Professional Documents
Culture Documents
SIXTH EDITION
Cover image
Title page
Copyright
Dedication
Section Editors
Contributors
Reviewers
Preface
Acknowledgments
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PROCEDURE 28: Noninvasive Positive Pressure Ventilation: Continuous Positive Airway Pressure (CPAP) and Bilevel
Positive Airway Pressure (BiPAP)
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 29: Arterial-Venous Oxygen Content Difference and Oxygen Transport (Delivery) and Consumption
Calculations
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 35: Invasive Mechanical Ventilation (Through an Artificial Airway): Volume and Pressure Modes
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 36: Standard Weaning Criteria: Negative Inspiratory Force or Pressure, Positive Expiratory Pressure,
Spontaneous Tidal Volume, Vital Capacity, and Rapid Shallow Breathing Index
PREREQUISITE NURSING KNOWLEDGE
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PATIENT AND FAMILY EDUCATION
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PROCEDURE 71: Left Atrial Catheter: Care and Assisting with Removal
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 73: Pulmonary Artery Catheter Insertion (Assist) and Pressure Monitoring
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 83: Implantable Venous Access Device: Access, Deaccess, and Care
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 87: Brain Tissue Oxygen Monitoring: Insertion (Assist), Care, and Troubleshooting
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 88: Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), Intracranial Pressure Monitoring, Care,
Troubleshooting, and Removal
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 89: Combination Intraventricular/Fiberoptic Catheter Insertion (Assist), Monitoring, Nursing Care,
Troubleshooting, and Removal
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 90: Jugular Venous Oxygen Saturation Monitoring: Insertion (Assist), Patient Care, Troubleshooting, and
Removal
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 91: Lumbar Subarachnoid Catheter Insertion (Assist) for Cerebrospinal Fluid Drainage and Pressure
Monitoring
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 97: Cervical Tongs or Halo Ring: Application for Use in Cervical Traction (Assist)
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 99: Pin Site Care: Cervical Tongs and Halo Pins
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 101: Epidural Catheters: Assisting with Insertion and Pain Management
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 103: Peripheral Nerve Blocks: Assisting with Insertion and Pain Management
PREREQUISITE NURSING KNOWLEDGE
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PATIENT AND FAMILY EDUCATION
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PROCEDURE 115: Use of a Massive Infusion Device and a Pressure Infusor Bag
PREREQUISITE NURSING KNOWLEDGE
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Introduction
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PATIENT AND FAMILY EDUCATION
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PROCEDURE 132: Small-Bore Feeding Tube Insertion Using an Electromagnetic Guidance System (CORTRAK®)
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 133: Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, and Jejunostomy Tube Care
PREREQUISITE NURSING KNOWLEDGE
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PROCEDURE 139: Calculating Doses and Flow Rates and Administering Continuous Intravenous Infusions
PREREQUISITE NURSING KNOWLEDGE
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Index
CRITICAL CARE NURSING PROCEDURES
Negative-Pressure Wound Therapy, 1182
