Adults up to 30 mm/hr
Children up to 10 mm/hr
4. Arterial Blood gases

a. pH 7.35-7.45
b. PCO2 35-45 mm Hg
c. HCO3- 22-26 mEq/L
d. PO2 arterial 80-100 mm Hg
e. Oxygen saturation 95-100%
f. Urine specimens
1. Types
1. random
1. obtained from client voiding naturally, from
urinary catheter or diversion bag
2. used for routine urinalysis
2. clean-voided or midstream
1. after appropriate cleansing of urethral
meatus, client collects urine after initial
stream has cleansed urethra
2. used for culture and sensitivity
3. men should retract foreskin and cleanse glans
3. sterile
 1. obtained directly from indwelling urinary
catheter
2. needle and syringe used to obtain specimen
from special port within urinary catheter
3. sterile technique maintained
4. timed
1. used for tests of renal function and urine
composition (creatinine clearance, steroids,
hormones)
2. first urine specimen is discarded and for next
period of time, all urine is collected
3. client may be required to void at specific
times
4. missed specimens or those contaminated with
feces or other elements render the test
invalid
5. client voids last specimen at end of timed
period
2. Specimen should be refrigerated if it is to be kept for more
than one hour
3. Immediate information on pH, glucose, protein, ketones
and blood can be obtained by using commercial reagent
stick
4. Pediatric considerations
1. offer small child fluid about 30 minutes before
needed specimen
2. use terms that child can understand to explain
procedure
3. use special collection bags for newborns and infants
5. Common tests
1. routine urinalysis tests and normal values
2. pH: 4.6-8.0
3. protein: up to 10mg/ml
4. glucose: negative
5. ketone: negative
6. blood: up to two RBCs
7. specific gravity: < 1.025
8. microscopic examination
1. wbc's: zero to eight per high powered field
2. bacteria: negative
3. casts: negative
6. Culture and sensitivity
1. used to determine bacterial growth and specific
antibiotics that are effective against those specific
bacteria
2. requires sterile or clean-voided specimen
 7. Urine values
g. Urine specimens
1. Types
1. random
1. obtained from client voiding naturally, from
urinary catheter or diversion bag
2. used for routine urinalysis
2. clean-voided or midstream
1. after appropriate cleansing of urethral
meatus, client collects urine after initial
stream has cleansed urethra
2. used for culture and sensitivity
3. men should retract foreskin and cleanse glans
3. sterile
1. obtained directly from indwelling urinary
catheter
2. needle and syringe used to obtain specimen
from special port within urinary catheter
3. sterile technique maintained
4. timed
1. used for tests of renal function and urine
composition (creatinine clearance, steroids,
hormones)
2. first urine specimen is discarded and for next
period of time, all urine is collected
3. client may be required to void at specific
times
4. missed specimens or those contaminated with
feces or other elements render the test
invalid
5. client voids last specimen at end of timed
period
2. Specimen should be refrigerated if it is to be kept for more
than one hour
3. Immediate information on pH, glucose, protein, ketones
and blood can be obtained by using commercial reagent
stick
4. Pediatric considerations
1. offer small child fluid about 30 minutes before
needed specimen
2. use terms that child can understand to explain
procedure
3. use special collection bags for newborns and infants
5. Common tests
1. routine urinalysis tests and normal values
2. pH: 4.6-8.0
 3. protein: up to 10mg/ml
4. glucose: negative
5. ketone: negative
6. blood: up to two RBCs
7. specific gravity: < 1.025
8. microscopic examination
1. wbc's: zero to eight per high powered field
2. bacteria: negative
3. casts: negative
6. Culture and sensitivity
1. used to determine bacterial growth and specific
antibiotics that are effective against those specific
bacteria
2. requires sterile or clean-voided specimen
7. Urine values

NORMAL URINE VALUES

1. Acetone Negative
2. Specific gravity < 1.025
3. Osmolality 850 mOsm/L
4. Creatinine clearance
Men 90-140 ml/min
Women 85-125 ml/min
5. Glucose negative
6. Granular casts occasional
7. pH 4.6-8.0
8. Phenylketonuria negative
9. Protein negative
10.Sodium (24 hour) 100-260 mEq/24 hours
11.Urobilinogen 0.1-1.0 Ehrlich U/dl
Other specimens
1. Fecal (stool) specimen
1. used to determine presence of blood (Guaiac test),
fat and for cultures
2. aseptic technique required
3. client must defecate into clean dry bedpan to avoid
contaminating specimen with urine or water (only a
sample is required)
4. timed test for fecal fat may be performed
2. Sputum specimen
1. microbiologic examination of secretions from the
respiratory tract
2. may be obtained from patient expectoration or via
suctioning
3. client should brush teeth and gargle before specimen
collection
 4. indications: suspected pneumonia and malignancy
5. tests include a Gram stain and culture and sensitivity
3. Gastric analysis
1. masures gastric secretions under fasting conditions
2. histamine is injected via nasogastric tube and
secretions are aspirated
3. indications: suspected gastric ulcer or malignancy
4. before test, client NPO for about eight hours and no
smoking
5. instruct client to expectorate saliva rather than
swallow it
6. withhold the following drugs for 24 hours prior to
test: antacids, anticholinergics, alcohol, H2 blockers,
reserpine and adrenergic blockers

Arms Forward Stretch

Instructions

Sit up straight. This exercise may be done in a half lotus sitting position or in a
chair.
Bring your arms up to shoulder level. Clasp your hands together and press them
onto your chest. Lift your head up and stare at the ceiling, hold this position a
second or two, let the muscles in the neck area stretch. Drape a towel around
your neck if this movement is difficult for you .
INHALE then EXHALE and lower your head, press your chin onto your chest.
Simultaneously stretch your arms straight out in front of your chest at shoulder
level. Inhale and return the hands to the chest and lift the head up and back.
This is 1 set, do 3 sets.
Pleural fluid analysis
obtained via thoracentesis (see Respiratory
Diagnostic tests on page 6 of this lesson)
indications: inflammation, infection or malignancy
Peritoneal fluid analysis
obtained via paracentesis (see Gastrointestinal
Diagnostic tests on page 6 of this lesson)
indications: gross ascites
 Cerebrospinal fluid analysis (a listing of normal
cerebrospinal fluid values can be found in the Taber's
Glossary)
obtained via lumbar, cisternal or ventricular
puncture (See Neurologic Diagnostic tests on page 6
of this lesson) (illustration )
indications: inflammation, infection

Dia
gnostic Tests--Common Laboratory Tests
o Gastrointestinal disorders
o Cardiovascular disorders
o Respiratory disorders
o Neurological disorders: cerebrospinal fluid
o Musculoskeletal disorders: blood tests
o Integumentary disorders
o Endocrine and hormonal disorders
o Renal system
o Genitourinary system
o Hematologic disorders
Diagnostic Tests--Other
o Visualization tests: endoscopy, laparoscopy
Direct inspection of a body part using an instrument with a
light (endoscope, laparoscope)
 Performed by inserting the instrument directly into a body
opening or into a body cavity via a surgical incision
Fiberoptic instruments may be used to enhance client
comfort, to improve instrument flexibility, and to facilitate
visualization
May be performed under local or general anesthesia

COMMON LABORATORY TESTS FOR GASTROINTESTINAL DISORDERS

1. Blood
a. CBC
b. Serum electrolytes
c. Serum chemistry
d. Enzyme-linked immunosorbent assays (ELISA)
e. Serum amylase
f. Differential blood count
g. Prothrombin time
h. ALT, AST, Alanine aminotransferase, LDH
i. Serum bilirubin
j. Glucose
k. Ammonia
l. Serum lipase
m. Alkaline phosphatase
2. Stool
a. Occult blood
b. pH
c. Ova & parasites
d. Qualitative fat
e. Reducing substances
f. Bacterial cultures
g. Vital pathogens
h. Leukocytes
3. Urine
a. Osmolality
b. Sodium
c. Potassium
d. Nitrogen
e. Urobilinogen
f. pH

COMMON LAB TESTS FOR CARDIOVASCULAR DISORDERS

1. Serum Chemistry
2. Serum Electrolytes
3. Alanine aminotransferase (AST) 5-40 IU/L
4. Creatine kinase CK
Male 55-170U/L
Female 30-135 U/L
 5. CK - MB (isoenzyme) 0-7 U/L
6. Lactic dehydrogenase (LDH)
LDH1 22%-36%
LDH2 35%-46%
LDH313%-26%
LDH4 3%-10%
LDH5 2%-9%
7. CBC
8. Lipid levels
9. Prothrombin time
10.Alkaline phosphatase
11.ESR
12.Arterial Blood Gases
13.Troponin

COMMON LAB TESTS FOR RESPIRATORY DISORDERS

1. Blood
a. arterial Blood gases
b. blood cultures
c. hemoglobin
d. hematocrit
e. CBC
f. serum electrolytes
g. RAST
h. immunoglobulins
i. cultures Profile II
2. Urine
a. UA
b. culture and sensitivities
c. casts
3. Throat: sputum culture and sensitivites
4. Skin
a. PPD

