Ateneo de Zamboanga University

NURSING SKILLS OUTPUT (NSO)

NEBULIZATION

I. DESCRIPTION

If you have asthma, your doctor may prescribe a nebulizer as treatment or breathing
therapy. The device delivers the same types of medication as metered-dose inhalers (MDIs),
which are the familiar pocket-sized inhalers. Nebulizers may be easier to use than MDIs,
especially for children who aren’t old enough to properly use inhalers, or adults with severe
asthma.

A nebulizer turns liquid medicine into a mist to help treat your asthma. They come in electric or
battery-run versions. They come in both a portable size you can carry with you and a larger size
that’s meant to sit on a table and plug into a wall. Both are made up of a base that holds an air
compressor, a small container for liquid medicine, and a tube that connects the air compressor
to the medicine container. Above the medicine container is a mouthpiece or mask you use to
inhale the mist.

II. MATERIALS/EQUIPMENTS

 Nebulizer

III. PROCEDURE

- Explain the procedure to the patient and obtain informed consent.

- Prepare the equipment (Fig 1).

- Check the prescription chart to ensure that the nebulised drug has been prescribed and is due to be
administered (Fig 2).

- Check the expiry date of the solution to be nebulised.

- Ensure the patient is in a comfortable position, as upright as possible.

- If a nebulised bronchodilator is being administered, it is standard practice to obtain a pre and post-
administration peak expiratory flow (PEF) reading (Jevon, 2007).

- Place the compressor near the patient and plug it into the mains. Clean following local infection control
policy and ensure the filter is in place.
- Assemble the nebuliser.

- Connect the tubing between the nebuliser and the compressor.

- Unscrew the top and pour the prescribed solution into the nebuliser chamber (Fig 3).

- Ensure the top is firmly reapplied.

- Turn on the compressor: the solution to be nebulised should begin to ‘mist’.

- Assist the patient to apply the mask or mouthpiece (Fig 4).

- Remind the patient that it is important to breathe through the mouth and not to talk during the
procedure (Porter-Jones, 2000).

- Ask the patient to tap on the nebuliser chamber every few minutes - this will help to prevent
condensation developing.

- Once ‘misting’ has stopped, switch off the compressor and remove the mask or mouthpiece. There is
usually a small volume of solution at the bottom of the chamber.

- Wash and dry the nebuliser chamber and place the pack in its package for storage.

- Offer the patient a drink.

- Document that the nebuliser has been administered following local protocols.

- In some hospitals it is usual practice to repeat the measurement of PEF (Fig 5).

- Wash and dry hands.

IV. DIAGRAM/ILLUSTRATIONS
V. NURSING RESPONSIBILITIES

1. BEFORE PRECEDURE

 Verify the order and as well as identify the patient

 Prepare necessary materials

2. DURING PROCEDURE

 Observe sterile technique for the whole procedure

3. AFTER PROCEDURE

 Give water to the patient

 Advise the patient to take a rest after taking nebulizer.

Sources:

https://www.nursingtimes.net/clinical-archive/respiratory/respiratory-procedures-use-of-a-
nebuliser/200213.article

http://emedicine.medscape.com/article/1902703-overview#a2
 Ateneo de Zamboanga University

NURSING SKILLS OUTPUT (NSO)

SUCTION ORAL/ENDOTRACHEAL

I. DESCRIPTION

Endotracheal tubes (ET tubes or ETT, also known as tracheal tubes or TTs) consist of a transparent
airway tube with graduated markings which posesses a standard connector at one end and may possess
a hole in the side, near the tip (known as the 'Murphy eye'). Most tubes available are radio opaque.
Some ETTs are 'plain' as described above but 'cuffed' versions also exist that possess an inflatable cuff at
the other end of the tubing, which is attached to a pilot balloon via a narrow inflatable tube.
In addition, ET tubes exist that are reinforced with spiral wire, designed to minimise crushing and kinking
and to withstand high pressure levels

II. MATERIALS/EQUIPMENTS

 Mask
 Laryngoscopes
 Endotracheal tubes
 Ancillary equipment

III. PROCEDURE

 Where possible, this procedure requires two clinicians. If clinician deems it necessary, she/he
may undertake the procedure without assistance and in this situation should alert other nearby
members of staff that ETT suction is occurring.
 Explain to parents what is about to occur.
 To determine suction catheter size:

ETT Size (mm) Suction Catheter Size

2.5 5 FG

3.0 - 3.5 6 - 7 FG
4.0 - 4.5 8 FG

 Set the suction pressure at -80-100 cmH2O. Suction pressure may be lower for a small or
unstable infant, or higher to remove thick or tenacious secretions. Maximum pressure should
not be higher than -200 cmH2O.
 Pre-silence alarms.
 Primary clinician performs hand hygiene, dons gloves on both hands and protecting key parts
attaches appropriate sized suction catheter to suction tubing. Ensuring that the suction catheter
does not touch anything that could contaminate it e.g. bed linen.
 Observe pre-suction physiological parameters.
 When the primary clinician and assistant are ready, assistant disconnects ETT from ventilator
tubing at ETT adaptor. For HFOV and HFJV use the suction port at the end of the ETT (closed
suction) unless otherwise ordered by the medical staff (See Special Considerations).
 Primary clinician passes suction catheter to predetermined length, ensuring catheter is only
passed the length of the ETT.
 Applying negative pressure, primary clinician gently rotates suction catheter as it is being
withdrawn from the ETT
 Negative pressure should only be applied when the suction catheter is being withdrawn
from the ETT. For infants on HFJV see Special Considerations for suction procedure
recommendatio
 Duration of negative pressure should not exceed 6 seconds to prevent hypoxaemia
 Repetitive catheter passes are not used unless the volume of secretions indicates
another pass, or the clinician determines another pass is necessary
 To prevent accidental extubation, assistant gently holds infant’s head in steady position and
holds ETT steady while primary clinician suctions ETT.
 Assistant reconnects ventilator tubing to ETT when ETT suction complete, and continues to
provide containment and comfort to the infant.
 Allow the infant to rest prior to oropharyngeal and nasopharyngeal suction. The primary
clinician suctions infant’s oropharynx and nasopharynx. Oropharyngeal and nasopharyngeal
suction allows removal of secretions which accumulate in the oropharynx and nasopharynx. A
size 8 or 10 FG tube may be used to suction the oropharynx.
 Observe infant’s post-suction physiological parameters.
 Use a small amount of sterile water if needed to clear secretions from suction tubing.
 Turn off vacuum pressure. Dispose of contaminated catheter, remove gloves and perform hand
hygiene.
 Adjust ventilator settings to pre-suctioning baseline (if settings have been adjusted) when
indicated by stabilisation of infant’s oxygen saturations and heart rate.
 Ensure infant is left in a contained and comfortable position.
 Document effectiveness of and tolerance to suctioning.
 If the infant requires ETT suction, and a second clinician is unable to assist, the procedure is as
above, however the primary clinician will need to detach the ETT from the ventilator with one
hand, steady the tube using the same hand and insert the catheter to predetermined length
using “clean” hand. Care is especially required to steady the ETT and infant’s head to ensure the
infant does not accidentally self-extubate.
IV. DIAGRAM/ILLUSTRATION

V. NURSING RESPONSIBILITIES

BEFORE PROCEDURE

 Verify the order and as well as identify the patient

 Prepare necessary materials

DURING PROCEDURE

 Observe sterile technique for the whole procedure

AFTER PROCEDURE

 Document findings after the procedure

Sources:

http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Endotracheal_tube_suction_o
f_ventilated_neonates/
 Ateneo de Zamboanga University

NURSING SKILLS OUTPUT (NSO)

THORACOSTOMY TUBE CARE

I. DESCRIPTION

Tube thoracostomy is often used to treat pleural effusion, pneumothorax, hemothorax,

hemopneumothorax, and empyema. The use of chest tubes has been described as early as the
Hippocrates era (460 BCE) when metal chest tubes were used for the treatment of
empyema. [1, 2] Playfair is credited as being the first physician to use a water-sealed chest drainage
system in 1873 for treating a child with empyema thoracis. Chest tube placement techniques evolved
and were perfected during the 1918 flu epidemic in World War I and then during the management of
combat injuries in World War II.

II. MATERIALS/EQUIPMENT

 Chest drainage bottles (see description of drainage system below)

 Adequate length (1.5-2 m) of sterile, transparent, plastic tubing (eg, vinyl/silastic)
 Appropriate sterile connectors
 Adhesive tape
 Angled clamps (2) for clamping the tube when needed
 Distilled water to fill in the drainage bottle

III. PROCEDURE

1. Perform hand hygiene

2. Opening dressing pack and add sterile equipment and 0.9% saline
3. Don disposable gloves
4. Remove all dressings around the area
5. Clamp drain tubing
6. If there are multiple drains insitu, clamp all drains before removal. Once the required drains are
removed, unclamp remaining drains
7. Remove disposable gloves, perform hand hygiene and don sterile gloves
8. Place sterile towel under tubes
9. Clean around catheter insertion site and 1-2cm of the tubing with age appropriate skin cleaning
solution
10. If purse string present (cardiac patients) unwind in preparation for assistant to tie
11. Remove suture securing drain (ensuring purse string suture not cut)
12. Instruct patient exhale and hold if they are old enough to cooperate; if not, time removal with
exhalation as best as possible.
13. Pinching the edges of the skin together, remove the drain using smooth, but fast, continuous
traction.
 14. The assistant pulls purse string suture closed as soon as the drain is removed, tying 2 knots and
ensuring the suture is not pulled too tight. Cut tails of suture about 2cm from knot
15. If there is no purse string present remove drain and quickly seal hole with occlusive dressing
16. Instruct patient to breathe normally again
17. Apply occlusive dressing (bandaid for cardiac children) over site
18. Remove and discard equipment into a yellow infectious waste bag and tie
19. Perform hand hygiene

IV. DIAGRAM/ILLUSTRATION

V. NURSING RESPONSIBILITIES

BEFORE PROCEDURE

 Ensure Patient is fasted, has been administered adequate pain control, sedation and distraction
therapy
 Consider environment i.e. treatment room, privacy screens if in ward area etc
 Heparin infusions for cardiac patients should not be discontinued prior to drain removal

DURING PROCEDURE

 Observe sterile technique for the whole procedure

AFTER PROCEDURE

 Attend to patients comfort and sedation score as per procedural sedation guideline
  Clinical status is the best indicator of reaccumulation of air or fluid. CXR should be performed if
patient condition deteriorates
 Monitor vital signs closely (HR, SpO2, RR and BP) on removal and then every hour for 4 hours
post removal, and then as per clinical condition
 Document the removal of drain in the LDA flowsheet in EMR
 Remove sutures 5 days post drain removal
 Dressing to remain insitu for 24 hours post removal unless contaminated
 Complications post drain removal include pneumothorax, bleeding and infection of the drain
site

Sources:

http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Chest_Drain_Management/