Noninvasive Positive Pressure Ventilation: Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway
Pressure (BiPAP), 225
Organ Donation: Identification of Potential Organ Donors, Request for Organ Donation, and Care of the Organ Donor
1223
Oropharyngeal Airway Insertion, 74
Oxygen Saturation Monitoring with Pulse Oximetry, 121
Paracentesis (Assist), 988
Paracentesis (Perform), 981
Patient-Controlled Analgesia, 928
Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, and Jejunostomy Tube Care, 1201
Pericardial Catheter Management, 690
Pericardiocentesis (Assist), 364
Pericardiocentesis (Perform), 355
Peripheral Nerve Blocks: Assisting with Insertion and Pain Management, 936
Peripheral Nerve Stimulators, 303
Peripherally Inserted Central Catheter, 763
Peritoneal Dialysis, 1048
Peritoneal Lavage (Assist), 1002
Peritoneal Lavage (Perform), 994
Permanent Pacemaker (Assessing Function), 403
Pin Site Care: Cervical Tongs and Halo Pins, 904
Pressure Redistribution Surfaces: Continual Lateral Rotation Therapy and RotoRest™ Lateral Rotation Surface, 1124
Pronation Therapy, 129
Pulmonary Artery Catheter and Pressure Lines, Troubleshooting, 655
Pulmonary Artery Catheter Insertion (Assist) and Pressure Monitoring, 626
Pulmonary Artery Catheter Insertion (Perform), 617
Pulmonary Artery Catheter Removal, 648
Shunt Calculation, 259
Single-Pressure and Multiple-Pressure Transducer Systems, 670
Skin Graft Care, 1109
Small-Bore Feeding Tube Insertion and Care, 1206
Small-Bore Feeding Tube Insertion Using an Electromagnetic Guidance System (CORTRAK®), 1192
S tandard Weaning Criteria: Negative Inspiratory Force or Pressure, Positive Expiratory Pressure, S pontaneous Tida
Volume, Vital Capacity, and Rapid Shallow Breathing Index, 285
Suctioning: Endotracheal or Tracheostomy Tube, 79
Surgical Cricothyrotomy (Assist), 64
Surgical Cricothyrotomy (Perform), 58
Suture and Staple Removal, 1144
Temporary Transcutaneous (External) Pacing, 413
Temporary Transvenous and Epicardial Pacing, 429
Temporary Transvenous Pacemaker Insertion (Perform), 421
Thoracentesis (Assist), 219
Thoracentesis (Perform), 208
Tracheal Tube Cuff Care, 88
Tracheostomy Tube Care, 96
Transcranial Doppler Monitoring, 849
Transesophageal Echocardiography (Assist), 705
Twelve-Lead Electrocardiogram, 519
Use of a Massive Infusion Device and a Pressure Infusor Bag, 1057
Ventricular Assist Devices, 464
Weaning Process, 291
Withholding and Withdrawing Life-Sustaining Therapy, 1235
Wound Closure, 1133
Wound Management with Excessive Drainage, 1166
Copyright
Notice
Nursing is an ever-changing field. Standard safety precautions must be followed, but as new research and
clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary
or appropriate. Readers are advised to check the most current product information provided by the
manufacturer of each drug to be administered to verify the recommended dose, the method, and duration of
administration, and contraindications. It is the responsibility of the licensed prescriber, relying on experience
and knowledge of the patient, to determine dosages and the best treatment for each individual patient.
Neither the publisher nor the author assume any liability for any injury and/or damage to persons or
property arising from this publication.
This edition of the AACN Procedure Manual for Critical Care is dedicated to the memory of my dear friend
and colleague, Karen Carlson. Karen and I coedited the fourth and fifth editions of the AACN Procedure
Manual for Critical Care, and we had every intention of coediting this edition too. However, Karen’s cancer
progressed, and she lost her battle with cancer in December of 2007. This edition of the AACN Procedure
Manual for Critical Care is dedicated to Karen.
