- Oxygen delivery devices are classified into low-flow and high-flow systems, depending on whether they provide a fixed or variable amount of oxygen to the patient.

- Low-flow systems deliver a variable amount of oxygen that depends on the patient’s breathing pattern and rate. They include a nasal cannula, simple face mask, partial rebreather mask, and non-rebreather mask.

- High-flow systems deliver a fixed amount of oxygen that is independent of the patient’s breathing pattern and rate. They include a venturi mask, aerosol mask, face tent, tracheostomy collar, T-piece, and mechanical ventilator.

- The table below summarizes the characteristics, advantages, disadvantages, and nursing implications of each type of oxygen delivery device.

- Assess the patient’s need for oxygen therapy based on their history, physical examination, vital signs, ABG results, pulse oximetry readings, and clinical manifestations.

- Obtain a prescription for oxygen therapy that specifies the type of device, FiO2 or flow rate, duration, frequency, and indications for changing or discontinuing the therapy.

- Explain the purpose, benefits, risks, and procedure of oxygen therapy to the patient and their family members.

- Select the appropriate oxygen delivery device according to the prescription and the patient’s condition, preference, comfort, and tolerance.

- Apply the device correctly and securely to ensure adequate oxygen delivery and prevent dislodgement or leakage.

- Adjust the flow meter to deliver the prescribed FiO2 or flow rate.

- Connect the device to a humidifier if indicated to prevent mucosal dryness and irritation.

- Monitor the patient’s response to oxygen therapy by observing their respiratory rate, depth, rhythm, effort, breath sounds, skin color, level of consciousness, mental status, etc.

- Evaluate the effectiveness of oxygen therapy by measuring their PaO2 or SaO2 using ABG analysis or pulse oximetry.

- Document the type of device, FiO2 or flow rate, duration, frequency, response, effectiveness, complications, and education provided for oxygen therapy.

- Educate the patient and their family members on how to use and care for the oxygen delivery device, how to recognize and report signs of hypoxia or hypercarbia, how to prevent complications, and when to seek medical attention.

- Implement safety measures to prevent fire hazards, such as avoiding smoking, open flames, sparks, or flammable materials near the oxygen source, using cotton or wool clothing and bedding, and grounding electrical equipment.

- Oxygen toxicity: A condition caused by exposure to high concentrations of oxygen for prolonged periods of time. It can damage the lungs and other organs by producing free radicals that injure the cells. Signs and symptoms include dyspnea, cough, chest pain, substernal discomfort, crackles, decreased lung compliance, pulmonary edema, and respiratory failure.

- Carbon dioxide retention: A condition caused by increased levels of carbon dioxide in the blood due to hypoventilation or impaired gas exchange. It can occur in patients with chronic obstructive pulmonary disease (COPD) who rely on hypoxic drive to stimulate breathing. High concentrations of oxygen can suppress this drive and reduce the respiratory rate and depth. Signs and symptoms include headache, confusion, drowsiness, coma, and respiratory acidosis.

- Absorption atelectasis: A condition caused by the collapse of the alveoli due to nitrogen washout. Nitrogen is normally present in the alveoli and helps maintain their patency. High concentrations of oxygen can displace nitrogen and reduce the alveolar volume. Signs and symptoms include dyspnea, hypoxemia, decreased breath sounds, and increased respiratory rate.

- Fire hazard: A condition caused by ignition of oxygen-enriched air or materials near the oxygen source. Oxygen supports combustion and can cause rapid and intense burning. Sources of ignition include smoking, open flames, sparks, or flammable materials. Signs and symptoms include smoke, flames, heat, burns, and injuries.

- Oxygen therapy is a common and important intervention for patients with hypoxemia or hypoxia.

- Oxygen therapy requires careful assessment, prescription, application, monitoring, evaluation, documentation, education, and safety measures.

- Oxygen therapy can cause complications such as oxygen toxicity, carbon dioxide retention, absorption atelectasis, and fire hazard.

- Oxygen therapy is the administration of supplemental oxygen to increase the amount of oxygen available to the tissues and organs.

- Oxygen therapy is prescribed when the patient’s oxygen needs cannot be met by atmospheric or room air alone.

- The goal of oxygen therapy is to use the lowest fraction of inspired oxygen (FiO2) to achieve an acceptable blood oxygen level without causing harmful side effects.

- The effectiveness of oxygen therapy is evaluated by measuring the partial pressure of arterial oxygen (PaO2) or the arterial oxygen saturation (SaO2) using arterial blood gas (ABG) analysis or pulse oximetry.

- Oxygen delivery devices are classified into low-flow and high-flow systems. Low-flow systems deliver a variable amount of oxygen that depends on the patient’s breathing pattern and rate. High-flow systems deliver a fixed amount of oxygen that is independent of the patient’s breathing pattern and rate.

- The types of oxygen delivery devices include a nasal cannula, simple face mask, partial rebreather mask, non-rebreather mask, venturi mask, aerosol mask, face tent, tracheostomy collar, T-piece, and mechanical ventilator. Each device has its own characteristics, advantages, disadvantages, and nursing implications.

- Nursing interventions for patients receiving oxygen therapy include assessing the need for oxygen therapy; obtaining a prescription for oxygen therapy; explaining the purpose, benefits, risks, and procedure of oxygen therapy; selecting the appropriate device; applying the device correctly and securely; adjusting the flow meter; connecting the device to a humidifier if indicated; monitoring the response to oxygen therapy; evaluating the effectiveness of oxygen therapy; documenting the oxygen therapy; educating the patient and family members on how to use and care for the device; recognizing and reporting signs of hypoxia or hypercarbia; preventing complications; and seeking medical attention; implementing safety measures to prevent fire hazards.

- Complications of oxygen therapy include oxygen toxicity, carbon dioxide retention, absorption atelectasis, and fire hazard.

- Sterile suctioning is a procedure that involves applying negative pressure to remove secretions from the airway of a patient who has an artificial airway or impaired cough reflex.

- The purpose of sterile suctioning is to maintain airway patency, prevent infection, improve gas exchange, and promote comfort.

- Sterile suctioning is indicated for patients who have excessive or thick secretions that obstruct the airway, or who are unable to clear their own secretions due to decreased level of consciousness, neuromuscular weakness, or respiratory distress.

- Sterile suctioning is contraindicated for patients who have bleeding disorders, nasal or oral trauma, epiglottitis, croup, or laryngeal edema.

- Sterile suctioning can cause complications such as hypoxia, hypotension, bradycardia, arrhythmias, bleeding, infection, mucosal damage, bronchospasm, atelectasis, and increased intracranial pressure.

- Suctioning devices are machines that generate negative pressure to aspirate secretions from the airway. They can be wall-mounted or portable.

- Suctioning devices have a collection container for secretions, a pressure gauge to adjust the level of suction, a tubing system to connect the device to the catheter, and a control valve to regulate the suction.

- Suctioning catheters are flexible tubes that are inserted into the airway through the artificial airway or the nose or mouth. They have a tip with one or more openings to collect secretions, and a vent that allows intermittent suction by covering and releasing it with the thumb.

- Suctioning catheters come in different sizes and materials. The size is measured by the French scale (Fr), which indicates the external diameter of the catheter. The appropriate size of the catheter depends on the type and size of the artificial airway. Generally, the catheter should not exceed half of the internal diameter of the artificial airway.

- Suctioning catheters can be made of plastic, rubber, or silicone. They can be disposable or reusable. Disposable catheters are preferred for infection control purposes. Reusable catheters should be cleaned and sterilized after each use.

- Suctioning catheters can be open or closed. Open catheters are single-use catheters that are attached to the suction tubing directly. Closed catheters are multi-use catheters that are enclosed in a plastic sleeve that connects to the suction tubing. Closed catheters reduce the risk of infection and contamination, but they are more expensive than open catheters.

- Sterile suctioning is an invasive procedure that can introduce microorganisms into the lower respiratory tract and cause infection. Therefore, infection control measures are essential to prevent nosocomial pneumonia and other complications.

- Infection control measures include hand hygiene, personal protective equipment (PPE), sterile equipment and supplies, proper disposal of waste materials, and environmental cleaning.

- Hand hygiene is the most important measure to prevent cross-contamination. It involves washing hands with soap and water or using alcohol-based hand rub before and after contact with the patient or any potentially contaminated items.

- PPE consists of gloves, gown, mask, eye protection, and hair cover. It protects the health care worker from exposure to bloodborne pathogens and other infectious agents. It also prevents transmission of microorganisms from the health care worker to the patient or vice versa.

- Sterile equipment and supplies include suction device, tubing system, collection container, catheter, saline solution, gloves, and sterile drape. They should be opened and handled using aseptic technique, which involves avoiding contact with any non-sterile surfaces or items.

- Proper disposal of waste materials involves discarding used catheters, gloves, and other contaminated items into appropriate biohazard bags or containers. The collection container should be emptied and cleaned after each use or when it is full.

- Environmental cleaning involves wiping the suction device, tubing system, and other surfaces with disinfectant solution after each use or at least once a day. The suction device should be checked for proper functioning and maintenance regularly.

- The steps of performing sterile suctioning vary depending on the type of artificial airway that the patient has. The most common types of artificial airways are endotracheal tube (ETT), tracheostomy tube (TT), and nasopharyngeal tube (NPT).

- Endotracheal tube (ETT) is a plastic tube that is inserted through the mouth or nose into the trachea to provide mechanical ventilation or oxygenation. It is secured with tape or a cuff that is inflated to seal the airway.

- Tracheostomy tube (TT) is a metal or plastic tube that is inserted through a surgical opening in the neck into the trachea to bypass the upper airway obstruction or facilitate long-term ventilation. It can have an inner cannula that can be removed for cleaning and a cuff that can be inflated or deflated depending on the patient’s condition.

- Nasopharyngeal tube (NPT) is a soft rubber or plastic tube that is inserted through the nose into the pharynx to provide oxygenation or humidification. It is used for patients who have difficulty breathing through the mouth or who need frequent suctioning.

- The general steps of performing sterile suctioning for any type of artificial airway are as follows:

• Assess the patient’s need for suctioning by observing for signs and symptoms of airway obstruction, such as increased respiratory rate, decreased oxygen saturation, adventitious breath sounds, restlessness, agitation, cyanosis, or coughing.
• Check the prescriber’s order for suctioning, including the frequency, duration, pressure, and type of catheter.
• Gather the equipment and supplies needed for suctioning, such as suction device, tubing system, collection container, catheter, saline solution, gloves, sterile drape, PPE, oxygen source, and stethoscope.
• Explain the procedure to the patient and obtain consent if possible. Provide privacy and ensure comfort. Position the patient in semi-Fowler’s or Fowler’s position to facilitate breathing and drainage.
• Perform hand hygiene and don PPE. Open the sterile equipment and supplies using aseptic technique. Connect the suction tubing to the suction device and adjust the pressure according to the prescriber’s order. Test the suction by occluding the vent with the thumb.
• Preoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes before suctioning to prevent hypoxia. Monitor the patient’s vital signs and oxygen saturation during this step.
• Insert the catheter into the artificial airway using sterile technique. For ETT and TT, insert the catheter until resistance is met or until the patient coughs. For NPT, insert the catheter until it reaches the pharynx. Do not apply suction while inserting the catheter.
• Apply intermittent suction by placing and releasing the thumb over the vent while withdrawing the catheter slowly. Rotate the catheter between the thumb and forefinger to remove secretions from all sides of the airway. Limit each suction pass to no more than 10 seconds to prevent hypoxia and mucosal damage.
• Rinse the catheter and tubing with saline solution or water after each suction pass to clear secretions and prevent infection. Reoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes after each suction pass to restore oxygenation.
• Repeat steps 7 to 9 until no more secretions are obtained or until three passes are completed. Do not suction more than three times in a row to prevent complications. Allow at least one minute of rest between each suction pass to prevent fatigue and distress.

