NEUROLOGIC ASSESSMENT OBJECTIVES: 1. ________________________________________________________________________________ 2. ________________________________________________________________________________ 3.

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EQUIPMENTS: Reading material vials containing aromatic substances (e.g., vanilla and coffee) Opposite tip of cotton swab or tongue blade broken in half Penlight Tongue blade Cotton balls or cotton tipped applicators Reflex hammer

Snellen Chart vials containing sugar or salt two test tubes, one filled with hot water tuning fork

PERFORMANCE/RATIONALE/FINDINGS CHECKLIST PROCEDURE 1. See Standard Protocol before starting the procedure.

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2. Assess for clients cultural and educational background, values and beliefs. 3. Assess for sensory loss.

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

PROCEDURE 5. To test for clients REGISTRATION: a. Ask first if you may test his memory. b. Then say the names of 3 unrelated objects clearly and slowly about 1 second for each (e.g., hospital, cucumber, school). c. After you have said all three, ask him to repeat them. First repetition determines his score (0-3) but keep saying them until he can repeat all 3, up to 6 trials. d. If patient does not eventually learn all three, recall cannot be meaningfully tested. 6. To assess for clients ATTENTION and CALCULATION: a. Ask the patient to begin with 100 and count backwards by 7. Stop after 5 substractions (93, 86, 79, 72, 65) b. Score the total number of correct answers. c. If the patient cannot or will not perform this task, ask him to spell the word WORLD backwards. The score is the number of letters in correct order (e.g., dlrow=5; dlorw=3). 7. To assess for clients ability to RECALL: a. Ask the patient if he can recall the three words you previously asked him to remember. b. Score 0-3.

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PROCEDURE 8. To assess for clients LANGUAGE thru the following: a. NAMING: Show the client a wrist watch and ask him what it is. Repeat for Pencil. Score 0-3. b. REPITITION: Ask the client to repeat the sentence after you. Allow only one trial. Score 0 or 1. c. 3-STAGE COMMAND: Give the client a piece of plain blank paper and repeat the command. d. READING: On a blank piece of paper print the sentence CLOSE YOUR EYES in letters large enough for the client to see clearly. Ask him to read it and do what it says. Score 1 point only if he actually closes his eyes. e. WRITING: Give the patient a blank piece of paper and ask him to write a sentence for you. Do not dictate a sentence; it is to be written spontaneously. It must contain a subject and verb and be sensible. Correct grammar and punctuation. f. COPYING. On a clean sheet of paper, draw intersecting pentagons, each side about 1 inch, and ask him to copy it exactly as it is. All 10 angles must be present and two must intersect to score 1 point. Tremor and rotation are ignored. Estimate the clients level of sensorium along a continuum, from alert on the left to coma on the right.

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

PROCEDURE 10. To check for EYE OPENING RESPONSE: a. When you enter the clients room, try to close the door louder than the usual. If the client spontaneously opens his eyes, the score is 4. b. If without response, greet the client and ask him a simple question. If there is eye opening upon hearing you speak, the score is 3. c. If still with no response, elicit pain by pressing at the clients fingernail bed. Score then is 2 if the client opens his eyes upon feeling the pain. If still without response, the score is 1. 11. To check for the BEST VERBAL RESPONSE: a. Ask the client a simple question like, What time of the day it is? b. Base from his answer, grade him with appropriate score for his response as follows: ORIENTED: 5 CONFUSED: 4 INAPPROPRIATE WORDS: 3 INCOMPREHENSIBLE SOUNDS:2 NONE: 1 12. To test for the last category of GCS, BEST MOTOR RESPONSE to painful stimuli: a. Press the clients fingernail bed. b. Record BEST UPPER LIMB RESPONSE with the appropriate score as follows: OBEYS COMMANDS: 6 LOCALIZED PAIN: 5 FLEXION WITHDRAWAL: 4 ABNORMAL FLEXION: 3 ABNORMAL EXTENSION: 2 FLACCID: 1

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PROCEDURE 13. Add the clients score based from EYE OPENING RESPONSE, BEST VERBAL RESPONSE, and BEST MOTOR RESPONSE.

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14. To test for the clients DEEP TENDON REFLEXES: a. BICEPS REFLEX: Support the clients forearm on yours. Place your thumb on the biceps tendon and strike a blow on your thumb. b. TRICEPS REFLEX: Tell the client to let the arm just go dead as you suspend it by holding the upper arm. Strike the triceps tendon directly just above the elbow. Alternately, hold the clients write across the chest to flex the arm at the elbow, and tap the tendon. c. BRACHIORADIALIS REFLEX: Hold the clients thumb to suspend the forearms in relaxation. Strike the forearm directly about 2 to 3 cm above the radial styloid process. d. QUADRICEPS REFLEX (Knee jerk): Let the lower legs dangle freely to flex the knee and stretch the tendons. Strike the tendon directly just below the patella. e. ACHILLES REFLEX (Ankle jerk): Position the client with the knee flexed and the hip externally rotated. Hold the foot in dorsiflexion, and strike the Achilles tendon directly. f. For the client in the supine position, flex one knee and support that lower leg against the other leg so that it falls open. Dorsiflex the foot and tap the tendon.

PROCEDURE 15. To test for SUPERFICIAL REFLEXES: a. ABDOMINAL REFLEX: Have the client assume a supine position, with the knees slightly bent. Use the handle end of the reflex hammer to stroke the skin. Move from the side of the abdomen toward the midline at both the upper and lower abdominal levels. When the abdominal wall is very obese, pull the skin to the opposite side, and feel it contract toward the stimulus. b. PLANTAR REFLEX: Position the thigh in slight external rotation. With the rflex hammer, draw a light stroke up the lateral side of ths ole of the foot and inward across the ball of the foot, like an upside down J. c. CORNEAL REFLEX: Remove any contact lenses. With the client looking forward bring a wisp of cotton in from the side (to minimize defensive blinking) and lightly touch the cornea, not the conjunctiva. d. ABDOMINAL REFLEX: Have the client assume a supine position. With the knees slightly bent, use the handle end of the reflex hammer, a wood applicator tip, or the end of a split tongue blade to stroke the skin. Move from the side of the abdomen toward the midline at both the upper and lower abdominal levels.

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PROCEDURE 16. To test for the clients major muscle tone and strength, the following scale is used: MUSCLE FUNCTION LEVEL No evidence of contractility Slight contractility, no movement Full range of motion, gravity eliminated Full range of motion with gravity Full range of motion against gravity, with some resistance Full range of motion against gravity, With full resistance GRADE 0 1 2 3 4 5

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17. To assess for the MUSCLE TONE: a. The client is asked to allow an extremity (e.g., an arm) to relax or hang limp. b. The extremity is supported and each limb is grasped moving it through the normal range of motion. c. Do the same on the lower extremity.\ 18. To assess for the MUSCLE STREGNTH: a. Let the client assume a stable position and ask him to first flex the muscle to be examined and then to resist when you apply opposing force against that flexion. b. Instruct the client not to move the joint. c. To test for the STERNOCLEIDOMASTOID muscle, place hand firmly against clients upper jaw. Ask the client to turn head laterally against resistance.

PROCEDURE d. To test for the shoulder (trapezius), place hand over midline of clients shoulder, exerting firm pressure. Have the client raise shoulders against resistance. e. To test for the ELBOW 1) BICEPS: Pull down on forearm as client attempts to flex arm. 2) TRICEPS: As clients arm is flexed, apply pressure against forearm. Ask client to straighten arm. f. To test for the HIP 1) QUADRICEPS: When client is sitting, apply downward pressure to thigh. Ask client to raise leg up from the table. 2) GASTROCNEMIUS: Client sits holding shin of flexed leg. Ask him to straighten leg against resistance. 19. To test for the CRANIAL NERVES a. CRANIAL NERVE I: OLFACTORY NERVE 1) Occlude one nostril at a time and ask the client to sniff. 2) Ask the client to close his eyes and occlude one nostril at a time, presenting an aromatic substance. b. CRANIAL NERVE II: OPTICE NERVE (Central Visual Acuity) 1) If the client is wearing corrective glasses or contact lens, leave them on. Remove only reading glasses. 2) Position the client on a mark exactly 20 feet from the chart. Hand him an opaque card with which to shield one eye at a time. 3) Ask the client to read through the chart to the smallest line of letters possible. Encourage the person to try the next smallest line also. (Use a Snellen Chart E for clients who cannot read letter.)

