CLINICAL

PROCEDURES

OBJECTIVES

• To identify some common clinical procedures known as

diagnostics exams

• To properly identify the terms.

• To know the use of a diagnostics exam.

• To be knowledgeable on the nursing responsibilities involve in

each diagnostics.

• To know and be able to demonstrate the proper documentation

on each diagnostics.

OXYGEN THERAPY

The administration of oxygen (therapy) to patients needing additional O2 supply to meet

patients cardio-respiratory O2 demand via different delivery systems.

Indications:

1. Cardio-respiratory emergency – hypoxemia (low blood oxygen saturation less than SaO2 95

and PaO2 85.

2. Increased ventilator effort – dyspnea

3. Acute respiratory distress syndrome

4. Alveolar hypoventilation

5. Myocardial infarction

6. Cardiac arrhythmia

7. Respiratory diseases which results to respiratory acidosis owing to increased blood acid.

8. Massive trauma – high fever and burns

9. Carbon monoxide poisoning and sickle cell crisis – reduced blood oxygen carrying capacity

owning to haemoglobin and iron oxygen binding capability.

OXYGEN DELIVERY SYSTEMS

• Nasal cannula – oxygen is delivered thru cannula into patients nostrils

• Advantage

• Safe and simple

• Easily operated and tolerated

• Effective for low oxygen concentration

• Allows patient movement

• Inexpensive and disposable

• Disadvantage

• Can’t deliver higher than 40% O2 concentration

• May cause headaches or dry mucous membranes if flow rate exceeds 6L/minute

• Dislodges easily

• Simple mask – oxygen flows through an entry port at the bottom

and exits at large holes on the sides of mask.

• Advantage

• Can deliver 40% to 60% of oxygen concentration

• Disadvantage

• Hot and confining

• May irritate patients skin

• Interferes with talking and eating

• Tight seal required for higher oxygen may cause

discomfort.

• Nonbreather mask – the patient only breathes air from the bag through one-

way valves.

• Advantage

• Delivers the highest possible oxygen 60% to 90% if short to

intubation and mechanical ventilation

• Effective for short-term therapy

• Doesn’t dry mucous membranes

• Can be converted to partial rebreather mask

• Disadvantage

• Requires tight seal that may cause discomfort and difficult to

maintain

• May irritate patients skin

• Interferes with talking and eating

• CPAP mask – allows the spontaneous breathing patient to receive

continuous positive airway (CPAP) pressure with or without artificial airway.

• Advantage

• Noninvasively improves arterial oxygenation by increasing functional

residual capacity

• Alleviated the need for intubation

• Allows the patient to talk and cough without interrupting positive

pressure.

• Disadvantage

• Tight fit which may cause discomfort

• Interferes with talking and eating

• Risk of aspiration if patient vomits

• Risk of gastric distension and pneumothorax

• Venturi mask – mask is connected to a Venturi (mixes a specific volume of

air and oxygen).

• Advantage

• Delivers highly accurate oxygen concentration despite patients

respiratory problem

• With dial that changes oxygen concentration

• Allows addition of humidity and aerosols

• Disadvantage

• Confining

• May cause skin irritation

• Interferes with eating and talking

• Condensate may possibly collect and drip to patient

• Concentration alteration may happen if fit is loose and tubing kinks

NURSE RESPONSIBILITIES

• Assess the patient’s condition and verify if the patient has open airway before O2

administration.

• Explain the procedure and need for O2. Utilize GIE (greet the patient, identify

yourself and explain the procedure)

• Check the room for oxygen safety. If possible, replace electrical devices with non -

electrical ones.

• If the patient is a child and is in an oxygen tent, remove all toys that may produce

spark (free electron discharge principle). Oxygen supports combustion and may

cause a fire.

• Place oxygen precaution over patients bed and on the door if his room.

• Place the O2 delivery to the patient properly and stable.

• Monitor the patients response to ABG value.

CONTINUATION…

• Wipe moistures or perspiration from patients face if needed.

• Watch for OXYGEN TOXICITY. Concentration of O2 above 60% for 24 hrs.

• Remind the patient to cough and deep breathe to prevent ATELECTASIS.