- Remove the catheter and tubing from the artificial airway and disconnect them from the suction device. Discard the used catheter and gloves into a biohazard bag or container. Clean the collection container and tubing with disinfectant solution. Turn off the suction device.

- Assess the patient’s response to suctioning by monitoring vital signs, oxygen saturation, breath sounds, secretions, and comfort level. Provide oral or nasal care as needed. Reposition the patient and ensure safety .

- Perform hand hygiene and remove PPE. Dispose of waste materials according to facility policy. Clean the environment and equipment as needed .

- Document the procedure and findings, including the date, time, type, size, and frequency of suctioning, the amount, color, consistency, and odor of secretions, the patient’s tolerance and response, any complications or interventions, and any teaching or evaluation done.

- Nursing interventions and assessments before, during, and after sterile suctioning are aimed at ensuring patient safety, comfort, and optimal outcomes. They include the following :

• Before suctioning:
  • Obtain baseline data on vital signs, oxygen saturation, breath sounds, secretions, and comfort level.
  • Verify the prescriber’s order for suctioning and check for any contraindications or precautions.
  • Explain the procedure to the patient and provide reassurance. Answer any questions or concerns.
  • Gather the necessary equipment and supplies and check their expiration dates and functionality.
  • Perform hand hygiene and don PPE. Prepare a sterile field and open the sterile equipment and supplies using aseptic technique.
  • Connect the suction tubing to the suction device and adjust the pressure according to the prescriber’s order. Test the suction by occluding the vent with the thumb.
  • Preoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes before suctioning to prevent hypoxia.
• During suctioning:
  • Insert the catheter into the artificial airway using sterile technique. Do not apply suction while inserting the catheter.
  • Apply intermittent suction by placing and releasing the thumb over the vent while withdrawing the catheter slowly. Rotate the catheter between the thumb and forefinger to remove secretions from all sides of the airway. Limit each suction pass to no more than 10 seconds to prevent hypoxia and mucosal damage.
  • Rinse the catheter and tubing with saline solution or water after each suction pass to clear secretions and prevent infection. Reoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes after each suction pass to restore oxygenation.
  • Observe the patient’s vital signs, oxygen saturation, breath sounds, secretions, comfort level, and tolerance during suctioning. Watch for any signs of complications or adverse reactions, such as hypoxia, hypotension, bradycardia, arrhythmias, bleeding, infection, mucosal damage, bronchospasm, atelectasis, or increased intracranial pressure. Stop suctioning immediately if any of these occur and provide appropriate interventions.
  • Communicate with the patient throughout suctioning and provide encouragement and support.
• After suctioning:
  • Remove the catheter and tubing from the artificial airway and disconnect them from the suction device. Discard the used catheter and gloves into a biohazard bag or container. Clean the collection container and tubing with disinfectant solution. Turn off the suction device.

• Assess the patient’s response to suctioning by monitoring vital signs, oxygen saturation, breath sounds, secretions, and comfort level. Provide oral or nasal care as needed. Reposition the patient and ensure safety.
• Perform hand hygiene and remove PPE. Dispose of waste materials according to facility policy. Clean the environment and equipment as needed.
• Document the procedure and findings, including the date, time, type, size, and frequency of suctioning, the amount, color, consistency, and odor of secretions, the patient’s tolerance and response, any complications or interventions, and any teaching or evaluation done.

- The outcomes and effectiveness of sterile suctioning are evaluated by comparing the patient’s condition before and after suctioning, and by monitoring for any changes or improvements in the following indicators :

• Airway patency: The airway should be clear of secretions and obstruction after suctioning. The patient should have normal or improved breath sounds, respiratory rate, oxygen saturation, and chest expansion.
• Infection prevention: The patient should have no signs or symptoms of infection after suctioning, such as fever, chills, purulent or foul-smelling secretions, increased white blood cell count, or positive culture results.
• Gas exchange: The patient should have adequate oxygenation and ventilation after suctioning. The patient should have normal or improved arterial blood gas values, such as pH, PaO2, PaCO2, HCO3, and SaO2.
• Comfort: The patient should have minimal or no pain or discomfort after suctioning. The patient should have normal or decreased anxiety, agitation, restlessness, or dyspnea.
• Complications: The patient should have no complications or adverse reactions after suctioning, such as hypoxia, hypotension, bradycardia, arrhythmias, bleeding, infection, mucosal damage, bronchospasm, atelectasis, or increased intracranial pressure.

- Sterile suctioning is a medico-surgical procedure that involves applying negative pressure to remove secretions from the airway of a patient who has an artificial airway or impaired cough reflex.

- Sterile suctioning is indicated for patients who have excessive or thick secretions that obstruct the airway, or who are unable to clear their own secretions due to decreased level of consciousness, neuromuscular weakness, or respiratory distress.

- Sterile suctioning requires sterile equipment and supplies, such as a suction device, tubing system, collection container, catheter, saline solution, gloves, sterile drape, PPE, oxygen source, and stethoscope.

- Sterile suctioning involves inserting the catheter into the artificial airway using sterile technique, applying intermittent suction by placing and releasing the thumb over the vent while withdrawing the catheter slowly, rotating the catheter between the thumb and forefinger to remove secretions from all sides of the airway, rinsing the catheter and tubing with saline solution or water after each suction pass, reoxygenating the patient with 100% oxygen for 30 seconds to 3 minutes after each suction pass, and repeating these steps until no more secretions are obtained or until three passes are completed.

- Sterile suctioning can cause complications such as hypoxia, hypotension, bradycardia, arrhythmias, bleeding, infection, mucosal damage, bronchospasm, atelectasis, and increased intracranial pressure.

- Sterile suctioning requires nursing interventions and assessments before, during, and after the procedure to ensure patient safety, comfort, and optimal outcomes.

- Sterile suctioning is evaluated by comparing the patient’s condition before and after suctioning, and by monitoring for any changes or improvements in airway patency, infection prevention, gas exchange, comfort, and complications.

- A tracheostomy is an opening (stoma) created in the anterior wall of the trachea to provide a stable and secure airway. It is usually performed when the upper airway is obstructed or compromised by trauma, tumor, infection, or edema. It can also be done for patients who require long-term mechanical ventilation or frequent suctioning to prevent aspiration of secretions. A tracheostomy tube is inserted into the stoma to maintain its patency and facilitate ventilation.

- Tracheostomy tubes come in various sizes and angles to fit different patients’ anatomy and needs. They are made of metal, plastic, or silicone. Some common types of tracheostomy tubes are:

• Cuffed: A cuff is a balloon-like device that inflates around the tube to seal the trachea and prevent air leakage or aspiration. It is used for patients who need mechanical ventilation or have a high risk of aspiration. The cuff pressure should be monitored regularly and kept between 20 to 25 cm H2O to prevent tracheal damage.
• Uncuffed: An uncuffed tube has no cuff and allows air to flow around the tube. It is used for patients who can breathe spontaneously and have a low risk of aspiration. It also allows the patient to speak and cough more easily.
• Fenestrated: A fenestrated tube has one or more holes on the outer cannula that allow air to pass through the vocal cords when the inner cannula is removed. It is used for patients who are ready to wean from mechanical ventilation or need speech therapy. The fenestration should be covered by a cap or plug when suctioning or ventilating.
• Double-lumen: A double-lumen tube has two cannulas: an outer cannula that stays in place and an inner cannula that can be removed for cleaning or changing. The inner cannula provides a clear passage for air and secretions and reduces the risk of tube occlusion.

The components of a tracheostomy tube are:

• Flange: A flat plate that rests on the neck and holds the tube in place. It has holes for securing the tube with ties or straps.
• Obturator: A cone-shaped device that is inserted into the tube to guide its insertion and prevent injury to the tracheal wall. It is removed after the tube is in place.
• Pilot balloon: A small balloon that indicates the status of the cuff. It is connected to a valve that allows inflation or deflation of the cuff.
• Suction port: An opening on the tube that allows connection to a suction catheter for removing secretions.

- The nursing interventions for tracheostomy care include:

• Assessing the patient’s respiratory status, vital signs, oxygen saturation, and level of consciousness frequently.
• Monitoring the position, patency, and security of the tube and ensuring that it is not displaced or dislodged.
• Changing the dressing around the stoma daily or as needed using a sterile technique and observing for signs of infection, bleeding, or skin breakdown.
• Cleaning the stoma and the flange with normal saline or sterile water using cotton swabs or gauze pads.
• Changing the ties or straps when they are soiled, wet, or loose using a square knot and leaving enough space for one finger between the tie and the neck.
• Providing humidification and hydration to prevent drying and crusting of secretions.
• Performing tracheostomy care every 8 to 12 hours or as needed using a sterile technique and following these steps:
  • Gather equipment and supplies such as gloves, goggles, mask, gown, sterile towel, sterile gloves, sterile water or saline, hydrogen peroxide, suction catheter, suction machine, tracheostomy cleaning kit, new dressing, new ties or straps, and bag-valve-mask (BVM) ventilator system connected to an oxygen source.
  • Explain the procedure to the patient and obtain consent if possible.
  • Position the patient in semi-Fowler’s position with the head slightly hyperextended.
  • Put on gloves, goggles, mask, and gown if necessary.
  • Remove the old dressing and discard it in a moisture-resistant bag.
  • Inspect the stoma for signs of infection, bleeding, or skin breakdown and report any abnormal findings to the health care provider.
  • Remove the inner cannula if present and place it in a container with sterile water or saline.
  • Clean the inner cannula with a brush or pipe cleaner soaked in hydrogen peroxide and rinse it with sterile water or saline.
  • Reinsert the inner cannula and lock it in place.
  • Clean the outer cannula and the flange with cotton swabs or gauze pads soaked in hydrogen peroxide and rinse them with sterile water or saline.
  • Apply a new dressing around the stoma and secure it with tape or clips.
  • Change the ties or straps if needed using a square knot and leaving enough space for one finger between the tie and the neck.
  • Remove gloves and perform hand hygiene.
  • Put on sterile gloves and prepare to suction the tube.