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4) Test near vision using a newspaper. Hand the client an opaque card with which to shield one eye at a time. Hold the card in good light about 35 cm from the eye. c. CRANIAL NERVE III, IV and VI: OCULOMOTOR, TROCHLEAR, and ABDUCENS NERVES 1) Gauge the pupil size in millimeters. 2) Darken the room and ask the person to gaze into the distance. Advance a light from the side and note the response. 3) Gauge the pupil size in millimeters and compare with baseline. 4) Ask the person to focus on a distant object. Then have the person shift the gaze to a near object (e.g., your finger) held about 7 to 8 cm (3 inches) from the nose. 5) Record the normal response as PERRLA DIAGNOSTIC POSITION TEST 1) Ask the client to hold the head steady and to follow the movement of your penlight only with the eyes. Hold the target back about 12 inches so the client can focus on it comfortably, and move it to each of the six position; hold it momentarily, then back to center. Progress clockwise. d. CRANIAL NERVE V: TRIGEMINAL NERVE 1) MOTOR function: a) Assess the muscles of mastication by palpating the temporal and masseter muscles as the client clenches the teeth. Assess also for pain. b) Try to separate the jaws by pushing down on the chin. 2) SENSORY function: a) Ask the client to close his eyes then touch a cotton wisp to designated areas: forehead, cheeks and chin. Ask him to say now whenever the touch is felt.

3) CORNEAL REFLEX: a) Let the client remove contact lenses. With the client looking forward, bring a wisp of cotton from the side (to minimize defensive blinking) and lightly touch the cornea, not the conjuctiva. e. CORNEAL NERVE VII: FACIAL NERVE 1) MOTOR fuction: a) Note mobility and facial symmetry as the client responds to these requests: smile, frown, close eyes tightly (against your attempt to open them), lift eyebrow, show teeth and puff cheeks. Press the clients puffed cheeks in and note that the air should escape equally from both sides. 2) SENSORY function a) Apply to the tongue a cotton applicator covered with a solution of sugar or salt. Ask the client to identify the taste. f. CRANIAL NERVE VIII: ACOUSTIC (Vestibulocochlear) NERVE VOICE TEST 1) Test on ear at a time while masking hearing in the other ear to prevent sound transmission around the head. With your head 1 to 2 feet from the clients ear, exhale and whisper slowly some two syllable words (e.g., Monday, candy, peaceful). 2) Shield your lips as you speak. TUNING FORK TEST (Weber Test) 1) Activate the tuning fork, hold it by the stem and strike the tines softly on the back of your hand. b)

2) Place a vibrating tuning fork in the midline of the clients skull and ask if the tone sound the same in both ears or better in one. g. CRANIAL NERVE IX and X: GLOSSOPHARYNGEAL and VAGUS NERVES MOTOR function 1) Depress the tongue with a tongue blade, and note pharyngeal movements as the client says ahh or yawns; the uvula and the soft palate should rise in the midline, and the tonsillar pillars should move medially. 2) Touch the posterior pharyngeal wall with a tongue blade, and note the gag reflex. Also note that the voice sounds smooth and not strained. h. CRANIAL NERVE XI: SPINAL ACCESSORY NERVE 1) Examine the sternocleidomastoid and trapezius muscles for equal size. Check equal strength by asking the client to rotate the head forcibly against resistance applied to the side of the chin. Then ask the client to shrug the shoulders against resistance. i. CRANIAL NERVE XII: HYPOGLOSSAL NERVE 1) Inspect the tongue. No wasting or tremors should be present. Note the forward thrust in the midline as the client protrudes the tongue. Also ask the client to say bright, light, might 20. See Standard Protocol after the whole procedure.

ENDOTRACHEAL AND TRACHEOSTOMY TUBE SUCTIONING Definition: An endotracheal tube is inserted by the physician or nurse with specialized education through either the mouth or the nose and into the trachea with the guide of a laryngoscope. The tube terminates just superior to the bifurcation of the trachea into the bronchi. Because the tube passes through the epiglottis and glottis, the client is unable to speak while it is in place. A tracheostomy is a surgical incision into the trachea to insert a tube through which the patient can breathe more easily and secretions can be removed. It is performed more commonly as a prophylactic procedure so that secretions in there respiratory tract can be removed more effectively before a patients breathing is severely. Because the tracheostomy opens directly into the trachea, which is highly susceptible to infection, the nurse must have a thorough knowledge of sterile technique to care for and suction a tracheostomy. Parts Of A Tracheostomy Tube: 1. Inner cannula - the "sleeve" inside of the tracheostomy tube that can be removed for cleaning. 2. Neck plate (flange) - site for ties; prevents movement and skin-breakdown secondary to pressure points. 3. Obturator - a guide for positioning the actual trach tube. 4. Cuff - inflates with air inside the trachea to seal the trach wall, preventing aspiration and potential air leak around the cannula. Cuffed trach tubes are used predominately for patients who require mechanical ventilation with high pressures. For patients requiring only nocturnal ventilation, the cuff can be deflated during the day.

Types of Tracheostomy Tubes: Composition - The tube material is chosen on desired flexibility. Metal tubes (Jackson tubes) are rigid. Silicone tubes are very flexible. Polyvinyl chloride (PCV) tubes may be flexible or rigid. Shiley and Portex are plastic tubes. Double-cannula tube - Contains a removable, inner cannula. Double-cannula tubes are used mostly for children with thick, copious secretions. Cleaning the inner cannula avoids frequent tracheostomy tube (outer cannula) changes. Can be cuffed or un-cuffed depending on the indication. Single-cannula tube - Used mostly for infants and small children. Single-tubes are typically plastic and uncuffed. Fenestrated tube - Contains an opening on the superior portion of the cannula, where air can travel from the vocal cords, into the cannula, and up through the fenestration to the oropharynx. This allows the patient to vocalize.

Indications: This procedure is indicated when the client: 1. Has endotracheal or tracheostomy tube in place; 2. Is unable to cough and expectorate secretions effectively (e.g., infants and comatose patients); 3. Makes light bubbling or rattling breath sounds that indicate the accumulation of secretions in the respiratory tract; and 4. Is dyspneic or appears cyanotic.

Purposes: 1. To remove secretions that obstruct the airway; 2. To facilitate respiratory ventilation; 3. To obtain secretions for diagnostic purposes; and 4. To prevent infection that may result from accumulated secretions in the respiratory tract. Special Considerations: 1. Maintain the sterility of the dominant glove, suction catheter, normal saline, and syringe, if used. 2. Assess the clients respirations, pulse, color, breath sounds, and behavior before and after the procedure. 3. For clients who do not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning. 4. For clients who have copious secretions, increase the oxygen liter flow before suctioning. 5. Use appropriate suction pressure. 6. Restrict each suction time to 10 seconds and total suctioning time to no more than 5 minutes. 7. Reapply supplementary oxygen as required during and after the procedure. 8. Replenish supplies in readiness for the next suction. Equipments: 1. Rescuscitation bag (Ambu bag) connected to 100% oxygen 2. Sterile towel (optional) 3. Portable or wall suction machine with tubing and collection receptacle. 4. Sterile disposable container for fluids 5. Sterile normal saline or water 6. Sterile gloves 7. Goggles and mask if necessary 8. Gown (if necessary) 9. Sterile suction catheter 10. Y-connector 11. Sterile gauzes 12. Moisture-resistant disposable bag

PROCEDURE Assessment 1. Assess the needs of the patient with a tracheostomy/endotracheal tube for suctioning. Planning 2. Wash your hands. 3. Obtain tracheostomy or endotracheal suctioning kit. Implementation 4. Identify the patient. Assessment 5. Assess the needs of the patient with a tracheostomy/endotracheal tube for suctioning. Planning 6. Wash your hands. 7. Obtain tracheostomy or endotracheal suctioning kit. Implementation 8. Identify the patient.

