Cebu Doctors’ University

College of Nursing

NCM 112
Care of Clients with Problems in Oxygenation, Fluid and Electrolytes,
Infectious, Inflammatory, and Immunologic Response, Cellular
Aberrations (Acute and Chronic)

RLE 2M:
Chest Physiotherapy, Postural Drainage, Nebulization, Chest tube
Drainage Systems, Blood Transfusion

Submitted By:
KINTANAR, SOFIA REINA F.
MENDOZA, FEMAEYANI C.
NADERA, MARIA SHERELL
TECSON, USHUAIA VICTORIA O.
TICOD, CHERYL ANTOINETTE M.
TURBISO, JOLLY ANNE A.

Facilitators:

Ms. Angela G. Perez, MAN, RN

Date Submitted: August 25,2021

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 Course Learning Outcomes

CLO#1: define the key terms for chest physiotherapy, postural drainage and
nebulization, chest tube drainage systems and blood transfusion. (KINTANAR,
SOFIA REINA F. )

CLO#2: discuss the importance, indications and contraindications in chest

physiotherapy, postural drainage and nebulization, clients with chest tube drainage
systems and blood transfusion ( MENDOZA, FEMAEYANI C. )

CLO#3: classify the types of nebulizers, chest tube drainage systems, blood
products and their compatibilities (NADERA, MARIA SHERELL)

CLO#4: explain the proper storage and transport of blood and blood products
(NADERA, MARIA SHERELL)

CLO#5: trace and discuss the parts of the nebulizer, chest tube drainage system
and blood administration set (NADERA, MARIA SHERELL)

CLO#6: elaborate on the guidelines of chest physiotherapy, postural drainage,

nebulization, care of clients with a chest tube drainage and blood transfusion
(TECSON, USHUAIA VICTORIA O. )

CLO#7: explore on the possible complications when performing chest

physiotherapy, postural drainage and nebulization, caring for clients with chest tube
drainage systems and blood transfusion (TICOD, CHERYL ANTOINETTE M.)

CLO#8: examine the nursing responsibilities before, during and after chest
physiotherapy, postural drainage, nebulization, care of clients with a chest tube
drainage and blood transfusion (TURBISO, JOLLY ANNE A.)

CLO#9: utilize the nursing process in the care of clients and undergoing chest
physiotherapy, postural drainage, nebulization, drainage of chest fluids and blood
transfusion (TECSON, USHUAIA VICTORIA O. & MENDOZA, FEMAEYANI C.)

CLO#10: demonstrate beginning skills in performing and documenting chest

physiotherapy, postural drainage, nebulization, care of clients with a chest tube
drainage and blood transfusion (TICOD, CHERYL ANTOINETTE M.)

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LEARNING OUTCOMES:
After 7 hours of varied teaching-learning activities, the level III students will be
able to:

CLO#1: define the key terms for chest physiotherapy, postural drainage and
nebulization, chest tube drainage systems and blood transfusion.
● atelectasis
● emphysema
● bronchiectasis
● auscultatory points
● chest physiotherapy
Deep breathing exercises:
● pursed-lip breathing
● diaphragmatic breathing
● apical expansion
● basal expansion
● coughing exercises:
● quad coughing
● huff coughing
● cascade coughing
● chest vibration
● chest tapping / percussion
● postural drainage
● incentive spirometry
● nebulization
Care of clients with Chest tube drainage:
● pneumothorax
● hemothorax
● chylothorax
● thoracotomy
● thoracostomy
● chest tube
● chest tube drainage system
Blood Transfusion:
● blood transfusion
● recipient

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 ● donor
● plasma
● direct transfusion
● indirect transfusion
● blood typing
● blood screening
● cross matching
● anemia

CLO#2: discuss the importance, indications and contraindications in

● chest physiotherapy
● postural drainage
● nebulization
● clients with chest tube drainage systems
● blood transfusion

CLO#3: classify the types of nebulizers, chest tube drainage systems, blood
products and their compatibilities

Nebulizer types:
● Jet
● Ultrasonic wave
● Vibrating mesh

Types of chest tube drainage systems:

● One-bottle system
● Two-chamber system
● Three-chamber system
● Wet suction control
● Dry suction control

Blood products:
● Whole blood
● Packed red cells
● Platelet concentrates
● Fresh frozen plasma
● Plasma derivatives
● Cryoprecipitate

CLO#4: explain the proper storage and transport of blood and blood products
● Blood cold chain technique

CLO#5: trace and discuss the parts of the nebulizer, chest tube drainage system and
blood administration set
Parts of the:

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 ● Nebulizer
● Chest tube drainage system
● Blood administration set

CLO#6: elaborate on the guidelines of chest physiotherapy, postural drainage,

nebulization, care of clients with a chest tube drainage and blood transfusion
Guidelines of:
● chest physiotherapy
● postural drainage
● nebulization
● chest tube drainage systems
● blood transfusion

CLO#7: explore on the possible complications when performing chest physiotherapy,

postural drainage and nebulization, caring for clients with chest tube drainage
systems and blood transfusion
● Possible complications in clients with chest tubes and its
corresponding nursing interventions

CLO#8: examine the nursing responsibilities before, during and after chest
physiotherapy, postural drainage, nebulization, care of clients with a chest tube
drainage and blood transfusion

CLO#9: utilize the nursing process in the care of clients and undergoing chest
physiotherapy, postural drainage, nebulization, drainage of chest fluids and blood
transfusion

CLO#10: demonstrate beginning skills in performing and documenting chest

physiotherapy, postural drainage, nebulization, care of clients with a chest tube
drainage and blood transfusion

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 CLO#1: define the key terms for chest physiotherapy, postural drainage
and nebulization, chest tube drainage systems and blood transfusion.

1. atelectasis
- Refers to the closure or collapse of the alveoli and often is described in
relation to chest x-ray findings and/or clinical signs and symptoms.

2. Emphysema
- Is an accumulation of thick, purulent fluid within the pleural space, often with
fibrin development and a loculated (walled-off) area where infection is
located.

3. bronchiectasis
- Is a chronic, irreversible dilation of the bronchi and bronchioles that result
from distraction of muscles and elastic connective tissue.

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4. auscultatory points
- Is an important part of the assessment of the respiratory system and is also
used for cardiac and gastrointestinal examination.

5. chest physiotherapy
- Includes postural drainage, chest percussion and vibration, and breathing
retaining. The goal is to remove bronchial secretions, improve ventilation and
increase the efficiency of the respiratory muscles.

5.1 Deep breathing exercises:

● 5.1.1 pursed-lip breathing
- Is a technique that allows people to control their oxygenation
and ventilation. The technique requires a person to inspire
through the nose and exhale through the mouth at a slow
controlled flow.

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● 5.1.2 diaphragmatic breathing
- Refers to a flattening of the dome of the diaphragm during
inspiration, with resultant enlargement of the upper abdomen as
air rushes in.

● 5.1.3 apical expansion

- It refers to a pattern of breath that contains most movement to
the upper chest. Patient in sitting position. Apply pressure
(usually unilaterally) below the clavicle with the fingertips.

●5.1.4 basal expansion

- Is done by having the patient sitting while leaning forward onto
a pillow, and placing one’s hands over the posterior aspect of
lower ribs. One will ask the patient to breathe out as you feel
the rib cage move downward and inward. As they breathe out,
you will place a firm downward pressure into the ribs with the
palm of your hand. Prior to inspiration, apply a quick downward
and inward stretch to the chest, then tell the patient to expand

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 the lower ribs against your hand as they breathe in. Apply
gentle manual resistance to the lower rib area to increase
sensory awareness.

● 5.2 coughing exercises:

● 5.2.1 quad coughing
- This technique is for patients without abdominal muscle control
such as those with spinal cord injuries. After a maximal
inspiration, the patient coughs while an assistant exerts gentle
upward and inward pressure with both hands on the abdomen.