- Suctioning a tracheostomy tube is a sterile, invasive technique that requires a nurse or a respiratory therapist. It is done to remove secretions from the tube and prevent obstruction, infection, or hypoxia. The steps of suctioning a tracheostomy tube are:

• Review the health care provider’s orders and the patient’s nursing plan of care.
• Gather equipment and supplies such as gloves, goggles, mask, gown, sterile towel, sterile gloves, sterile water or saline, hydrogen peroxide, suction catheter, suction machine, pulse oximeter, oxygen source, and bag-valve-mask (BVM) ventilator system.
• Explain the procedure to the patient and obtain consent if possible.
• Position the patient in semi-Fowler’s position with the head slightly hyperextended.
• Perform hand hygiene and don gloves, goggles, mask, and gown if necessary.
• Remove the old dressing and discard it in a moisture-resistant bag.
• Inspect the stoma for signs of infection, bleeding, or skin breakdown and report any abnormal findings to the health care provider.
• Assess the patient’s respiratory status, vital signs, oxygen saturation, and level of consciousness before suctioning.
• Provide humidification and hydration to the patient to prevent drying and crusting of secretions.
• Hyperoxygenate the patient before and after suctioning using a BVM ventilator system connected to an oxygen source.
• Lower the side rail and place a sterile towel or a waterproof pad across the patient’s chest.
• Turn on the suction machine and set the pressure to the appropriate level according to the patient’s age:

• Check the pressure by occluding the end of the connecting tube with a gloved hand.
• Pour sterile saline into a container and open a suction catheter kit.
• Don sterile gloves and pick up the sterile catheter with the dominant hand.
• With the non-dominant hand, pick up the connecting tubing and connect it to the suction catheter.
• Moisten the tip of the catheter in the sterile saline and occlude the Y-port to check suction.
• Remove the inner cannula if present and place it in a container with sterile water or saline.
• With the dominant hand, gently insert the catheter into the tracheostomy tube until resistance is met. Do not occlude the Y-port or apply suction when inserting the catheter.
• Apply suction by intermittently occluding the Y-port on the catheter with the thumb of your non-dominant hand, and gently rotate and withdraw the catheter. Do not apply suction for more than 10 seconds at a time.
• Rinse the catheter with sterile saline between each suctioning attempt. Limit suctioning attempts to three per session. Allow at least one minute between each attempt for oxygenation. Monitor oxygen saturation throughout suctioning.

- Tracheostomy is a life-saving procedure, but it also carries some risks and complications that require prompt recognition and management. Some of the potential complications and emergency situations related to tracheostomy are:

• Bleeding: Bleeding can occur during or after the tracheostomy procedure due to injury to the blood vessels, erosion of the tracheal wall, or infection. Bleeding can be minor or massive and can cause airway obstruction, hypovolemia, or shock. To manage bleeding, apply direct pressure to the site, elevate the head of the bed, notify the health care provider, and prepare for possible transfusion or surgical intervention.
• Infection: Infection can occur at the stoma site or in the lower respiratory tract due to contamination of the tube or secretions. Infection can cause inflammation, edema, pus formation, fever, increased secretions, or foul odor. To prevent and treat infection, use sterile technique for tracheostomy care and suctioning, change the tube and dressing as ordered, administer antibiotics as prescribed, and monitor for signs and symptoms of infection.
• Tracheomalacia: Tracheomalacia is a condition where the tracheal wall becomes soft and weak due to constant pressure exerted by the cuff. It causes tracheal dilation and erosion of cartilage, leading to loss of tissue integrity. Tracheomalacia can manifest as an increased amount of air required in the cuff to maintain the seal, a larger tracheostomy tube required to prevent an air leak at the stoma, food particles seen in tracheal secretions, or reduced tidal volume on the ventilator. To prevent and manage tracheomalacia, use an uncuffed tube as soon as possible, monitor cuff pressure and air volumes closely, and detect changes.
• Tracheal stenosis: Tracheal stenosis is a narrowing of the tracheal lumen due to scar formation from irritation of the tracheal mucosa by the cuff. It impairs tissue integrity and airflow. Tracheal stenosis is usually seen after the cuff is deflated or the tracheostomy tube is removed. It can present as increased coughing, inability to expectorate secretions, difficulty breathing or talking, stridor, or cyanosis. To prevent and manage tracheal stenosis, prevent pulling or traction on the tracheostomy tube, properly secure the tube in the midline position, maintain proper cuff pressure, minimize oronasal intubation time, and perform tracheal dilation or surgical intervention if needed.
• Tracheoesophageal fistula (TEF): TEF is a hole created between the trachea and the anterior esophagus due to excessive cuff pressure that causes erosion of the posterior wall of the trachea. It allows communication between the respiratory and digestive systems. The patient at highest risk also has a nasogastric tube present. TEF can cause similar manifestations as tracheomalacia, such as increased air in cuff needed to achieve a seal, food particles seen in tracheal secretions, reduced tidal volume on the ventilator, as well as increased coughing and choking while eating. To prevent and manage TEF, maintain cuff pressure, monitor the amount of air needed for inflation and detect changes, progress to a deflated cuff or cuffless tube as soon as possible, manually administer oxygen by mask to prevent hypoxemia, use a small soft feeding tube instead of a nasogastric tube for tube feedings, perform a gastrostomy or jejunostomy if indicated, monitor for TEF and aspiration signs.
• Trachea-innominate artery fistula: Trachea-innominate artery fistula is a rare but life-threatening complication where a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure causes necrosis and erosion of the innominate artery (a large artery that branches from the aortic arch). It can result in massive hemorrhage into the trachea that can be fatal within minutes. Trachea-innominate artery fistula can manifest as pulsation of the tracheostomy tube in synchrony with the heartbeat, sudden bright red bleeding from the tube or stoma, hypotension, tachycardia, or shock. To prevent and manage trachea-innominate artery fistula, ensure proper positioning and alignment of the tube, monitor for signs of bleeding, apply direct pressure to stop bleeding, notify health care provider immediately, prepare for emergency surgery, and administer fluids and blood products as ordered.

- Patients with a tracheostomy need education and support to cope with their condition and promote their recovery. Some of the patient education and support topics for tracheostomy are:

• Anatomy and physiology of the respiratory system and the purpose and function of the tracheostomy tube
• Care and maintenance of the tracheostomy tube, stoma, dressing, and ties or straps
• Suctioning technique, frequency, and indications
• Humidification and hydration methods and importance
• Signs and symptoms of infection, bleeding, or other complications and when to seek medical attention
• Communication methods such as speaking valves, electronic devices, or writing tools
• Swallowing assessment and evaluation and dietary modifications if needed
• Medication administration and management
• Activity level and exercise recommendations
• Emotional and psychological support and coping strategies
• Resources and referrals for home care, rehabilitation, or support groups

- Tracheostomy is a surgical procedure that creates an opening in the trachea to provide a stable and secure airway. It is indicated for patients who have upper airway obstruction, require long-term mechanical ventilation, or need frequent suctioning. Tracheostomy tubes come in various types and components to suit different patients’ needs. Nursing interventions for tracheostomy care include assessing, monitoring, cleaning, changing, humidifying, and suctioning the tube and stoma. Potential complications and emergency situations related to tracheostomy include bleeding, infection, tracheomalacia, tracheal stenosis, tracheoesophageal fistula, and trachea-innominate artery fistula. Patient education and support for tracheostomy include anatomy and physiology, care and maintenance, suctioning, humidification, hydration, infection prevention, complication recognition, communication, swallowing, medication administration, activity level, exercise, emotional support, coping strategies, resources, and referrals.

- A tracheostomy is an opening in the trachea to provide a stable and secure airway.

- Tracheostomy tubes come in various types and components such as cuffed, uncuffed, fenestrated, double-lumen, flange, obturator, pilot balloon, suction port.

- Nursing interventions for tracheostomy care include assessing, monitoring, cleaning, changing, humidifying, and suctioning the tube and stoma using sterile technique.

- Suctioning a tracheostomy tube is a sterile invasive technique that requires a nurse or a respiratory therapist. It is done to remove secretions from the tube and prevent obstruction, infection, or hypoxia. The steps of suctioning a tracheostomy tube are: review orders, gather equipment, explain procedure, position patient, perform hand hygiene, don PPE, remove old dressing, inspect stoma, assess respiratory status, provide humidification, hyperoxygenate patient, lower side rail, place towel or pad, turn on suction machine, set pressure, check pressure, pour saline, open catheter kit, don sterile gloves, pick up catheter, connect tubing, moisten catheter, occlude Y-port, remove inner cannula, insert catheter until resistance, apply suction by occluding Y-port intermittently while rotating and withdrawing catheter, rinse catheter between attempts, limit attempts to three per session with one minute between each attempt for oxygenation.

- Potential complications and emergency situations related to tracheostomy include bleeding (apply direct pressure), infection (use sterile technique), tracheomalacia (use uncuffed tube), tracheal stenosis (prevent pulling or traction), tracheoesophageal fistula (maintain cuff pressure), trachea-innominate artery fistula (ensure proper positioning).

- Patient education and support for tracheostomy include anatomy and physiology, care and maintenance, suctioning, humidification, hydration, infection prevention, complication recognition, communication, swallowing, medication administration, activity level, exercise, emotional support, coping strategies, resources,and referrals.

- Chest tubes are hollow, flexible tubes that are inserted into the pleural space (the space between the lungs and the chest wall) or the mediastinum (the space between the lungs that contains the heart, great vessels, and other structures) to drain air, blood, pus, or fluid and restore normal intrathoracic pressure.

- Chest tubes are connected to a drainage system that collects the drainage and prevents air or fluid from re-entering the chest cavity.

- Chest tube insertion is a sterile, invasive procedure that requires a physician’s order and informed consent from the patient.

- Chest tube care and management are essential nursing skills that involve monitoring, assessing, documenting, and troubleshooting the chest tube and drainage system.

- The main indications for chest tube insertion are:

• Pneumothorax: a collection of air in the pleural space that causes lung collapse
• Hemothorax: a collection of blood in the pleural space that compresses the lung
• Pleural effusion: an accumulation of fluid in the pleural space that impairs gas exchange
• Empyema: an infection of the pleural space that produces pus
• Chylothorax: a leakage of lymphatic fluid into the pleural space
• Postoperative thoracic surgery: to prevent or treat complications such as atelectasis, pneumothorax, or bleeding

- The main contraindications for chest tube insertion are:

• Coagulopathy: a bleeding disorder that increases the risk of hemorrhage
• Skin infection: a source of contamination that increases the risk of infection
• Lung adhesion: a condition where the lung is attached to the chest wall, making it difficult to insert the chest tube

- There are four main types of chest tube drainage systems:

• Wet suction: a system that uses water to create suction and a water seal
• Dry suction: a system that uses a mechanical regulator to create suction and a water seal
• Dry-Wet suction: a system that uses a mechanical regulator to create suction and water to create a water seal
• Mediastinal: a system that drains air or fluid from the mediastinum without suction or water seal

- The common components of chest tube drainage systems are:

• Collection chamber: a chamber that collects the drainage from the chest tube and has a calibrated scale to measure the amount and rate of drainage
• Water-seal chamber: a chamber that contains water (usually 2 cm) and acts as a one-way valve to prevent air or fluid from returning to the chest cavity. It also allows for monitoring of intrapleural pressure changes by observing fluctuations (tidaling) or bubbling in the water column.
• Suction-control chamber: a chamber that regulates the amount of suction applied to the chest cavity by using either water (usually 20 cm) or a mechanical regulator. It also indicates the presence and level of suction by observing gentle bubbling in the water column or an orange bellows in the regulator.
• Tubing: a set of tubing that connects the chest tube to the drainage system and has clamps, stopcocks, or caps to control or occlude the flow of air or fluid. The tubing should be patent, secured, and free of kinks, loops, or dependent areas.