• Never administer oxygen at more than 2L per minute to patient with chronic

lung disease.

• Long term oxygen therapy of 12 to 17 hours daily may help patient to sleep

better, survive longer and may reduce pulmonary hypertension.

DOCUMENTATION

• Record the date and time of oxygen administration

• The delivery device used

• Oxygen flow rate

• Patients vital signs

• Skin colour and respiratory characteristics

• Subjective response before and after initiation of therapy

CENTRAL VENOUS THERAPY

A central venous catheter is a sterile catheter inserted through a large vein,

commonly subclavian vein and terminates in the superior vena cava. CV allows long-term safe

administration of drugs, fluids and nutrition and blood products.

Advantages:

• Allows monitoring of CV pressure

• Permits aspiration of blood samples

• Allows large bolus of I.V. fluids administration

• Emergency access when peripheral access is difficult

• CV line decreases patient’s anxiety and preserves peripheral veins.

Disadvantage

• Increases the risk of pneumothorax, sepsis, thrombus formation,

vessel and adjacent organ perforation

• CV line decreases patients mobility, difficult to insert and costly

• May cause pain upon insertion and when moving.

• Pneumothorax typically occurs on catheter insertion but may not

be noticed after completion of the procedure.

• Phlebitis may occur.

• Sepsis occurs later during the infusion therapy.

NURSE RESPONSIBILITIES

• Wash hands and use sterile gloves when touching the CV line.

• Sterile technique is at top priority.

• Reinforce nurse explanation to the procedure. Utilize GIE.

• Make sure that the patient has signed a consent form.

• Check history for hypersensitivity to latex, iodine and local anaesthetic.

• Turn the patients head away from the site when inserting, inspecting and removing.

• Flush the CV line to maintain its patency using sterile saline solution.

• Flush and inspect the catheter once every 8hours 3cc to 5cc of solution.

• Chest X-ray will confirm the proper placement of the catheter and infuse D5W or normal

saline solution at keep-vein open rate.

CONTINUATION…

• Stay alert for signs of air embolism such as sudden onset of

pallor, cyanosis, dyspnea, coughing, tachycardia progressing to

syncope and shock.

• If any of these have been observed, place the patient to his

left side in Trendelenburg position and notify the physician.

• Change the dressing every 48 hours or 7 days if transparent

semipermeable dressing is used.

• To prevent air embolism, close the catheter clamp or have the

patient perform Valsalva’s manuever, when valves hub is open

to air.

DOCUMENTATION

• Record the time and date of insertion, length and location of the catheter.

• Solution used

• Practitioners name

• Patients response to procedure

• Documents the time of X-ray and its result.

• Take note of the time of dressing applied and antimicrobial agent applied.

• Note the condition of the site.

CENTRAL VENOUS MONITORING

The practitioner inserts the CVP lines and advance it until it reaches the end or lies

near the right atrium. The reflection of pressure at end diastole and when connected to a

manometer, the catheter measures CV pressure.

Advantages:

• Helps assess cardiac function

• Evaluates venous return to the heart

• Indirectly gauge how well the heart is pumping

• Also provides access for large vessel for rapid, high volume fluid administration

• Allows frequent blood withdrawal while minimizing patient anxiety

NURSE RESPONSIBILITIES

• Normal CVP ranges from 5 to 10cm H2O (of water) or 2 to 6 mm Hg.

• Any heart condition may affect CVP reading.

• Sterile technique is at high priority before and after CVP monitoring.

• Patient should be flat on bed before CVP reading.

• Observe for signs of infection.

• I.V. solution should be change every 24 hours. I.V. tubing every 48 hours

and CV catheter every 72 hours.

• Air should be prevented from going into the CV line.

• Contamination of CV line and site should be taken into consideration.

ELECTROCARDIOGRAPHY

This measures the heart’s electrical activity as waveforms. Impulses

moving through the hearts conduction system create electrical current that can

be monitored. Electrodes are used to detect these current.

INDICATIONS:

1. To identify myocardial ischemia

2. Infarction (3 types)

3. Rhythm (arrhythmia and dysrhythmia) and conduction disturbance (left/right

bundle branch block)

4. Chamber enlargement

5. Electrolyte imbalances

6. Drug toxicity

7. Other heart related condition/disease

PRINCIPLES OF ECG

• Standard 12-lead ECG uses a series of electrodes placed on patients chest and

extremities to assess the heart from 12 different views (leads).