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PROCEDURE Assessment 9. Assess the needs of the patient with a tracheostomy/endotracheal tube for suctioning. Planning 10. Wash your hands. 11. Obtain tracheostomy or endotracheal suctioning kit. Implementation 12. Identify the patient. 13. Provide privacy. 14. Explain the procedure carefully.

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Ask the responsive patient to cough.

An explanation should also be given to the unresponsive patient.

PROCEDURE 15. Establish a way patient can communicate. 16. Test suction apparatus. a. Turn on either the wall suction or the portable suction machine. b. Place your thumb over the end of the unsterile tubing that is attached to the suction equipment and test for pull. c. Keep the suction regulated to a range of efficiency, usually low to medium. 17. Position the patient: Supine or mid-fowlers with head slightly toward you if conscious; lateral position facing you if unconscious. 18. Put on eye protection and mask. 19. Prepare 5 mL sterile saline in a syringe; remove needle.

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PROCEDURE 20. Open kit and prepare equipment. a. Place drape or towel over patients chest. b. Put on gloves.

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c. Open and pour saline. d. Attach catheter to suction tubing, and moisten catheter in normal saline solution. 21. Attach breathing bag to oxygen source. 22. Attach breathing bag to tracheostomy/endotracheal tube and provide three breaths as the client inhales. If the client has copious secretion, do not hyperventilate with a resuscitator. Instead, keep the regular O2 device on and increase the liter flow or adjust the FiO2 to 100% for several breaths before suctioning. 23. Instill saline into tracheostomy/endotracheal tube (if this is the policy).

PROCEDURE 24. Quickly but gently insert the catheter without applying any suction. Insert the catheter about 12.5 cm (5 inches) for adults with Tracheostomy tube or until the client coughs or you feel resistance. 25. Perform suctioning. A. Apply intermittent suction for 5-10 seconds by placing the non-dominant thumb over the thumb port. B. Rotate the catheter by rolling it between you thumb and forefinger while slowly withdrawing it.

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C. Rinse the catheter with sterile water of normal saline solution. D. Provide ventilation immediately after the suction catheter is removed (usually done by an assistant) to supply needed oxygen. E. Stop the procedure when there is persistent coughing.

PROCEDURE 26. Observe the patient for dyspnea and skin color changes. 27. If these symptoms of hypoxia occur, provide additional deep breaths of oxygen. 28. Turn off the suction and listen for clear breath sounds. 29. If the breathing sounds are not clear, repeat steps 17a through d. 30. If the breathing sounds clear, use the breathing bag to provide three or four deep breaths of oxygen. 31. Disconnect the catheter from the suction tubing. 32. Pull sterile glove over catheter to cover it, and remove eye protection and mask. 33. Discard disposable equipment, and take nondisposable equipment to appropriate place for cleaning. 34. Wash your hands.

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PROCEDURE 35. Perform oral hygiene.

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Evaluation 36. Evaluate using the following criteria: a. Tracheostomy/endotracheal tube securely in place. b. Respiratory rate and depth normal. c. Breath sounds clear. d. Patient resting comfortably. Documentation 37. Document the procedure and observations. Include the amount and description of suction returns and any other relevant assessments.

DEFLATING AND INFLATING A CUFFED TRACHEOSTOMY TUBE Definition: A cuffed trachestomy tube compounds the nursing care requirements of the patient in acute respiratory failure. To give intelligent, knowledgeable care, it is essential to have a thorough understanding of the cuffed tube its design, purpose, principles of use, and the potential dangers associated with it. The cuff is so design that when it is properly inflated, it forms a seal between the tracheostomy tube and the trachea, preventing air from entering or escaping around the tube. The cuff, usually made of soft rubber, encircles the lower portion of the outer cannula of the tracheostomy tube. Once the tracheostomy tube is in place in the patients trachea, the cuff is inflated to form the seal. The only route of effective air exchange; with the cuff inflated, is the lumen of the tracheostomy tube. The inflated cuff also reduces the possibility of aspiration of secretions into the lower trachea and bronchi. Nothing gets by the seal created in the trachea by the inflated cuff. Purposes: Cuffed tracheastomy tubes are generally inflated: 1. During the first 12 hours after a tracheostomy; 2. When the client is being ventilated or receiving IPPB therapy, to prevent leakage; 3. When the client is eating or receiving oral medications, and for a prescribed period of time following meals or medications (e.g., 30 minutes), to prevent aspiration; and 4. When the client is comatose, to prevent aspiration of oropharyngeal secretions. At other times the cuff is deflated. If double-cuffed tubes are used, deflation and inflation must be done at regular intervals according to the manufacturers directions. Critical Elements: For cuff deflation: 1. Maintain asepsis when suctioning. 2. Suction the oropharngeal cavity adequately before cuff deflation. 3. Withdraw the correct amount of air while the client inhales and while providing a positive pressure breath if ordered.

4. If the cough reflex is stimulated after deflation, suction the lower airway. For cuff inflation: 1. Inflate the cuff on inhalation. 2. Follow the minimal leak technique.

3. Make sure the cuff pressure does not excess 15-20 mm Hg or 25 cm H2O.
4. Clamp the inflation tube if required. 5. Document the exact amount of air used to inflate the cuff.

Equipments: 1. Equipment needed for suctioning the oropharyngeal cavity 2. 5- to 10- ml syringe 3. Stethoscope 4. Rubber-tipped hemostat 5. Manual resuscitator (Ambu bag) 6. Manometer specifically designed to measure cuff pressure (if available) 7. Sterile three-way stopcock (optional)

PROCEDURE 1. Check the physicians orders to determine when the cuffed

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tube should be inflated. 2. Assist the client to a semi-fowlers position unless

contraindicated. Clients receiving positive pressure ventilation should be placed in a supine position so that secretions above the cuff site are moved up into the mouth. 3. Assess the clients respiration, pulse, color, breath sounds, and behavior. Deflating the Cuff 4. Suction the oropharyngeal cavity before inflating the cuff. Discard the catheter after use. 5. If a hemostat is clamping the cuff inflation tube, unclamp it. Some tubes have one-way valves that replace the hemostat. 6. Attach the 5- or 10-ml syringe to the distal end of the inflation tube, making sure the seal is tight. 7. Suction the lower airway with a sterile catheter, if the cough reflex is stimulated during cuff deflation.

PROCEDURE 8. Assess the clients respirations, and suction the client as needed. If the client experiences breathing difficulties, reinflate the cuff immediately. Inflating the Tracheal Cuff 9. Add the least amount of air following the manufacturers recommendations, to create a minimal air leak. The minimal leak technique is designed to prevent tracheal damage and is performed as follows: a. Inflate the cuff on inhalation, and place your stethoscope on the clients neck adjacent to the trachea. b. Listen for squeaking or gurgling sounds, which indicate a leak. c. If no leak is present, slowly remove 0.2-0.3 ml more air. d. Listen again for sounds.

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PROCEDURE e. The cuff is inflated sufficiently when: You cannot hear the clients voice. You cannot feel any air movements from the clients mouth, nose, or tracheostomy site. You hear a slight or no leak from the positive pressure ventilation when auscultating the neck adjacent to the trachea during inspiration. 10. Measure the cuff pressure: a. Attach the cuffs pillow port to the cuff pressure manometer.