● 5.2.2 huff coughing

- This technique allows the air to move past the mucus in the
airways to the deeper mucus and can help mobilize secretions
from smaller to larger airways. A huff cough is performed by
taking a deep breath and then forcing the air out of your lungs
with your mouth open.

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 ● 5.2.3 cascade coughing
- Ask the client to take a slow, deep breath and hold it for 2
seconds, while contracting expiratory muscles. Tell the client to
open the mouth and perform a series of coughs throughout
exhalation, thereby coughing at lowered lung volumes. This
helps for airway clearance and maintains a patent airway in
clients with large volumes of sputum.

● 5.3 chest vibration

- A technique of applying manual compression and tremor to the
chest wall during the exhalation phase of respiration.

● 5.4 chest tapping / percussion

- Is carried out by cupping the hands and lightly stroking the
chest wall in a rhythmic fashion over the lung segment to be
drained.

6. postural drainage

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 - Allows the force of gravity to assist in the removal of bronchial secretions.

7. incentive spirometry
- Is a method of deep breathing that provides visual feedback to encourage the
patient to inhale slowly and deeply to maximize lung inflation and prevent or
reduce atelectasis.

8. nebulization
- The conversion of a liquid into a fine mist or spray, especially for inhalation
therapy.

B. Care of clients with Chest tube drainage:

1. pneumothorax
- Occurs when the parietal or visceral pleura is breached and the pleural space
is exposed to positive atmospheric pressure.

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2. hemothorax
- Partial or complete collapse of the lung due to blood accumulating in the
pleural spaces; may occur after surgery or trauma.

3. chylothorax
- Is a rare condition in which lymphatic fluid leaks into the space between the
lung and chest wall. When this fluid builds up in the lungs, it can cause severe
cough, chest pain and difficulty breathing.

4. thoracotomy
- Surgical opening into the chest cavity. During this procedure, a surgeon
makes an incision in the chest wall between your ribs, usually to operate on
your lungs. Through this incision, the surgeon can remove part or all of a
lung.

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5. thoracostomy
- Is a small incision of the chest wall, where a flexible tube is inserted through
the incision on the side of the chest into the pleural space with maintenance
of the opening drainage. It is used to remove air or fluid from the
intrathoracic space. It is most commonly used for the treatment of a
pneumothorax.

6. chest tube
- Is a hollow, flexible tube placed into the chest. It acts as a drain. Chest tubes
drain blood, fluid, or air from around the lungs, heart, or esophagus. The tube
around your lung is placed between your ribs and into the space between the
inner lining and the outer lining of your chest cavity.

7. chest tube drainage system

- Have a suction source, a collection chamber for pleural drainage, and a
mechanism to prevent air from reentering the chest inhalation.

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 C. Blood Transfusion:

1. blood transfusion
- Administration of blood and blood components.

2. recipient
- Is the person on the receiving end of something.

3. donor
- A person who provides blood for transfusion.

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4. plasma
- Portion of blood; it contains various proteins, such as albumin, globulin,
fibrinogen and other factors necessary for clotting, as well as electrolytes,
waste products and nutrients.

5. direct transfusion
- The obvious method of performing a direct transfusion is by making an
end-to-end anastomosis between an artery of the donor and a vein of the
recipient. It requires donor-recipient proximity and relies on quick
transference to mitigate clotting. Transfusion from a donor artery to a
recipient vein occurs spontaneously upon connection.

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6. indirect transfusion
- An indirect transfusion, where donations are made, the blood stored, and
later transfused into a patient.

7. blood typing
- Is a method to tell what type of blood you have. Blood typing is done, so you
can safely donate or receive a blood transfusion. It is also done to detect a
substance called Rh factor on the surface of your red blood cells.

8. blood screening
- Its objective is to detect markers of infection in order to prevent the release
of infected blood and blood components for clinical use. Blood screening
strategies are designed to assure the safety of blood units, but should not be
used for notifying blood donors of reactive test results.

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9. cross matching
- Is a way for your healthcare provider to test your blood against a donor’s
blood to make sure they are fully compatible. Crossmatching takes 45 minutes
to an hour. It’s essentially a trial transfusion done in test tubes to see exactly
how your blood will react with potential blood donors.

10. anemia
- Is a condition in which the hemoglobin concentration is lower than normal; it
reflects the presence of fewer than normal number of erythrocytes (RBC)
within the circulation.

CLO#2: discuss the importance, indications and contraindications in

Chest Physiotherapy
○ Importance
■ Chest Physiotherapy (CPT) removes bronchial secretions,
improves ventilation and increase the efficiency of the
respiratory muscle
■ CPT helps patients breathe more freely and tp get more oxygen
into the body
○ Indication
■ Patients with:
● Chronic Obstructive Pulmonary Disease (COPD)
○ CPT assist sputum clearance in an attempt to
reduce symptoms of paroxysmal coughing, slow
the decline in lung function, reduce exacerbation
frequency and hasten the recovery from

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 exacerbations
● Cystic Fibrosis (CF)
○ The lungs of people with cystic fibrosis produce
excess mucus. CPT helps in airway clearance
through techniques such as percussion and
vibration.
● Bronchiectasis
○ Bronchiectasis is a lung condition that causes
coughing up mucus due to scarred tissue in the
bronchi, or the passages that let air into the lungs.
Chest vibrations can loosen and thin mucus which
allows airway clearance.
● Bronchitis
○ Bronchitis is an infection of the main airways of
the lungs (bronchi), causing them to become
irritated and inflamed.Chest percussion and
vibration to help loosen lung secretions.
● Lung abscess
○ Lung abscess is defined as necrosis of the
pulmonary tissue and formation of cavities
containing necrotic debris or fluid caused by
microbial infection.
● Pleural effusion
○ Pleural effusion is the build-up of excess fluid
between the layers of the pleura outside the lungs.
Physiotherapy has an important role in stabilizing
and controlling breathing. It aids in chest fluid
drainage and in clearing chest secretions
■ It also keeps the lungs clear to prevent pneumonia after
surgery or during periods of immobility

○ Contraindication
■ Patient with:
● Bleeding disorder, Over burns, open wounds, skin
infection of the thorax
○ Can cause discomfort due to physical positions or
manipulations
● Osteoporosis and Fractured ribs
○ Patient may feel uncomfortable due to pain from
the techniques applied in chest physiotherapy.

● Postural Drainage
○ Importance
■ Postural drainage allows force of gravity to assist in the removal
of bronchial secretions and prevents or relieve bronchial
obstruction caused by the accumulation of secretions
○ Indication
■ Diseases with increased production or viscosity of mucus

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 ■ Prolonged bed rest
■ Painful incision causing restricted deep breathing and coughing
■ Patients on ventilator
■ Patients with:
● COPD
○ Postural drainage assist sputum clearance in an
attempt to reduce symptoms of paroxysmal
coughing, slow the decline in lung function.
● Cystic fibrosis
○ The lungs of people with cystic fibrosis produce
excess mucus. Postural Drainage is a way to help
people with cystic fibrosis (CF) breathe with less
difficulty with the use of gravity
● Bronchiectasis
○ Bronchiectasis is a lung condition that causes
coughing up mucus due to scarred tissue in the
bronchi, or the passages that let air into the lungs.
Postural drainage can loosen and thin mucus
through the use of gravity which allows airway
clearance.
● Pneumonia
○ It allows gravity to help drain the mucous to the
top of the lungs where it can be removed more
easily. It can be an important way to prevent
pneumonia.