- The nursing responsibilities for chest tube care and management include:

• Preparing the patient for chest tube insertion by explaining the procedure, obtaining informed consent, administering analgesia or sedation, positioning the patient, monitoring vital signs, oxygen saturation, and pain level, assisting with sterile technique, applying dressing and securing tubing, and obtaining a chest x-ray to confirm placement.
• Monitoring and assessing the patient’s respiratory status, vital signs, pain level, wound site, chest tube function, drainage system function, drainage amount, color, and consistency, and documenting findings at least every four hours or as ordered.
• Maintaining the chest tube patency by avoiding kinks, loops, or dependent areas in the tubing, keeping the drainage system below the chest level, and milking or stripping the tubing only if ordered and with caution to prevent increased intrathoracic pressure or damage to the lung tissue.
• Maintaining the chest tube function by ensuring that the water levels are adequate and stable in the water-seal and suction-control chambers, that the suction source is connected and working properly, that the tubing is clamped only when necessary and for a short time, and that the drainage system is intact and upright.
• Preventing complications by observing for signs of infection, bleeding, air leak, tension pneumothorax, subcutaneous emphysema, or re-expansion pulmonary edema, and intervening accordingly by administering antibiotics, applying pressure dressing, locating and sealing the air leak source, notifying the physician, releasing the clamp, administering oxygen, or diuretics as ordered.
• Educating the patient and family about the purpose and function of the chest tube and drainage system, the expected outcomes and potential complications, the importance of deep breathing, coughing, incentive spirometry, pain management, mobility, and nutrition, and the discharge instructions and follow-up care.

- The potential complications and interventions for chest tube malfunction or removal are: Open in browser

- The procedure for chest tube removal involves:

• Obtaining a physician’s order and informed consent from the patient
• Administering analgesia or sedation as ordered
• Preparing sterile supplies such as dressing, suture removal kit, petroleum gauze
• Positioning the patient in semi-Fowler’s position with affected arm raised above head
• Instructing the patient to perform Valsalva maneuver (exhale forcefully with mouth closed) or hold breath at end expiration
• Cutting sutures and removing chest tube quickly with one motion
• Applying occlusive dressing with petroleum gauze over wound site
• Instructing patient to resume normal breathing
• Obtaining a

- Obtaining a chest x-ray to confirm chest tube removal and absence of pneumothorax

• Monitoring and assessing the patient’s respiratory status, vital signs, pain level, wound site, and dressing for any signs of complications such as infection, bleeding, air leak, or pneumothorax
• Educating the patient and family about the wound care, activity restrictions, signs and symptoms to report, and follow-up care

- Chest tubes are lifesaving devices that are used to drain air, blood, pus, or fluid from the pleural space or the mediastinum and restore normal intrathoracic pressure

- Chest tube care and management require knowledge and skills in preparing the patient for chest tube insertion, monitoring and assessing the patient and the drainage system, maintaining the chest tube patency and function, preventing and managing complications, and removing the chest tube safely

- Chest tube care and management are collaborative efforts that involve the physician, nurse, patient, and family

- Chest tubes are inserted into the pleural space or the mediastinum to drain air, blood, pus, or fluid

- Chest tubes are connected to a drainage system that collects the drainage and prevents air or fluid from re-entering the chest cavity

- Chest tube drainage systems have four main types: wet suction, dry suction, dry-wet suction, and mediastinal

- Chest tube drainage systems have common components: collection chamber, water-seal chamber, suction-control chamber, and tubing

- Chest tube care and management involve preparing the patient for chest tube insertion, monitoring and assessing the patient and the drainage system, maintaining the chest tube patency and function, preventing and managing complications, and removing the chest tube safely

- Chest tube complications include infection, bleeding, air leak, tension pneumothorax, subcutaneous emphysema, and re-expansion pulmonary edema

- A nasogastric (NG) tube is a flexible plastic tube that is inserted through the nose, down the esophagus, and into the stomach. It can be used for various purposes, such as:

• Decompressing the stomach by removing gas and fluids.
• Feeding the patient with liquid nutrition or medications.
• Lavaging the stomach to remove toxins or blood.
• Obtaining gastric samples for diagnostic tests.

- There are different types of NG tubes, depending on their size, shape, and function. Some common ones are:

• Levin tube: a single-lumen tube with holes near the tip that is used for decompression or feeding. It requires intermittent suction.
• Salem sump tube: a double-lumen tube with one lumen for decompression or feeding and another lumen for air venting. It allows continuous suction without collapsing the stomach wall.
• Dobhoff tube: a small-bore tube with a weighted tip that is used for feeding. It has a stylet (wire) inside that helps guide the tube into the stomach or duodenum. It requires radiographic confirmation of placement.

- The insertion of an NG tube is a sterile or clean procedure that requires a medical order and informed consent from the patient or their representative. It also requires careful assessment of the patient’s condition, anatomy, and ability to cooperate. Some indications for NG tube insertion are:

• Gastric obstruction, ileus, or bowel perforation.
• Gastric bleeding or poisoning.
• Malnutrition or dysphagia.
• Gastric analysis or pH monitoring.

- Some contraindications or cautions for NG tube insertion are:

• Facial trauma, nasal surgery, or deviated septum.
• Esophageal varices, stricture, or diverticulum.
• Coagulopathy or anticoagulant therapy.
• Increased intracranial pressure or skull fracture.

- Some potential complications or risks of NG tube insertion are:

• Nasal irritation, bleeding, or ulceration.
• Esophageal perforation, bleeding, or spasm.
• Aspiration pneumonia or pulmonary edema.
• Gastric erosion, ulceration, or perforation.

- The equipment needed for NG tube insertion may vary depending on the type of tube and the purpose of insertion. However, some common items are:

• NG tube of appropriate size and type (usually 14 to 18 French for adults).
• Water-soluble lubricant (or mannequin lube).
• Topical anesthetic spray or gel (optional).
• Tape measure and marker or tape to mark the insertion distance.
• Clean gloves and protective eyewear.

- The procedure for NG tube insertion may vary depending on the type of tube and the purpose of insertion. However, some common steps are:

• Explain the procedure to the patient and obtain informed consent. Assess the patient’s condition, anatomy, and ability to cooperate. Check for any contraindications or cautions. Gather the necessary equipment and supplies.
• Choose the side for tube insertion and spray topical anesthetic in this nostril and the pharynx at least 5 minutes before tube insertion. If time permits, give 4 mL of 10% lidocaine via a nebulizer or insert 5 mL of 2% lidocaine gel into the nares.
• Measure the insertion distance by placing the tip of the tube at the tip of the nose, then extending it to the earlobe and then to the xiphoid process. Mark this distance with a marker or tape.
• Lubricate the tip of the tube with water-soluble lubricant. Position the patient in a high-Fowler’s position with the head tilted forward. If the patient is unconscious or intubated, position them in a supine position with the head of the bed elevated to 30 degrees.
• Insert the tube through the nostril with gentle pressure and a slight twisting motion. Ask the patient to swallow water or saliva as the tube advances. If resistance is felt, withdraw the tube slightly and try another direction. Do not force the tube or insert it deeper than the marked distance.
• Verify the placement of the tube by using one or more of the following methods:
  • Aspirate gastric contents with a syringe and check the pH. A pH of 5.5 or less indicates gastric placement.
  • Inject air through the tube while auscultating over the stomach. A whooshing sound indicates gastric placement. However, this method is not reliable and should be used with caution.
  • Obtain a chest x-ray and confirm that the tip of the tube is below the diaphragm and in the stomach. This is the most accurate method and should be used for small-bore tubes or when other methods are inconclusive.
  • Secure the tube to the nose with tape or a commercial device. Make sure there is no tension on the tube and that it does not interfere with breathing or swallowing. Label the tube with the date, time, type, and length of insertion.
  • Connect the tube to a feeding bag, syringe, or suction device as ordered. Adjust the flow rate, volume, and frequency of feeding or suctioning as prescribed. Monitor for any signs of complications such as aspiration, bleeding, infection, or displacement.
  • Document the procedure, including:
    • The type, size, and length of the tube.
    • The method and result of placement verification.
    • The patient’s tolerance and response to the procedure.
    • The type, rate, volume, and frequency of feeding or suctioning.
    • The appearance, amount, and pH of gastric aspirate.
    • The condition of the nose, mouth, and skin around the tube.
    • Any teaching done or referrals made.

- The nursing care for patients with NG tubes involves the following aspects:

• Assessing the patient’s condition, vital signs, fluid and electrolyte balance, nutritional status, and comfort level at least every 4 hours or as ordered.
• Checking the tube placement, patency, and security at least every 4 to 8 hours or as ordered. If the tube is dislodged, kinked, or clogged, do not attempt to reinsert or flush it. Notify the physician and obtain a new order for tube insertion.
• Providing oral and nasal hygiene at least every 4 hours or as needed. Use a soft toothbrush, mouthwash, and lip balm to clean the mouth and teeth. Use a moist cotton swab or gauze to clean the nostrils and apply a thin layer of petroleum jelly to prevent dryness and irritation.
• Monitoring for any signs of complications such as aspiration, bleeding, infection, or displacement. Some signs are:
  • Coughing, choking, wheezing, or dyspnea.
  • Hematemesis, melena, or hemoptysis.
  • Fever, purulent drainage, or erythema around the tube site.
  • Nausea, vomiting, abdominal distension, or pain.
• Educating the patient and family about the purpose, procedure, and care of the NG tube. Teach them how to:
  • Recognize and report any signs of complications.
  • Maintain proper positioning and head elevation during and after feeding or suctioning.
  • Perform oral and nasal hygiene and tube care as instructed.
  • Measure and record the intake and output of fluids.
  • Administer medications through the tube as prescribed .

- NG tube insertion is a common procedure that can be used for various purposes such as decompression, feeding, lavage, or diagnosis. It requires a medical order and informed consent from the patient or their representative. It also requires careful assessment of the patient’s condition, anatomy, and ability to cooperate. It involves measuring the insertion distance, lubricating the tube tip, inserting the tube through the nostril, verifying the placement of the tube, securing the tube to the nose, connecting the tube to a feeding bag, syringe, or suction device as ordered, and documenting the procedure. The nursing care for patients with NG tubes involves assessing the patient’s condition and comfort level, checking the tube placement and patency, providing oral and nasal hygiene, monitoring for any signs of complications, and educating the patient and family about the purpose, procedure, and care of the NG tube.

 - NG tube is a flexible plastic tube that is inserted through the nose into the stomach for various purposes.

 - NG tube insertion requires a medical order and informed consent from the patient or their representative.

 - NG tube insertion involves measuring the insertion distance, lubricating the tube tip, inserting the tube through the nostril, verifying the placement of the tube, securing the tube to the nose, connecting the tube to a feeding bag, syringe, or suction device as ordered, and documenting the procedure.

- Nursing care for patients with NG tubes involves assessing the patient’s condition and comfort level, checking the tube placement and patency, providing oral and nasal hygiene, monitoring for any signs of complications, and educating the patient and family about the purpose, procedure, and care of the NG tube.

- A continuous passive ROM machine is a device that moves a joint through a prescribed range of motion without active muscle contraction by the patient. It is used by patients who have stiffness, swelling, pain, or limited mobility in a joint due to surgery, injury, or disease. It can also prevent complications such as contractures, adhesions, or thrombosis. The most common joints that are treated with a continuous passive ROM machine are the knee and the shoulder.

The nurse should set up and operate a continuous passive ROM machine by following these steps:

• Obtain a physician’s order for using a continuous passive ROM machine that specifies the joint, speed, duration, frequency, and range of motion.
• Explain the procedure and its benefits to the patient and obtain informed consent.
• Position the patient comfortably on a bed or a chair and secure the device to the affected joint according to the manufacturer’s instructions.
• Adjust the settings of the device according to the physician’s order and start the machine.
• Monitor the patient’s vital signs, pain level, comfort, and response to the device throughout the session.
• Stop the machine and remove it from the patient after completing the session or as ordered by the physician.