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

not exceed 15-20 mm Hg or 25 cm H2O. 11. Clamp the inflation tube with the hemostat if the tube does not have a one-way valve. 12. Remove the syringe. 13. Determine the exact amount of air used to inflate the cuff. 14. Document the time of the deflation and/or inflation, the amount of air withdrawn and/or injected, and your assessments.

CLEANING A DOUBLE-CANNULA TRACHEOSTOMY TUBE Definition: The Universal is most commonly used tracheostomy tube. Also known as the "double-luman" or "double-cannula" tube, the Universal consists of three parts: the outer cannula (with cuff and pilot tube), the inner cannula, and the obturator.

Purposes: 1. To maintain the patency of the tube; and 2. Prevent infection. Equipments: 1. Sterile bowls for the cleaning solutions 2. Cleaning solutions: hydrogen peroxide and sterile normal saline 3. Sterile nylon brush or pipe cleaners to clean the lumen of the inner cannula 4. Sterile gauze squares or sterile cotton-tipped applicator sticks to clean the flange of the outer cannula 5. Sterile gloves (1 pair and 1 glove or 2 pairs) 6. Clean glove

Critical Elements: 1. Suction the inner cannula before its removal. 2. Remove the tracheostomy dressing and inner cannula with your nondominant clean hand. 3. Wear sterile gloves on both hands to clean the tube. 4. Inspect the cannula for cleanliness and remove excess liquid from it before insertion. 5. Suction the outer cannula before insertion the inner cannula. 6. Lock the inner cannula after insertions. PROCEDURE 1. Don an unsterile glove on the nondominant hand and a sterile glove on your dominant hand. 2. Suction the entire length of the inner cannula prior to its removal. 3. With your nondominant hand, which is wearing a clean glove, remove and discard the tracheostomy dressing. RATIONALE 1 2 3 4 5

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

turning the lock about 900 counterclockwise. 5. With the nondominant hand, remove the inner cannula by gently pulling it out toward you in line with its curvature. 6. Soak the inner cannula in the hydrogen peroxide solution for several minutes. PROCEDURE 7. Remove the gloves and replace with sterile gloves on both hands. RATIONALE 1 2 3 4 5

8. Remove the cannula from the soaking solution Clean the lumen and entire inner cannula thoroughly, using the pipe cleaners or brush moistened with sterile saline. 9. Agitate the cannula for several seconds in the sterile saline. 10. Inspect the cannula for cleanliness by holding it at eye level and looking though it into the light. If encrustations are evident, repeat steps 6, 8, and 9. 11. After rinsing the cannula, gently tap it against the inside edge of the sterile solution bowl. 12. Dry the inside of the cannula by using two or three pipe cleaners twisted together. Do not dry the outer surface. 13. Suction the outer cannula. 14. Clean the flange of the outer cannula if necessary, using cotton-tipped applicators or gauze squares moistened with sterile saline.

PROCEDURE 15. Grasp the outer flange of the inner cannula and insert the cannula in the direction of its curvation.

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16. Lock the inner cannula in place by turning the lock clockwise
about 900 to an upright position. 17. Gently pull on the inner cannula to ensure that the position is secure. 18. Clean the tracheostomy site, and apply a new tracheostomy dressing. 19. Document removal, cleaning, and reinsertion of the cannula and all assessments.

PROVIDING TRACHEOSTOMY CARE Definition: The nurse provides tracheostomy care for the client with a new or recent tracheostomy to maintain patency of the tube and reduce the risk of infection. Initially, a tracheostomy may need to be suctioned and clean as often as every 1 to 2 hours. After the initial inflammation response subsides, tracheostomy care may only need to be done once or twice a day, depending on the client. Purposes: 1. To maintain airway patency. 2. To maintain cleanliness and prevent infection at the tracheostomy site 3. To facilitate healing and prevent skin excoriation around the tracheostomy incision 4. To promote comfort. Special Considerations: 1. Suction the inner cannula before its removal. 2. Remove the tracheostomy dressing and inner cannula with your non-dominant clean hand. 3. Wear sterile gloves on both hands to clean the tube. 4. Inspect the cannula for cleanliness and remove excess liquid from it before insertion. 5. Lock the inner cannula after insertion. 6. Assess the status of the incision and surrounding skin. 7. Use noncotton-filled gauze square for cleaning and for the dressing. 8. Securely support the tracheostomy tube when cleaning it, and when applying the dressing and tie tapes. 9. Always fasten clean ties before removing soiled ties unless an assistant to hold the tracheostomy tube in place is available.

Equipments: Scissors 1 pair of clean gloves 1 pair of sterile gloves Hydrogen peroxide Normal saline Tracheostomy kit (4x4-inch gauze, cotton-tipped applicators, tracheostomy dressing, basin, small bottle brush or pipe cleaner, twill tape or tracheostomy ties/collar) Oral care equipment Bag for soiled dressings

PROCEDURE Assessment 1. Although done routinely after tracheostomy care, assess the patients dressing for drainage or soiling. Planning 2. Wash your hands. 3. Obtain tracheostomy care kit. Implementation 4. Identify the patient. 5. Provide privacy. 6. Explain what you are going to do.

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PROCEDURE 7. Put on clean gloves, and remove old dressing and discard. a. Hold tube while you remove dressing. b. Place your fingers around tube while you remove dressing. 8. Remove gloves and wash hands. 9. Put on sterile gloves. 10. With sterile, moistened swabs, clean around edges of tracheostomy opening. 11. Note any redness or swelling. 12. Prepare the dressing using precut or 4x4 gauze squares: a. If 4x4 gauze, open first fold. b. Fold in half lengthwise. c. Fold each end toward center. 13. Secure the tube by gently holding in place. Cut and remove soiled tape.

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PROCEDURE 14. Position new dressing. a. Thread tape through flange on one side. b. Bring tape around back of patients neck. c. Pass tape through opposite flange. d. Tie tape securely at side of neck. It is helpful for you or the patient to hold a finger under the tape as it is tightened.

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15. Check tube placement. 16. Perform oral care. 17. Dispose of equipment.

PROCEDURE 18. Remove gloves, and wash your hands. Evaluation 19. Evaluate, using the following criteria: a. Tracheostomy tube securely in place. b. No redness or swelling present. c. No secretions present. d. Dressing and tapes clean and dry. e. Absence of stale or foul-smelling breath. Documentation 20. Document procedure and any observations such as status of surrounding skin and amount of type of drainage.

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ASSISTING WITH THE INSERTION AND REMOVAL OF A CHEST TUBE Definition: Chest tubes are inserted and removed by the physician with the nurse assisting. Both procedures require sterile technique and must be done without introducing air or microorganisms into the pleural cavity. After the insertion, an x-ray film is taken to confirm the position of the tube. Chest tubes are generally removed within 5-7 days. Before removal, the tube is clamped with two large, rubber-tipped clamps for 1-2 days to assess for signs of respiratory distress and to determine whether air or fluid remains in the pleural space. An x-ray film of the chest is generally taken 2 hours after tube clamping to determine full lung expansion. If the client develops signs of respiratory distress or the film indicates pneumothorax, the tube clamps are removed, and chest drainage is maintained. If neither occurs, the tube is removed. Another x-ray film of the chest is often taken after removal to confirm full lung expansion.

Equipment: For tube insertion: - A sterile chest tube tray, which includes . Drapes . A 10-ml syringe . Sponges to clean the insertion area with antiseptic . A 1-in. #22 gauge needle . A 5/8-in. #25 gauge needle for the local anesthetic . A scalpel . Forceps . Two rubber-tipped clamps for each tube inserted . Several 4 x 4 gauze squares . Split drain gauzes . A chest tube with a trocar . Suture materials (eg, 2-0 silk with a needle) For tube removal: - Clean gloves to remove the dressing - Sterile gloves to remove the tube - A pleural drainage system with sterile drainage tubing and connectors - A Y-connector, if two tubes will be inserted - Sterile gloves for the physician and the nurse - A vial of local anesthetic (eg, 1% lidocaine) - Alcohol sponges to clean the top of the vial - Antiseptic (eg, povidone-iodine) - Tape (nonallergenic is preferable) - Sterile petrolatum gauze (optional) to place around the chest tube

- A sterile suture removal set, with forceps and suture scissors - Sterile petrolatum gauze - Several 4 x 4 gauze squares - Air-occlusive tape, 2 or 3 in. wide (nonallergenic is preferred) Intervention: Assessment Essential data include . Vital signs for baseline data and then every 4 hours.