○ Contraindication
■ Severe hemoptysis
● It can further complicate bleeding
■ Untreated acute conditions
● Severe pulmonary edema
○ Pulmonary edema which collects in the dependent
areas; postural drainage would cause extreme
dyspnea and probably worsen the situation.
● Pulmonary embolism
Gravity aids with postural drainage which can
further complicate when blood clots travel further
deep into the lungs.
● Pneumothorax
○ Pneumothorax is a collapsed lung and postural
drainage cause more harm than healing when it is
applied
■ Recent neurosurgery
● Head down position may cause increase intracranial
pressure (ICP)

● Nebulization

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○ Importance
■ Nebulisers use oxygen, compressed air or ultrasonic power to
break up medication solutions and deliver a therapeutic dose of
aerosol particles directly to the lungs
■ Helps in hydrating dried, retained secretions and promotes
expectoration of secretions
■ It also aids in bronchial hygiene by restoring and maintaining
mucus blanket continuity
■ Nebulization therapy can be used to treat respiratory
diseases or respiratory-related symptoms in
emergency care. It can also be used as a prophylactic
measure of airway management in other diseases.
(SHAPE)
● S
○ (Relief airway Spasm): to relieve
bronchospasm, coughing and wheezing
● H
○ (Humidify): to humidify airway
● A
○ (Anti-inflammation): to achieve an
anti-inflammatory effect
● P
○ (Prevent): to prevent respiratory
complications such as airway
inflammation, obstruction, atelectasis,
infection, and asphyxia
● E
○ (Expectorant): promote expectoration

○ Indication
■ Patients with:
● Bronchospasms
○ Medication administered through nebulizers allows
efficient way to widen your airways and help you
breath easier.
● Chest tightness and Respiratory congestions
○ Nebulizer treatments drastically reduce coughing,
sputum production, and chest tightness, allowing
you to breathe easier.
● Excessive and thick mucus secretions
○ Nebulization thins and reduce sputum production
● Pneumonia
○ While most cases of pneumonia can be treated
with rest, antibiotics, or over-the-counter
medications, some cases require hospitalization. If
you're hospitalized with pneumonia, you might
receive a breathing treatment through a nebulizer.
■ Delivery of bronchodilator drugs

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 ● On acute attack of asthma
■ Administration of antibiotics and antifungal agents
■ Aid in expectoration
● Inhalation of hypertonic saline has been found to
increase clearance of bronchial secretions
■ Local analgesia
● To relieve dyspnea in patients such as those suffering
from alveolar carcinoma
○ Contraindication
■ Patients with:
● Unstable and increased blood pressure
○ Medications used in nebulisation raise
the heart rate, causing palpitations and
tremor. Some bronchodilators can affect
the heart. The most common and
noticeable effect is a racing heartbeat.
● Individuals with cardiac irritability
○ Bronchodilators like albuterol and
salmeterol can affect the heart. The
most common and noticeable effect is a
racing heartbeat. They do raise the
heart rate, causing palpitations and
tremor.
● Persons with increased pulses
○ Medications used in nebulisation side
effects include a rapid heart rate
(tachycardia) or feelings of fluttering or
a pounding heart (palpitations)
● Unconscious patients

● Clients with Chest Tube Drainage Systems

○ Importance
■ Chest Tube Drainage System prevents air or fluid/or blood from
re-entering the chest with inhalation
○ Indication
■ Patients with:
● Malignant Effusions (Pleurodesis)
○ Help get the lung to stick up the chest
wall and reduce the risk of new
build-up or fluid
● Pneumothorax
○ Thoracotomy remove fluid and air as promptly as
possible, prevent drained air and fluid from
returning to the pleural space

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 ● Fluid collections
○ Allows a more effective drainage
○ Contraindication
■ The only absolute contraindication for tube
thoracostomy is the lack of informed consent or
patient cooperation
■ Patients with:
● Coagulopathy or platelet dysfunction
○ It might complicate during the insertion of chest
tubes
● Pulmonary, pleural, or thoracic adhesions
○ instrumental access to the pleural cavity
without image-guidance in patients with
substantial pleuro-pulmonary adhesions
or multi loculations
● Skin infection
○ at the chest-tube insertion site

● Blood Transfusion
○ Importance
■ Blood transfusion are given to increase oxygen-carrying capacity
and intravascular volume
● Hemoglobin value will have to be a clinical judgement
based on many factors such as cardiovascular status,
age, arterial oxygenation, and cardiac output
■ Increases the circulating blood volume after surgery, trauma, or
hemorrhage
■ Increases the number of RBCs and maintaining hemoglobin
levels in patients with severe anemia
■ Provides selected cellular components as replacement therapy
(e.g., clotting factors, platelets, albumin). +
○ Indication
■ Patients with:
● Trauma
○ The rapid and consistent delivery of
blood, plasma, platelets and other
clotting products to trauma patients is
essential to maintain clotting during
hemorrhage
● Surgery
○ Blood transfusions replace blood that is
lost through surgery or injury or provide
it if your body is not making blood
properly.
● Hemorrhage
○ Red blood cell transfusions are used to

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 treat hemorrhage and to improve
oxygen delivery to tissues
● Critically-ill
○ Contraindication
■ Evidence of infections/ risk of bacteremia
● may cause sepsis
■ Active seizure disorder
● They are prone to adverse donor reactions, specifically,
syncope and convulsions.
■ Megaloblastic anemia
● Vitamin B12 or folate deficiency - transfusion
may cause heart failure and death
■ Angina
● Transfusions increase risk of heart attack or stroke. Chest
pain is a common clinical dilemma and is rarely reported
as part of suspected adverse events in transfusion
recipients.

CLO#3: classify the types of nebulizers, chest tube drainage systems,

blood products and their compatibilities

Nebulizer types:

● Jet
use pressurized gas/air to draw the liquid medication from the
nebulizer cup through a thin capillary. The pressurized air or gas is provided
by the compressor. The liquid medication is converted into aerosol or mist
comprising small and large particles. Smaller particles are inhaled, and
larger particles hit the walls inside the medication cup and enter back into
the reservoir.

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 ● Ultrasonic wave
This makes an aerosol through high-frequency vibrations. The particles
are larger than with a jet nebulizer.

● Vibrating mesh
Liquid passes through a very fine mesh to form the aerosol. This kind
of nebulizer puts out the smallest particles. It’s also the most expensive.

Types of chest tube drainage systems:

● One-bottle system (Dry Suction)

The simplest form of underwater seal drainage systems. This system
can drain both fluid and air. The distal end of the drainage tube must remain
under the water surface level.There is always an outlet to the atmosphere to
allow air to escape.It is suitable for use with a simple pneumothorax, when
the vent is left open to the atmosphere, or following a pneumonectomy when
the tubing is clamped and released hourly

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 ● Two-chamber system
This system is suitable for the drainage of air and fluid. The first
chamber is for collection of fluid and the second is for the collection of air. As
the two are separate, fluid drainage does not adversely affect the pressure
gradient for evacuation of air from the pleural space. A separate chamber for
fluid collection enables monitoring of volume and expelled matter.

● Three-chamber system
Suction is required when air or fluid needs a greater pressure gradient
to move from the pleural space to the collection system. Suction may be
applied via a third bottle or a suction chamber.

● Wet suction control (Traditional Water Seal)

Regulate suction pressure by the height of the column of water in the
suction control chamber. The water seal acts like a one-way valve that
allows continuous closed gravity drainage of pleural cavity contents (fluid
and/or air) out of the lung. The term “primarily” for suction or water seal
refers to which therapy is used the majority of time the chest tube is in
place.

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 ● Dry suction control (Dry Suction Water Seal)
Regulate suction pressure mechanically rather than with a
column of water. In a dry suction water seal operating system, fluids
drain from the patient directly into a large collection chamber via a
6-foot patient tube (3/8" I.D.). As drainage fluids collect in this
chamber, the nurse will record the amount of fluid that collects on a
specified schedule.

