SUCTIONING ORAL-NASAL SECRETIONS

• Many patients with respiratory problems must be suctioned to remove excess secretions and mucus from the airway.
• Suctioning may also be indicated in unconscious patients or in patients with an ineffective cough.
• A new sterile suction kit is used each time the patient is suctioned so that the organisms are not introduced into the lungs.

Procedure

• Assemble equipment and explain procedure to patient
• Place conscious patient in semi-Fowler’s position
• Wash hands and set up equipment,opening sterile suction package
• Place sterile glove on hand that will hold catheter

Procedure cont’d

• Pick up sterile catheter and connect to suction tubing that is held with the unsterile hand
• Moisten the catheter with sterile saline, check functioning of suction machine
• Gently insert the catheter through the nostril with the suction off
• Once the catheter is inserted down to the end of the trachea(stimulating the cough reflex)

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Procedure cont’d

• Begin suctioning which lasts about 10-15 seconds
• The entire process of entering,suctioning,and withdrawal should not exceed a total of 20seconds.(suctioning stops oxygen inhalation and hypoxia may result)
• Slowly withdraw the catheter in a rotating motion while suctioning continues

Procedure cont’d

• Repeat suctioning until the mucus disappears, with the patient given time to rest and breathe normally between suctioning.
• The patient may be given oxygen before and after passage of the catheter
• Flush the catheter with sterile normal saline between suctionings .

Procedure cont’d

• Suctioning pressures of 80-100mmHg are used for the adult patient.(a vacuum pressure in excess of 120mmHg causes trauma to the delicate respiratory mucosa,bleeding can occur.
• Suctioning pressure for a child is 95-110mmHg and for an infant is 50-95mmHg

CARDIAC CATHETERIZATION

• It is an invasive diagnostic procedure in which one or more radiopaque catheters are introduced into heart and selected blood vessels to measure pressures and to determine oxygen saturation in the various heart chambers
• The procedure is carried out in cardiac catheterization lab.

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Purposes

• Cardiac catheterization is used to visualize the heart chambers ,arteries and great vessels.
• It is used most often to evaluate patients with chest pain
• This test is also used to determine the effects of valvular heart disease
• Right heart catheterization is also used to identify pulmonary emboli and to calculate cardiac output,this is the most accurate method to determine cardiac output.

Purposes cont’d

• To identify, locate and quantitate the severity of atherosclerotic,occlusive coronary artery disease.
• To evaluate the severity of acquired and congenital cardiac valvular or septal defects
• To determine the presence and degree of congenital cardiac abnormalities such as transposition of great vessels,patent ductus arteriosus and anomalous venous return to the heart.

Purposes cont’d

• To evaluate the success of previous cardiac surgery or balloon angioplasty
• To evaluate cardiac muscle function
• To identify and quantify ventricular aneurysms
• To identify and locate acquired disease of the great vessels such as atherosclerotic occlusion or aneurysms within the aortic arch

Purposes cont’d

• To obtain clear picture of cardiac anatomy prior to heart surgery
• To allow infusion of fibrinolytic agents directly into the occluded coronary artery to restore coronary blood flow
• To detect shunts

Procedure

• A catheter is passed into the heart through a peripheral vein or artery,depending on whether catheterization of the right or left side of the heart is being performed
• Through the catheter pressures are recorded and radiographic dyes are injected
• With the assistance of a computer,cardiac output and other measurements of cardiac function can be determined
• It is performed under sterile conditions.

Vessels used

• In right sided heart catheterization,usually the subclavian, brachial, femoral or internal jugular vein into the right atrium, right ventricle and pulmonary artery
• In left sided heart catheterization,usually the right femoral artery or brachial artery to aorta and left ventricle. It can also be performed transseptally from right atrium into left atrium and then left ventricle

Vessels used cont’d

• Blood samples for analysis of oxygen content are also obtained
• The catheter is advanced with appropriate guidance into the desired position
• As the catheter is placed into the great vessels of the heart chamber,pressures are monitored and recorded

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Vessels used cont’d

• After pressures are obtained,angiographic visualization of the heart chambers, valves and coronary arteries is achieved with the injection of radographic dye.