COMMON LAB TESTS FOR NEUROLOGICAL DISORDERS: CEREBROSPINAL FLUID

(illustration )

1. Appearance colorless, clear

2. Pressure 50-180 mm H2O
3. Protein
a. Lumbar 15-50 mg/dl
b. Cisternal 15-25 mg/dl
c. Ventricular 6-15 mg/dl
4. Cell Count
a. RBCs negative
 b. WBCs 0-5
5. Glucose 50-80 mg/dl
6. Gram stain negative for organisms
7. Culture and sensitivity: no growth

COMMON LAB TESTS FOR MUSCULOSKELETAL DISORDERS: BLOOD TESTS

1. ESR
2. C-reactive protein
3. CBC
4. Serum cultures
5. Serum Calcium
6. ANA
7. Creatinine

COMMON LAB TESTS FOR INTEGUMENTARY DISORDERS

1. Blood
CBC
Cultures
IgE
Eosinophils
Titers
IFA
ELISA (Enzyme-linked immunosorbent assays)
2. Skin/wound
 Cultures
Scrapings, smears
Patch testing
Microscopic exam

COMMON LAB TESTS FOR ENDOCRINE AND HORMONAL DISORDERS

1. Blood or serum
a. Serum electrolytes

b. Plasma Fasting ACTH

8 AM <60 pg/ml

4 PM 10-50 pg/ml

c. Plasma Aldosterone Concentration (PAC)

Supine 10-160 ng/liter

Upright 8.9-58 ng/dl

d. Plasma Renin Activity (PRA)

e. Plasma Cortisol

f. Catecholamines

g. Thyroid hormone levels: TSH 0.35-6.20 U/ml

h. Fasting Blood Sugar

i. Blood insulin levels

j. Growth hormone

Male: <5 ng/dl

Female: <10 ng/dl
k. Cosyntropin

l. ESR

m. CRP

2. Urine
 a. 17-hydroxysteroids

b. Free catecholamines

c. Osmolality

d. Glucose tolerance test

3. Karyotyping

4. Water deprivation study

COMMON LAB TESTS FOR THE RENAL SYSTEM

A. Blood
CBC
Serum chemistry
Serum electrolytes
Serum osmolality
Lipid levels
B. Urine
pH
Osmolality
Specific gravity
Sodium
Creatinine
Sediment
Creatinine clearance
Casts

(illustration 1 , illustration 2 )

Culture and sensitivity

 COMMON LAB TESTS FOR THE GENITOURINARY SYSTEM
A. Urine
culture and sensitivity
pregnancy
osmolality
WBC
RBC
casts
specific gravity
ketones
esterase
nitrates
B. Blood
serum electrolytes, creatinine, BUN
 osmolality
CBC
uric acid
ESR
CRPp
serum mucoprotein
serum complement
pregnancy
estrogen and progesterone levels
RPR
HIV assay - ELISA
antibody responses: ASO, ASKase, AHase, ADNase-B
prostate-specific antige

COMMON LAB TESTS FOR HEMATOLOGIC DISORDERS

A. Blood
Complete blood count (CBC)
Differential blood count
Sickle cell trait
Laboratory tests for Anemias and Leukemias
Transferrin saturation
Serum ferritin
Serum folic acid
Serum iron
Serum total iron-binding capacity
Vitamin B12 assay
Reticulocyte count
B. Laboratory tests for hemolytic disorders
Serum haptoglobin
Hemoglobin electrophoresis
Osmotic fragility
RBC enzyme assays
RBC survival time
C. Laboratory tests for bleeding disorders (illustration )
Platelet count
Bleeding time
Partial thromboplastin time or activated partial thromboplastin
time
Prothrombin time
Thrombin time
Prothrombin consumption time
Platelet aggregation
Fibrinogen level I
Fibrinogen degradation
Antithrombin III
Coagulation factor assays
A. Uses
A. diagnostic: permits inspection and obtaining biopsies
B. therapeutic: remove polyps or foreign bodies,
implant radioactive seeds
 6. Nursing interventions in endoscopy, laparoscopy
a. tell the client about the procedure
b. when it involves the respiratory system remove
dental appliances before procedure
c. keep client NPO before procedure for 6 to 12 hours
d. after bronchoscopy or laryngoscopy hoarseness is
normal; watch for laryngospasm or bronchospasm
e. watch client carefully until gag and swallowing
reflexes return
7. If the client is to undergo general anesthesia, give
perioperative care
8. Post arthroscopy
a. apply pressure dressing and ice
b. caution client to avoid excessive use of joints for 48
hours
c. permit weight bearing on knees
9. Mild analgesics may relieve post-procedure discomfort
10. Trapped carbon dioxide in the abdominal and pelvic
cavities may cause mild shoulder pain
B. X-rays (roentgenograms)
6. Noninvasive test in which radiation is passed through a
specific body part to display a picture of the internal
aspects of that part
7. Used to
a. determine shape, size and position of organs
b. indicate presence of fluid lines, foreign bodies,
infiltrates
c. determine configuration, density and vascular
markings of organs
d. determine injury, fracture, degeneration,
inflammation, perforations, calculi (stones) or
masses
e. types of x-ray
I. chest
II. musculoskeletal
III. skull
IV. spine
V. mastoid
VI. sinus
VII. breast
VIII. kidneys, ureters, bladder (KUB)
8. Nursing interventions for x-ray procedures
a. instruct client about procedure
b. shield the client's genitals
c. do not x-ray pregnant women
 d. for chest x-ray, remove all the client's jewelry or
garments containing metal clasps or buttons
C. Contrast radiography
6. Visualization of x-ray enhanced by using contrast medium
7. Contrast medium may be ingested, injected through a tube
or catheter or given intravenously
8. Contrast medium may be barium, iodine, or air
9. Cineradiography: rapid sequence x-rays that film motion
10. Fluoroscopy: projection of x-rays onto screen for
continuous observation of motion
11. Barium contrast studies
a. barium swallow
b. upper gastrointestinal and small bowel series
c. barium enema
d. specific nursing interventions with barium
I. low residue diet or clear liquid diet for two
days
II. client NPO after midnight
III. use cathartic: magnesium citrate, GoLYTELY
IV. before test, give suppository or enema
V. retained barium may harden and cause an
obstruction; examine client's stools; a mild
laxative or cleansing enema may be ordered
to help client expel barium
VI. clear liquid before and force fluids after a
barium procedure
VII. encourage drinking of more fluids to aid in
elimination of barium
e. white stools for 24 to 72 hours are common
12. Air contrast studies
a. ventriculogram: air injected via direct puncture of
lateral cerebral ventricles.
b. positive contrast medium may also be injected
c. pneumoencephalogram
13. Iodine-based contrast media
a. intravenous cholangiogram (IVC)
b. visualizes bile ducts
c. special nursing interventions
I. low residue diet for one day prior to test
II. npo after midnight
14. Intravenous pyelogram (IVP): visualization of kidney and
urinary system
15. Other types of contrast studies
a. arteriographic and venographic studies
b. cerebral arteriography
c. fluorescein arteriography
 d. cardiac catheterization
e. digital vascular imaging
f. scintiscan
g. pulmonary arteriography
h. renal arteriography
i. venography
j. lymphangiography
k. myelogram: visualization of the spinal cord using
water-soluble or oil agent
I. special nursing interventions
I. clear liquid breakfast then NPO
II. client must lie flat for eight to 12 hours
after test if oily contrast medium is
used
III. force fluids post-test to replace
cerebrospinal fluid
IV. mild analgesics may be ordered post-
test for headache
16. General nursing interventions in all contrast studies
a. check for hypersensitivity to contrast medium
b. observe for allergic reactions post-test
17. Air contrast studies
a. ventriculogram: air injected via direct puncture of
lateral cerebral ventricles.
b. positive contrast medium may also be injected
c. pneumoencephalogram
18. Iodine-based contrast media
a. intravenous cholangiogram (IVC)
b. visualizes bile ducts
c. special nursing interventions
I. low residue diet for one day prior to test
II. npo after midnight
19. Intravenous pyelogram (IVP): visualization of kidney and
urinary system
20. Other types of contrast studies
a. arteriographic and venographic studies
b. cerebral arteriography
c. fluorescein arteriography
d. cardiac catheterization
e. digital vascular imaging
f. scintiscan
g. pulmonary arteriography
h. renal arteriography
i. venography
j. lymphangiography
 k. myelogram: visualization of the spinal cord using
water-soluble or oil agent
I. special nursing interventions
I. clear liquid breakfast then NPO
II. client must lie flat for eight to 12 hours
after test if oily contrast medium is
used
III. force fluids post-test to replace
cerebrospinal fluid
IV. mild analgesics may be ordered post-
test for headache
21. General nursing interventions in all contrast studies
a. check for hypersensitivity to contrast medium
b. observe for allergic reactions post-test
D. Ultrasound studies
6. Noninvasive test
7. Uses high frequency sound waves (5000-20,000 Hz) to
detect vibrations reflected off soft tissues
8. Vibrations become electrical impulses, displayed on TV
screen
9. Transducer placed on client's skin transmits the sound
waves
10. Tissues of varying density reflect (echo) the sound
differently
11. Uses
a. to determine size, shape, position and motion of
organs
b. to detect masses
c. to define boundaries between organs
d. to determine fetal age and/or abnormalities
e. types
I. heart
II. eye
III. gall bladder
IV. liver
V. spleen
VI. pancreas
VII. renal/bladder
VIII. testes
IX. fetal
X. peripheral vasculature: doppler ultrasound
used to measure peripheral blood pressure
and pulses
12. Nursing intervention in ultrasound studies
a. explain test to client
b. bladder and fetal test require full bladder
E. Electrodiagnostic studies
6. Representation of electrical activity in certain organs
7. Electrocardiogram (ECG or EKG):
a. records electromechanical activity of myocardium,
electrical axis of the heart
b. the ECG records two basic events: depolarization
and repolarization (illustration )
c. the ECG records electrical activity as specific waves
I. P-wave: sinus node generates impulse; atria
depolarize
II. PR interval: time for impulse to travel from
sinus node through atria to atrioventricular
node, the Bundle of His, the bundle branches
and the ventricles; range: 0.12-0.20 seconds
III. QRS complex: ventricle depolarizes and
contracts (systole)
IV. T wave: ventricle repolarizes, ready for next
systole
V. ST segment: time between ventricular
depolarization and repolarization
d. used to determine presence of ischemic cardiac
disease and cardiac conduction disturbances
8.