Blood products:

Compatibility Indication Infusion Time

Blood Product

Whole blood - Whole blood - Red cell - 150‐200

contains both replacement in mL/hour
RBCs and acute blood loss - Within 30
plasma, the with hypovolaemia. minutes of
compatibility - Exchange removing from
of both transfusion. refrigerator
requiring

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 consideration
. Group O
whole blood
provides
“universal
donor” RBCs
when the
ABO group of
the recipient
is unknown.
Red cell
concentrates - Must be ABO - Replacement of red - Standard blood
[packed red and Rh cells in anaemic filter (170–260
blood cells compatible patients. µm) and tubing
(PRBC)] - Crossmatch
required

- Crossmatch - Rate is 1–2

required ml/minute
(60–120
ml/hour) for first
15 minutes. May
be increased if
well tolerated
with no adverse
reaction. One
unit usually
takes 1.5–2
hours to infuse,
but may be
infused over up
to 4 hours in
volume sensitive
patients.

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Platelet - Preferred Treatment of bleeding due - Standard
concentrates ABO and blood filter
to:
(PC) Rh (170–260
compatible µm) and
● Platele with donor ● Thrombocytopenia. tubing
ts – plasma - Transfuse
● Platelet function
single - Must slowly
donor defects.
have (60–120
confirme ● Prevention of ml/hour) for
d blood bleeding due to the first 15
group. minutes,
● Platelet - Rh thrombocytopenia where
random compatib as in bone marrow possible.
ility - Recommended
failure
importan infusion time
t for Rh is 60 minutes
(D) per dose.
negative - Maximum
women infusion time is
of 4 hours.
child-bea
ring
potential

Fresh Frozen
Plasma (FFP) - Should Conditional indications: - Standard
be ABO blood filter
compati (170–260
● Massive blood
ble µm) and
- Rh transfusion. tubing
compatibility ● Acute DIC if there - Transfuse slowly
not generally (60 –120
required. are coagulation
ml/hour) for the
- Confirmed abnormalities and 15 minutes,
blood group where possible.
the patient is
required
bleeding.
● Liver disease, with
abnormal
coagulation and
bleeding –
prophylactic use to

28
 reduce prothrombin
time (PT) to
1.6‐1.8 x normal
for liver biopsy.
● Cardiopulmonary
bypass surgery –
use in the presence
of bleeding but
where abnormal
coag‐ ulation is not
due to heparin.
Routine
perioperative use is
not indicated.
● Severe sepsis,
particularly in
neonates
(independent of
DIC).
● Plasmapheresis.

Cryoprecipitate - ABO As an alternative to Factor - Standard

compatibil blood filter
VIII concentrate in the
ity (170–260
preferred treatment of inherited µm) and
but not deficiencies of: tubing
required - Recommen
- Confirmed ded
blood group ● von Willebrand
infusion
required Factor (von time is
Willebrand’s 10–30
minutes
disease). per dose.
● Factor VIII - Maximum
infusion time is
(haemophilia A).

29
 ● As a source of 4 hours.
fibrinogen in
acquired
coagulopathies;
e.g. DIC.
● Can be used in
isolated Factor XIII
deficiency

CLO#4: explain the proper storage and transport of blood and blood
products
● Blood cold chain technique

The blood cold chain is a systematic process for the safe storage and transportation
of blood from its collection from the donor to its administration to a patient who
requires transfusion. It is referred to as a ‘cold chain’ because blood, being a
biological substance, must be kept cold in order to reduce bacterial contamination
and to prolong its life. Whole blood is warm when collected but must be cooled
down to 4 °C and kept at this temperature until the point of transfusion.

The purpose of a transfusion is to provide blood components that improve the

haematological status of the patient. Various blood components can be yielded from
a donation of whole blood. Most blood banks are able to separate red cells and
plasma components. Some are able to prepare other products, such as platelet
concentrates and cryoprecipitate. These products are often referred to as ‘wet
products’. Other plasma products, generally referred to as plasma derivatives, can be
extracted from plasma by a pharmaceutical process called plasma fractionation. All
of these products have a specific benefit to the patient. However, in order for the
blood component or plasma derivative to provide that benefit, it must be transfused
in a viable state. Blood must be stored and transported in equipment that meets
defined standards of performance, and by staff who correctly follow established
procedures at all times.
There are three main activities involved in the blood cold chain process:

Storage: which keeps blood at the correct temperature from the time it
is collected up to the time it is transfused.

Packing and transportation: which includes equipment and materials

needed to move blood components safely through the blood cold chain.

Maintenance of equipment: which provides the proper management,

infrastructure and backup needed to ensure a reliable, sustainable and
safe blood supply.

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Blood cold chain process:

CLO#5: trace and discuss the parts of the nebulizer, chest tube drainage
system and blood administration set

Parts of the:

● Nebulizer

● Nebulizer compressor
The compressor is the base of the system. It pumps air into the
medication cup to create a breathable mist.
● Nebulizer cup
This is the reservoir where measured liquid medication goes.
● Mouthpiece/mask
This is the opening through which the mist is inhaled. ...

31
● Tubing
The tubing delivers air from the compressor to the medication cup.
● Tubing connectors
These connect the tubing to the compressor and nebulizer cup.

● Chest tube drainage system

● Collection Chamber
This chamber collects and measures output which can be marked at
regular time intervals. The characteristics of the output can also be visually
assessed (ie, milky chylothorax after initiation of nutrition may suggest
thoracic duct injury).
● Water Seal Chamber
The water-seal chamber serves as a o​ne-way valve – air can escape
from the pleural space but cannot reenter. This is accomplished by
maintaining a column of sterile water at 2 cm.
● Suction Control Chamber
Suction is applied via the suction port, and on drainage systems like
the Atrium, suction strength can be directly toggled. When we “water seal” a
patient, suction is removed and drainage is monitored to gravity along with
signs of air reaccumulation (repeat chest x-ray in a few hours, symptoms of
dyspnea, etc.) Depending on the physician’s preference and clinical
circumstances, this is often a good test prior to removing the chest tube.

32
 ● Blood administration set

● Needles and Catheters

Needle size depends on the size and integrity of a patient's vein. An
18-gauge needle is standard, but a needle or catheter as small as 23-gauge
can be used for transfusion if necessary. The smaller the gauge, the slower is
the flow rate and the higher is the risk of clotting.
● Leukocyte Removal Filters
Special bedside filters may be provided by the Transfusion Service
when pre-storage leukocyte-reduced red cells or platelets are not available.
Red cell and platelet filters do not use the same technology for leukocyte
removal and are not interchangeable.
● IV Pumps
Mechanical pumps may be useful for controlling the very slow infusion
rates required by neonatal and pediatric patients, but care is needed to avoid
hemolysis
● Blood Warmers
Blood warmers are used to prevent cardiac arrhythmia associated with
the rapid infusion of large volumes of cold blood. Blood should not be
warmed to a temperature that causes hemolysis. Only temperature-controlled
and monitored in-line devices are acceptable for use, and some require
special software.
● IV Solutions and Medications
Normal Saline (0.9% sodium chloride) can be added to blood, but
drugs and medications must never be added.
● Infusion Rates

33
 Packed red blood cells can be diluted with 0.9% NaCl to decrease
viscosity and improve flow rate. Platelets are transfused through platelet
filters at a rate which allows a pool of random donor platelets or a single
donor platelet to be transfused within 30 to 60 minutes. FFP is usually
transfused through a standard blood filter at a rate of 30 to 60 minutes per
bag. Cryoprecipitate is infused through a standard blood filter at a rate of 4
to 10 mL/minute. At this rate, a pool of 10 bags can be infused in
approximately 30 minutes.