Section Editors
Michael W. Day, RN , MSN , CCRN
, T rauma C are C oordinator, P rovidenc e S ac red Heart M edic al C enter and C hildren’s Hospital, S pokane
Washington
Mary Beth F lynn Makic, RN , PhD, CN S, CCN, S Researc h Nurse S c ientist, University of C olorado Hospital; A ssistant P rofessor, A djoint,
University of Colorado, Denver, College of Nursing, Aurora, Colorado
Professional Development Specialist, Cardiac Services, Swedish Medical Center, Seattle, Washington
Clinical Practice Specialist, American Association of Critical-Care Nurses, Aliso Viejo, California
Clinical Practice Specialist, American Association of Critical-Care Nurses, Aliso Viejo, California
Critical Care Clinical Nurse Specialist, Walter Reed Army Medical Center, Washington, DC
Clinical Nurse Specialist, Blood and Marrow Transplant Unit, Thomas Jefferson University Hospital, Philadelphia,
Pennsylvania
Nurse Educator, Intermediate Surgical Intensive Care Unit, Thomas Jefferson University Hospital; Adjunct Clinical
Assistant Professor, Villanova University, Philadelphia, Pennsylvania; and Villanova, Pennsylvania
Clinical Nurse Specialist, Department of Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
Clinical Nurse Specialist, Nurse Practitioner, Medical Intensive and Intermediate Care Units, Thomas Jefferson University
Hospital, Philadelphia, Pennsylvania
Critical Care Nurse Practitioner, Colorado Pulmonary Intensivists, Inc., Littleton Adventists Hospita, lLittleton, Colorado
Critical Care Clinical Nurse Specialist, National Naval Medical Center, Bethesda, Maryland
Unit Coordinator, Medical ICU, University of Kansas Hospital, Kansas City, Kansas
Staff Nurse, 2N CICU, Providence Sacred Heart Medical Center, Spokane, Washington
Critical Care Nurse Practitioner, Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas
Clinical Nurse Specialist, Emergency Care Regional Director, Clinical Services, EmCare, Inc., San Antonio, Texas
Critical Care Staff Development Specialist, Christiana Care Health System, Newark, Delaware
Staff Development Nurse, Transplant and Urology Surgery 7N/NE, Thomas Jefferson University Hospital, Philadelphia,
Pennsylvania
Clinical Nurse Specialist, Cardiac Care Unit, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Clinical Nurse Specialist, Neurosciences, WakeMed Health & Hospitals, Raleigh, North Carolina
Facility Administrator, DaVita Dialysis Services, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
Critical Care Educator, Providence Sacred Heart Medical Center, Spokane, Washington
Clinical Nurse Specialist, University of Pennsylvania Medical Center; Lecturer, Clinical Nurse Specialist, University of
Pennsylvania School of Nursing, Philadelphia, Pennsylvania
Clinical Practice Specialist, American Association of Critical-Care Nurses, Aliso Viejo, California
Adjunct Professor, School of Nursing/UCLA School of Nursing, Ronald Reagan UCLA Medical Center, Los Angeles,
California
Clinical Registered Nurse, Specialty Areas, University of Colorado Hospital, Aurora, Colorado
Director of Nursing Practice Integration, Nursing Administration, Cox Health Care System, Springfield, Missouri
Nurse Clinician, Nutrition Support Service, William Beaumont Hospital, Royal Oak, Michigan
Supervisor, Blood Donor Center, Blood Bank, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
Nurse Practitioner, Division of Cardiology, University of Maryland Medical Center, Baltimore, Maryland
Advanced Practice Nurse, Cardiovascular Critical Care, Heart Center, Sinai Hospital of Baltimore, Baltimore, Maryland
Director, Strategic Alliances & Professional Education, Edwards Lifesciences, Irvine, California
Cardiac and Vascular Nurse Practitioner, Montgomery General Hospital, Olney, Maryland
Hematology/BMT Nurse Practitioner, Greenebaum Cancer Center, University of Maryland Hospital, Baltimore,
Maryland
Clinical Nurse Specialist, Cardiac Intermediate Care Unit, Hospital of the University of Pennsylvania, Philadelphia,
Pennsylvania
Clinical Nurse Educator, Cardiac Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
Open Heart Clinical Specialist, The NIH Heart Center at Suburban Hospital, Bethesda, Maryland
Senior RN, Blood Donor Center, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
Nurse Clinician, Neurology Critical Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
Advanced Practice Nurse, Hematology/Oncology/BMT, The Cancer Institute of New Jersey, New Brunswick, New Jersey
Teaching Associate, Department of Neurological Surgery, University of Washington School of Medicine; Senior Clinical
Expert, Harborview Medical Center, Seattle, Washington
Clinical Nurse Specialist, Critical and Progressive Care Units, Homestead Hospital, Homestead, Florida
Clinical Nurse Specialist, Cardiovascular Services, Baylor University Medical Center, Dallas, Texas
Research Assistant and Doctoral Student, Biobehavioral Nursing and Health Systems, University of Washington; Clinical
Instructor, University of Washington School of Nursing, Seattle, Washington