- The nurse should monitor for complications such as bleeding, infection, nerve damage, or mechanical failure from using a continuous passive ROM machine. The nurse should also inspect the device regularly for cleanliness and functionality and report any problems to the appropriate personnel.

- Enteral nutrition (EN) is the delivery of nutrients directly into the gastrointestinal (GI) tract through a tube, catheter, or stoma.

- EN is indicated for patients who have a functional GI tract but are unable to meet their nutritional needs orally due to impaired swallowing, anorexia, facial trauma, oral cancer, etc.

- EN is contraindicated for patients who have a nonfunctional or inaccessible GI tract due to obstruction, ileus, peritonitis, severe diarrhea, vomiting, etc.

- EN has several advantages over parenteral nutrition (PN), such as lower cost, lower risk of infection, fewer metabolic complications, and preservation of gut integrity and immunity.

- EN also has some potential complications, such as aspiration, tube displacement or occlusion, diarrhea, nausea, vomiting, abdominal distension or cramping, electrolyte imbalance, dehydration, etc.

- EN formulas vary in their composition, osmolality, caloric density, fiber content, and protein quality.

- EN formulas can be classified into four main types:

• Standard or polymeric formulas: These contain intact proteins, carbohydrates, and fats that require normal digestion and absorption. They provide 1 to 1.5 kcal/mL and are suitable for most patients with normal or mildly impaired GI function. Examples include Ensure, Isocal, and Osmolite.
• Hydrolyzed or elemental formulas: These contain predigested proteins (peptides or amino acids), carbohydrates (glucose or maltodextrin), and fats (medium-chain triglycerides) that require minimal digestion and absorption. They provide 1 to 1.5 kcal/mL and are suitable for patients with impaired GI function or malabsorption. Examples include Peptamen, Vivonex, and NutriHep.
• Disease-specific formulas: These are designed to meet the special nutritional needs of patients with specific diseases or conditions. They may have modified amounts of protein, carbohydrates, fats, vitamins, minerals, electrolytes, or other nutrients. Examples include Nepro (for renal disease), Glucerna (for diabetes), Pulmocare (for respiratory disease), and Impact (for trauma or surgery).
• Modular formulas: These are single-nutrient preparations that can be added to other formulas or foods to increase the caloric or protein content. They may contain protein (ProMod), carbohydrates (Polycose), fats (Microlipid), or fiber (Benefiber).

- EN can be delivered through different routes depending on the patient’s condition, anatomy, and expected duration of therapy.

- EN routes can be classified into two main categories:

• Gastric routes: These involve placing a tube into the stomach through the nose (nasogastric tube) or the abdominal wall (gastrostomy tube). Gastric routes are preferred for short-term (<4 weeks) or long-term (>4 weeks) EN in patients with normal gastric emptying and low risk of aspiration. Gastric routes allow for larger volumes and bolus feedings. Examples of gastric tubes include Levin tube (single-lumen), Salem sump tube (double-lumen), percutaneous endoscopic gastrostomy (PEG) tube, and surgical gastrostomy tube.
• Intestinal routes: These involve placing a tube into the duodenum or jejunum through the nose (nasoduodenal or nasojejunal tube) or the abdominal wall (jejunostomy tube). Intestinal routes are preferred for short-term (<4 weeks) or long-term (>4 weeks) EN in patients with impaired gastric emptying or high risk of aspiration. Intestinal routes require smaller volumes and continuous feedings. Examples of intestinal tubes include Dobbhoff tube (small-bore), percutaneous endoscopic jejunostomy (PEJ) tube, and surgical jejunostomy tube.

- EN can be administered by different methods depending on the patient’s tolerance, nutritional needs, and type and location of the tube.

- EN methods can be classified into four main types:

• Bolus method: This involves rapidly delivering 250 to 400 mL of formula through a syringe or funnel into the tube four to six times a day. This method takes about 10 minutes per feeding and mimics normal meal patterns. This method is suitable for gastric tubes only and may cause nausea, vomiting, aspiration, abdominal cramping, or diarrhea in some patients.
• Intermittent method: This involves delivering 300 to 400 mL of formula over 30 to 60 minutes by gravity drip or pump infusion every 3 to 6 hours. This method uses a feeding bag and allows for more flexibility and mobility. This method is suitable for gastric or intestinal tubes and may cause similar complications as the bolus method in some patients.
• Continuous method: This involves delivering a constant rate of formula over 8 to 24 hours by pump infusion. This method uses a feeding bag and requires close monitoring and frequent flushing of the tube. This method is suitable for intestinal tubes or patients with poor tolerance to other methods and may cause fewer complications than the bolus or intermittent methods in some patients.
• Cyclic method: This involves delivering a higher rate of formula over 8 to 16 hours, usually at night, by pump infusion. This method uses a feeding bag and allows for more freedom and oral intake during the day. This method is suitable for gastric or intestinal tubes or patients who are transitioning from EN to oral nutrition and may cause similar complications as the continuous method in some patients.

- EN requires careful nursing interventions to ensure safe and effective delivery of nutrition and prevention of complications.

- Nursing interventions for EN can be divided into three phases:

• Initiation phase: This involves preparing the patient, verifying the tube placement, checking the residual volume, and starting the feeding. The nurse should:
  • Obtain a baseline assessment of the patient’s weight, height, body mass index (BMI), nutritional status, laboratory values, fluid balance, and bowel function.
  • Educate the patient and family about the purpose, procedure, benefits, and risks of EN.
  • Confirm the type, route, method, rate, volume, frequency, and duration of EN ordered by the physician.
  • Ensure that the tube is correctly placed in the desired location by checking the external markings, aspirating gastric contents and testing their pH (should be <5), or obtaining an x-ray confirmation.
  • Check the residual volume (the amount of formula left in the stomach) before each feeding or every 4 to 6 hours for continuous feedings by aspirating with a syringe. The residual volume should be less than 200 mL or 10% of the previous feeding volume. If the residual volume is higher, the nurse should stop the feeding, return the aspirate to the stomach, and notify the physician.
  • Start the feeding at a low rate (25 to 50 mL/hour) and gradually increase it by 10 to 20 mL/hour every 8 to 12 hours until the desired rate is reached. Monitor the patient’s tolerance and response to EN.
• Maintenance phase: This involves monitoring the patient’s condition, maintaining the tube patency and integrity, preventing infection and aspiration, and providing oral hygiene and comfort measures. The nurse should:
  • Assess the patient’s vital signs, weight, fluid balance, nutritional status, laboratory values, bowel function, and skin integrity at least daily.
  • Adjust the rate, volume, frequency, and duration of EN according to the patient’s needs and tolerance. Record the intake and output of EN.
  • Flush the tube with at least 30 mL of water before and after each feeding or medication administration or every 4 hours for continuous feedings to prevent clogging. Use sterile water for immunocompromised patients.
  • Change the feeding bag and tubing every 24 hours or according to the manufacturer’s instructions to prevent bacterial growth. Label the bag and tubing with date and time of initiation.
  • Elevate the head of the bed at least 30 degrees during and for at least one hour after each feeding to prevent aspiration. Do not position the patient flat or on the right side unless ordered by the physician.
  • Provide oral hygiene every 4 hours or as needed to prevent dryness, cracking, infection, or halitosis. Apply lip balm or moisturizer as needed.
  • Rotate and secure the tube every day to prevent pressure ulcers or erosion at the insertion site. Cleanse the site with soap and water or saline solution and cover it with a sterile dressing as needed.

• Termination phase: This involves discontinuing EN when the patient’s nutritional needs can be met orally or when EN is no longer indicated or tolerated. The nurse should:
  • Collaborate with the physician, dietitian, and speech therapist to determine the readiness and plan for oral nutrition. Assess the patient’s ability to swallow, chew, and digest food.
  • Gradually decrease the rate, volume, frequency, and duration of EN while increasing the oral intake. Monitor the patient’s tolerance and response to oral nutrition.
  • Flush the tube with at least 30 mL of water and clamp it before removing it. Gently withdraw the tube while the patient takes deep breaths or coughs. Discard the tube and dressing appropriately.
  • Observe the patient for any signs of bleeding, infection, or perforation at the insertion site. Apply pressure and a sterile dressing as needed.
  • Document the date, time, reason, and method of termination of EN. Record the patient’s condition and response to oral nutrition.

- EN requires regular evaluation and monitoring of the patient’s condition, response, and outcomes to determine the effectiveness and appropriateness of the therapy. The nurse should :

• Compare the patient’s actual intake with the prescribed intake and calculate the percentage of goal attainment. The patient should receive at least 75% of the prescribed intake to meet the nutritional needs.
• Compare the patient’s weight, BMI, nutritional status, laboratory values, fluid balance, and bowel function with the baseline and expected values. The patient should maintain or improve these parameters within normal ranges.
• Compare the patient’s tolerance and complications with the expected outcomes. The patient should have minimal or no adverse effects from EN.
• Compare the patient’s oral intake and readiness for oral nutrition with the expected outcomes. The patient should progress to oral nutrition as soon as possible and discontinue EN when no longer needed.

- EN is the delivery of nutrients directly into the GI tract through a tube, catheter, or stoma.

- EN is indicated for patients who have a functional GI tract but are unable to meet their nutritional needs orally.

- EN is contraindicated for patients who have a nonfunctional or inaccessible GI tract.

- EN has several advantages over PN, such as lower cost, lower risk of infection, fewer metabolic complications, and preservation of gut integrity and immunity.

- EN also has some potential complications, such as aspiration, tube displacement or occlusion, diarrhea, nausea, vomiting, abdominal distension or cramping, electrolyte imbalance, dehydration, etc.

- EN formulas vary in their composition, osmolality, caloric density, fiber content, and protein quality. They can be classified into standard or polymeric formulas, hydrolyzed or elemental formulas, disease-specific formulas, and modular formulas.

- EN can be delivered through different routes depending on the patient’s condition, anatomy, and expected duration of therapy. They can be classified into gastric routes and intestinal routes.

- EN can be administered by different methods depending on the patient’s tolerance, nutritional needs, and type and location of the tube. They can be classified into bolus method, intermittent method, continuous method, and cyclic method.

- EN requires careful nursing interventions to ensure safe and effective delivery of nutrition and prevention of complications. Nursing interventions for EN can be divided into initiation phase, maintenance phase, and termination phase.

- EN may encounter some problems that require prompt identification and intervention to prevent serious complications. Some of the common problems and solutions are aspiration, tube displacement or occlusion, and diarrhea.

- EN requires regular evaluation and monitoring of the patient’s condition, response, and outcomes to determine the effectiveness and appropriateness of the therapy.

- Mobility devices are assistive devices that help patients with impaired mobility to move around independently or with minimal assistance. They include crutches, canes, walkers, wheelchairs, scooters, and continuous passive ROM (range of motion) machines. Mobility devices can improve the quality of life, functional status, and psychological well-being of patients with mobility impairments. They can also prevent complications such as pressure ulcers, contractures, muscle atrophy, venous stasis, and respiratory infections.

- Mobility devices are prescribed by a physician or a physical therapist based on the patient’s condition, needs, goals, and preferences. The type and size of the device should be appropriate for the patient’s height, weight, strength, balance, coordination, and comfort. The device should also be compatible with the patient’s environment and lifestyle.