CLO#6: elaborate on the guidelines of chest physiotherapy, postural

drainage, nebulization, care of clients with a chest tube drainage and
blood transfusion
Guidelines of:

● Chest Physiotherapy
- Auscultate the patient’s chest before and after the procedure
- The patient’s chest should be should be auscultated before and after
the
- procedure
- Chest percussion on the chest wall should be performed rhythmically
with a cupped hand
● The following areas are to be avoided :
- Spine
- Breastbone
- Stomach
- Lower ribs or back (to prevent injury to the spleen on the
left, liver on the right and kidneys on the lower back)

- The patient’s skin integrity over the area where CPT is to be done
should
- be checked
- Patient should be adjusted to an appropriate position
- The kidney basin lined with tissue should be offered to the patient

● Postural Drainage
- Auscultate the lungs sounds before and after the procedure
- The patient should be positioned depending on the area of the lung
affected
- The procedure is performed two to four times daily before meals, this
is to prevent nausea, vomiting and aspiration.
- The prescribed bronchodilators, water or saline is nebulized and

34
 inhaled before postural drainage
- Patient is provided with an emesis basin, sputum cup and paper tissues
and should be in a comfortable position.
- Patient should remain 10 to 15 minutes in each position
- Patients should breathe in slowly through the nose and out slowly
through the pursed lips, this is to help keep the airways open so that
secretions can drain.
- The patient may brush his or her teeth and use a mouthwash before
resting.

● Nebulization
- The patient is positioned in an upright position
- Lung sounds, pulse and respiration should be assessed before and
after the procedure was performed
- The compressor should be checked if it is functioning well before
performing the procedure
- Ensure that the two ends of the tubing are connected to the nebulizer
cup and the air compressor.
- The usage of the different administration sets such as the mouthpiece
and mask should be instructed properly.
- Chest tapping is performed after nebulization
- Instruct the patient to inhale then hold his/her breath for 5-10 seconds
and then slowly exhale.
- Do aftercare
- The documentation of procedure must contain
medication used
time and date of procedure done
any reaction from the patient
lung sounds
characteristic of secretions

● Chest Tube Drainage Systems

- Ensure that all connection tubes are patent and connected securely
- Never lift drain above chest level
- The unit and all tubing should be below patient’s chest level to
facilitate drainage
- Tubing should have no kinks or obstructions that may inhibit drainage
- Ensure all connections between chest tubes and drainage unit are tight
and secure
- Connections should have cable ties in place
- Tubing should be anchored to the patient’s skin to prevent pulling of
the drain
- Ensure the unit is securely positioned on its stand or hanging on the
bed

35
 - Ensure the water seal is maintained at 2cm at all times
- Maintain appropriate fluid in the water seal in wet suction systems.
- When suction is off, air vent should be kept open

● Blood Transfusion
- The patient should sign an informed consent due to the reason that
the procedure is invasive.
- The reasons for the transfusion should be expounded
- Blood bag should be gently rotated
- Ensure that all air bubbles are out of the tubing through priming the
blood with NSS
- The request form and the data in the laboratory records with the data
printed in the blood unit should be check:
- Wrap the blood unit with a towel if it is still cold
- Blood set spike should remain sterile and not touch the lining of the
- kidney basin
- The Y-port of the mainline tubing should be disinfected
- Place the hypoallergenic tape from the bottom up of the y-port
- Transfuse blood slowly for the 1st 15 minutes:
Adult: 15-20 gtts/min.
Pediatrics: 10-15 gtts/min
- If there are any reactions, stop the transfusion immediately
- Take the patient’s vital signs at the peak of the transfusion
- Ensure patient’s comfort. Do after care.
- ​The documentation of procedure must contain:
A. Type and volume of blood product infused
B. Serial number
C. Time and length of transfusion
D. Vital signs prior, during (peak of transfusion) and after 30
minutes of the transfusion.
E. Response to the therapy
F. Any adverse reactions
G. Interventions done for reactions.

CLO#7: explore on the possible complications when performing chest

physiotherapy, postural drainage and nebulization, caring for clients with
chest tube drainage systems and blood transfusion

● Chest Physiotherapy and Postural Drainage

● Hypoxemia
Chest Percussion may be associated with a fall in the oxygen
saturation, but when short periods of percussion (<30 sec) have been combined

36
with three or four thoracic expansion exercises, no fall in oxygen saturation has
been seen.

Possible Intervention:

Administer higher oxygen concentrations during procedure if potential for or

observed hypoxemia exists.
If the patient’s oxygen saturation lowers during treatment, administer 100%
oxygen, and stop therapy immediately, return the patient to the original resting
position, and consult a physician immediately. Ensure adequate ventilation.
Hypoxemia during postural drainage may be avoided in unilateral lung
disease by placing the involved lung uppermost with the patient on his or her side.

● Increased Intracranial Pressure

Postural drainage can produce physiologic and anatomic stresses that

are potentially detrimental to specific patients. The head-down position, which is
commonly used, is best avoided in patients with intracranial disease. The decreased
venous return from the head could increase intracranial pressure.

Possible Intervention:

Stop therapy, return the patient to the original resting position, and consult
the physician.

● Acute Hypotension during Procedure

Hypotension that is due to changes in preload can be induced by

positional change.

Possible Intervention:

Continual assessment of patients’ tolerance during the procedure is

necessary. Vital signs, oxygenation monitoring, general appearance, level of
consciousness, and subjective comments by the patient are all part of the appraisal
process.

● Pulmonary Hemorrhage

Blood drains posteriorly block the independent airway in the supine

position, which will result in the dorsal units of the lungs being able to receive
oxygen without blood flow or blood being able to flow without oxygen.
The effect of gravity plays an important role in the propensity of the
posterior part of the lung to be affected mainly by pulmonary hemorrhage.

Possible Intervention:

37
 Stop therapy, return the patient to the original resting position, and call the
physician immediately. Administer oxygen and maintain an airway until the
physician responds.

● Pain or Injury to Muscles, Ribs, or Spine

Injuries such as rib fractures arise from blunt chest trauma which may
have happened prior to physiotherapy.

Possible Intervention:

Stop therapy that appears directly associated with pain or problem, exercise
care in moving patients, and consult physicians about pain medicines.

● Vomiting and Aspiration

Possible Intervention:

Stop therapy, clear airway and suction as needed, administer oxygen,

maintain airway, return patient to previous resting position, and contact physician
immediately.

● Arrhythmias

Individuals experiencing major arrhythmias had a significantly

decreased BP and respiratory rate with an increased heart rate during
postural drainage and chest percussion (PDP). Arrhythmias are common
during PDP of critically ill patients

Action To Be Taken/Possible Intervention:

Stop therapy, return the patient to a previous resting position, administer or

increase oxygen delivery while contacting a physician.

● Nebulization:
Possible effects and reactions after nebulization therapy are as follows:
● Palpitations
● Tremors
● Tachycardia
● Headache
● Nausea
● Bronchial-spasms

Interventions:
1. Use minimal doses for minimal periods since drug tolerance can occur with
prolonged use.

38
 2. Maintain a beta-adrenergic blocker (cardioselective beta-blocker, such as
atenolol, which should be used with respiratory distress) on standby in case
cardiac arrhythmias occur.
3. Do not exceed recommended dosage; administer pressurized inhalation drug
forms during the second half of inspiration, because the airways are open
wider and the aerosol distribution is more extensive.

● Clients with chest tube drainage systems:

1. Pneumothorax

Clamping a pleural drain in the presence of a continuing air leak may result in
a tension pneumothorax or possibly worsening surgical emphysema.

Signs and symptoms include: Decreased SpO2, increased WOB, diminished

breath sounds, decreased chest movement, complaints of chest pain, tachycardia
or bradycardia, hypotension

Interventions:
● Notify medical staff
● Request urgent CXR
● Ensure drain system is intact with no leaks, or blockages such as kinks or
clamps
● Prepare for insertion/ repositioning of chest drain

2. Bleeding at the drain site

Technical causes such as tube malposition, blocked drain, and chest drain
dislodgement may lead to hemorrhage during the insertion of chest tube at drain
site.