- Scissors to cut the tape - An absorbent linen-saver pad - A moistureproof bag - Sterile swabs or applicators in sterile containers to obtain a specimen (optional)

. Breath sounds. Auscultate bilaterally for baseline data. Diminished or absent breath sounds indicate inadequate lung expansion and recurrent pneumothorax after chest drainage is established. . Clinical signs of pneumothorax before and after chest tube insertion. Leakage or blockage of a chest tube can seriously impair ventilation. Signs include sharp pain on the affected side; weak, rapid pulse; pallor; vertigo; faintness; dyspnea; diaphoresis; excessive coughing; and blood-tinged sputum. . Chest movements. A decrease in chest expansion on the affected side indicates pneumothorax. . Dressing site. Inspect the dressing for excessive and abnormal drainage, such as bleeding or foul-smelling discharge. Palpate around the dressing site and listen for a crackling sound indicative of subcutaneous emphysema can result from a poor seal at the chest tube insertion site. It is manifested by a crackling sound that is heard when the area around the insertion site is palpated. . Level of discomfort. Analgesics often need to be administered before the client moves or does deepbreathing and coughing exercises.

Chest Tube Insertion: PROCEDURE 1. Assist the client to a lateral position with the area to receive the tube facing upward. Determine from the physician whether to have the bed in the supine position or semi-Fowlers position. 2. Open the chest tube tray and the sterile gloves on the overbed table. Pour antiseptic solution onto the sponges. Be sure to maintain sterile technique. 3. Wipe the stopper of the anesthetic vial with an alcohol sponge. After the physician dons the gloves and cleans the insertion area with antiseptic solution, invert the vial and hold it for the physician to withdraw the anesthetic. 4. Support and monitor the client as required, while the physician anesthetizes the area, makes a small incision, inserts the tube, either clamps the tube or immediately connects it to the drainage system, and then sutures the tube to the skin. 5. Optional: Don sterile gloves. Wrap a piece of sterile petrolatum gauze around the chest tube. Place drain gauzes around the insertion (one from the top and one from the bottom). Place several 4 x 4 gauze squares over these. RATIONALE 1 2 3 4 5

PROCEDURE 6. Remove your gloves, if donned, and tape the dressings, covering them completely. 7. Tape the chest tube to the clients skin away from the insertion site. 8. Tape the connections of the chest tube to the drainage tube and to the drainage system. 9. Coil the drainage tubing, and secure it to the bed linen, ensuring enough slack for the person to turn and move. 10. When all drainage connections are completed, ask the client to a. Take a deep breath and hold it for a few seconds. b. Slowly exhale. 11. Assess the clients vital signs every 15 minutes for the first hour following tube insertion and then as ordered, eg, every hour for 2 hours, then every 4 hours or as often as health indicates.

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PROCEDURE 12. Auscultate the lungs at least every 4 hours for breath sounds and the adequacy of ventilation in the affected lung. 13. Place rubber-tipped chest tube clamps at the bedside. 14. Assess the client regularly for signs of pneumothorax and subcutaneous emphysema.

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Chest Tube Removal: PROCEDURE 1. Administer an analgesic, if ordered, 30 minutes before the tube is removed. 2. Ensure that the chest tube is securely clamped. 3. Assist the client to a semi-Fowlers position or to a lateral position on the unaffected side. 4. Put the absorbent pad under the client beneath the chest tube. 5. Open the sterile packages, and prepare a sterile field. RATIONALE 1 2 3 4 5

PROCEDURE 6. Wearing sterile gloves, place the sterile petrolatum gauze on a 4 x 4 gauze square. 7. Removed the soiled dressings, being careful not to dislodge the tube. Remove the underlying gauzes, which may contain drainage. Discard soiled dressings in the moistures-resistant bag. 8. The physician will a. Don sterile gloves. b. Hold the chest tube with forceps. c. Cut the suture holding the tube in place. d. Instruct the client to either inhale or exhale fully and hold the breath while removing the tube. e. Place the prepared petrolatum gauze dressing over the insertion site immediately after tube removal. 9. While the physician is removing the tube, remove gloves and prepare three 15-cm (6 in.) strips of air-occlusive tape.

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PROCEDURE 10. After the gauze dressing is applied, completely cover it with the air-occlusive tape. 11. If a specimen is required for culture and sensitivity, use a swab to obtain drainage from inside the chest tube, while the physician holds the tube. 12. Monitor the vital signs, and assess the quality of the respirations as health indicates, eg, every 15 minutes for the first hour following tube removal and then less often. 13. Auscultate the clients lungs every hour for the first 4 hours to assess breath sounds and the adequacy of ventilation in the affected lung. 14. Assess the client regularly for signs of pneumothorax, subcutaneous emphysema, and infection.
15. Document the date and time of chest tube insertion or removal and the name of the physician. For insertion, document the insertion site, drainage system used, presence of bubbling, vital signs, breath sounds by auscultation, and any other assessment findings. For removal, document the amount, color, and consistency of drainage, vital signs, and the specimen obtained for culture, if taken.

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

Assess the clients vital signs, bilateral breath sounds and chest movements, skin color, character of sputum, and level of discomfort before and after chest tube insertion and removal. Maintain sterile technique.

For chest tube insertion: Apply appropriate dressings to the chest tube site. Tape the chest tube to the client appropriately to prevent dislocation. Tape all chest and drainage tube connections. Place rubber-tipped chest tube clamps at the bedside.

For chest tube removal: Administer ordered analgesic before the procedure. Clamp the chest tube securely before the procedure. Quickly provide an airtight dressing over the insertion site after removal.

ESTABLISHING A CHEST DRAINAGE SYSTEM Definition: Before setting up a chest drainage system, determine from the physicians orders the type of system and whether suction is required. Surgical aseptic technique is followed strictly when setting up chest drainage to prevent microorganisms from entering the system and subsequently entering the clients pleural cavity. Equipment: Sterile distilled water Adhesive tape Sterile clear plastic tubing Sterile tubing connectors A drainage rack. Racks are supplied by the manufacturer for disposable unit systems Two rubber-tipped Kelly clamps Suction apparatus, if ordered The drainage system

If the agency does not supply partially assembled systems, the following equipment is needed: For a one-bottle system: A sterile 2-L bottle A sterile short glass tube A sterile long glass tube A sterile rubber stopper with two holes For a two-bottle gravity system: Two sterile 2-L bottles Sterile clear plastic tubing Three sterile short glass tubes One sterile long glass tube Two sterile rubber stoppers with two holes

For a two-bottle suction system: Two sterile 2-L bottles Sterile clear plastic tubing Three sterile short glass tubes Two sterile long glass tube Two sterile rubber stoppers: one with two holes

Two sterile long glass tubes Three sterile rubber stoppers: with two holes, and one with three holes

For a Pleur-evac or Argyle system Sterile distilled water A sterile 50-ml Asepto (bulb) syringe

For a three-bottle system: Three sterile 2-L bottles Sterile clear plastic tubing Five sterile short glass tubes

For a Thora-Drain III system: Bottle of sterile distilled water or normal saline. This system has larger caps through which water can be poured directly from the bottle.

PROCEDURE One-Bottle System: 1. Fill the bottle with about 300 ml of sterile distilled water 2. Insert one short glass tube and one long glass tube through the rubber stopper. 3. Attach the rubber stopper with the glass tubes to the bottle. Make sure the long glass tube is submerged in the water about 2 cm (0.75 in.)