Contraindications

• Patients who are unable to co-operate during the test
• Patients who would refuse intervention if an amenable lesion is found
• Patients with an iodine dye allergy who have not received preventive medication for allergy
• Patients who are pregnant,because of radiation exposure to the foetus

Contraindications cont’d

• Patients with renal disorders,because iodinated contrast is nephro-toxic
• Patients with bleeding tendencies

Procedure and patient care

• Before
• Explain the procedure to the patient
• Obtain written permission from the fully informed patient
• Allay the patient’s fears and anxieties regarding the test
• Instruct the patient to abstain from oral intake for at least 4-8 hours before the test.

Before cont’d

• Prepare the catheter insertion site by shaving and scrubbing the skin.
• Mark the patient’s peripheral pulses with a pen before catheterization. This will facilitate post catheterization assessment of the pulses at the affected and non affected extremities
• Provide appropriate pre catheterization sedation as ordered by the physician

Before cont’d

• Instruct the patient to void before going to the catheterization laboratory
• Remove all valuables and dental prosthesis before transporting the patient to the catheterization laboratory.
• Obtain iv access for delivery of iv fluids and cardiac drugs if necessary

During

• Take the patient to the cardiac catheterization laboratory
• Note the following procedural steps
• The chosen catheter insertion site is prepared and draped in a sterile manner
• The desired vessel is punctured with a needle
• A wire is placed through the needle and into the catheter

During cont’d

• The angiographic catheter is threaded on top of the wire
• Once the catheter is in the desired location,the appropriate cardiac pressures and volumes are measured
• Cardiac ventriculography is performed with controlled injection of contrast.

During cont’d

• Each coronary artery is catheterized. Cardiac angiography is then carried out with a controlled injection of contrast.
• During the injection, x-ray films are rapidly made .
• The patient’s vital signs must be monitored constantly during this procedure.

During cont’d

• This test is usually performed by a cardiologist in approximately one hour
• Tell the patient that during the injection he/she may experience a severe hot flush. This is uncomfortable but lasts only 10-15seconds
• Note that some patients have a tendency to cough as the catheter is placed into the pulmonary artery

During cont’d

• Verbally support the patient as the x-ray films are taken because the loud noises may frighten the patient.

After

• Monitor the patient’s vital signs
• Apply pressure to the site of vascular access
• Keep the patient on bed rest for 4-8hours to allow for complete sealing of the arterial puncture site
• Keep the affected extremity extended and immobilised with sand bags to decrease bleeding

After cont’d

• Assess the patient’s pulses of both extremities and compare with pre procedural baseline values
• Encourage the patient to drink fluids to maintain adequate hydration,dehydration may be caused by the diuretic action of the dye.
• Instruct the patient to report chest pain and bleeding or sudden discomfort from the catheter insertion site immediately.

THORACENTESIS

• Thoracentesis involves the aspiration of fluid or air from the pleural space
• Normally there is only enough fluid to lubricate the pleura so that they can move freely
• Thoracentesis relieves pulmonary compression and respiratory distress

Thoracentesis cont’d

• By removing accumulated air or fluid that results from injury or such conditions as tuberculosis,cancer or heart failure
• It also provides a specimen of pleural fluid or tissue for analysis and allows for instillation of chemotherapeutic agents or other medications into the pleural space.

Thoracentesis cont’d

• Aspiration of air or fluid may be indicated to relieve pain,dyspnoea and other symptoms of pleural pressure.
• Thoracentesis is contraindicated in patients with bleeding disorders
• Thoracentesis should be used cautiously in patients who are uncoperative ,have uncontrolled coughing, an uncertain pleural fluid location, one functional lung.

Equipment

• A prepackaged thoracentesis tray that typically includes the following:
• Sterile gloves
• Sterile drapes
• Antiseptic solution
• 1%or 2%lidocaine
• 5ml syringe with 21Gand 25G needles for anaesthetic injection

Equipment cont’d

• 17G thoracentesis needle for aspiration or teflon catheter
• 50ml syringe
• Three-way stopcock and tubing
• Sterile specimen containers
• Sterile hemostat
• Sterile 4inch*4inch gauze pads

Equipment cont’d

• The following are also needed:-
• Occlusive dressing
• Sphygmomanometer
• Gloves
• Stethoscope
• Laboratory request slips
• Drainage bottles.