Interventions:
● Don gloves
● Apply pressure to insertion site
● Place occlusive dressing over site
● Notify medical staff
● Check drain chamber to ensure no excessive blood loss

3. Infection of insertion site

The chest tube itself can be involved in different pathogenic pathways like
colonization of the chest tube tip and cutaneous tract with skin flora; colonization of
the tube lumen caused by contamination; hematogenous seeding of the tube from
another infected site; and contamination of the lumen of the chest tube.

Interventions:
● Notify medical staff
● Swab wound site

39
 ● Consider blood cultures

4. Accidental disconnection of system

Interventions:
● Clamp the drain tubing at the patient end. Clean ends of drain and
reconnect. Ensure all connections are cable tied. If a new drainage system is
needed, cover the exposed patient end of the drain with sterile dressing
while a new drain is set up. Ensure clamp removed when problem resolved
● Check vital signs
● Alert medical staff

5. Accidental drain removal

● Apply pressure to the exit site and seal with steri-strips. Place an occlusive
dressing over the top
● Check vital signs
● Alert medical staff.

6. Unable to remove chest drain

Intervention:
If the drain is unable to be removed with reasonable traction being applied, notify
the responsible medical team.

● Blood Transfusion

1. Febrile Non-Hemolytic Reaction

Usually caused by cytokines from leukocytes in transfused red cell or platelet

components, causing fever, chills, or rigors. In the transfusion setting, a fever is
defined as a temperature elevation of 1º C or 2º F.
Prevention:
Can be diminished and even prevented by further depleting the blood components
of donor leukocytes.

Intervention:
Antipyretic medications can be given to prevent fever, although this is not advisable
as it may cover the beginning of a more serious transfusion reaction.

2. Acute Hemolytic Reaction, Transfusion-Associated Circulatory

Overload (TACO), Bacterial Contamination, Transfusion-Related
Acute Lung Injury (TRALI), Delayed Hemolytic Reaction, Disease
Acquisition

Interventions:
● Stop the transfusion. Maintain the IV line with normal saline given at a slow
rate.

40
 ● Assess the patient carefully
● Notify the physician of assessment findings and implement the treatments
prescribed.
● Continue to monitor vital signs
● Notify the blood bank that a suspected transfusion reaction has occurred and
send the blood container and tubing back to the blood bank for repeat typing
and culture.
● If a Hemolytic Transfusion Reaction or Bacterial Infection is suspected:
○ Obtain the appropriate blood specimens from the patient
○ Collect a urine sample as soon as possible to detect hemoglobin in the
urine
○ Document the reaction according to the institution’s policy
CLO#8: examine the nursing responsibilities before, during and after
chest physiotherapy, postural drainage, nebulization, care of clients with
a chest tube drainage and blood transfusion

Chest Physiotherapy
➢ BEFORE
○ Verify the order.
○ Confirm the client's ID. Compare the name with the name on the
client's ID bracelet using two client identifiers according to your
facility's policy. Do not start the treatment if the client is not wearing
an ID bracelet.
○ Provide privacy and explain the procedure to the client
○ Wash your hands, don gloves, a face shield, and a gown, and follow
standard precautions.
➢ DURING
○ Auscultate the client's lungs.
○ Position the client as ordered.
○ Monitor the client's response to the treatment. Be alert for significant
color changes, particularly if the client becomes dusky.
➢ AFTER
○ Dispose of secretions appropriately.
○ Auscultate the client's lungs
○ Documentation

Postural Drainage
➢ BEFORE
○ Secure doctor’s order
○ Explain the procedure to the client.
○ Do medical handwashing
➢ DURING
○ Take vital signs.
○ Perform respiratory assessment.
○ Assist the client to assume appropriate position

➢ AFTER

41
 ○ Assist patient to resume a comfortable position
○ Do auscultation
○ Document the reaction of the patient, and the characteristics of the
secretion.

Nebulization
➢ BEFORE
○ Check the physician’s order for nebulization
○ Explain the purpose and procedure to the client
○ Gather all the materials and equipment needed. Check the medication
and compare it with the ticket.
○ Perform medical handwashing.
○ Bring all materials and equipment to client’s bedside
○ Identify the client. Check the ID band or let him/her state his/her
name and birthday.
○ Position client upright and assess lung sounds, pulse and respiration
○ Perform medical hand washing.
➢ DURING
○ Compare the medication with the ticket for the second time and third
time
○ Reassess lung sounds, oxygen saturation if ordered, pulse and
respirations.
➢ AFTER
○ Give health teachings or chest physiotherapy and coughing exercises.
○ Do after care. Rine the equipment in warm water and allow it to air
dry on a clean towel.
○ Perform medical hand washing.
○ Document accurately

Chest tube drainage

➢ BEFORE
○ Review the patient chart for the reason for the chest tube and location
and insertion date.
○ Perform hand hygiene.
○ Identify the patient using two identifiers and explain the assessment
process to the patient.
○ Create privacy to assess the patient and drainage system.
➢ DURING
○ Complete respiratory assessment, ensure the patient has minimal pain,
and measure vital signs.
○ Place the patient in semi-Fowler’s position for easier breathing.
➢ AFTER
○ Measure date and time, and the amount of drainage, and mark on the
outside of the chamber. Record amount and characteristics of the
drainage on the fluid balance sheet and patient chart.
○ Encourage frequent position changes as well as deep-breathing and
coughing exercises.

42
 ○ The following should be documented and assessed according to
agency policy:
■ Presence of air leaks
■ Fluctuation of water in water-seal chamber
■ Amount of suction
■ Amount of drainage and type
■ Presence of crepitus (subcutaneous emphysema)
■ Breath sounds
■ Patient comfort level or pain level
■ Appearance of insertion site and/or dressing

Blood Transfusion
➢ BEFORE
○ Check the patient’s chart
○ Explain the procedure and the reason for transfusion.
○ Gather other materials needed
○ Perform medical hand washing
➢ DURING
○ Take patient’s vital signs
○ Ensure patient’s comfort
○ Observe the patient closely for any adverse reactions
○ Take the patient’s vital signs at the peak of the transfusion.
➢ AFTER
○ Ensure patient’s comfort. Do after care.
○ Take the patient’s vital signs again 30 mins after transmission of
transfusion.
○ Document the following:
■ Type and volume of blood product infused
■ Serial number
■ Time and length of transfusion
■ Vital signs prior, during (peak of transfusion) and after 30
minutes of the transfusion.
■ Response to the therapy
■ Any adverse reactions
■ Interventions done for reactions.

43
CLO#9: utilize the nursing process in the care of clients and undergoing
chest physiotherapy, postural drainage, nebulization, drainage of chest
fluids and blood transfusion

➢ Chest Physiotherapy
❖ Assessment
-Know the patient's medical history certain conditions are
contraindicated in this procedure
-Assess vital signs for database
-Assess for airway patency
-Assess for the area to be chest percussed
-Assess for lung sounds
-Check for patient’s medication
-Assess patient's tolerance of different position changes
-Note presence of sputum, evaluate its equality, color, amount ,odor
and consistency

❖ Diagnosis : Ineffective airway clearance related to retained secretions

in the lungs

❖ Planning
- Patient will have clear, open airways as evidenced by normal
breath sounds, normal rate of respirations, and the ability to
expectorate secretions.
❖ Intervention
- Emphasize the importance of changing of positions for the lung
secretions to be eliminated
- Instruct client to take fluids to promote elimination of secretions
- Perform chest percussion in order for the secretions to be
loosen and easier for expectoration
- Give medications as prescribed by the physician, such as
antibiotics, mucolytic agents, bronchodilators
❖ Evaluation
- Patient is able to maintain a normal airway and was able to
expectorate the lung secretions.