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PROCEDURE 4. Place the bottle in the drainage rack on the floor beside the clients bed. 5. Connect the clear plastic tubing to the long glass tube and to the clients chest tube. 6. Securely tape all tubing connections. 7. Place a strip of adhesive tape vertically on the drainage bottle to mark and assess the fluid level at prescribed periods. 8. Two-Bottle Gravity System 9. Follow steps 1-3 to set up the water-seal bottle. 10. Insert two short glass tubes through the second rubber stopper, attach the stopper securely to the collection bottle, and place both bottles in the drainage rack on the floor. 11. Connect clear plastic tubing to the long glass tube in the water- seal bottle, and attach it to the nearer short glass tube in the collection bottle.

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PROCEDURE 12. Connect clear plastic tubing to the remaining short glass tube in the collection bottle and to the clients chest tube. 13. Follow steps 6-7. Two Bottle Suction System: 14. Follow steps 1-3 to set up the water-seal (and collection) bottle. 15. Fill the suction-control bottle with sterile distilled water to the level for the required suction. 16. Insert one long glass tube and two short glass tubes through the second stopper, attach the stopper securely to the suctioncontrol bottle, and place both bottles in the drainage rack on the floor.

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PROCEDURE 17. Connect the clear plastic tubing: a. Between the short glass tube in the water-seal bottle and one of the short glass tubes in the suction-control bottle. b. Between the long glass tube in the water-seal bottle and the clients chest tube. c. Between the remaining short glass tube of the suctioncontrol bottle and the suction source. 18. Follow steps 6-7. Three Bottle System: 19. Follow steps 1-3 to set up the water-seal bottle. 20. Insert two short glass tubes through the remaining two-hole stopper, and attach the stopper securely to the collection bottle. 21. Insert two short glass tubes and one long glass tube through the three-hole rubber stopper.

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PROCEDURE 22. Add sterile distilled water to the sucton-control bottle. Make sure the long glass tube will be submerge to the ordered length; then attach the stopper securely to this bottle. 23. Place the bottles on a drainage rack on the floor, with the water-seal bottle in the middle. 24. Connect the clear plastic tubing: a. Between the long glass tube of the water-seal bottle and the nearer short glass tube of the collection bottle. b. Between the remaining short glass tube of the collection bottle and the clients chest tube. c. Between the short glass tube of the water-seal bottle and the nearer short glass tube of the suction-control bottle. d. Between the remaining short glass tube of the suctioncontrol bottle and the suction source. 25. Follow steps 6-7. 26. Pleur-evac, Argyle, or Thoro-Drain III System

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PROCEDURE 27. Open the package unit. 28. Remove the plastic connector or cap from the tube attached to the water-seal chamber. (The Argyle system has two waterseal chambers; do both.) 29. Using a 50-ml Asepto syringe with the bulb removed, fill the water-seal chamber with sterile distilled water up to the 2-cm mark. The Thoro-Drain III System has a line indicating the amount of water required. Use of an Asepto syringe is not necessary for this system. Then reattach the plastic connector or cap. 30. If the physician has ordered suction, remove the diaphragm (cap) on the suction-control chamber. 31. Using the 50-ml syringe if required, fill the suction-control chamber with distilled water to the ordered level or 20-25 cm, and replace the cap. 32. Place the system in the rack supplied, or attach it to the bed frame. 33. Attach the longer tube from the collection chamber to the clients chest tube.

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PROCEDURE 34. If suction is ordered, attach the remaining shorter tube to the suction source, and return it on. Inspect the suction chamber for bubbling. Gentle bubbling indicates an appropriate suction level. 35. If suction has not been ordered, keep the shorter rubber tube unclamped. 36. Tape all tubing connections, but do not completely cover the entire tubing connectors with tape. 37. Unclamp the clients chest tube and inspect the system for air leaks. 38. Document the establishment of the chest drainage system and the nursing assessments.

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Critical Elements of Establishing A Chest Drainage System: Maintain sterility of the distilled water, the inside of collection bottles, rubber stoppers, and the ends of tubing, tubing connectors, and glass rods. Set up the prescribed system correctly: Securely tape all tubing connections, allowing visibility of drainage through tubing connectors. If suction is used, inspect the suction chamber for continuous gentle bubbling to ensure appropriate suction level.

MONITORING A CLIENT WITH CHEST DRAINAGE Definition: Policies and procedures vary considerably from agency to agency in regard to chest drainage interventions. Certain interventions, such as milking a chest tube to maintain patency, may be prohibited. The nurse must therefore review agency policies before intervening. Equipment: Two rubber-tipped Kelly clamps A sterile petrolatum gauze A sterile drainage system Antiseptic swabs Sterile 4 x 4 gauzes Air-occlusive tape A mechanical chest tubing stripper, if ordered Specimen supplies, if needed: . A povidone-iodine swab . A sterile #18 or #20 gauge needle . A 3-or 5-ml syringe . A needle protector . A label for the syringe . A laboratory requisition

Intervention: Essential data include . Vital signs for baseline data and then every 4 hours. . Breath sounds. Auscultate bilaterally for baseline data. Diminished or absent breath sounds indicate inadequate lung expansion and recurrent pneumothorax after chest drainage is established. . Clinical signs of pneumothorax before and after chest tube insertion. Leakage or blockage of a chest tube can seriously impair ventilation. Signs include sharp pain on the affected side; weak, rapid pulse; pallor; vertigo; faintness; dyspnea; diaphoresis; excessive coughing; and blood-tinged sputum. . Chest movements. A decrease in chest expansion on the affected side indicates pneumothorax. . Dressing site. Inspect the dressing for excessive and abnormal drainage, such as bleeding or foul-smelling discharge. Palpate around the dressing site and listen for a crackling sound indicative of subcutaneous emphysema can result from a poor seal at the chest tube insertion site. It is manifested by a crackling sound that is heard when the area around the insertion site is palpated. . Level of discomfort. Analgesics often need to be administered before the client moves or does deepbreathing and coughing exercises.

PROCEDURE Safety Precautions: 1. Keep two 15- to 18-cm (6-7-in.) rubber-tipped Kelly clamps within reach at the bedside, to clamp the chest tube in an emergency, eg, if leakage occurs in the tubing. 2. Keep one sterile petrolatum gauze within reach at the bedside to use with an air-occlusive material if the chest tube becomes dislodged. 3. Keep an extra drainage system unit available in the clients room. In most agencies the physician is responsible for changing the drainage system except in emergency situations, such as malfunction or breakage. In these situations: a. Clamp the chest tubes b. Reestablish a water-sealed drainage system. c. Remove the clamps, and notify the physician. 4. Keep the drainage system below chest level and upright at all times, unless the chest tubes are clamped.

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PROCEDURE 5. If the chest tube becomes disconnected from the drainage system: a. Have the client exhale fully. b. Clamp the chest tube close to the insertion site with two rubber-tipped clamps placed in opposite directions. c. Quickly clean the ends of the tubing with an antiseptic, reconnect them, and tape them securely. d. Unclamp the tube as soon as possible. e. Assess the client closely for respiratory distress. 6. If the chest tube becomes dislodged from the insertion site: a. Remove the dressing, and immediately apply pressure with the petrolatum gauze, your hand, or a towel. b. Cover the site with sterile 4 x 4 gauze squares. c. Tape the dressing with air-occlusive tape. d. Notify the physician immediately e. Assess the client for respiratory distress every 15 minutes or as health indicates.

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PROCEDURE 7. Do not empty a drainage bottle unless there is an order to do so. Commercial systems cannot be emptied. 8. If the drainage system is accidentally tipped over: a. Immediately return it to the upright position. b. Ask the client to take several deep breaths.

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c. Notify the nurse in charge and the physician. d. Assess the client for respiratory distress.