Preparation

• Assemble all equipment at the patient’s bedside or in the treatment room
• Explain the procedure to the patient
• Obtain informed consent for this procedure
• Inform the patient that movement or coughing should be minimized to avoid inadvertent needle damage to the lung or pleura during the procedure

Preparation cont’d

• Administer a cough suppressant before the procedure,if the patient has a troublesome cough
• Have the patient’s x-rays available

implementation

• Explain the procedure to the patient,inform him that he may feel some discomfort and a sensation of pressure during the needle insertion
• Provide privacy and emotional support
• The procedure is performed under strict sterile technique

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Implementation cont’d

• The patient is usually placed in an upright position,with the arms and shoulders raised and supported on a padded overhead table. This position spreads the ribs and enlarges the intercostal space for insertion of the needle.
• Patients who cannot sit upright are placed in a side-lying position on the unaffected side with the side to be tapped uppermost

Implementation cont’d

• Remind the patient not to cough, breathe deeply,or move suddenly during the procedure to avoid puncture of the visceral pleura or lung
• Obtain baseline vital signs and assess respiratory function
• The needle insertion site which is determined by percussion,auscultation and examination of a chest x-ray film,ultrasound scan or fluoroscopy is aseptically cleansed and anaesthetized locally.

Implementation cont’d

• After draping the patient and injecting the anaesthetic,the physician attaches a three-way stopcock with tubing to the aspirating needle and turns the stop cock to prevent air from entering the pleural space through the needle
• Attach the other end of the tubing to the drainage bottle

Implementation cont’d

• The physician then inserts the needle into the pleural space and attaches a 50ml syringe to the needle’s stopcock
• A hemostat may be used to hold the needle in place and prevent pleural tear or lung puncture.
• As an alternative the physician may introduce a Teflon catheter into the needle,remove the needle,and attach a stopcock and syringe or drainage tubing to the catheter to reduce the risk of pleural puncture by the needle.

Implementation cont’d

• Support the patient verbally throughout the procedure, and keep him informed of each step.
• Assess him for signs of anxiety and provide reassurance as necessary
• Check vital signs regularly during the procedure
• Observe the patient for signs of distress such as pallor,vertigo, faintness,weak and rapid pulse,decreased blood pressure, dyspnoea tachypnoea chest pain,blood tinged mucus and excessive coughing.

Implementation cont’d

• Assist the physician, as necessary in specimen collection and fluid drainage.
• After the physician withdraws the needle or catheter ,apply pressure to the puncture site using 4inch by 4inch gauze pad. Then apply a new sterile gauze pad,and secure it with an occlusive dressing
• Place the patient in a comfortable position, take his vital signs and assess his respiratory status

Implementation cont’d

• Label the specimen properly and send them to the laboratory
• Discard equipment
• Check the patient’s vital signs and the dressing for drainage every 15mins for one hour
• A chest x-ray is usually done afterward to check for pneumothorax

Special considerations

• To prevent pulmonary oedema and hypovolaemic shock after thoracentesis, fluid is removed during the first 30mins
• Removing the fluid increases the negative intrapleural pressure,which can lead to oedema if the lung does not re-expand to fill the space
• Pleuritic or shoulder pain may indicate pleural irritation by the needle point

Complications

• Pneumothorax can occur if the needle punctures the lung and air enters the pleural cavity
• Haemoptysis may occur if the lung is punctured
• Pyogenic infection can result from contamination during the procedure

Complications cont’d

• Haemothorax may result if the thoracentesis needle punctures one of the intercostal vessels
• Other potential difficulties include pain,cough.anxiety,subcutaneous haematoma,and vasovagal syncope.