Exercise stress test

a. records myocardial response to exercise
b. used to determine ischemic heart disease and
cardiovascular fitness before exercise programs
c. exercise level is progressively raised while ECG is
monitored
d. blood pressure and blood gases may be measured
e. nursing interventions
I. encourage client to immediately report any
symptoms during and after test
II. client should dress for exercise and bring a
change of clothing
9. Ambulatory electrocardiography (Holter monitor)
 a. records myocardial activity continuously for 24 or 48
hours
b. portable device
c. used to detect cardiac rhythm disturbances over
time
d. correlated with client's activity
e. specific nursing intervention: client must keep a
diary that records both activity and any symptoms
during test
10. Electrophysiology studies
a. an invasive measure of cardiac electrical activity
b. electrical catheter is inserted into right atrium via a
peripheral vein
c. an ECG records each electrical stimulation of heart
and how the heart responds
d. used to determine cardiac dysrhythmias

Neck Stretch Variation

Instructions

Sit up straight. Clasp your hand behind your neck.

INHALE Pull your elbows back and look up. Hold for several seconds, then
EXHALE and gently lower your head making sure that the spine remains
straight. Bring the elbows down and in, try to touch them. Let the weight of
your arms pull slightly on the back of the neck.
Now INHALE and lift he head and arms up. Look up, with the elbows out and
back.
This is 1 set, do 3 sets.
Electroencephalogram (EEG) (illustration )
records electrical activity at various brain sites
specific nursing interventions
do not stop anticonvulsant medications
the night before test, adult clients should
have minimal sleep
hair should be washed prior to test
after test, help client remove paste
Electromyogram
 records electrical activity in muscle sites
nursing: explain to client that small needle will be
inserted into one or more muscles or electrodes are
placed on the skin overlying the muscle
Electrocochleogram
measures auditory function
nursing intervention: be aware that client may
experience vertigo
Electronystagmogram: record of electrical activity of eye
during spontaneous, positional and calorically-invoked
nystagmus
Doppler ultrasound: used to detect deep vein thrombosis
General nursing interventions in electrodiagnostic studies
always explain test to client
client must remain still during test unless instructed
to do otherwise
client should avoid stimulants before test
o
 Radioisotope scans
Intravenous injection of a radioactive substance followed
by a series of pictures taken by a special scanning device to
detect passage of the substance through the body
Types
brain scan: used to detect intracranial lesions such
as neoplasms, brain abscess, cerebral hemorrhage,
acute infarction and arteriovenous malformation
cisternography: used to assess cerebrospinal fluid
circulation
thyroid uptake and scan: used to localize functioning
versus non-functioning thyroid tissue
ventilation/Perfusion scan: used to diagnose
pulmonary emboli
bone scan: used to diagnose metastatic cancer and
traumatic, inflammatory or infectious
musculoskeletal conditions
liver scan: used to screen for hepatic metastasis,
cirrhosis and hepatitis
spleen scan: used to identify splenic infarct,
metastasis, tumors, cysts and abscesses
renal scan: useful in monitoring rejection of a
transplanted kidney and in the detection of tumors,
abscesses, cysts, renal vascular disease and trauma
125 I Fibrinogen uptake: used to detect the presence
of deep vein thrombosis
Nursing interventions
explain test to the client
check for allergies, particularly to iodine
for renal scans, client may excrete radionuclide
after the test, so pregnant caregivers should not
handle client's urine for at least 24 hours after the
test.
do not schedule client for more than one
radioisotope study on one day
results of tests using radioactive iodine may be
affected by
dietary intake of iodine
use of antithyroid drugs
drugs containing iodine
o Tomography and resonance imaging (illustration )
Computerized tomography (CT) scans
use a roentgen ray and a computer to provide
accurate images of cross sections of the body
a non-invasive procedure using very little radiation
that visualizes slices of tissues
 usually takes less than one hour
sharper images than conventional x-rays
contraindicated in pregnancy
nursing interventions
explain test to client
some clients may require mild sedation
client must lie very still
client receives radiopaque solution to
visualize blood vessels
client is NPO past midnight when contrast is
used
if barium studies were done, wait at least four
days for CT scan, or barium will obscure film
Positive emission tomography (PET)
uses an intravenous injection of radioactive
substance followed by a head scan
various shades of color indicate levels of glucose
metabolism in the brain
nursing interventions: same as CT scan
Magnetic resonance imaging (MRI)
tomography based on the magnetic behavior of
protons in the body tissues
used to detect neurologic and musculoskeletal
disorders
contraindicated in clients with metal implants such
as pacemakers, aneurysm clips, medication patches
that are foil backed, metallic orthopedic devices,
can be uncomfortable with multiple tattoos
nursing interventions
explain test to client
client must lie very still
client may become claustrophobic in chamber
soft humming sound may annoy some clients
client must remove all metal jewelry and
watches
H. Biopsy
1. Removal of small piece of body tissue for exam by
pathologist
2. May be accomplished via needle aspiration, punch biopsy,
endoscopy, laparoscopy or surgery
3. May be performed under local or general anesthesia
4. Uses: to differentiate normal from abnormal tissue
5. Types
a. brain
b. thyroid
c. lung
d. pleura
e. lymph node
f. bone marrow
g. muscle
h. nerve
i. synovial
j. bladder, urethra
k. prostate
l. vagina, cervix or uterus
m. skin
n. liver
o. breast
6. Nursing interventions
a. explain test to client
b. review client history for signs of bleeding disorders
 c. if the client is awake, they will experience
discomfort or pain during test
d. if general anesthesia is used, implement
perioperative care
e. observe client for signs of bleeding and infection at
biopsy site
f. mild analgesics may be ordered for post-test
discomfort
I. Skin
1. Tuberculin skin testing
a. PPD (Purified protein derivative) is injected
intradermally
b. indicates whether client has been infected with
Mycobacterium tuberculosis or has been in contact
with infected individual
c. site checked at 24 and 48 hours after administration
d. contraindicated in clients with active tuberculosis,
or previous BCG vaccine
e. positive reaction: induration (elevated, red, and
hard) of 10 mm or greater
f. negative reaction: no change at site or some
response, yet less than 10 mm and only elevated or
red
2. Allergy skin testing
a. antigen is injected intradermally or by scratching
the skin
b. site checked in 20 minutes after administration
c. indicates sensitivity to antigens
d. positive reaction: redness, swelling tenderness at
site
e. complication: anaphylactic reaction
3. Schick test
a. intradermal injection of toxin in one arm and toxoid
in the other
b. areas examined at 24 and 36 hours after
administration
c. determines presence of diphtheria antitoxins in the
blood
d. positive reaction: site of toxin injection: redness,
swelling and tenderness. Maximum reaction in one
week. Toxoid site shows no reaction
e. negative reaction: no reaction at either site
4. Nursing interventions in skin tests
a. circle the injection site(s)
b. instruct client not to wash circled area(s)
J. Ear & balance - audiometric tests (illustration )
1. Screening audiometry
a. 20dB tone is presented at 500, 1000, and 2000 Hz,
and
b. 25dB tone at 4000 Hz
2. Impedance audiometry
a. useful in detecting middle ear disorders
b. evaluates resistance to flow of sound
3. Tympanometry
a. measures compliance of tympanic membrane with
variations in air pressure in the external ear canal
b. determines the amount of negative pressure in the
middle ear
4. Romberg test (for balance)
a. assess vestibular function
b. client stands with feet together and eyes closed
c. minimal swaying expected
5. Caloric test
a. tests function of eighth cranial nerve
b. cold and warm water instilled into external ear canal
c. normal finding:

Cold water -> rotary nystagmus away from

irrigated ear

Warm water -> rotary nystagmus toward the

irrigated ear

d. test can cause nausea

6. Tympanocentesis
a. aspiration of middle ear fluid
b. commonly done during myringotomy
c. fluid is cultured
K. Gastrointestinal tract
1. Esophageal function studies
a. client swallows three thin tubes which pass into
stomach
b. transducers measure esophageal pressures

2. Paracentesis (illustration )
a. drains abdominal fluid of client with ascites
b. small incision is made just below umbilicus
and trocar is inserted
c. nursing interventions
i. client should void before procedure
ii. sit client with feet firmly on floor
iii. remove fluid slowly over a period of 30-
90 minutes to prevent sudden changes
in blood pressure
iv. monitor client for hypovolemia or
electrolyte imbalance
v. observe incision site for leaking or
bleeding
 vi. obtain and label specimens for
laboratory analysis

L. Respiratory
2. Pulmonary function tests
a. use a spirometer and record how efficiently
lungs exchange oxygen and carbon dioxide
b. client sits upright, wears noseclip and
breathes into mouthpiece.
c. uses
i. to diagnose lung disease
ii. to evaluate the extent of functional
disability
iii. to evaluate lung function pre-
operatively
iv. to evaluate how lungs respond to
bronchodilators

d. measurements:
 *Abnormal Values: values less than 80% of predicted norm.

e. nursing interventions in pulmonary function tests

i. explain test to client
ii. client will wear clip on nose
2. Thoracentesis
e. insertion of large bore needle into pleural space
f. uses
i. to obtain pleural fluid for analysis
ii. to remove pleural fluid
iii. to instill medications
g. nursing interventions
i. position client either sitting upright with arms
and shoulders on overbed table, or in side
lying position
ii. stress that client must stay very still during
procedure
iii. explain that client will feel some pressure
iv. post-procedure, place client on unaffected
side for at least 1 hour
 v. check vital signs frequently
vi. watch for signs of pneumothorax,
subcutaneous emphysema or shock
vii. obtain and label specimens for analysis
3. Pulse oximetry
e. measures oxygen saturation; less accurate than
arterial blood gas (ABG)
f. monitors oxyhemoglobin saturation noninvasively
(illustration )
g. technique
i. probe clips to end of finger or earlobe and
passes a light through tissue
ii. light is absorbed by photodetector
iii. oximetry calculated from how much light
RBCs absorb
iv. arterial saturation is displayed; normal SaO2
more than/or equal to 93%
h. pulse oximetry unreliable if there is
i. bright light shining on sensor
ii. tremor or seizure on extremity where probe is
placed
iii. poor perfusion to location where probe is
placed
iv. cardiac arrest
v. intravascular dye circulating in the blood
stream
vi. abnormal hemoglobin, such as
carboxyhemoglobin and methemoglobin
i. if pulse oximetry shows significant changes, verify its
results with ABG (arterial blood gas) assay

4. Pilocarpine test (iontophoresis) or sweat test

a. measures sodium and chloride excretion from sweat
glands
 b. often first test performed for diagnosing cystic
fibrosis
c. usually performed on infants
d. pilocarpine is administered to stimulate sweat glands
e. perspiration is analyzed for sodium and chloride
content
f. normal findings
i. sodium < 90 mEq/L
ii. chloride < 60 mEq/L
g. nursing interventions: none
2. Neurological system
4. Lumbar puncture (LP)(Spinal Tap) (illustration )
a. needle inserted into the subarachnoid space
between L3 and S1
b. uses
i. measure cerebrospinal fluid (CSF) pressure
ii. obtain CSF for visual and laboratory
examination
iii. to inject medications, anesthetic agents,
diagnostic agents.
5. Contraindicated if client has increased intracranial pressure
(ICP)
6. Place client in lateral decubitus position (knee-chest)
7. Complications include post-puncture headache
8. CSF findings
9. Nursing interventions
a. explain procedure to client
b. administer sedative if ordered
c. assist client to maintain proper position and stillness
during procedure
d. maintain standard precautions
e. label specimens sequentially
f. provide emotional support as procedure can be
painful
g. post-procedure
i. keep client flat on back from four to 12 hours
ii. give analgesics & ice pack as ordered
iii. perform neuro checks and vital signs
prequently to assure stability
iv. encourage fluids unless contraindicated
v. observe for post-puncture headache, leakage
of CSF, tingling sensation, numbness or pain in
lower extremities
 Cerebrospinal Fluid (CSF)

Definition: A watery cushion that protects the brain and spinal cord from
physical impact and bathes the brain in electrolytes and proteins.

Formation: The fluid is formed by the choroid plexuses of the lateral and third
ventricles. That of the lateral ventricles passes through the foramen of Monro
to the third ventricle, and through the aqueduct of Sylvius to the fourth
ventricle. There it may escape through the central foramen of Magendie or the
lateral foramina of Luschke into the cisterna magna and to the cranial and
spinal subarachnoid spaces. It is reabsorbed through the arachnoid villi into the
blood in the cranial venous sinuses, and through the perineural lymph spaces of
both the brain and the cord. (illustration 1 , illustration 2 ).

Characteristics: The fluid is normally watery, clear, colorless, and almost

entirely free of cells. The initial pressure of spinal fluid in a side-lying adult is
about 100 to 180 mm of water. On average, the total protein is about 15 to 50
mg/dl, and the concentration of glucose is about two-thirds the concentration
of glucose in the patient's serum. Its pH, which is rarely measured clinically, is
slightly more acidic than the pH of blood. Its concentration and alkaline
reserve are similar to those of blood. It does not clot on standing. Turbidity
suggests an excessively high number of cells in the fluid, typically white blood
cells in infection or red blood cells in hemorrhage.

CSF may appear red following a recent subarachnoid hemorrhage or when the
lumbar puncture that obtained the CSF caused traumatic injury to the dura
that surround the fluid. Centrifugation of the fluid can distinguish between
these two sources of blood in the spinal fluid: the supernatant is usually
stained yellow (xanthochromic) only when there has been a recent
subarachnoid hemorrhage.

Many conditions may cause increases in total protein: infections, such as acute
or chronic meningitis; multiple sclerosis (when oligoclonal protein bands are
present); Guillain-Barr syndrome; and chronic medical conditions like cirrhosis
and hypothyroidism (when diffuse hypergammaglobulinemia is present). The
concentration of glucose in the CSF rises in uncontrolled diabetes mellitus and
drops precipitously in meningitis, sarcoidosis, and some other illnesses.
Malignant cells in the CSF, demonstrated after centrifugation or filtering, are
hallmarks of carcinomatous meningitis.

Microorganisma: The CSF is normally sterile. Meningococci, streptococci,

Haemophilus influenzae , Listeria monocytogenes , and gram-negative bacilli
are recovered from the CSF only in cases of meningitis. Syphilitic meningitis is
usually diagnosed with serological tests for the disease, such as the venereal
disease research laboratory (VDRL) test, the rapid plasma reagin (RPR) test, or
the fluorescent treponemal antibody test. Cryptococcal infection of the CSF
may be demonstrated by India ink preparations, or by latex agglutination tests.
Tuberculous meningitis may sometimes be diagnosed with Ziehl-Neelsen stains,
but more often this is done with cultures. These last three infections (syphilis,
cryptococcosis, and tuberculosis) are much more common in patients who have
acquired immunodeficiency syndrome (AIDS) than in the general population.

7. Intracranial pressure (ICP) monitoring

a. invasive: measuring device is placed
i. in a ventricle
ii. in a subarachnoid space
iii. outside dura mater
iv. within parenchyma
b. types of devices include aventricular catheter; a
subarachnoid bolt; an epidural sensor
c. changes in intracranial pressure are converted to an
electrical impulse by a transducer and displayed on a
screen or on graph paper
d. measurements include volume-pressure
relationships, pressure waves and cerebral perfusion
pressures
e. normal ICP: 10-15 mm Hg
f. nursing interventions
i. maintain strict sterile technique
ii. maintain patency of device
iii. observe for CSF leaks or bleeding, signs of
infection
iv. monitor pressure and report deviations