MONITORING AND MAINTAINING THE DRAINAGE SYSTEM PROCEDURE 1. Check that all connections are secured with tape. 2. Milk or strip the chest tubing as ordered and only in accordance with agency protocol. Too vigorous milking can create excessive negative pressure that can harm the pleural membranes and/ or surrounding tissues. Always verify the physicians orders before milking the tube; milking of only short segments of the tube may be specified. To milk a chest tube, use a mechanical stripper, or follow these steps: a. Lubricate about 10-20 cm (4-8 in.) of the drainage tubing with lubricating gel, soap, or hand lotion, or hold an alcohol sponge between your fingers and the tube. b. With one hand, securely stabilize and pinch the tube at the insertion site. c. Compress the tube with the thumb and forefinger of your other hand and milk it by sliding them down the tube, moving away from the insertion site. d. If the entire tube is to be milked, reposition your hands farther along the tubing, and repeat steps a-c in progressive overlapping steps, until you reach the end of the tubing. RATIONALE 1 2 3 4 5

PROCEDURE 3. Inspect the drainage in the collection container at least every 30 minutes during the first 2 hours after chest tube insertion and every 2 hours thereafter. Every 8 hours mark the time, date, and drainage level on a piece of adhesive tape affixed to the container, or mark it directly on a disposable container. Note any sudden change in the amount or color of the drainage. If drainage exceeds 100 ml/hour or if a color changes indicates hemorrhage, notify the physician immediately. 4. In gravity drainage systems, check for fluctuation (tidaling) of the fluid level in the water-seal glass tube of a bottle system or the water-seal chamber of a commercial system as the client breathes. Normally, fluctuations of 5-10 cm occur until the lungs has reexpanded. In suction drainage systems, the fluid line remains constant.

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5. To check for fluctuation in suction systems, temporarily disconnect the system. Then observe the fluctuation.

PROCEDURE 6. Check for intermittent bubbling in the water of the water-seal bottle or chamber. 7. Check for gentle bubbling in the suction-control bottle or chamber. 8. Inspect the air vent in the system periodically to make sure it is not occluded. A vent must be present to allow air to escape. 9. Inspect the drainage tubing for kinks or loops dangling below the entry level of the drainage system.

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Detecting Air Leaks: Continuous bubbling in the water-seal collection chamber normally occurs for only a few minutes after a chest tube is attached to drainage, since fluid and air initially rush out from the intrapleural space under high pressure. Continuous bubbling that persists indicates an air leak. PROCEDURE 1. To determine the source of an air leak follow the next steps sequentially. a. Check the tubing connection sites. Tighten and retape any connection that seems loose. b. If bubbling continues, clamp the chest tube near the insertion site and see if the bubbling stops while the client takes several deep breaths. Chest tube clamping must be done only for a few seconds at a time. c. If bubbling stops, follow step 20. The source of the air leak is above the clamp, ie, between the clamp and the client. It may be either at the insertion site or inside the client. d. If bubbling continues, follow step 21. The source of the air leak is below the clamp, ie, in the drainage system below the clamp. RATIONALE 1 2 3 4 5

PROCEDURE 2. To determine whether the air leak is at the insertion site or inside the client: a. Unclamp the tube and palpate gently around the insertion site. If the bubbling stops, the leak is at the insertion site. To remedy this situation, apply a petrolatum gauze and a 4 x 4 gauze around the insertion site and secure these dressings with adhesive tape. b. If the leak is not at the insertion site, it is inside the client and may indicate a dislodged tube or a new pneumothorax, a new disruption of the pleural space. In this instance leave the tube unclamped, notify the physician, and monitor the client for signs of respiratory distress. 3. To locate an air leak below the chest tube clamp: a. Move the clamp a few inches farther down and keep moving it downward a few inches at a time. Each time the clamp is moved, check the water-seal collection chamber for bubbling. The bubbling will stop as soon as the clamp is placed between the air leak and the water-seal drainage. b. Seal the leak when you locate it by applying tape to that portion of the drainage tube.

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

clamped, the air leak is in the drainage device. To remedy this situation the drainage system must be replaced and the physician notified. Client Care: 4. Encourage deep-breathing and coughing exercises every 2 hours. Have the client sit upright to perform the exercises, and splint the tube insertion site with a pillow or with a hand to minimize discomfort. 5. While the client takes deep breaths, palpate the chest for thoracic expansion. Place your hands together at the base of the sternum so that your thumbs meet. As the client inhales, your thumbs should separate at least 2.5-5 cm (1-2 in.). Note whether chest expansion is symmetric. 6. Reposition the client every 2 hours. When the client is lying on the affected side, place rolled towels beside the tubing. 7. Assist the client with range-of-motion exercises of the affected shoulder three times per day to maintain joint mobility.

PROCEDURE 8. When transporting and ambulating the client: a. Attach rubber-tipped forceps to the clients gown for emergency use. b. Keep the water-seal unit below chest level and upright. c. If it is necessary to clamp the tube, remove the clamp as soon as possible. d. Disconnect the drainage system from the suction apparatus before moving the client, and make sure the air vent is open. Take a Specimen of Chest Drainage: 9. Specimens of chest drainage may be taken from a disposable chest drainage system, since these systems are equipped with-sealing ports. If a specimen is required: a. Use a povidone-iodine swab to wipe the self-sealing diaphragm on the back of the drainage collection chamber. Allow it to dry. b. Attach a sterile #18 or #20 gauge needle to a 3- or 5-ml syringe, and insert the needle into the diaphragm. c. Aspirate the specimen, attach the needle protector, label the syringe, and send it to the laboratory with the appropriate requisition form.

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Critical Elements of Monitoring A Client With Chest Drainage: Assess the client for signs of pneumothorax. Keep two rubber-tipped Kelly clamps, one sterile petrolatum gauze, and an extra drainage system available for emergency situations. Always keep the drainage system below chest level. Empty drainage systems only if ordered. Make sure the system is airtight. Make sure there is fluctuation or bubbling in the appropriate bottle or chambers. Keep air vents open. Prevent tubing obstruction. Know what to do if the chest tube becomes disconnected or dislodged or if the drainage system tips over.

ASSISTING WITH A CAST APPLICATION

Purpose: To support and protect injured bones and soft tissue, reducing pain, swelling, and muscle spasm, maintains alignment and prevents movement of the bones while it heals.

Special Considerations: Before and after cast application: 1. Assess for signs of restricted circulation 2. Take the clients pulse rate, respiratory rate, and blood pressure Administer ordered analgesics before cast application Before cast is applied, remove clothing from the body area and rings from fingers of the affected limb Ensure safe storage of the clients valuables Wash the skin area to receive the cast and dry it thoroughly if ordered Stabilize and support the limb appropriately during cast application. Remove excess cast material from clients skin after application. Document assessment and interventions.

Equipment: Rolls of cast materials Plastic lined bucket of water at the prescribed 1. Tepid water for Plaster of Paris and water activated 2. cast or A thermostatically controlled hydro collator or a boiler or cooking pot with a temperature- regulating thermometer for a thermoplastic cast. Stockinet Cotton sheet wadding or padding Felt padding (optional) Plaster Splints (optional) Moisture- resistant drapes Rubber gloves Plastic aprons Water- soluble lubricant Plaster knife Large bandage scissors Pillows Damp cloth 1 2 3 4 5 Cool water at 26 C (80 F) for polyester and cotton

temperature:

PROCEDURE 1. Explain the procedure to the client, including the length of time the cast material requires for drying. Explain that the cast may feel warm during and after the application 2. Provide an analgesic as ordered 3. Assist the client into a comfortable sitting or lying position 4. Remove clothing from the body area and rings from fingers of the affected limb and give them to a family member or store safely in a locked safe. 5. Support the part to receive the cast

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PROCEDURE 6. Wash the skin area, and dry it thoroughly, if ordered. If there is no open wound, powder may be applied. 7. Provide stockinet of the correct size if used, and cut it several inches longer than the length of the extremity so that it will extend beyond the plaster edges. Then roll the stockinet to facilitate application. 8. Provide sheet wadding and felt pads as needed. Usually 2- 3 layers are applied. 9. Provide gloves for the physician prior to application of the cast material 10. Hand the physician the casting material or place the material within the physicians reach. Preparation of cast material varies depending on the type of casting material used 11. Squeeze a generous amount of water-soluble lubricant on the physicians gloves as requested

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PROCEDURE 12. Support the limb while the physician applies the stockinet, padding, and cast material. With one hand, grasp the clients toes for a leg cast or fingers for an arm cast, and with the other hand support beneath the limb areas on which the physician is not working. 13. After the cast is applied, pull the stockinet out over the proximal and distal cast opening edges, while the physician secures it in place with one or two layers of cast material. 14. Remove any excess cast material deposited accidentally on the clients skin. 15. Assess the client with special reference to the cast.