Documentation

• Record the date and time of thoracentesis,location of the puncture site,volume and description(colour, viscocity,odour) of the fluid withdrawn,specimen sent to laboratory,vital signs and respiratory assessment before during and after the procedure.
• Post procedural tests such as chest x-ray, complications and the nursing action taken and the patient’s reaction to the procedure.

CHEST TUBES AND DRAINAGE SYSTEMS

• The pleural space normally contains a thin layer of lubricating fluid that allows the viscera and parietal pleura to move without friction during respiration.
• An excess of fluid (haemothorax or pleural effusion) air(pneumothorax),or both in this space alters intrapleural pressure and causes partial or complete lung collapse.

Chest tube insertion cont’d

• Chest tube insertion allows drainage of air or fluid from the pleural space. Usually performed by a physician with the nurse assisting
• The insertion site varies depending on the patient’s condition and the physician’s judgement.

Chest tube insertion cont’d

• For pneumothorax, the 2^nd to 3^rd intercostal spaces are the usual sites because air rises to the top of the intrapleural space
• For hemothorax or pleural effusion, the 4^th to 6^th intercostal paces are common sites because fluid settles to the lower levels of the intrapleural space.

Chest tube insertion cont’d

• For removal of air and fluid,a chest tube is inserted into a high and low site.
• After insertion,one or more chest tubes are connected to a thoracic drainage system that removes air, fluid or both from the pleural space and prevents backflow into that space, thus promoting lung re expansion.

Thoracic drainage

• Thoracic drainage uses gravity and possibly suction to restore negative pressure and remove any material that collects in the pleural cavity
• A self-contained, disposable system combines drainage collection, a water seal, and suction into a single unit.

Thoracic drainage cont’d

• Specifically,thoracic drainage may be ordered to remove accumulated air,fluids(blood, pus chyle,serous fluids,gastric juices)or solids(blood clots) from the pleural cavity, to restore negative pressure in the pleural cavity or to re-expand a partially or totally collapsed lung

Equipment

• Thoracic drainage system(which can function as gravity draining systems or be connected to suction to enhance chest drainage) with tubing and connector.
• Sterile water
• Adhesive tape
• Two rubber-tipped Kelly clamps
• Sterile 50ml catheter tip syringe. Suction source if ordered.

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Implementation

• Confirm the patient’s identity
• Explain the procedure to the patient and wash your hands
• Maintain sterile technique throughout the entire procedure

Managing closed-chest underwater seal drainage

• Repeatedly note the character, consistency and amount of drainage in the drainage collection chamber
• Mark the drainage level in the drainage collection chamber by noting the time and date at the drainage level on the chamber every 8 hours(or more often if there is a large amount of drainage)

Closed under- water seal cont’d

• Check the water level in the water seal chamber every 8hours
• If necessary, carefully add sterile water until the level reaches the 20cm mark indicated on the water seal chamber of the commercial system
• Check for fluctuation in the water-seal chamber of the commercial system as the patient breathes

Closed- chest under water seal drainage cont’d

• Check for intermittent bubbling in the water-seal chamber. This occurs normally when the system is removing air from the pleural cavity
• Absence of bubbling indicates that the pleural space is sealed.
• Check water level in the suction –control chamber. If necessary ,add sterile water to bring the level to the 20cm line or as ordered

Under-water seal cont’d

• Periodically check that the air vent in the system is working properly.(occlusion of the air vent results in a buildup of pressure in the system that could cause the patient to develop a tension pneumothorax
• Coil the system’s tubing, and secure it to the edge of the bed, be sure the tubing remains at the level of the patient

Under-water seal cont’d

• Avoid lifting the drainage system above the patient’s chest because fluid may flow back into the pleural space
• Keep two rubber-tipped clamps at the bedside to clamp the chest tube if system cracks or to locate an air leak in the system
• Encourage the patient to cough frequently and breathe deeply to help drain the pleural space and expand the lungs.