Staff Nurse Anesthetist/Clinical Preceptor, Gonzaga University/Sacred Heart Medical Center, School of Anesthesia,
Spokane, Washington
Nurse Practitioner, Heart Failure/Heart Transplant, Toronto General Hospital, Toronto, Ontario, Canada
Assistant Clinical Professor, School of Nursing, University of California Los Angeles; Clinical Nurse Specialist, Ronald
Reagan UCLA Medical Center, Los Angeles, California
Clinical Practice Specialist, American Association of Critical-Care Nurses, Aliso Viejo, California
Clinical Nurse Specialist, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore,
Maryland
Nurse Practitioner, Cardiovascular Surgery and the Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac
Centre, Toronto General Hospital, University Health Network; Clinical Associate, Lawrence S. Bloomberg Faculty of
Nursing, University of Toronto, Toronto, Ontario, Canada
Clinical Nurse Specialist, Medical ICU, University of Maryland Medical Center, Baltimore, Maryland
Adult Nurse Practitioner, Department of Anesthesiology and Pain Medicine, University of Washington; Nurse
Practitioner Pain Relief Service, Harborview Medical Center, Seattle, Washington
Nurse Manager 2 South ICU, Providence Sacred Heart Medical Center, Spokane, Washington
Acute Care Nurse Practitioner, Nationally Registered Paramedic, Advanced Practice Nurse, Department of Emergency
Medicine, Fulton County Medical Center, McConnellsburg, Pennsylvania
Assistant Professor, Department of Medicine/Neurology, Duke University Medical Center; Staff Nurse Level 4, Duke
Neurocritical Care Unit, Durham, North Carolina
Cherryl Parcon, RN
Peritoneal Dialysis Nurse, DaVita Dialysis Services, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
Critical Care Clinical Nurse Specialist, Park Nicollet Methodist Hospital, St Louis Park, Minnesota
Joya D. Pickett, MSN, CCNS, ACNS-BC, CCRN
Clinical Instructor, University of Washington, Biobehavioral Nursing and Health Sciences; Critical Care Clinical Nurse
Specialist, Swedish Medical Center, Seattle, Washington
Nurse Practitioner, General Surgery, Director of Nursing, Surgical and Perioperative Care, VA Puget Sound Health Care
System, Seattle, Washington
Director, Clinical Nurse Specialists and Nursing Research, Critical Care Clinical Nurse Specialist, St Vincent Hospital,
Indianapolis, Indiana
Associate Professor, Department of Nursing College of Notre Dame; Adult Nurse Practitioner in Thoracic Surgery, Union
Memorial Hospital, Baltimore, Maryland
Clinical Nurse Specialist, Medical Pulmonary Critical Care, Christiana Care Health System, Newark, Delaware
Clinical Practice Specialist, American Association of Critical-Care Nurses, Aliso Viejo, California
Clinical Dietitian, Trauma and Critical Care, Baylor University Medical Center, Dallas, Texas
Clinical Nurse Specialist, Burn Unit and F6/6 (GYN, Plastics, ENT, Urology), University of Wisconsin Hospital and
Clinics, Madison, Wisconsin
Assistant Professor, School of Nursing, Critical Care CNS, Ball Memorial Hospital, Muncie, Indiana
Clinical Nurse, ABLS National Faculty, University of Colorado Hospital, Aurora, Colorado
Clinical Nurse Specialist for Emergency Services, Albert Einstein Health Network, Philadelphia, Pennsylvania
Nurse Anesthetist, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, Washington
Critical Care Clinical Nurse Specialist–IMC, Palomar Pomerado Health, Escondido, California
Neurosurgery Nurse Practitioner, Department of Neurological Surgery, Hospital and Clinics, University of Wisconsin
School of Medicine and Public Health, Madison, Wisconsin
Critical Care Education Coordinator, Christiana Care Health System, Newark, Delaware
Clinical Nurse Specialist, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore,
Maryland
Critical Care Clinical Nurse Specialist, Nursing Education and Research Center, Veterans Affairs Maryland Health Care
System, Baltimore, Maryland
Clinical Nurse Specialist, Educator, Consultant, Advancing Nursing LLC, Northville, Michigan
Nurse Educator, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
Cardiovascular Clinical Nurse Specialist, Cardiac Intensive Care Unit and Cardiac Telemetry Unit, Mission Hospital,
Mission Viejo, California
Director/Nurse Practitioner, Palliative and Restorative Integrated Services Model, Oakwood Healthcare System,
Dearborn, Michigan
Cardiology Nurse Practitioner, Kaiser Permanente Mid-Atlantic States, Silver Spring, Maryland
Clinical Nurse Specialist, Neurosciences Critical Care Unit, The Johns Hopkins Hospital, Baltimore, Maryland
Preface
In this time of dramatic change in healthcare, it is with great pleasure that we present the sixth edition of the AACN
Procedure Manual for Critical Care. The changes that our colleagues will find in this edition are a direct reflection of the
ongoing knowledge and technology explosion that has been a part of the new century. Although every a empt was
made to capture current clinical practice, we recognize that critical care clinical practice is dynamic, and therefore, any
resource to support that practice must be considered a work in progress.