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16. Provide firm support for the cast.

17. Gather and dispose the used materials appropriately

18. Document

CLIENT CARE IMMEDIATELY AFTER A CAST APPLICATION Equipment: Soft, pliable pillows RATIONALE 1 2 3 4 5

PROCEDURE 1. Assess the toes and fingers for nerve or circulatory impairments every 30 mins for several hours following application and then every 3 hours for the first 24-48 hours or until all signs and symptoms of impairment are negative 2. Immediately after the cast is applied, place it on pillows. Avoid using plastic or rubber pillows. 3. Support the cast in the palms of your hands rather than your fingertips 4. Control swelling by elevating arms or legs on pillows or, for leg fracture, by elevating the foot of the bed 5. Report excessive swelling and indications of neurovascular impairments to the physician or nurse in charge. 6. Apply ice packs to a hip spica cast

PROCEDURE 7. Expose the cast to the circulating air 8. Check agency policy about the recommended turning frequency for clients with different kinds of cast 9. Avoid the use of artificial means to facilitate drying. This means including fans, hairdryers, infrared lamps, and electric heaters 10. Monitor drainage for 24-72 hours after surgery. Outline the stained area every 8 hours. 11. Never ignore any complaints of pain, burning or pressure. If patient is unable to communicate, be alert to changes in temperament, restlessness, or fussiness. 12. Give pain medications selectively 13. Do not disregard the cessation of persistent pain or discomfort complaints 14. Document

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CONTINUING CARE FOR CLIENTS WITH CASTS

Special Considerations: Remove crumbs of plaster from the skin, petal rough cast edges. For bed- confined patients, provide skin care over all bony prominences and turn the clients at least every 4 hours Keep the cast clean and dry Encourage clients to move toes or fingers of the casted extremity frequently Provide necessary instructions about cast care, ways to move safely, activity allowed, exercises, elevating the involved extremity, signs of neurovascular problems, ways to handle itching

Equipment: Rubbing alcohol Mineral, olive, or baby oil to apply to the skin after cast removal Adhesive tape Scissors Damp washcloth for Plaster of Paris Warm water and a mild soap for synthetic casts Pillows Fracture pan RATIONALE 1 2 3 4 5

PROCEDURE 1. Wash crumbs of plaster from the skin with a damp cloth and feel along the cast edges or areas that press into the clients skin. It may be necessary to use a duck billed cast bender to bend cast edges that may irritate the skin 2. Cover rough edges of the cast when it is dry. If the stockinet has not been used to line the cast, petal the edge with small strips of adhesive tape.

PROCEDURE 3. Check the cast daily for foul odors 4. Discourage the patient from using long sharp objects to scratch under the cast 5. When cast is removed, dry, flaky and encrusted skin is observed, remove this debris gently and gradually by: a. Apply oil (mineral, olive, or baby) b. Soak the skin with warm water and dry it c. Caution the client not to rub the area too vigorously d. repeat steps a and b for several days Keeping the Cast Clean and Dry 6. Tub baths and showers are contraindicated. POP cast is kept clean by wiping it with a damp cloth. Place a bib or towel over a body cast to catch spills. If a spill does wet the cast, allow the area to air dry. 7. Use a fracture bedpan for people with long leg, hip spica, or body casts.

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PROCEDURE 8. Before placing the client on the bed pan, tuck plastic or other waterproof material around the top of a long leg cast or in around the perineal cutout. Remove plastic when elimination is completed

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9. For people with long leg casts, keep the cast supported on pillows while the client is on bed pan.

10. For clients with hip spica casts, support both extremities and the back on pillows so that they are as high as the buttocks

11. When removing the bedpan, hold it securely while the client is turning or lifting the buttocks. After removing the bedpan, thoroughly clean and dry the perineal area

PROCEDURE 12. Synthetic casts: Synthetic casts can be cleaned readily and may, with the physicians permission, be immersed in water if polypropylene stockinet and padding were applied. a. Wash the soiled area with warm water and a mild soap

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b. Thoroughly rinse the soap from the cast

c. Dry thoroughly to prevent skin maceration and ulceration under the cast.

d. If the cast is immersed in water, the cast and underlying padding and stockinet must be dried thoroughly. First blot excess water from the cast with a towel. Then use a handheld blow-dryer on the cool or warm setting, directing the air stream in a sweeping motion over the exterior of the cast for about 1 hour or until the client no longer feels a cold clammy sensation like that produced by a wet bathing suit.

PROCEDURE Turning and Positioning Clients 13. Place pillows in such a way that: a. Body parts press against the cast edges as little as possible. b. Toes, heels, elbows, etc., are protected from pressure against bed surface. c. Body alignment is maintained

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14. Plan and implement a turning schedule incorporating all possible positions.

Exercise 15. Unless contraindicated, encourage active ROM exercises for all joints on the affected extremities, as well as on the joints proximal and distal to the cast

16. Encourage the client to move the toes and/or fingers of the casted extremity as frequently as possible.

PROCEDURE 17. With the physicians approval, teach isometric (muscle setting) exercises.

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18. Teach isometric exercises on the clients unaffected limb before the person applies it to the affected limb. Demonstrate muscle palpation while the client is carrying out the exercise.

19. Document assessments and nursing implementations on the appropriate records.

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

Guidelines: All traction should have a counter traction to prevent the client from being pulled by the force of traction against the pulleys or the bed, thus negating the traction To apply and maintain the correct amount of traction, all traction weights should be hanging freely and the ropes should not touch any part of the bed. The traction force should follow an established line of pull. The line of pull determines the position and alignment of the body as prescribed by the physician Traction should always be applied while the client is in proper body alignment in a supine position

Equipment: Protective skin devices, e.g. heel protectors Trapeze Rubbing alcohol Antiseptic agent Sterile gauze dressing Picking forceps RATIONALE 1 2 3 4 5

PROCEDURE 1. Inspect the traction apparatus regularly, whenever you are at the bedside or at prescribed intervals, such as every 2 hours 2. Provide protective devices and measures to safeguard the skin. E.g. heel protectors, pillows, etc) massage the skin.

PROCEDURE 3. Maintain the client in supine position unless there are other orders 4. Provide a trapeze to assist the client to move and lift the body for back care if the person is unable to turn, e.g., if the client has balanced suspension traction 5. Do not remove skeletal and adhesive skin traction. 6. Non adhesive skin traction is intermittent and can be removed; check agency policy about any orders required. Remove weights first; then unwrap the bandage and provide skin care. Rewrap the limb and slowly reattach the weights 7. Provide pin site care and this varies with different hospital protocols. Carefully inspect the site Use sterile technique Remove crusts with a rolling technique Cover sites with a sterile barrier Determine the frequency of care by the amount of drainage

RATIONALE

PROCEDURE 8. Teach client deep breathing and coughing.

RATIONALE

9. Teach the client appropriate exercises

10. Document