• The 12 leads

• Three standard bipolar limb leads (I, II, III)

• Three unipolar augmented leads (aVR, aVL, aVF)

• Limb and augmented limb show the heart from frontal plane

• Six unipolar precordial leads (V1 to V6)

• Precordial leads show the heart from horizontal plane.

• The created electrical graph ECG complex is called PQRST.

• ECG variations include stress ECG and ambulatory (Holter monitoring) ECG.

KEY STEPS IN ECG MONITORING• Prepare the materials and equipment needed.

• Confirm the patients identity.

• Set up the machine close to the patient and the bed.

• Explain the procedure briefly to the patient. Emphasize that no electrical current will enter his body.

• Have the patient lie straight flat on bed with his arms on his side. May raise the head of the bed for comfort. Expose the arms and legs and drape the patient. Arms and legs should be relaxed.

• If the bed is too narrow, place the patient’s hands under his buttocks to prevent muscle tension, shivering and trembling.

• Make sure that the feet and other body parts are not touching the bed.

• Select flat and fleshy parts to place the electrodes.

• Clip hairy parts and clean area for oil and other substance to enhance electrode contact.

• Connect the electrodes to the patient body.

ECG ELECTRODE DIAGRAM

SPECIAL CONSIDERATIONS

• Patient touching the metallic object may cause abnormal (wavy) waveforms

• Safety of the patient is at high priority, raise bed side-rails to prevent fall.

• Do not place other highly electro-conductive devices near the patient which

may cause electric shock.

• Ensure that the patient is breathing normally and relaxed to prevent

abnormal reading.

• Coins, steel belt, dentures and other metallic object should be removed prior

to the procedure.

• Drape the patient to provide privacy.

DOCUMENTATION

• Label the ecg recording with the patients name, room number.

• Document in the nurse note the test’s date and time as well as significant

responses by the patient while performing the procedure.

• Note other significant clinical information on the ECG as needed/requested.

ECG WAVEFORMS, PATHWAYS AND

COMPONENTS

An ECG waveform has three basic component: P wave, QRS complex and T wave.

These elements are further divided into PR interval, J point, ST segment, U wave and QT interval.

• P wave and PR interval

P wave – atrial depolarization

PR interval – time of impulse to travel from SA node to AV node and bundle of His. PR

interval measures from beginning of P wave to beginning of QRS complex.

• QRS complex

QRS complex – ventricular depolarization (time of impulse to travel through bundle branches

to the Purkinje fibers).

Q wave – first negative deflection

R wave – first positive deflection

S wave – second negative deflection

• J point and ST segment

Marking the end of the QRS complex. J point also indicates the beginning of ST

segment. ST segment represents part of ventricular repolarization.

• T wave and U wave

T wave represents ventricular repolarization. The U wave follows T wave but usually not

seen.

• QT interval

QT represents ventricular depolarization and repolarization. It extends from the

beginning of QRS complex to end of T wave.

PULSE AND EAR OXIMETRY

Performed intermittently or continuously, to monitor arterial blood oxygen indirectly

and noninvasively. SpO2 denotes arterial oxygen saturation measured noninvasively and

SaO2 denotes arterial blood oxygen measured directly and invasively.

NURSE CONSIDERATIONS

• Select a finger or ear lobe for the test and massage the area to circulation and

vascularization.

• Use clinical judgement to evaluate readings.

• Elevated bilirubin level may falsely lower SpO2

• Elevated carboxyhemoglobin or methemoglobin level may falsely elevated SpO2 reading.

• If possible, correlate SpO2 reading with ABG result.

• SpO2 may be used during respiratory arrest but cannot be used for cardiac arrest.

• SpO2 reading for ear and pulse are 95% to 100% for adults and 93% to 100% for healty

full-term neonates and 1 hour after birth.

• Lower levels of SpO2 indicates low oxygen perfusion (hypoxemia).

• PaO2 and SpO2 do not exactly determine oxygen in the blood.