AACN is dedicated to the care of patients with critical illness or injury and their families. AACN’s vision is of a
healthcare system driven by the needs of patients and their families in which critical care nurses make their optimal
contribution. Toward that vision, our hope is that this edition of the AACN Procedure Manual for Critical Carewill be a
useful resource for critical care nurses in providing quality patient care.
The sixth edition of the AACN Procedure Manual for Critical Carewill be an asset for nurses across the spectrum of
acute and critical care practice. The manual includes a comprehensive review of state-of-the-art information on acute and
critical care procedures. The following procedures related to new and emerging trends have been added:
• Surgical Cricothyrotomy (Perform and Assist)
• Noninvasive Positive Pressure Ventilation: Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway
Pressure (BiPAP)
• Arterial Pressure-Based Cardiac Output Monitoring
• Fecal Containment Devices and Bowel Management System
• Small-Bore Feeding Tube Insertion Using an Electromagnetic Guidance System (CORTRAK®)
• Intraosseous Devices
All procedures have been revised to reflect changes in practice. With the increased presence of advanced practice
nurses in critical care units, this edition of the AACN Procedure Manual for Critical Carenot only contains procedures
commonly performed by critical care nurses but also includes an even greater number of procedures performed by
advanced practice nurses than the fifth edition. Each advanced practice procedure has an AP designation in the Table of
Contents and a special AP icon and explanatory footnote on the first page of each procedure.
Because we recognize that the procedures included in this manual are only a portion of the repertoire needed by
today’s critical care practitioners to skillfully care for critically ill patients, we recommend it be used in conjunction with
AACN Core Curriculum for Critical Care Nursing, AACN Certification and Core Review for High Acuity and Critical Car
and AACN Advanced Critical Care Nursing.
T he AACN Procedure Manual for Critical Careis designed so that information within each procedure can be found
quickly. To provide high-quality care to seriously ill patients, we need resources that provide us with readily available
need-to-know information. This edition, like the fifth, is organized in units, with most of the units having several
sections. All procedures are designed in the same style and begin with the following:
• Purpose of the procedure.
• Prerequisite Nursing Knowledge, which includes information the nurse needs before performing the procedure.
• Equipment list, which includes equipment necessary to perform the procedure. Some of the procedures identify
additional equipment that may be necessary based on individual situations.
• Patient and Family Education, which identifies essential information that should be taught to patients and their
families.
• Patient Assessment and Preparation, which includes specific assessment criteria that should be obtained before the
procedure and describes how the patient should be prepared for the procedure.
Each step-by-step procedure includes:
• Steps, Rationales, and for some steps, Special Considerations.
• Associated research and appropriate figures and tables.
• Expected Outcomes, including the anticipated results of the procedure.
• Unexpected Outcomes, including potential complications or untoward outcomes of the procedure.
• Patient Monitoring, which includes information related to assessments and interventions that should be completed.