Under water seal cont’d

• Tell him to sit upright for optimal lung expansion and to splint the insertion site while coughing to minimize pain
• Check the rate and quality of the patient’s respirations and auscultate his lungs periodically to assess air exchange in the affected lung
• Tell the patient to report breathing difficulties immediately

Under-water seal drainage cont’d

• Notify the doctor immediately if the patient develops cyanosis, rapid or shallow breathing subcutaneous emphysema ,chest pain or excessive bleeding
• Check the chest tube dressing every four hours.
• Palpate the area surrounding the dressing for crepitus or subcutaneous emphysema(which indicates that air is leaking into the subcutaneous tissue surrounding the insertion.)

Under-water seal drainage cont’d

• Encourage active or passive range-of- motion (ROM) exercises for the patient’s arm on the affected side if he has been splinting the arm. usually the thoracotomy patient will splint his arm to decrease his discomfort.
• Give ordered pain medication,as needed, for comfort and to help with deep-breathing, coughing and ROM exercises.

Under-water seal drainage cont’d

• Reposition the patient every two hours ,when the patient is lying on the affected side ,place rolled towels beside the tubing
• Frequent position changes promote drainage,prevent complications and provide comfort
• Rolled towels prevent occlusion of the chest tube by the patient’s weight.

Under water seal drainage cont’d

• When moving and mobilising the patient
• Attach chest drain forceps to the patient’s gown or clothing for emergency use
• Keep the water –seal unit below chest level and upright
• disconnect the drainage system from the suction apparatus before moving the patient and make sure the air vent is open

Complications

• Tension pneumothorax may result from excessive accumulation of air, drainage, or both and eventually may exert pressure on the heart and aorta ,causing a precipitous fall in cardiac output

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Documentation

• Record the date and time thoracic drainage began ,type of system used, amount of suction applied to the pleural cavity,presence or absence of bubbling or fluctuation in the water-seal chamber,initial amount and type of drainage and the patient’s respiratory status

LUMBAR PUNCTURE

• Lumbar puncture involves the insertion of a sterile needle into the subarachnoid space of the spinal canal.
• Usually between the 3^rd and the 4^th lumbar vertebra.
• Because the spinal cord divides into a sheaf below the level of the 3^rd lumbar vertebra to prevent the spinal cord from being punctured.

Purposes

• To determine the presence of blood in cerebrospinal fluid(CSF)
• To obtain CSF specimen for laboratory analysis
• To inject dyes for contrast in radiologic studies
• The pressure of the CSF which flows freely between the brain and the spinal column may be measured during the procedure

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Purposes for lumbar puncture cont’d

• It is also used to administer drugs or anaesthetics
• To relieve intracranial pressure(ICP)by removing CSF
• To administer antibiotics intrathecally that is into the spinal cord in certain cases of infections

Lumbar puncture cont’d

• A successful lumbar puncture requires that the patient be relaxed, an anxious patient is tense and the increased anxiety may cause an increase in the pressure reading
• The normal range of spinal fluid pressure with the patient in a lateral position is 70-200mm H20(water).Pressures over 200mm H2O are considered abnormal.

Lumbar puncture cont’d

• A lumbar puncture may be quite dangerous in the presence of an intracranial mass lesion, because intracranial pressure is decreased by the removal of CSF and the brain may herniate downward through the tentorium and the foramen magnum.
• This procedure is performed by a physician and requires sterile technique and careful patient positioning.

Equipment

• Overbed table
• One or two pairs of sterile gloves for the physician
• Sterile gloves for the nurse
• Face masks
• Antiseptic solution
• Sterile gauze pads
• Alcohol pads

Equipment cont’d

• Sterile fenestrated drape
• 3-5ml syringe for local anaesthetic
• 25Gor3/4 inch sterile needle for injecting anaesthetic
• Local anaesthetic (usually 1% lidocaine)
• 18G or 20G or 3 ½ inch spinal needle with stylet (22G needle for children)

Equipment cont’d

• Three-way stopcock
• Manometer
• Small adhesive bandage
• Three sterile collection tubes with stoppers
• Laboratory request forms
• Light source
• (disposable lumbar puncture trays contain most of the needed sterile equipment).