- The nurse plays an important role in assessing the patient’s mobility status, teaching the patient how to use the device correctly and safely, monitoring the patient’s progress and response to the device, and preventing or managing any complications or problems related to the device.

- Crutches are devices that transfer weight from the legs to the upper body. They are used by patients who have weakness, injury, or surgery on one or both lower extremities. Crutches can be made of wood or metal and have three parts: a handgrip, an axillary bar, and a tip. There are different types of crutches such as axillary crutches, forearm crutches, platform crutches, and strutter crutches.

- The nurse should measure the patient for crutches by following these steps:

• Have the patient stand upright with shoes on and arms at the sides.
• Place two fingers horizontally under the axilla and measure from this point to a point 6 inches lateral to the heel of the foot. This is the length of the crutch.
• Adjust the handgrip so that it is level with the patient’s wrist when the elbow is flexed at 30 degrees.
• Check that there is a 2-inch space between the top of the crutch and the axilla when the patient stands upright with shoulders relaxed.

- The nurse should teach the patient how to use crutches by following these steps:

• Instruct the patient to hold the crutches firmly by the handgrips and place them 6 inches in front and to the side of each foot.
• Teach the patient different gaits depending on their weight-bearing status. The most common gaits are:
  • Four-point gait: The patient moves each leg alternately with each opposing crutch. This gait is used for partial weight-bearing on both legs.
  • Three-point gait: The patient moves both crutches and then moves both legs simultaneously. This gait is used for non-weight-bearing on one leg.
  • Two-point gait: The patient moves one crutch simultaneously with the opposite leg. This gait is used for partial weight-bearing on both legs.
  • Swing-through gait: The patient moves both crutches forward together and then swings both legs forward past them. This gait is used for non-weight-bearing on both legs.

- Teach the patient how to sit down and stand up with crutches by following these steps:

• To sit down: Back up to a sturdy chair until it touches the back of your legs. Hold both crutches in one hand by their handgrips. Reach back with your other hand and grasp the armrest or seat of the chair. Lower yourself slowly into the chair while keeping your injured leg extended.
• To stand up: Move to the edge of your seat. Hold both crutches in one hand by their handgrips. Push yourself up with your other hand on the armrest or seat of your chair while keeping your injured leg extended. Balance yourself before putting your weight on your crutches.

- The nurse should monitor for complications such as nerve damage, skin breakdown, falls, or infection from using crutches. The nurse should also inspect the crutches regularly for wear and tear and replace them if needed.

- Canes are devices that provide partial support to patients who have weakness or instability on one side of the body. They are used by patients who have arthritis, stroke, or injury on one lower extremity. Canes can be made of wood or metal and have a single tip, a tripod tip, or a quad tip. The most common type of cane is the single-tip cane.

- The nurse should measure the patient for a cane by following these steps:

• Have the patient stand upright with shoes on and arms at the sides.
• Adjust the height of the cane so that it is level with the patient’s wrist when the elbow is flexed at 30 degrees.
• Check that the patient can grip the handle comfortably and securely.

- The nurse should teach the patient how to use a cane by following these steps:

• Instruct the patient to hold the cane in the hand opposite to the affected leg.
• Teach the patient to move the cane forward about 6 inches and then move the affected leg forward to the level of the cane. Then move the unaffected leg past them.
• Teach the patient to use stairs with a cane by following these steps:
  • To go up: Hold the cane in one hand and the handrail in the other. Step up with your unaffected leg first, then bring your affected leg and your cane up to the same step.
  • To go down: Hold the cane in one hand and the handrail in the other. Step down with your affected leg and your cane first, then bring your unaffected leg down to the same step.

- The nurse should monitor for complications such as falls, muscle strain, joint pain, or infection from using a cane. The nurse should also inspect the cane regularly for wear and tear and replace it if needed.

Mobility devices are important tools that can help patients with impaired mobility to improve their function, independence, and quality of life. The nurse has a key role in assessing, teaching, monitoring, and preventing complications related to mobility devices. The nurse should also collaborate with other health care professionals such as physicians, physical therapists, occupational therapists, and social workers to provide holistic care for patients who use mobility devices.

- Bandaging is the process of applying a material or device to a wound or injured body part to protect it from further damage, promote healing, prevent infection, control bleeding, reduce swelling, provide support, or immobilize the area.

- Bandages can be classified into two main categories: dressings and binders.

• Dressings are materials that are applied directly to the wound surface to absorb drainage, prevent contamination, and facilitate healing. They can be dry, moist, wet-to-dry, nonadherent, occlusive, or impregnated with substances such as antiseptics, antibiotics, or silver.
• Binders are materials that are wrapped around a body part to hold a dressing in place, provide compression, support a weak or injured area, or shape a body contour. They can be elastic, inelastic, tubular, triangular, or circular.

- Bandaging is an essential skill for nurses who care for patients with wounds or injuries. It requires knowledge of wound assessment, bandage selection, application techniques, monitoring methods, and patient education.

- There are many types of bandages available for different purposes and situations. Some of the common ones are:

• Gauze: A thin, woven fabric that is used to cover wounds or hold dressings in place. It can be sterile or nonsterile, plain or impregnated with substances such as petrolatum or zinc oxide. It can also be used to pack wounds or apply pressure to bleeding areas.
• Elastic: A stretchable fabric that is used to provide compression or support to a body part. It can be adhesive or nonadhesive, cohesive or noncohesive. It can also be used to reduce edema or prevent venous stasis.
• Muslin: A cotton fabric that is used to make straps or slings for traction or immobilization. It can also be used to shape body contours such as breasts or abdomen.
• Outing flannel: A soft fabric that is used to provide warmth and comfort to a body part. It can also be used to prevent skin irritation from other bandages.
• Tubular: A cylindrical fabric that is used to cover fingers, toes, arms, legs, or other tubular structures. It can be elastic or inelastic, knitted or woven. It can also be used to hold dressings in place or provide mild compression.
• Triangular: A triangular-shaped fabric that is used to make slings for arm injuries or splints for finger injuries. It can also be used to cover head wounds or apply pressure to bleeding areas.
• Circular: A circular-shaped fabric that is used to cover circular structures such as eyes, ears, nose, mouth, or anus. It can also be used to hold dressings in place or provide mild compression.

- Bandages are indicated for various reasons depending on the type of wound or injury and the desired outcome. Some of the common indications are:

• To protect the wound from contamination, trauma, or friction.
• To promote wound healing by creating a moist environment, removing necrotic tissue, delivering medications, or stimulating granulation tissue formation.
• To prevent wound infection by reducing bacterial load, preventing foreign bodies from entering the wound, or enhancing immune response.
• To control wound bleeding by applying direct pressure, elevating the injured area, or constricting blood vessels.
• To reduce wound edema by applying compression, elevating the injured area, or improving venous return.
• To provide wound support by stabilizing the wound edges, reducing tension on the wound, or preventing wound dehiscence or evisceration.
• To immobilize the injured area by restricting movement, maintaining alignment, or preventing further damage.
• To shape the body contour by applying pressure, molding the tissue, or correcting deformities.

- Bandages are contraindicated for some situations where they may cause harm or interfere with healing. Some of the common contraindications are:

• To cover wounds that are infected, gangrenous, or malodorous, as they may trap bacteria, toxins, or odors and worsen the condition.
• To apply compression to wounds that are ischemic, necrotic, or have impaired circulation, as they may compromise blood flow and oxygen delivery and increase tissue damage.
• To immobilize joints that are inflamed, infected, or have limited range of motion, as they may aggravate the inflammation, impair drainage, or cause joint stiffness.
• To shape body contours that are distorted by tumors, cysts, or masses, as they may compress the underlying structures and cause pain, obstruction, or rupture.

- Bandages can cause complications if they are applied incorrectly, inappropriately, or excessively. Some of the common complications are:

• Skin irritation or breakdown due to friction, pressure, moisture, or allergic reaction to the bandage material or substance.
• Wound infection due to contamination, poor aseptic technique, inadequate wound cleansing, or prolonged use of occlusive bandages.
• Wound dehiscence or evisceration due to excessive tension on the wound edges, inadequate wound support, or sudden movement or coughing.
• Circulation impairment due to tight bandaging, edema formation, arterial occlusion, or venous thrombosis. This can lead to pain, numbness, tingling, cyanosis, pallor, coldness, or pulselessness of the affected area.
• Nerve damage due to compression, stretching, or entrapment of the nerve by the bandage. This can lead to sensory loss, motor weakness, paralysis, or neuropathic pain of the affected area.
• Muscle atrophy or contracture due to prolonged immobilization, disuse, or lack of exercise of the affected area. This can lead to muscle wasting, weakness, stiffness, or deformity of the affected area.

- Bandaging requires following some general principles and techniques to ensure its effectiveness and safety. Some of the general principles and techniques are:

• Assess the wound and the surrounding skin before applying a bandage. Check for signs of infection, bleeding, drainage, odor, pain, edema, color, temperature, sensation, and pulses of the affected area.
• Prepare the wound and the surrounding skin before applying a bandage. Cleanse the wound with normal saline or an appropriate solution. Debride any necrotic tissue if indicated. Apply an appropriate dressing to the wound surface. Protect the surrounding skin with a barrier cream or film if needed.
• Choose an appropriate bandage for the wound and the desired outcome. Consider the type, size, shape, location, depth, and condition of the wound. Consider the purpose, function, and duration of the bandage. Consider the patient’s preference, comfort, mobility, and ability to care for the bandage.
• Apply the bandage using proper techniques and precautions. Use aseptic technique if the wound is open or sterile. Use clean gloves and equipment if the wound is closed or clean. Start from the distal end of the body part and work proximally. Wrap the bandage evenly and smoothly without wrinkles or creases. Overlap each layer by one-half to two-thirds of its width. Secure the bandage with tape, clips, pins, ties, or velcro. Avoid applying too much pressure or tension on the bandage. Avoid covering bony prominences or joints with tape or adhesive. Avoid constricting blood vessels or nerves with tight bandaging. Leave some space for swelling or dressing changes if needed.
• Remove the bandage using proper techniques and precautions. Loosen and unwrap the bandage gently and slowly from proximal to distal end of the body part. Avoid pulling or tearing the bandage from the wound surface. Use scissors or a bandage remover to cut the bandage if it is stuck or adhered to the wound surface. Dispose of the used bandage in a biohazard bag or container.
• Document the bandaging process in the patient’s record. Include the date, time, type, size, and location of the bandage. Include the wound assessment, dressing type, and bandage application technique. Include the patient’s response, tolerance, and education. Include any problems, complications, or interventions related to the bandage.
• Monitor the bandage and the wound regularly and as ordered. Check for signs of infection, bleeding, drainage, odor, pain, edema, color, temperature, sensation, and pulses of the affected area. Check for signs of skin irritation or breakdown, wound dehiscence or evisceration, circulation impairment, nerve damage, muscle atrophy or contracture related to the bandage. Compare the findings with the baseline and previous assessments.
• Change the bandage and the dressing as needed and as ordered. Follow the same principles and techniques as for applying a new bandage. Consider the wound condition, healing stage, drainage amount, infection risk, and patient preference when changing the bandage and dressing. Use aseptic technique if the wound is open or sterile. Use clean technique if the wound is closed or clean.
• Educate the patient and family about bandage care. Teach them how to recognize and report signs of infection, bleeding, drainage, odor, pain, edema, color change, temperature change, sensation loss, pulse loss, skin irritation or breakdown, wound dehiscence or evisceration, circulation impairment, nerve damage, muscle atrophy or contracture related to the bandage. Teach them how to check and maintain the bandage and dressing. Teach them how to change the bandage and dressing if indicated. Teach them how to prevent complications related to the bandage. Teach them how to promote wound healing and prevent wound recurrence.