44
➢ Postural Drainage
❖ Assessment
- Know the patient's medical history certain conditions are
contraindicated in this procedure
- Assess vital signs for database
- Assess for lung sounds
- Assess the respiratory rate and depth
- Note presence of sputum, evaluate its equality, color, amount
,odor and consistency
- Observe the flaring of the nostrils of the patient, this could
indicate that the patient is having a hard time breathing

❖ Diagnosis : Ineffective airway clearance: adventitious breath sounds r/t

retained secretions

❖ Planning
- Patient will be able to demonstrate absence of congestion with
breath sounding clear, noiseless respirations, and improved
oxygen exchange

❖ Intervention
- Monitor respirations and breath sounds, note the rate and
sounds
- Elevate the head to open airway and encourage ambulation to
promote elimination of the lung secretions
- Suction nose,mouth, and trachea prn to clear airway when
excessive secretions are blocking airway or when patient is
unable to swallow or cough effectively
- Encourage client to increase fluid intake to promote loosening of
the secretions
- Administer medications as prescribed by the attending physician

❖ Evaluation
- Patient was able to expectorate the lung secretions and has a
patent airway with normal breath sounds.

45
➢ Nebulization
❖ Assessment
- Assess for lung sounds
- Know the patient's medical history certain conditions are
contraindicated in this procedure
- Assess breath sounds such as wheezes and stridor
- Assess for patient’s respiratory rate, depth and rhythm
- Assess for patient’s vital signs
- Assess the patient’s Oxygen saturation

❖ Diagnosis: Ineffective breathing pattern : use of accessory muscles to

breathe r/t presence of thick secretions

❖ Planning
- Patient will be able to manifest a decreased sign of respiratory
effort and demonstrate appropriate behavior to help improve
breathing patterns.

❖ Intervention
- Promote adequate rest and limit performance of activities
- Encourage slower/deeper respirations, use of pursed-lip
technique to assist the client in “taking control” of the situation
- Monitor pulse oximetry to verify improvement of oxygen
saturation
- Teach client in the use of relaxation techniques
- Encourage a position of comfort
- Administer medications as prescribed by the Physician

❖ Evaluation
- Patient is able to demonstrate behaviors of an improved
breathing pattern. The client has manifested a decreased sign of
respiratory effort.

46
➢ Chest tube Drainage systems
❖ Assessment
- Assess patient’s vital signs
- Know the patient's medical history certain conditions are
contraindicated in this procedure
- Assess for lung sounds
- Observe for presence of air leaks
- Note for amount of suction, drainage and type
- Observe any signs of infection
- Pain assessment should be conducted frequently

❖ Diagnosis: Acute pain: 8/10 Pain Score related to chest tube insertion

❖ Planning
- Patient will be able to report pain is controlled and relief

❖ Intervention
- Verify doctor’s order. Inform the client and explain the purpose of
the procedure.
- Obtain and record baseline vital signs
- Wash hands thoroughly with soap and warm water and don
sterile gloves before coming in contact with the patient.
- Check dressing is clean and intact
- Chest tubes are painful as the parietal pleura is very sensitive.
Patients require regular pain relief for comfort, and to allow them
to complete physiotherapy
- The nurse should make a note of the level of drainage at the
end of his or her shift. Also, document the color and amount of
the drainage in the patient’s notes.
- Ensure drain is secure to prevent it falling out use a 'tag' of tape
to secure to skin

❖ Evaluation
- Patient verbalizes there is a relief of pain and discomfort.

47
➢ Blood Transfusion
❖ Assessment
- Assess patient’s vital signs
- Know patient’s medical history certain conditions are
contraindicated in this procedure
- Note for any signs of infection on transfusion site
- Observe for any potential transfusion reactions
- Note for any signs and symptoms of circulatory workload
❖ Diagnosis: Risk for impaired skin integrity related to mechanical trauma
❖ Planning
- Patient will demonstrate good fluid balance, normal electrolyte
and blood chemistry values.
❖ Intervention
- Verify doctor’s order. Inform the client and explain the purpose of
the procedure.
- Check for cross matching and typing. To ensure compatibility
- Obtain and record baseline vital signs
- Practice strict asepsis
- Warm blood at room temperature before transfusion to prevent
chills.
❖ Evaluation
- Patient demonstrates adequate cardiac output, remains free
from infection and maintains good skin integrity with no lesions
or pruritus.

48
CLO#10: demonstrate beginning skills in performing and documenting
chest physiotherapy, postural drainage, nebulization, care of clients with
a chest tube drainage and blood transfusion

NEBULIZATION

DEFINITION:
NEBULIZATION - to disperse fine particles of liquid or medication or
mist inhalation into the deeper passage of the respiratory tract using an air
compressor or nebulizer.

PURPOSE:
> delivers medications to the lungs
> helps in hydrating dried, retained secretions
> promotes expectoration of secretions
> aids in bronchial hygiene by restoring and maintaining mucus blanket continuity
MATERIALS:

A lined tray containing:

> Medication (nebule)
>Medication ticket
> Administration set:
-Nebulizer tubing
-Nebulizer chamber/cup
-Nebulizing mask or mouthpiece
-Kidney basin
-Tissue wipes
-Stethoscope
-Waste receptacle
-Glass of water, oral care set
-Clean towel

*To be carried separately: air compressor or nebulizing machine

PROCE RATIO
DURE NALE

1. Check the physician’s order for To ensure safety and security upon giving the
nebulization. medication to the patient.

2. Explain the purpose and procedure to the In order for the client to understand the
client procedure and to build rapport with the client.

49
3. Ascertain that the client had signed the To ensure that the client has been told about
informed consent. procedure and that the client agreed that the
nurse will perform the procedure.

4. Gather all the materials and equipment To have an assurance that it is the right
needed. Check the medication and medication that you are administering.
compare with the ticket.

5. Perform medical handwashing. To avoid cross contamination with different

microorganisms.

6. Bring all materials and equipment to To practice the principle of saving time and
client’s bedside. energy during the procedure.

7. Identify client. Check the ID band or let To ensure that you are giving the medication
him/her state his/her name and birthday. to the right patient.

8. Plug in the air compressor to the In order for the air compressor to start
electrical outlet. functioning and to check that the air
compressor is functioning well.

9. Position client upright and assess lung Through positioning the client upright will
sounds, pulse and respiration. help the nurse assess the lungs sounds, pulse
and respiration clearly and loudly.

10. Perform medical hand washing. To avoid cross contamination to the patient
and among the healthcare workers.

11. Compare the medication with the ticket To apply one of the ten rights of the patient
for the second time. which is right medication.

12. Connect the parts of the nebulization To ensure that all of the nebulization set are
set. Remove the nebulizer cup from the connected to each other securely. By screwing
device and open it. Place the medication the top portion of the nebulizer cup back in
inside the chamber. Screw the top portion place secures the medication inside the
of the nebulizer cup back in place. chamber in order to avoid spillage.

13. Make sure that the two ends of the To avoid spillage of the medication inside the
tubing are connected to the nebulizer cup nebulizer cup and so that there will be proper
and the air compressor respectively. air flow.

14. Compare the medication with the ticket To ensure that you are administering the
for the third time. right medication to the patient

50
15. Turn on the air compressor. Check that This is to prepare for the procedure to begin.
a fine medication mist is produced. Checking that a fine medication mist is
Administer medication through: produced shows that the medication is ready.

Face Mask:
-instruct the client to slightly open the This is to ensure that the medication will be
mouth. Ensure that the tie is not too tight properly administered. In order for the patient
and comfort is provided. to be comfortable during the procedure.