N. Cardiovascular system
1. Hemodynamic monitoring: invasive cardiac catheter
a. reflects left ventricular end diastolic pressure
b. use of a balloon-tipped, flow-directed catheter to
provide continuous monitoring (illustration )
c. catheter introduced via subclavian vein or by
cutdown and passed through right side of heart to
pulmonary artery
d. may be inserted at the bedside or under fluoroscopy
e. normal parameters
 f. complications of hemodynamic monitoring
i. pneumothorax
ii. dysrhythmias
iii. infection, sepsis, thrombophlebitis
g. nursing interventions: monitor values, assess and
change dressings, maintain patency with fluids,
calibrate equipment, remove lines, obtain specimens
h. Intra-arterial pressure
i. catheter in a major artery and attached to
transducer
ii. most common site: radial artery
iii. usually inserted at bedside
iv. also used to obtain arterial blood gas samples and
other diagnostic studies
v. normal parameters
1. peak systolic: 100 mm Hg
2. end diastolic: 60-80 mm Hg
3. mean 70-90 mm Hg
vi. complications: clot formation, decreased or absent
pulse, hematoma, infection, hemorrhage
i. Cardiac output (CO)
i. volume of blood heart beats per minute
ii. thermodilution technique using blood temperature
changes
iii. known volume of solution is injected at a specific
rate into the right atrium
iv. temperature-sensitive probe measures temperature
of blood as it passes through catheter
v. contraindications: bleeding disorders,
immunosuppression
 vi. cardiac output (CO) (heart rate x stroke volume) 4-
8L/min
vii. nursing care of client with cardiac catheter
1. explain procedure to client
2. obtain baseline vital signs and rhythm strip
3. place client in supine position
4. calibrate pressure monitor
5. obtain chest x-ray to guide catheter
placement
6. obtain arterial blood gases as ordered
7. change dressings and tubing as ordered
8. maintain patency of catheter
9. monitor and record vital signs and pressures
as ordered
10.observe for complications

The Horizontal Arm Stretch

Instructions

Bring the arms up to shoulder level and move them forward in front of the
chest. Press the palms together. INHALE.
Now EXHALE and lower your head pressing the chin into the nap of the neck.
Now INHALE, move your arms apart. Lift the head up, continue to move your
arms apart and backward as far as is comfortable and lift your head up, looking
up, press the arms back so that you can feel the contraction in the shoulder
blades. Hold for a short time and continue this arm movement forward then
backward in rhythm with the breath.
Do this only twice.
Procedures
o General nursing interventions for all procedures
Explain procedure to client and significant others. Use a
translator if indicated.
Obtain written consent for all invasive procedures that
carry risk (e.g., lumbar puncture not venipuncture)
Allow client to ask questions, express concerns, fears
Help client relieve his or her anxiety
Involve significant others in procedure as appropriate
 Carry out procedure according to institutional policy and
procedure
Provide emotional support during procedure
Tell client what is going to happen during procedure
Post-procedure, observe for complications
Record all procedures and client's response to them
Obtain and label all specimens and send to lab for analysis
Document character of all specimens obtained
Maintain medical asepsis
Initiate standard precautions as indicated by CDC guidelines
o Gastrointestinal intubation
Routes
nasopharynx: nasogastric, nasointestinal
oropharynx
through abdominal wall by incision: gastrostomy,
jejunostomy
via endoscopy: percutaneous endoscopic gastrostomy
(PEG) or jejunostomy, (PEJ)
Requires a provider's order
Uses
diagnostic
gastric decompression
gastric irrigation
feeding
Nasogastric and nasointestinal
types of tube
nasogastric
single lumen: Levine
Salem
nasointestinal
single lumen: Cantor, Harris
double lumen: Miller-Abbott
complications of prolonged nasal intubation
nasal erosion, sinusitis
pharyngitis, esophagitis, esophageal sphincter
incompetence
gastric ulceration, pulmonary aspiration
aspiration risk is higher with nasal tubes
nursing interventions in gastric or intestinal
intubation:
5. Gastrostomy/jejunostomy
a. tube placement is in upper left quadrant of abdomen
b. for clients who cannot tolerate nasal route, or for
long term enteral feeding
c. provides more secure and reliable access
d. nursing care
 i. cleanse skin around insertion site daily with
warm water and mild soap
ii. apply dressing if indicated
iii. observe for complications
e. complications
i. skin breakdown at insertion site
ii. infection
iii. seepage of enteral formula or gastric drainage

Consider your individual peak time when scheduling your examination. For
example
if you are a morning person
schedule a morning exam.

C. Ostomy
1. Surgical procedure which creates an opening into the
abdominal wall for fecal or urinary elimination
(enterostomy)
2. Portion of intestinal mucosa or ureter brought through
abdominal wall creating a stoma through which feces or
urine drains
3. Types
a. bowel: ileostomy or colostomy (illustration )
b. urinary diversions
i. ileal conduit (ileal loop)
ii. ureterostomies
4. Ileostomy
a. stool is liquid, frequent, highly alkaline, contains
digestive enzymes
b. requires constant pouching and frequent emptying
5. Colostomy: thicker, formed stool
a. transverse colon: must be pouched at all times
b. sigmoid colon: can be managed by daily irrigation, so
no need for pouch
6. Urinary diversions
a. ileal loop or conduit
i. a segment of the ileum is removed and used
as a passage for urine
ii. one end forms a stoma on the abdominal wall,
the other is sutured closed
iii. the ureters are implanted into the segment
iv. a pouch is worn to collect urine
v. remainder of bowel is reanastamosed. Client
has normal bowel movements through anus
vi. urine should be yellowish; may contain mucus
shreds
b. continent urinary diversion
i. reservoir for urine made from parts of small
or large bowel
ii. client needs no pouch
iii. reservoir is catheterized at specific times to
drain urine
c. ureterostomy
i. one or both ureters are brought through the
abdominal wall to form a stoma(s)
ii. stomas are pouched to collect urine
 iii. usually a temporary measure performed on
infants until ileal loop can be done
iv. complications include skin breakdown,
infection, necrosis
7. Nursing interventions for a client with ostomy; additional
guidelines for nursing care:
a. empty pouches when they are about 1/3 to 1/2 full
b. if needed, protect skin around ileostomy stoma
c. ostomies threaten body image.
d. fears of mutilation, shame, rejection are common
e. clients may feel powerless because they cannot fully
control bodily functions
f. assist client to establish normal elimination routine.
Report immediately if:
i. stoma oozes blood when touched
ii. you see blood in pouch
iii. you see bleeding from stoma
iv. urinary diversion output is less than 30cc/hour
v. urine smells foul
vi. there is blood in urine, or it is very cloudy
vii. client reports burning sensation around base
of urinary diversion stoma
viii. client reports back pain, chills, or fever
g. teach client
i. the types of equipment and their use
ii. how to irrigate colostomy
iii. prevention of complications
iv. how to avoid constipation, diarrhea, excessive
gas
v. that it is vital to drink plenty of fluids

Additional information about ostomies can be found in Lesson 5: Basic Care

and Comfort

D. Casts
1. Externally applied structure that holds bone in one position
2. Uses
a. immobilization
b. prevent bone or muscle deformity
c. support of a weakened limb
d. promote healing
e. permit early weight bearing on affected limb
3. Types of casting materials
a. plaster of paris
i. natural material
ii. indicated in cases of
 severely displaced fractures
unstable fracture fragments
iii. when multiple castings are indicated: serial
casting
iv. application: takes at least 24 hours to dry
v. advantages
low allergic response
offers rigid protection
easy to apply
inexpensive
vi. disadvantages
long drying time (24 to 48 hours)
weight - plaster casts are heavy
materials may crumble and disintegrate
at edges
not waterproof
b. fiberglass
i. synthetic material
ii. indicated in cases of
non-displaced fractures
long term casting
iii. advantages
light weight
easy to apply
moisture-proof
fast: dries in 15 minutes, cures in one
hour
colors and patterns help client adjust
to immobilization
iv. disadvantages
short drying time requires speed and
accuracy
more rigid than plaster; may bind if
tissues swell
extra rigidity may cause tissue
breakdown under the cast
more expensive than plaster castings
4. Types of casts
a. short arm/leg
i. cylindrical cast
ii. allows for flexion or extension of elbow and
knee
b. long arm/leg
i. cylindrical cast
ii. does not allow elbow or knee to move
c. spica arm/hip
 i. support bar is applied between extremities
ii. permits greater stabilization
iii. cut window over epigastrium for patient
comfort after eating
5. Cast application
a. cast must extend to the joint above and below the
point of fracture
b. assessment prior to cast application
i. skin: inspect for irritation, laceration, skin
breakdown
ii. neurovascular status check
iii. edema/swelling
c. windowing:
i. square or diamond hole cut in cast over
certain area
ii. indications
observation of surgical incision
observation of skin
relieve pressure over bony prominence
iii. nursing interventions
cast may crack at window site -
weakest part of the cast
appropriate padding/petaling of open
window
d. bivalving
i. indications
swelling
infection or high potential for infection
pain
ii. techniques
lengthwise splitting of the cast with
cast saw
apply ace wrap or tape to hold cast
together
still immobilizes
e. petaling
i. edging the cast with soft padding or moleskin
ii. indications
prevent irritation or skin breakdown at
rough edges of cast
protect cast from perspiration, feces,
urine
protect perineal area