- The following are some examples of how to apply various bandages for different body parts and wound types :

• Gauze bandage for a hand wound: Wash your hands and put on gloves. Cleanse the wound with normal saline or an appropriate solution. Apply a nonadherent dressing to the wound surface. Cut a piece of gauze bandage about 2 inches longer than the hand. Wrap it around the hand starting from the wrist and moving toward the fingers. Overlap each layer by one-half to two-thirds of its width. Secure the end with tape or a clip. Check for circulation and sensation of the fingers.
• Elastic bandage for an ankle sprain: Wash your hands and put on gloves. Elevate the injured ankle above the heart level. Apply an ice pack to reduce swelling and pain. Cut a piece of elastic bandage about 4 inches longer than the ankle circumference. Wrap it around the ankle starting from the foot and moving toward the calf. Overlap each layer by one-half to two-thirds of its width. Secure the end with tape, a clip, or velcro. Check for circulation and sensation of the foot.
• Muslin bandage for a shoulder sling: Wash your hands and put on gloves. Fold a triangular-shaped muslin bandage in half along its longest side to form a right angle. Place it over the injured shoulder with one end hanging over the chest and the other end hanging over the back. Tie the ends together at the side of the neck opposite to the injured shoulder. Adjust the sling to support the arm at a right angle to the body. Check for circulation and sensation of the hand.
• Outing flannel bandage for an abdominal incision: Wash your hands and put on gloves. Cleanse the incision site with normal saline or an appropriate solution. Apply a nonadherent dressing to cover the incision site. Cut a piece of outing flannel bandage about 6 inches longer than the abdomen circumference. Wrap it around the abdomen starting from below the navel and moving upward. Overlap each layer by one-half to two-thirds of its width. Secure the end with tape, a clip, or velcro. Check for breathing comfort and incision integrity.

- Bandaging is an important skill for nurses who care for patients with wounds or injuries. It involves applying a material or device to a wound or injured body part to protect it from further damage, promote healing, prevent infection, control bleeding, reduce swelling, provide support, or immobilize the area.

- Bandages can be classified into two main categories: dressings and binders. Dressings are materials that are applied directly to the wound surface to absorb drainage, prevent contamination, and facilitate healing. Binders are materials that are wrapped around a body part to hold a dressing in place, provide compression, support a weak or injured area, or shape a body contour.

- Bandages are indicated for various reasons depending on the type of wound or injury and the desired outcome. Bandages are contraindicated for some situations where they may cause harm or interfere with healing. Bandages can cause complications if they are applied incorrectly, inappropriately, or excessively.

- Bandaging requires following some general principles and techniques to ensure its effectiveness and safety. Bandaging also requires regular monitoring, changing, and documenting of the bandage and the wound. Bandaging also requires educating the patient and family about bandage care.

- Bandaging is the process of applying a material or device to a wound or injured body part for various purposes.

Bandages can be dressings or binders depending on their function and location.

- Bandages have indications, contraindications, and complications that need to be considered before applying them.

- Bandaging involves assessing, preparing, choosing, applying, removing, documenting, monitoring, changing, and educating about the bandage and the wound.

- Bandaging requires proper techniques and precautions to ensure its effectiveness and safety.

- Intravenous (IV) therapy is the delivery of liquid substances directly into a vein.

- IV therapy may be used for various purposes, such as:

• Correcting electrolyte abnormalities
• Delivering medications
• Administering blood products
• Fluid replacement
• Specialized medication such as chemotherapy
• Nutrition
• Dialysis
• Hemodynamic monitoring

- IV therapy requires surgical asepsis, which is the elimination of all microorganisms from an object or area.

- IV therapy involves various types of IV access, materials, sites, complications, and nursing interventions.

- There are two main types of IV access: peripheral and central.

Peripheral IV Access

• Peripheral IV access involves inserting a catheter into a vein in the hand or arm.
• Peripheral IV access is suitable for short-term therapy (less than a week) and low-risk fluids or medications.
• Peripheral IV access may also be used for specialized placement in the external jugular vein or the dorsal foot vein.
• Peripheral IV access requires a tourniquet to constrict the vein and make it more visible and palpable.
• Peripheral IV access uses angiocatheters that range from 14 to 24 gauge in size. The gauge refers to the diameter of the catheter; the larger the gauge, the smaller the diameter. The choice of gauge depends on the type and viscosity of the fluid or medication, the size and condition of the vein, and the duration of therapy.
• Peripheral IV access may cause complications such as infiltration, phlebitis, infection, hematoma, nerve damage, or extravasation.

Central IV Access

• Central IV access involves inserting a catheter into a large vein that leads directly to the heart.
• Central IV access is suitable for long-term therapy (more than a week) and high-risk fluids or medications that require rapid dilution or precise infusion rates.
• Central IV access may be achieved through percutaneous central lines, peripherally inserted central catheters (PICCs), tunneled catheters, or implanted ports.
• Central IV access does not require a tourniquet but may require ultrasound guidance or fluoroscopy to locate the vein and confirm placement.
• Central IV access uses catheters that range from 16 to 24 gauge in size. The choice of gauge depends on the type and volume of fluid or medication, the number of lumens (channels) needed, and the patient’s condition.
• Central IV access may cause complications such as pneumothorax, hemothorax, air embolism, infection, thrombosis, or catheter malposition.

- Veins are blood vessels that carry blood back to the heart. Veins are unlike arteries in that they are:

• Superficial: they lie close to the skin surface and can be seen as dark red lines
• Non-pulsatile: they do not have a rhythmic contraction that can be felt
• Valved: they have one-way valves that prevent backflow of blood

- Veins have three layers of tissue:

• Tunica adventitia: the outermost layer that provides support and protection
• Tunica media: the middle layer that contains smooth muscle and elastic fibers
• Tunica intima: the innermost layer that lines the lumen (space) of the vein and prevents clotting

- The materials needed for starting a peripheral IV include:

• Absorbent disposable sheet (chuck or towel) to protect the bed or surface from spills
• Aseptic cleansers such as chlorhexidine, alcohol, or betadine to disinfect the skin
• Tourniquet to apply pressure and constrict the vein
• Angiocatheter of appropriate size and gauge to insert into the vein
• IV fluid or saline lock to connect to the catheter and maintain patency
• Saline-filled syringe to flush the catheter and check for blood return
• OpSite or prepared tape strips to secure and cover the catheter and site
• Gloves to protect the nurse and the patient from contamination
• Gauze (several pieces of 4x4 or 2x2) to apply pressure and stop bleeding

- The choice of IV site depends on several factors, such as:

• The type and duration of therapy
• The size and condition of the vein
• The patient’s preference and comfort
• The patient’s medical history and current status
• The potential for complications or interference

- Some general guidelines for choosing an IV site are:

• Go by “feel”, not by sight. Palpate the vein for “bounce” or resilience.
• Use warm compresses and allow the arm to hang dependently to fill the veins.
• Apply the tourniquet 10 mmHg below the known systolic pressure. Arterial flow continues with maximum venous constriction.
• Avoid areas of joint flexion, such as the wrist or antecubital fossa, as they may cause kinking or dislodgement of the catheter.
• Start distally and use the shortest length/smallest gauge access device that will properly administer the prescribed therapy.
• Rotate sites every 72 to 96 hours or as needed to prevent complications.
• Avoid veins that are sclerosed, thrombosed, inflamed, infected, or injured.

- Some common peripheral IV sites are:

• Cephalic vein: located on the lateral side of the arm, near the thumb. It is large and easy to access but may be more painful.
• Basilic vein: located on the medial side of the arm, near the pinky finger. It is large and easy to access but may be more prone to infiltration or nerve damage.
• Median cubital vein: located in the antecubital fossa, between the cephalic and basilic veins. It is large and easy to access but may be more affected by joint flexion or movement.
• Dorsal metacarpal veins: located on the back of the hand, between the knuckles. They are small and superficial but may be more comfortable and less likely to interfere with activities.

- The steps for inserting a peripheral IV catheter are:

1. Verify the order for IV therapy and gather all the necessary materials.
2. Identify the patient using two identifiers and explain the procedure, purpose, and potential risks. Obtain informed consent if required.
3. Perform hand hygiene and don gloves.
4. Select an appropriate IV site and apply a tourniquet about 4 inches above it. Assess for a suitable vein by palpating for bounce and observing for color and size.
5. Cleanse the site with an aseptic cleanser using a circular motion from the center outward. Allow it to dry completely.
6. Remove the cap from the angiocatheter and hold it like a pencil with your dominant hand. Stabilize the vein with your non-dominant hand by pulling the skin taut below the site.
7. Insert the needle into the vein at a 10 to 30 degree angle, with the bevel up. Advance it until you see a flash of blood in the chamber.
8. Lower the angle of the needle and advance it slightly further into the vein. Slide the catheter off the needle and into the vein until only the hub is visible.
9. Release the tourniquet and activate the safety mechanism on the needle. Dispose of it in a sharps container.
10. Attach the IV fluid or saline lock to the hub of the catheter. Flush it with saline using a syringe and check for blood return and signs of infiltration or phlebitis.
11. Stabilize and secure the catheter with Opsite or tape strips. Cover it with an occlusive dressing that allows visualization of the site.
12.  Label the dressing with your initials, date, time, gauge, and lot number of the catheter.
13. 13. Adjust the infusion rate according to the order and monitor the patient for any adverse reactions or complications.
14. Document the procedure, the site, the type and amount of fluid or medication, the infusion rate, the patient’s response, and any interventions or outcomes.

- Nursing interventions for IV therapy are the actions that nurses take to ensure the safety and effectiveness of IV therapy. Some of the nursing interventions for IV therapy are:

- Pre-IV Therapy Interventions

• Verify the order for IV therapy and gather all the necessary materials.
• Identify the patient using two identifiers and explain the procedure, purpose, and potential risks. Obtain informed consent if required.
• Perform hand hygiene and don gloves.
• Select an appropriate IV site and apply a tourniquet about 4 inches above it. Assess for a suitable vein by palpating for bounce and observing for color and size.
• Cleanse the site with an aseptic cleanser using a circular motion from the center outward. Allow it to dry completely.

- Intra-IV Therapy Interventions

• Insert the needle into the vein at a 10 to 30-degree angle, with the bevel up. Advance it until you see a flash of blood in the chamber.
• Lower the angle of the needle and advance it slightly further into the vein. Slide the catheter off the needle and into the vein until only the hub is visible.
• Release the tourniquet and activate the safety mechanism on the needle. Dispose of it in a sharps container.
• Attach the IV fluid or saline lock to the hub of the catheter. Flush it with saline using a syringe and check for blood return and signs of infiltration or phlebitis.
• Stabilize and secure the catheter with Opsite or tape strips. Cover it with an occlusive dressing that allows visualization of the site.

Label the dressing with your initials, date, time, gauge, and lot number of the catheter.

Adjust the infusion rate according to the order and monitor the patient for any adverse reactions or complications.

- Post-IV Therapy Interventions

Discontinue the IV when ordered or indicated by removing the dressing, the catheter, and applying pressure to the site with gauze.

Inspect the catheter tip for intactness and report any missing fragments.