Mouthpiece:
-instruct the client to place the mouthpiece This is to secure the mouthpiece to the mouth
into the mouth and grasp it securely with and for the medication to be properly
teeth and lips. administered.

16. Instruct client to inhale slowly and In order for the patient to be able to inhale
deeply through the mouth. Hold each the medication properly.
breath for 5-20 seconds before
exhaling.

17. Continue the inhalation technique This is to ensure that the medication has
(usually about 15 minutes). Once the fine been inhaled properly by the patient.
mist decreases in amount, gently flick the Through flicking the sides of the nebulizer cup
sides of the nebulizer cup. will help the medication drop to where it can
be misted.

18. Turn off the air compressor until all This is to ensure that all medications has
medications has been aerosolized and been aerosolized before removing the
remove the mask/mouthpiece. mask/mouthpiece.

19. Perform chest tapping if not This is to strengthen breathing muscles, and
contraindicated and instruct on coughing loosen and improve drainage of thick lung
techniques. secretions.

20. Perform oral care. To give comfort to the patient after the
procedure.

21. Reassess lung sounds, oxygen To see if there are any abnormal findings on
saturation if ordered, pulse and the lung sounds and oxygen saturation.
respirations.

22. Give health teachings or chest For the patient to have insights on what to
physiotherapy and coughing exercises. do after the procedure. Through chest
physiotherapy or coughing exercises will help
the lungs of the patient to loosen lung
secretions.

23. Do after care. Rine the equipment in To avoid contamination of microorganism to

warm water and allow to air dry on a the equipment.
clean towel.

24. Perform medical hand washing. To avoid cross contamination with the
microorganisms.

51
 25. Document accurately. So that the nurse will have a proof that the
procedure has been done.

TRANSFUSION OF BLOOD AND BLOOD

PRODUCTS

DEFINITION:
BLOOD TRANSFUSION - the transfer of blood components from one person (the
donor) into the bloodstream of another person (recipient).

PURPOSE:
>To replace blood or blood component loss as a result of trauma, surgery or
disease condition.

MATERIALS:

A lined tray with:

>Sterile kidney basin
>0.9% NaCl (Normal Saline Solution/NSS)
>Blood administration set
>Bandage scissors
>Alcohol swabs
>Waste receptacle
>Hypoallergenic tape
>Tissue paper
>Small hypotray

PROCEDURE RATIONALE

1. Check the patient’s chart for the To ensure safety and security that you are giving
following: the right order of the doctor, the right number of
A. Physician’s written order blood units, the type of blood product, the right type
B. Number of blood units of infusion, for the nurse to ensure that the blood
C. Type of blood product type on the blood bag is matched to the patient’s
D. Type of infusion chart, lastly for the cross-matching results to ensure
E. Blood typing safety to the patient and to avoid mismatching of the
f. Cross-matching results results.

2. Fill up the blood This is to assure that the physician requested for a
request form. blood transfusion to the patient.

3. Call the laboratory. Ask if blood To apply the principle of saving time and energy
typing and cross-matching are during the procedure. This is to ensure that both
done and if the blood unit is ready. blood typing and cross-matching was done.

4. Go to the patient’s room. Explain To build rapport with the client and to give some
the procedure and the reason for insights to the client about the procedure.
transfusion.

52
5. Ascertain that the patient To ensure that the client has been told about
had signed the informed procedure and that the client agreed that the nurse
consent form. will perform the procedure.

6. Go to the laboratory and get the This is to ensure safety and security that you are
blood unit from the laboratory giving the blood transfusion to the right patient, the
technologist. Check with the right blood type and blood group. Through
technologist the request form and cross-matching result will help the nurse to see if
the data in the laboratory records there are no miss-matching of the blood between
with the data printed in the blood the donor and the patient.
unit: Collaborating with the technologist and checking the
data of the laboratory records will help avoid
A. Patient’s name mistakes right before the procedure.
B. Blood type and blood group
C. Cross-matching result
D. Blood unit and serial number
E. Expiration date of the unit
F. Presence of bubbles and
sediments

7. Bring the blood unit to the nurse’s To ensure the safety and security of the patient. To
station. Check again for the second have an assurance that it is the right blood unit to be
time, the same set of data with the administered to the patient.
physician; and for the third time, with
another registered nurse.

8. Gather other materials needed. To save time and energy during the
procedure.

9. Perform medical hand washing. To avoid contamination to the patient and to

the nurse herself.

10. Open sterile packs aseptically. To apply the principal of sterility.

11. Rotate the blood bag gently. Through gently rotating the blood bag will
avoid for the blood components to be
coagulated.

12. Prime the blood set with NSS. Ensure Priming the blood set with NSS helps the blood
that all air bubbles are out of the tubing. components to go up. This is to prevent air
from entering the circulatory system.

13. Remove the NSS and connect the blood To ensure connection to the blood bag and
set to the blood bag, then prime the blood preparation for the blood transfusion. Priming
set with the blood into the kidney basin, is needed to ensure air does not enter the
patient’s body.

14. Place the primed blood set with blood This is to prepare all the materials needed for
bag, hypoallergenic tape, waste receptacle the procedure.
and alcohol swab on the small hypotray.

53
15. Bring the small hypotray with the To save time and energy and to be ready for
materials to the patient’s room. the procedure to be done.

16. Take patient’s vital signs. To see if the patient’s vital signs are within the
normal range right before the procedure.

17. Prepare a strip of hypoallergenic This is to save time and energy during the
tape and place patient’s towel under procedure.
the arm with IV.

18. Disinfect the Y-port of the mainline To avoid contamination to the Y-port of the
tubing. mainline tubing.

19. Hang the blood bag. Insert the Securing the connection with hypoallergenic
needle of the blood set into the Y-port. tape helps the blood set to be in place and for
Secure the connection with the blood to be transfused smoothly.
hypoallergenic tape.

20. Close off the mainline, then open the This is to regulate the amount of blood being
regulator of the blood set. delivered to the patient depending on the
amount in a specific time he/she is required.

21. Transfuse blood slowly for the 1st 15

minutes. This is because severe reactions most
commonly present during the first 15 minutes
A. Adult: 15-20 gtts/min. of transfusion.
B. Pediatrics: 10-15 gtts/min.

22. Observe the patient closely for any

adverse reactions.

A. If there are any reactions, stop This is to ensure the safety and security of the
the blood transfusion patient during the procedure. Referring it to
immediately. Regulate the main the physician helps the nurse to prevent any
line to 10 gtts/min., take the complication that may arise.
vital signs and then refer to the In order for the procedure to be done and to
physician. follow the physician’s order for the prescribed
B. If there are no reactions, rate.
regulate the blood transfusion to
the prescribed rate.

23. Take the patient’s vital signs at the For the nurse to see if there are any abnormal
peak of the transfusion. findings of the patient’s vital signs during the
peak of the transfusion.

24. When the transfusion is done, close off To stop blood from flowing to the patient's
the blood line, then open the main line and system and to continue prescribed
regulate to the prescribed rate. maintenance fluid.

25. Remove the blood set from In preparation for after care since
the Y-port. Remove the drape. transfusion is complete.

54
26. Ensure patient’s comfort. Do after To provide comfortability to the patient.
care.

27. Take the patient’s vital signs again To ensure that the patient’s vital signs are
30 mins after transmission of at normal range after the transmission of
transfusion. transfusion.

28. Document the following:

A. Type and volume of blood product

infused In order to have a documentation of findings
B. Serial number so that other health care providers may also
C. Time and length of transfusion see it and be made aware of the results of
D. Vital signs prior, during (peak the blood transfusion.
of transfusion) and after 30
minutes of the transfusion.
E. Response to the therapy
F. Any adverse reactions
G. Interventions done for reactions.

55
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