6. Nursing interventions: post cast application

a. plaster of paris casts
 i. handle fresh cast carefully (first 48 hours)
indentations may cause pressure points
under the cast
handle the cast with open palms of
hands
ii. do not apply pressure to the cast
iii. do not cover the cast - allow to air dry
b. all casts
i. repeated neurovascular checks
capillary refill time
warmth
color
motion checks
o patient can move toes and
fingers of affected limb
o if not, a nerve is compressed
ii. sensation: numb or tingling may mean nerve
compressed
iii. drainage

i. observe for wound drainage

ii. record size, color, amount; and circle area on cast with felt tipped
marker and date and time
iii. check odor of drainage
b. teach client
i. keep cast dry and intact
ii. to avoid placing any objects, powders, or
lotions inside of or through cast
iii. describe indications and therapeutic use of
casting for immobilization
iv. proper use of assistive devices
v. how to assess environment for potential
mobility hazards
vi. to inspect cast daily for foul odor, cracks
7. Nursing interventions for cast removal with a mechanical
saw
a. explain procedure to client
b. inform client that
i. cast removal is painless
ii. client will feel heat and vibration
iii. saw is noisy but will not cut client
iv. inspect tissue under cast for signs of
inflammation or infection
v. if skin is intact apply lotion to moisturize skin
c. teach client
i. underlying skin may be scaly and dry
 ii. to perform range of motion exercises as
ordered
iii. to use moisturizing lotion on dry skin
2. Traction - pulling force and opposing force applied to injured
extremity
6. Longitudinal - when only one force is applied
7. Traction angle - direction of the force in relation to the
affected extremity
8. Countertraction - opposing force to the pull of the traction;
most often is provided by the person's body weight
9. Vector force - resultant force produced when two traction
forces are applied to a limb
10.Purposes
a. reduce, realign and promote healing of fractured
bones
b. decrease muscle spasms
c. immobilize area of body
d. rest inflamed, diseased or painful joint
e. treat/correct deformities
f. reduce and treat dislocations
g. prevent the development of contractures
h. expand a joint space during arthroscopy
i. reduce muscle spasms in low back pain or cervical
whiplash
11.Types of traction
a. manual traction
i. use of the hands to exert a pulling force
ii. generally used during an emergency
iii. temporary measure - cannot be maintained
for extended periods
b. skin traction
i. pulling force is applied directly to the skin
through the use of foam splints, skin traction
strips and tape
ii. temporary measure

PRINCIPLES OF TRACTION
A. Maintain the prescribed line of pull
1. Especially important in patients with fractures
2. Maintain proper body alignment
B. Always maintain continuous pull unless intermittent traction is
prescribed
C. Prevent friction
1. Friction will alter the line of pull
2. Friction will impair the traction's efficiency
3. But never lubricate pulleys
D. Identify and maintain counteraction
1. Countertraction is the force opposing the pull of traction
2. Generally provided by the patient's body
3. If countertraction is not maintained the patient is not in traction
4. Sign of loss of countertraction is that the patient slides down in
bed
5. Especially problematic with Buck's Traction
6. Keep bed flat
7. Elevate the foot of the bed with shock blocks
E. Counter traction for pelvic traction is generally achieved by putting the
bed in the William position (both knees and hips are flexed at 30
degrees)
A. types of skin traction
 iv. complications
skin breakdown
detachment of traction device
v. limitation: can apply only five to seven lbs.
loading force
d. skeletal traction

iv. traction applied directly to the bone

v. pins are placed through the affected limbs and attached to pulling force
vi. can be tolerated for longer periods - up to four months
 vii. greater weight can be used - 15-40 lbs.
viii. types of skeletal traction
balanced suspension
o used for displaced, overriding or
comminuted fractures
o preoperative treatment prior to
surgical pinning
d. skull tong/halo traction

iv. burr holes drilled into skull and tongs inserted and attached to weights
or halo bolts inserted then attached to body cast
v. tongs used for cervical fractures preoperatively
d. static traction
e. continuous traction pull
f. dynamic traction
g. intermittent application of traction
h. straight traction
i. running
7. Complications

c. infection at pin site

d. skin breakdown
e. muscle weakness
f. osteomyelitis

MECHANICS OF TRACTION EQUIPMENT

1. Frame - Should be loaded to maximize its stability before adding
additional traction systems
2. Plain Bars
3. Cross Clamps - Positioned so that turn knobs are on top of horizontal
bars
4. Traction Bars
5. Pulleys
a. do not lubricatre- Decreased friction markedly changes the line
of pull
b. must move freely
1. Patient positioning for traction
1. supine
2. perpendicular to the ends of the bed
3. affected limb in proper body alignment
4. head of the bed is flat or semi fowlers (maximum of
20 to 30 degrees elevation)
5. a trapeze for client to shift position and upper range
of motion provided
2. Nursing interventions
1. explain procedure to client
 2. assess neurovascular status of affected area/limb at
least every four hours
1. color
2. temperature
3. motion
4. sensation
5. pulse quality
6. presence/absence of edema
3. always compare affected limb to unaffected limb for
baseline measurement
4. skeletal cervical or halo traction: assess cranial
nerves III - IX
5. skin assessment
1. high risk for developing pressure sores
2. remove Buck's traction boots every two hours
to inspect skin integrity
3. assess pressure areas every two hours
6. pin assessment: observe for drainage, signs of
infection
7. maintain principles of traction
8. administer appropriate medications
9. beware of immobility's multi-system effects
10.allow patient to verbalize fear and concerns
11.encourage involvement of family members
12.provide diversional activities
c. Mobilization devices: orthotic, prosthetic, crutch, cane, walker
1. Orthotic
1. braces designed to prevent deformity, increase
efficacy of gait, control alignment and/or promote
ambulation
2. types of orthotic
1. ankle/foot (AFO)
2. knee/ankle/foot (KAFO)
3. hip/knee/ankle/foot (HKAFO)
4. thoracolumbar or sacral (TLSO)
2. Prosthetic: artificial limbs for all extremities
3. Crutches
1. a wooden or metal staff
2. used when no or minimal weight bearing is desired
3. may be temporary or permanent
4. types
1. axillary: a padded curved surface at top which
fits under the axilla and a crossbar forms the
handgrip
1. for axillary crutches, measure client's
height; distance between crutch pad
 and axilla; distance from axilla to
client's heel; Crutch pads should be
three to four finger widths under axilla
2. complication: crutch palsy--paralysis of
elbow and wrist due to crutch pressure
on axilla
5. forearm (Lofstrand): an adjustable metal band that
fits around the forearm with an adjustable handgrip

Information about crutch walking can be found in Lesson 5: Basic Care and
Comfort
or client to navigate stairs with crutches, remember "up with the good, down
with the bad."

To go up stairs, lead with the unaffected "good" leg, and follow with the
affected "bad" leg.

To go down stairs, lead with the affected "bad" leg, and follow with the
unaffected "good" leg.

4. Canes: straight-legged, quad; all need rubber tips

5. Walkers
a. extremely light devices that have four widely placed
legs and handgrips on an upper bar; need rubber
tips. May have rollers instead of tips.
b. client moves the walker forward and steps into it,
then moves it forward again
c. caution should be used to avoid overloading client's
personal item baskets
6. Wheelchairs: manual, electric
7. Nursing interventions with mobilization devices
a. explain procedure to client
b. assess client's readiness including muscle strength
and range of motion
c. safety is prime issue
d. observe client initially for orthostatic hypotension
e. assess environmental risks
f. nurse should stand close to client during initial
attempts at using mobilization devices.
g. provide emotional support
h. resize device as children grow
i. teach client
i. proper use of device
ii. findings of complications
 iii. how to climb stairs, maneuver on various
surfaces
iv. how to maneuver on and off toilet, chair, tub,
shower, car
v. don't look at your feet, look ahead
vi. how to troubleshoot equipment for defects,
signs of wear
vii. wear stable shoes, same heel height as when
device fitted
2. Hemodialysis - cleansing the blood of accumulated waste products
4. Uses
a. short term therapy in acutely ill clients
b. long term use in clients with end-stage renal disease
5. Hemodialysis requires five things
a. access to patient's circulation (usually via fistula)
b. access to a dialysis machine and dialyzer with a
semipermeable membrane
c. the appropriate solution (dialysate bath)
d. time: 12 hours each week, divided in three equal
segments
e. place: home (if feasible) or a dialysis center
6. Three ways to access to client's circulation for dialysis:

4. Procedure for hemodialysis

a. patient's circulation is accessed
b. unless contraindicated, heparin is administered (see
Lesson 6: Pharmacological and Parenteral Therapies)
 c. heparinized (heparin: natural clot preventer) blood
flows through a semipermeable membrane in one
direction
d. dialysis solution surrounds the membranes and flows
in the opposite direction
e. dialysis solution is:
i. highly purified water
ii. sodium, potassium, calcium, magnesium,
chloride and dextrose
iii. either bicarbonate or acetate, to maintain a
proper pH
f. via the process of diffusion, wastes are removed in
the form of solutes (metabolic wastes, acid-base
components and electrolytes)
g. solute wastes can then be discarded or added to the
blood
h. ultrafiltration removes excess water from the blood
i. after cleansing, the blood returns to the client via
the access
5. Complications related to vascular access in hemodialysis
a. infection
b. catheter clotting
c. central venous thrombosis
d. stenosis or thrombosis
e. ischemia of the affected limb
f. development of an aneurysm