Implementation

• Confirm the patient’s identity
• Explain the procedure to the patient to ease his anxiety and ensure his coperation
• Ensure that a consent form has been signed

Positioning for lumbar puncture

• Have the patient lie on his side at the edge of the bed with his chin tucked to his chest and his knees drawn up to his abdomen.
• Make sure the patient’s spine is curved and his back is at the edge of the bed. This position widens the spaces between the vertebrae,easing insertion of the needle.

Positioning cont’d

• To help the patient maintain this position, place your hands behind his neck and the other hand behind his knees and pull gently.
• Hold the patient firmly in this position throughout the procedure to prevent accidental needle displacement.

Implementation cont’d

• Inform the patient that he may experience headache after lumbar puncture but reassure him that his coperation during the procedure minimizes such effect.
• Immediately before the procedure provide privacy and instruct the patient to void.
• Wash your hands thoroughly.

Implementation cont’d

• Provide adequate lighting at the puncture site
• Position the patient and re-emphasize the importance of remaining as still as possible to minimize discomfort and trauma.
• The physician cleans the puncture site with sterile gauze pads soaked in antiseptic solution

Implementation cont’d

• The area is draped with fenestrated drape to provide a sterile field
• Clean the injection port of a multidose vial of anaesthetic with an alcohol pad
• Then invert the vial 45degrees so that the physician can insert a 25Gneedle and syringe and withdraw the anaesthetic for injection.

Implementation cont’d

• Before the physician injects the anaesthetic tell the patient he will experience a transient burning sensation and local pain. Ask him to report any other persistent pain or sensations.
• When the physician inserts the sterile spinal needle into the subarachnoid space between the 3^rd and 4^th lumbar vertebrae, instruct the patient to remain still and breathe normally.

Implementation cont’d

• If the lumbar puncture is being performed to administer contrast media for radiologic studies or spinal anaesthetic, the physician injects the dye or anaesthetic at this time.
• When the needle is in place , the physician attaches a manometer with a 3-way stopcock to the needle hub to read the CSF pressure.

Implementation cont’d

• The physician then detaches the manometer and allows CSF to drain from the needle hub into the collection tubes.
• When he has collected 2-3ml in each tube, mark the tubes in sequence , insert a stopper to secure them and label them

Implementation cont’d

• After the physician collects the specimen and removes the spinal needle, clean the puncture site with povidine iodine and apply a small adhesive bandage.
• Send the CSF specimens to the laboratory immediately.

Special considerations

• During lumbar puncture, watch closely for signs of adverse reaction such as , elevated pulse rate, pallor and clammy skin. Alert the physician immediately.
• The patient may be instructed to lie flat for 8-12 hours after the procedure to allow the restoration of spinal fluid to prevent postspinal headache.

Special considerations cont’d

• Collected CSF specimens must be sent to the laboratory immediately, they cannot be refrigerated .
• Encourage the patient to drink fluids after the procedure to reduce the risk of spinal headache
• Check the puncture site for redness, swelling and drainage every hour for the first 4hours and then every 4hours for the next 24hours.

Queckenstedt’s test

• This is a lumbar manometric test which may be performed by compressing the jugular veins on each side of the neck during lumbar puncture.
• The increase in pressure caused by the compression is noted, then the pressure is released and pressure readings are made at 10-second intervals.

Queckenstedt’s test cont’d

• Normally, CSF pressure rises in response to compression of the jugular veins and returns quickly to normal when the compression is released.
• A slow rise and fall in pressure indicates a partial block due to a lesion compressing the spinal subarachnoid pathways.
• If there is no pressure change, a complete block is indicated.

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Queckenstedt’s test cont’d

• This test is not performed if an intracranial lesion is suspected.

Complications

• Headache is the most common adverse effect of lumbar puncture, others include
• Reaction to the anaesthetic
• Meningitis , epidural or subdural abscess, bleeding into the spinal canal.
• CSF leakage through the dural defect remaining after needle withdrawal.

Complications cont’d

• Local pain caused by nerve root irritation
• Oedema or haematoma at the puncture site
• Transient difficulty voiding and fever

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Documentation

• Record the initiation and completion times of the procedure
• The patient’s response
• Administration of drugs
• Number of specimens collected
• The colour, consistency and any other characteristics of the collected specimen.