The rationale for each item is described, and conditions that necessitate notification of an advanced practice nurse or
physician are identified.
• Documentation that describes what should be documented after the procedure is performed.
• References are included, and the majority of procedures also include Additional Readings.
This edition of the AACN Procedure Manual for Critical Careincludes several icons that are common to many of the
procedures. These icons include:
A procedure with the AP icon should be performed only by physicians, advanced practice nurses, and other
healthcare professionals (including critical care nurses) with additional knowledge, skills, and demonstrated competence
per professional licensure or institutional standard.
A procedure step with the HH icon designates that hand hygiene should be performed. This step is essential to
reduce the transmission of microorganisms and is part of Standard Precautions.
A procedure step with the PE icon designates that personal protective equipment should be applied. Personal
protective equipment may include gloves, protective eyeglasses, masks, gowns, and any additional equipment needed to
protect the nurse or provider performing the procedure. The application of personal protective equipment reduces the
transmission of microorganisms, minimizes splash, and is part of Standard Precautions.
A procedure step with the VP icon designates that the correct patient is identified using two identifiers. It is essential
that prior to performing a procedure, the nurse ensures the correct identification of the patient for the intended
intervention.
A reference with the CR icon is a classic reference. A classic reference is a reference that is more than 5 years old at
the time the procedure was written and meets the following criteria:
• It is widely cited in the literature and impacts practice.
• It is considered a standard work of established excellence.
• It is the foundation for practice.
In the nursing profession, the quest to have our practice driven by research has never been greater. Once again, this
edition of the AACN Procedure Manual for Critical Careuses a research-based leveling system. As available, this research-
based information is provided to indicate the research-based strength of recommendation for various interventions.
Although we believe that this is a major step forward in promoting research-based practice, the paucity of research
available in many procedures also speaks loudly to the need for further investigation. The research-based leveling system
is the same as is used for AACN Protocols for Practice and includes:
• Level A: Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently
support a specific action, intervention, or treatment.
• Level B: Well-designed controlled studies with results that consistently support a specific action, intervention, or
treatment.
• Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized
controlled trials with inconsistent results.
• Level D: Peer-reviewed professional organizational standards with clinical studies to support recommendations.
• Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional
organizational standards without clinical studies to support recommendations.
• Level M: Manufacturer’s recommendations only.
Given the nature of critical care, many of the included procedures use electrical equipment. This manual makes the
assumption that all equipment is maintained by the institution’s bioengineering department according to accepted
national and state regulations for the individual piece of equipment.
We hope that you find this book an essential resource for clinical practice.
Debra Lynn-McHale Wiegand
Acknowledgments
This edition of the AACN Procedure Manual for Critical Carecould not have been published without the help of
numerous invaluable individuals. First, I want to thank AACN for giving me the opportunity to edit this edition. M y
deepest gratitude is extended to Ellen French, who was Publishing Director for AACN. Ellen believed in Karen Carlson
and me when we first started coediting the AACN Procedure Manual for Critical Care,and she continued to support me
when I was faced with the challenge of editing this text without Karen at my side. I am especially thankful for Ellen’s
expertise, time, advice, support, and understanding during the development of this book.
I am very grateful that I had the opportunity to work with the talented, hard-working, and dedicated editorial staff at
Elsevier. I want to extend a special thank you to M aureen Iannuzzi, my editor. M aureen’s leadership was an essential
component to the success of the publication. M aureen provided important guidance and support throughout the entire
publication process. I also want to thank Robin Levin Richman and her predecessor, Jennifer Ehlers, S enior
Developmental Editors, for coordinating the day-to-day progress of the book. Jennifer and Robin were fun to work with
and approached challenges with patience and kindness. I also want to thank Julia Curcio, Editorial Assistant; Anne
Konopka, S enior Project M anager; Karen M oehlman, Copyeditor; Kim Denando, Designer; and Jeff Pa erson
Publishing S ervices M anager for all of their hard work and commitment to the process of producing this book. In
addition, I want to thank S uzanne Toppy, M anaging Editor, M osby Nursing S kills, for all of her work as she coordinated
the review process. The Elsevier team worked very hard to produce this quality textbook.