The Backward Hand Press

Instructions

Sit with the spine straight. Reach the hands behind the back. First touch the
fingers together, then try to press the palms together.
Lift the hands up as high on the back as is comfortable for you. Hold for as long
as is you can. Breathe normally.
Follow with shoulder lifts.
Nursing interventions
explain procedure to client
 monitor hemodynamic status continuously
monitor acid-base balance
monitor electrolytes
ensure sterility of system
maintain a closed system
discuss diet and restrictions on:
protein intake
sodium intake
potassium intake
fluid intake
reinforce adjustment to prescribed medications that
may be affected by the process of hemodialysis
monitor for complications of dialysis related to:
arteriosclerotic cardiovascular disease
congestive heart failure
stroke
infection
gastric ulcers
hypertension
calcium deficiencies (bone problems such as
aseptic necrosis of the hip joint)
anemia and fatigue
depression, sexual dysfunction, suicide risk
o Continuous ambulatory peritoneal dialysis (CAPD)
A form of intracorporeal dialysis that uses the peritoneum
for the semipermeable membrane.
Advantages of CAPD versus hemodialysis
more freedom
less physical and psychosocial interference
fewer dietary and fluid restrictions
simple and easy to use
provides satisfactory biochemical control of uremia
Procedure for CAPD
an indwelling catheter is permanently implanted in
the peritoneum
for each dialysis exchange: to this catheter, attach a
connector and insert it into a sterile plastic bag of
dialysate solution.
infuse the solution via gravity for ten minutes
(average two liter volume)
the solution now dwells in the peritoneal cavity for a
length of time specified by the health care provider,
usually four to six hours.
at the end of the dwell time, the solution is released
and drained into a bag, via gravity.
 drainage time is approximately ten to 20 minutes,
during which time ultrafiltration occurs.
clients average four exchanges per day, including
one overnight which allows for uninterrupted sleep
during the night.
Complications related to CAPD
infection
infectious peritonitis
catheter malfunction
communication between the peritoneum and the
pleural cavity
leakage of dialysate
hyper- or hypovolemia
bleeding
obstruction
Nursing interventions
explain procedure to client
assist health care provider according to institutional
procedure
monitor intake and output
observe for signs of complications
record characteristics of output dialysate
teach client
dietary restrictions
how to weigh self daily
that if infections occur, CAPD will not be
feasible long-term
findings of infection
strict aseptic technique
to wash hands before and after dialysis
exchanges
that skipping exchanges raises risk of renal
failure
to inspect bag before use for leaks, alteration
in color
discuss early warning signs of peritonitis:
abdominal pain
cloudy peritoneal fluid
abdominal tenderness
malaise
o Cardiovascular
Intraaortic balloon pump (IABP)
device that helps blood circulate after myocardial
failure
sausage-shaped balloon is threaded via
femoral artery into aorta
 balloon inflates with diastole and deflates
with systole
used to treat cardiogenic shock
contraindications:
aortic regurgitation
dissection
abdominal aortic aneurysm
complications
insertion site:
infection
bleeding
hematoma
diminished or absent pulse
thrombus
generalized
aortic dissection or perforation
thrombocytopenia
dysrhythmias
myocardial failure
nursing interventions
explain procedure to client
obtain informed consent
take baseline vital signs, hemodynamic
parameters and ECG
monitor vital signs, hemodynamic status and
ECG as ordered
monitor client's level of consciousness (LOC)
obtain arterial blood gases as ordered
provide emotional support to client and family
monitor intake and output
client must not bend leg in which balloon was
inserted
monitor for complications
fever
Pacemakers
a battery-powered pulse generator that stimulates
the heart via electrodes that touch myocardium
use:
hemodynamic and life support
to correct dysrhythmias
types
atrial pacing
ventricular pacing
atrioventricular sequential and physiologic
pacing
three kinds of pacemakers
 asynchronous (fixed rate): pace at a preset
rate, regardless of persons rhythm
demand (standby): pace only if intrinsic rate
declines below rate set on pacemaker
synchronous: sensing circuit detects atrial and
ventricular activity
indications for pacing
symptomatic bradyarrhythmia
symptomatic tachyarrhythmia
asystole
prophylaxis in persons with high risk
bradycardia
diagnosis of dysrhythmias during
electrophysiologic testing
Pacemakers
a battery-powered pulse generator that stimulates
the heart via electrodes that touch myocardium
use:
hemodynamic and life support
to correct dysrhythmias
types
atrial pacing
ventricular pacing
atrioventricular sequential and physiologic
pacing
three kinds of pacemakers
asynchronous (fixed rate): pace at a preset
rate, regardless of persons rhythm
demand (standby): pace only if intrinsic rate
declines below rate set on pacemaker
synchronous: sensing circuit detects atrial and
ventricular activity
indications for pacing
symptomatic bradyarrhythmia
symptomatic tachyarrhythmia
asystole
prophylaxis in persons with high risk
bradycardia
diagnosis of dysrhythmias during
electrophysiologic testi

f. types of pulse generators

i. temporary pacemakers
transvenous approach is most common:
Catheter electrode inserted via
 peripheral vein and connected to
external pulse generator
transthoracic: used primarily during
cardiac surgery; catheter electrode is
placed directly into heart
ii. permanent pacemakers: transvenous
catheter electrode is passed through
right heart and connected to small
generator
generator is implanted subcutaneously
on chest wall, usually in upper right
quadrant
lithium-powered battery can last up to
ten years

g. complications of pacemakers
i. infection
ii. perforation of myocardium
iii. pneumothorax
iv. hemothorax
v. dysrhythmias
vi. thrombosis
vii. failure
viii. syncope
ix. hypotension
x. pallor
xi. hiccups
xii. shortness of breath
h. nursing interventions
i. explain procedure to client
ii. initiate preoperative care
iii. post-procedure
initiate post-anesthesia care
monitor vital signs and ECG as ordered
maintain bed rest as ordered
observe for signs of complications
iv. teach client
pacemaker's set rate
how to take pulse (rate and rhythm)
findings of pacemaker failure, wound
infection
activity limitations
 hazards: high output electrical
generators: welding equipment, radar,
microwaves, MRI
importance of carrying medical alert
jewelry and information
need for periodic battery replacement
avoidance of contact sports and those
that involve swinging arms (golf,
hunting)
importance of medical follow-up
i. nursing interventions
i. explain procedure to client
ii. initiate preoperative care
iii. post-procedure
initiate post-anesthesia care
monitor vital signs and ECG as ordered
maintain bed rest as ordered
observe for signs of complications
iv. teach client
pacemaker's set rate
how to take pulse (rate and rhythm)
findings of pacemaker failure, wound
infection
activity limitations
hazards: high output electrical
generators: welding equipment, radar,
microwaves, MRI
importance of carrying medical alert
jewelry and information
need for periodic battery replacement
avoidance of contact sports and those
that involve swinging arms (golf,
hunting)
importance of medical follow-up
2. Automatic implantable cardioverter-defibrillator (AICD)
g. pulse generator implanted in subcutaneous pocket.
When it detects ventricular tachycardia or
ventricular fibrillation, it delivers electrical shock to
heart
h. used to treat life-threatening ventricular
dysrhythmias
i. complications
i. infection
ii. malfunction
iii. battery failure
j. nursing interventions
 i. explain procedure to client
ii. care of the surgical client
iii. administer medications as ordered
iv. monitor ECG as ordered
v. provide emotional support and reassurance
vi. teach client
findings of defibrillation discharge
importance of routine follow-up
findings of complications
limit activity as ordered
avoid strong magnetic fields
wear medical alert jewelry and
information
assure client that no household
appliance will affect AICD