Apply a sterile dressing to the site and observe for bleeding or hematoma.

Document the procedure, the site, the type and amount of fluid or medication, the infusion rate, the patient’s response, and any interventions or outcomes.

- Complications of IV therapy are problems that may arise from inserting, maintaining, or removing an IV catheter or administering IV fluids or medications. Some of the possible complications of IV therapy and their nursing management are:

Infiltration

- Infiltration is the leakage of fluid or medication into the surrounding tissue due to dislodgement or puncture of the vein by the catheter. Signs and symptoms of infiltration include:

• Swelling, pallor, coolness, or pain at or near the insertion site
• Decreased or stopped flow rate
• Absence of blood return
• Edema or tightness of skin
• Blanching or blisters

- Nursing management for infiltration includes:

- Stop the infusion immediately and disconnect the tubing from the catheter.

- Remove the catheter gently and apply pressure to the site with gauze until the bleeding stops.

- Elevate the affected extremity above heart level to reduce swelling.

- Apply a warm or cold compress depending on the type of fluid infiltrated.

- Start a new IV line in another site, preferably on another extremity.

- Document the incident, the actions taken, and the patient’s response.

Phlebitis

- Phlebitis is the inflammation of a vein due to mechanical, chemical, or bacterial irritation from the catheter or fluid. Signs and symptoms of phlebitis include:

• Redness, warmth, tenderness, or pain along the course of the vein
• Swelling or induration at or near the insertion site
• Palpable cord along the vein
• Fever or chills
• Purulent drainage from the site

- Nursing management for phlebitis includes:

- Stop the infusion immediately and disconnect the tubing from the catheter.

- Remove the catheter gently and apply pressure to the site with gauze until bleeding stops.

- Apply a warm compress to the affected area to relieve pain and inflammation.

- Start a new IV line in another site, preferably on another extremity.

- Culture the catheter tip and the site if infection is suspected.

- Administer antibiotics, analgesics, or anti-inflammatory agents as ordered.

- Document the incident, the actions taken, and the patient’s response.

Infection

- Infection is the invasion of microorganisms into the bloodstream or the insertion site due to poor aseptic technique, prolonged use of the same catheter, or contamination of the fluid or equipment. Signs and symptoms of infection include:

• Fever, chills, malaise, or headache
• Redness, warmth, tenderness, or pain at or near the insertion site
• Purulent drainage from the site
• Swelling or induration at or near the insertion site
• Positive blood culture

- Nursing management for infection includes:

• Stop the infusion immediately and disconnect the tubing from the catheter.
• Remove the catheter gently and apply pressure to the site with gauze until bleeding stops.
• Culture the catheter tip and the site to identify the causative organism.
• Start a new IV line in another site, preferably on another extremity.
• Administer antibiotics, antipyretics, or analgesics as ordered.
• Monitor the patient’s vital signs, white blood cell count, and temperature.
• Document the incident, the actions taken, and the patient’s response.

Hematoma

- Hematoma is the collection of blood in the tissue due to puncture of an artery or a vein by the needle or catheter. Signs and symptoms of hematoma include:

• Ecchymosis or bruising at or near the insertion site
• Swelling or bulging at or near the insertion site
• Pain or discomfort at or near the insertion site
• Difficulty advancing the catheter into the vein
• Arterial blood return instead of venous blood return

Nursing management for hematoma includes:

Stop the infusion immediately and disconnect the tubing from the catheter.

Remove the catheter gently and apply pressure to the site with gauze until bleeding stops.

Apply a cold compress to the affected area to reduce swelling and pain.

Elevate the affected extremity above heart level to reduce bleeding.

Start a new IV line in another site, preferably on another extremity.

Document the incident, the actions taken, and the patient’s response.

Nerve Damage

- Nerve damage is the injury to a nerve due to compression, stretching, or puncture by the needle or catheter. Signs and symptoms of nerve damage include:

• Numbness, tingling, or burning sensation at or near the insertion site
• Sharp pain radiating along the nerve pathway
• Weakness or paralysis of the affected extremity
• Difficulty moving or flexing the affected extremity
• Loss of sensation or function of the affected extremity

- Nursing management for nerve damage includes:

• Stop the infusion immediately and disconnect the tubing from the catheter.
• Remove the catheter gently and apply pressure to the site with gauze until bleeding stops.
• Assess the neurovascular status of the affected extremity by checking the pulse, the capillary refill, the sensation, and the movement.
• Notify the physician and report the findings and the incident.
• Administer analgesics, anti-inflammatory agents, or steroids as ordered.
• Refer the patient to a neurologist or a physical therapist as needed.
• Document the incident, the actions taken, and the patient’s response.

Extravasation

- Extravasation is the leakage of vesicant fluid or medication into the surrounding tissue due to dislodgement or puncture of the vein by the catheter. Vesicants are fluids or medications that can cause severe tissue damage such as necrosis, ulceration, or blistering if they escape from the vein. Examples of vesicants include chemotherapy agents, potassium chloride, calcium chloride, sodium bicarbonate, and phenytoin. Signs and symptoms of extravasation include:

• Swelling, redness, pain, burning, or stinging at or near the insertion site
• Decreased or stopped flow rate
• Absence of blood return
• Blistering, ulceration, necrosis, or sloughing of skin
• Tissue damage that may extend to tendons, nerves, muscles, or bones

- Nursing management for extravasation includes:

• Stop the infusion immediately and disconnect the tubing from the catheter.
• Remove the catheter gently and apply pressure to the site with gauze until the bleeding stops.
• Identify the type and amount of vesicant that extravasated.
• Notify the physician and report the findings and the incident.

Administer an antidote or a neutralizing agent as ordered. Some examples of antidotes or neutralizing agents are:

- Hyaluronidase: for phenytoin, norepinephrine, dopamine, or vinca alkaloids

- Sodium thiosulfate: for cisplatin

- Dimethyl sulfoxide (DMSO): for anthracyclines

- Nitroglycerin paste: for vasopressors

- Cold compress: for vinca alkaloids, etoposide, or mitomycin C

- Warm compress: for anthracyclines, mannitol, or calcium gluconate

Apply a sterile dressing to the site and monitor for signs of tissue damage.

Document the incident, the actions taken, and the patient’s response.

In summary, these are some of the main points from these notes:

• IV therapy is the delivery of liquid substances directly into a vein for various purposes.
• IV therapy requires surgical asepsis, which is the elimination of all microorganisms from an object or area.
• IV therapy involves various types of IV access, materials, sites, complications, and nursing interventions.
• Peripheral IV access involves inserting a catheter into a vein in the hand or arm. It is suitable for short-term therapy and low-risk fluids or medications.
• Central IV access involves inserting a catheter into a large vein that leads directly to the heart. It is suitable for long-term therapy and high-risk fluids or medications that require rapid dilution or precise infusion rates.
• Veins are blood vessels that carry blood back to the heart. They are superficial, non-pulsatile, and valved. They have three layers of tissue: tunica adventitia, tunica media, and tunica intima.
• The materials needed for starting a peripheral IV include an absorbent disposable sheet, an aseptic cleanser, a tourniquet, an angiocatheter, an IV fluid or saline lock, a saline-filled syringe, Opsite or tape strips, gloves, and gauze.
• The choice of IV site depends on several factors, such as the type and duration of therapy, the size and condition of the vein, the patient’s preference and comfort, the patient’s medical history and current status, and the potential for complications or interference.
• Some common peripheral IV sites are the cephalic vein, the basilic vein, the median cubital vein, and the dorsal metacarpal veins.

The steps for inserting a peripheral IV catheter are: verify the order; identify the patient; perform hand hygiene; select an appropriate site; apply a tourniquet; cleanse the site; insert the needle; advance the catheter; release the tourniquet; dispose of the needle; attach the fluid or saline lock; flush the catheter; stabilize and secure the catheter; label the dressing; adjust the infusion rate; and document the procedure.

• Nursing interventions for IV therapy are pre-, intra-, and post-IV therapy interventions that ensure the safety and effectiveness of IV therapy.

Some possible complications of IV therapy are infiltration, phlebitis, infection, hematoma, nerve damage, and extravasation .

Nursing management for each complication involves stopping the infusion; removing the catheter; applying pressure, a compress, or an antidote to the site; starting a new IV line; notifying the physician; administering medications; monitoring the patient; and documenting the incident .

• Documentation of IV therapy is the recording of all the relevant information about the IV therapy in the patient’s medical record. It is important for communication, evaluation, legal evidence, and quality and safety standards.

- Documentation of IV therapy is the recording of all the relevant information about the IV therapy in the patient’s medical record. Documentation of IV therapy is important for:

• Communicating with other healthcare providers
• Evaluating the effectiveness and outcomes of IV therapy
• Providing legal evidence of care
• Ensuring quality and safety standards

- Some of the information that should be documented for IV therapy are:

• The date and time of IV insertion, maintenance, or discontinuation
• The type, size, and lot number of the catheter
• The location and condition of the insertion site
• The type, amount, and rate of fluid or medication infused
• The patient’s response to IV therapy, including vital signs, pain level, and comfort level
• Any complications or adverse reactions that occurred and how they were managed
• Any patient education or instructions given about IV therapy

- In summary, these are some of the main points from these notes:

• IV therapy is the delivery of liquid substances directly into a vein for various purposes.
• IV therapy requires surgical asepsis, which is the elimination of all microorganisms from an object or area.
• IV therapy involves various types of IV access, materials, sites, complications, and nursing interventions.
• Peripheral IV access involves inserting a catheter into a vein in the hand or arm. It is suitable for short-term therapy and low-risk fluids or medications.
• Central IV access involves inserting a catheter into a large vein that leads directly to the heart. It is suitable for long-term therapy and high-risk fluids or medications that require rapid dilution or precise infusion rates.
• Veins are blood vessels that carry blood back to the heart. They are superficial, non-pulsatile, and valved. They have three layers of tissue: tunica adventitia, tunica media, and tunica intima.
• The materials needed for starting a peripheral IV include an absorbent disposable sheet, an aseptic cleanser, a tourniquet, an angiocatheter, an IV fluid or saline lock, a saline-filled syringe, Opsite or tape strips, gloves, and gauze.
• The choice of IV site depends on several factors, such as the type and duration of therapy, the size and condition of the vein, the patient’s preference and comfort, the patient’s medical history and current status, and the potential for complications or interference.
• Some common peripheral IV sites are the cephalic vein, the basilic vein, the median cubital vein, and the dorsal metacarpal veins.

- The steps for inserting a peripheral IV catheter are: verify the order; identify the patient; perform hand hygiene; select an appropriate site; apply a tourniquet; cleanse the site; insert the needle; advance the catheter; release the tourniquet; dispose of the needle; attach the fluid or saline lock; flush the catheter; stabilize and secure the catheter; label the dressing; adjust the infusion rate; and document the procedure.

• Nursing interventions for IV therapy are pre-, intra-, and post-IV therapy interventions that ensure the safety and effectiveness of IV therapy.

- Some possible complications of IV therapy are infiltration, phlebitis, infection, hematoma, nerve damage, and extravasation .

- Nursing management for each complication involves stopping the infusion; removing the catheter; applying pressure, a compress, or an antidote to the site; starting a new IV line; notifying the physician; administering medications; monitoring the patient; and documenting the incident .

• Documentation of IV therapy is the recording of all the relevant information about the IV therapy in the patient’s medical record. It is important for communication, evaluation, legal evidence, and quality and safety standards.