Respiratory System
J. Artificial airways
1. Adult endotracheal tubes
a. polyvinyl tube with inflatable cuff
b. inserted through nose or mouth
c. distal end should be a few centimeters above the
carina
d. cuff around tube is filled with air
i. creates a seal in trachea
ii. air pressure in cuff < 25 cm H20 or client risks
pressure necrosis in the tracheal mucosa
e. size of tube varies with size of child or adult
f. pediatric tubes may not be cuffed
g. when tube is inserted, check for placement
i. listen for bilateral breath sounds
ii. look for bilateral chest movement
iii. chest x-ray
iv. measure exhaled carbon dioxide
v. measure pulse oximetry
h. nursing interventions
i. explain procedure to client
ii. regularly assess tube placement and security,
breath sounds, and bowel sounds
iii. mark tube length with teeth, or lips if
edentulous (toothless)
iv. suction to maintain airway patency; observe
secretions for color, consistency, and amount
v. assure inspired air is warmed and humidified
since upper airway is bypassed
 vi. provide oral hygiene and care for area around
the tube as indicated
vii. observe for skin breakdown around tube site
viii. observe for possible complications of
aspiration; oral/nasal pressure sores;
accidental extubation; and oral, nasal and
pharyngeal damage
2. Tracheostomy
a. surgical opening through the neck into the trachea
b. indications
i. head and neck surgery
ii. long term airway access; for long-term
mechanical ventilation
iii. emergency airway
c. post-op complications
i. tube dislodgement
ii. subcutaneous emphysema
iii. bleeding
iv. infection
d. components of tracheostomy tubes
i. outer cannula
ii. inner cannula
iii. obturator
e. nursing interventions
i. explain procedure to client
ii. regularly assess tube placement and security
iii. care for tracheostomy as ordered
iv. suction to maintain airway patency (see
below)
v. provide adequate hydration
vi. periodically clean inner cannula and stoma
site
vii. provide regular oral hygiene
viii. change trach tube as ordered
ix. watch for skin irritation/infection at insertion
site
x. teach client
1. trach care
2. suctioning procedure
3. findings of complications
4. how to handle accidental
dislodgement/extubation with
obturator
3. Airway suctioning
a. removing secretions from the airway
b. sites for suction
 i. nasopharynx, oropharynx, trachea, or bronchi
ii. through endotracheal tube or tracheostomy
c. equipment
i. use bulb syringe to suction nose/mouth of
neonates, infants
ii. catheter's outer diameter should be no larger
than one-half inner diameter of endotrachial
lumen
iii. determining length of catheter
1. measure from tip of nose to base of ear
to sternal notch
2. infant, young child: Insertion tolerance
range: eight to 14 cm
3. older child, adolescent: Insertion
tolerance range:14 to 20 cm
iv. sterile procedure in institution; clean
procedure at home.
v. suction when rhonchus is heard
vi. adjust vacuum pressure to between -80 and
-120 mm Hg
vii. insert suction catheter until resistance is met,
then withdraw catheter an inch or two
viii. apply suction intermittently when
withdrawing catheter
ix. rotate catheter during withdrawal
x. from time of insertion, spend no more than
five to ten seconds
xi. re-establish ventilation and oxygenation
xii. repeat procedure as indicated
xiii. pharyngeal suctioning: less depth, less risk of
complications than tracheal suctioning
d. nursing interventions
i. explain procedure to client
ii. explain that coughing, sneezing or gagging is
normal
iii. place client in semi-fowler's position if
condition allows
iv. maintain standard precautions
v. do not routinely instill saline into airway
vi. if secretions are thick, increase humidity of
inspired air and fluid intake
vii. provide patient with extra oxygen and extra
deep breaths before, during and after
procedure
1. if patient is receiving mechanical
ventilation, use ventilator
 2. if patient is breathing spontaneously,
use manual resuscitation bag or
instruct to deep breathe
viii. compare client's respiratory status before and
after suctioning
ix. do not force catheter
K. Oxygen delivery devices
1. Nasal cannula
a. used at flow rates five to six liters per minute (LPM)
b. higher flow rates can be very uncomfortable and
cause nasal bleeding
c. delivered oxygen (FIO2) depends on liter flow,
client's tidal volume and respiratory rate. Each liter
is approximately 4% O2 added to 21% O2 found in
room air.
d. nursing interventions
i. explain procedure to client
ii. ensure prongs are in the nares
iii. pad tubing around the ears, as indicated
2. Simple face mask
a. used at flow rates between 5 - 12 LPM
b. must have at least 5 LPM to wash out carbon dioxide
from exhalation; recommended flow is 8 to 10 LPM
c. delivered oxygen (FIO2) depends on liter flow,
client's tidal volume and respiratory rate
d. not commonly used
3. Venti-mask (venturi mask)
a. uses air-entrainment principle to deliver precise FIO2
b. due to entrainment, provides high rate of total flow
c. available in a range of FIO2
d. depending on FIO2, flow rate four to ten LPM
e. nursing interventions
i. explain procedure to client
ii. keep nasal cannula on stand-by for meals
iii. assure venturi device does not become
blocked by bedding
iv. assess for dry mucous membranes
4. Non-rebreather mask
a. mask with added reservoir bag
b. used at flow rates six to 15 LPM
c. provides highest percentage of O2 available from any
mask, from 60-100%
d. used for sickest clients
e. nursing interventions
i. explain procedure to client
ii. client requires close monitoring
 iii. intubation may be needed
iv. assure reservoir bag does not completely
collapse during peak inspiration
1. bag should deflate slightly when
patient inhales and expand when client
exhales.
2. if bag collapses at inspiration, increase
liter flow to bag
v. assure pop-off valves on mask are not stuck
and work properly
5. Home oxygen therapy: three types
a. compressed oxygen comes in tank or cylinder
b. liquid oxygen in reservoir
c. oxygen concentrator extracts and concentrates
oxygen from the air
6. Positive pressure devices
a. CPAP (continuous positive airway pressure)
i. compressor provides air flow to client
ii. baseline of noninvasive positive pressure is
maintained throughout inspiration and
exhalation
iii. used primarily to treat sleep apnea at home
for maintenance of patient upper airway
b. BiPAP (bi-level positive airway pressure)
i. provides a baseline of noninvasive positive
pressure throughout inspiration and
exhalation
ii. provides positive pressure assist during client's
own spontaneous inspiratory effort
iii. used for clients in respiratory failure to rest
client and improve oxygenation to avoid
intubation

Frequent short review sessions (one to two hours) are most productive, as is
reviewing one to two hours before sleep at night. Long

term recall is enhanced to 70 to 80% when one reviews and then sleeps at least
two hours.
L. Ventilators
1. Machines' purpose
a. support and maintain client ventilation
b. improve ventilation
c. improve oxygenation
d. decrease work of breathing
2. Ventilator control modes: assist and synchronized
a. assist-control
 i. preset rate at preset tidal volume
ii. if client initiates breath, machine delivers the
preset tidal volume
b. synchronized intermittent mandatory ventilation
(SIMV)
i. machine set to deliver a given rate at a preset
tidal volume
ii. clients can breathe on their own between
machine breaths but will determine own tidal
volume
iii. used to gradually decrease machine support of
breathing
3. Ventilator settings
a. tidal volume: amount of air delivered with each
machine breath
b. rate: number of breaths delivered by the machine in
a minute
c. FIO2: fraction of inspired oxygen
d. %O2: percent of oxygen (e.g., 60%)
4. Sighs: deep breaths (higher volume) delivered periodically
by ventilator
5. Positive end expiratory pressure (PEEP)
a. normal physiologic PEEP is equal or less than 5cm
H2O
b. provides a baseline of positive pressure throughout
exhalation
c. used to reduce airway collapse and intrapulmonary
shunting
6. Nursing interventions
a. explain equipment to client
b. monitor client's response to mechanical ventilation
c. assure ventilator is working properly
d. monitor artificial airway (as above)
e. assess and provide for adequate nutrition
f. monitor pulse oximetry and/or arterial blood gases
as ordered
M. Chest physiotherapy
1. Consists of coughing, chest wall percussion, vibration, and
postural drainage
2. Designed to improve airway clearance
3. Used for clients with retained tracheobronchial secretions
4. Cough: natural clearing mechanism
5. Chest wall percussion, vibration
a. percussion involves clapping chest with cupped
hands
 b. vibration is downward vibrating pressure with flat
hand; done during exhalation
6. Postural drainage (illustration 1 illustration 2 )
a. gravitational clearance of airway mucous from
various bronchial segments
b. uses 10 different body positions
7. Percussion and vibration done in each position;
simultaneously client coughs or nurse suctions to remove
loosened secretions
8. Nursing interventions
a. explain procedure to client
b. place client in desired position according to lobe
being drained
c. percuss each area for at least three minutes
d. encourage client to cough after each area is
percussed and vibrated
Drainage Systems
N. Chest drainage
1. Chest tube
a. tube placed in the pleural space to remove air, fluid,
or both
b. tube placed anterior and superior to remove air
c. tube placed posterior and inferior to remove fluid
d. mediastinal tube
i. drains blood or fluid from around heart
ii. no tidaling in mediastinal drainage because
tube is not placed in lung cavity
2. Chest drainage devices
a. collection chamber
i. collects fluid
ii. monitor rate and nature of drainage
b. water seal chamber
i. provides a one-way valve: air leaves chest,
cannot reenter it
ii. check for bubbling in this chamber: indicates
air leak
iii. if no bubbling, check water level in this
chamber
iv. check for tidaling
c. suction control chamber
i. negative pressure transmitted to pleural
space is determined by this chamber, not by
the setting on the wall vacuum
ii. wet chamber - suction level determined by
water level
iii. dry chamber - suction level determined by
mechanical setting
d. nursing interventions
i. explain procedure to client
ii. do not allow dependent loops to form in the
tubing; position the tubing on the bed so that
there is straight gravity drainage to the
collection device
iii. do not routinely strip or milk the tubing; allow
for gravity drainage
iv. do not routinely clamp the chest tube
v. if the tube becomes dislodged and patient has
air leak,
I. apply non-occlusive dressing to allow
air to leave the chest and prevent
tension pneumothorax
II. reinsert tube immediately
vi. tube dislodged, but patient has no air leak
I. apply occlusive dressing
II. monitor carefully for respiratory
distress
III. depending on client's condition, tube
may or may not need to be replaced