I want to extend a huge thank you to each of the section editors: M ichael Day, Eleanor Fi patrick, M ary Beth M akic,
and Teresa Preuss. The section editors coordinated the development and revision of each of the procedures within their
sections. I am very appreciative of all of their hard work and commitment to a quality product. I tremendously enjoyed
working with such an expert team.
This book would not be possible without the hard work and commitment from the contributors. The contributors are
the staff nurses and advanced practice nurses who revised the procedures and developed new procedures. Each
contributor worked very hard to ensure that each procedure included all of the information needed so that acute and
critical care nurses would have the most helpful information at their fingertips. I cannot thank each of the contributors
enough for their commitment to this book.
I also want to thank the staff nurses and advanced practice nurses who reviewed each of the procedures. At least two
reviewers critiqued each procedure and provided important feedback to the contributors. The reviewers’ critiques
improved the quality of each procedure. I am also grateful to Laura M cNamara and M ary Pat Aust, Clinical Practice
S pecialists at the AACN National Office, who dedicated a tremendous amount of time and energy reviewing this work.
Their critiques contributed to ensuring the quality of the AACN Procedure Manual for Critical Care.
On a personal note, I want to thank the critical care nurses who cared for my mother and my son when they were
critically ill. Nurses make a difference every day in the lives of patients and families. I also want to extend the biggest
thank you ever to my husband, Jim. There is not another man in the world that I would rather have by my side.
UNIT I
Pulmonary System
SECTION ONE
Airway Management
P R OC E D UR E 1
PURPOSE:
A Combitube may be used to provide an emergency airway during resuscitation of a profoundly unconscious
patient who needs artificial ventilation when endotracheal intubation is not readily available or has failed in
successfully establishing an airway.
The 37F size is used for patients 48 to 66 inches tall (122 to 168 cm).
Either size 37F or size 41F is applicable in patients 60 to 66 inches tall (152 to 168 cm).12
• For patients greater than or equal to 66 inches (168 cm), the 41F size should be used.
• The Combitube has a unique design that includes:
A double-lumen, semirigid airway
Blue lumen opening to the perforations between the cuffs
White lumen opening distal to the distal cuff
Each lumen fitted with a 15-mm male adapter
Two cuffs for occlusion
Proximal cuff (85 mL or 100 mL, depending on tube size) to occlude the hypopharynx
Distal cuff (12 mL or 15 mL, depending on tube size) to occlude either the esophagus or the trachea
Each cuff connected to a pilot balloon and valve: blue for proximal (No. 1), white for distal (No. 2)
Two black lines indicate the position of the patient’s teeth or gum line when the device is first inserted.
Because of the large inflated cuff in the hypopharynx, the Combitube needs no stabilization or securing after
placement.
• The correct placement of a Combitube in the airway is as follows:
Esophageal insertion (Figs. 1-2 and 1-3), in which the distal cuff occludes the esophagus and the proximal balloon
occludes the hypopharynx, allows ventilation via the blue lumen.
• Tracheal insertion (Fig. 1-4), in which the distal cuff occludes the trachea and the proximal balloon occludes the
hypopharynx, allows ventilation through the white lumen.
FIGURE 1-4 Combitube in tracheal position.
• Before the insertion of a Combitube, adequate ventilation of an unconscious patient with a mouth-to-mask or a bag-
valve-mask device is necessary.
• Use of the Combitube is contraindicated for airway management8,12 in the following cases:
Patients with an intact gag reflex
Patients with known esophageal disease
Patients who have ingested caustic substances
Patients with a known or suspected foreign body in the hypopharynx
Pediatric patients
• The Combitube contains latex and may cause an allergic reaction in patients or in personnel who handle the device
with a sensitivity to latex.12
• The Combitube is supplied either in a complete kit (with all of the necessary components for insertion), in soft or rigid
packaging, or as a single individual device (without any of the necessary components for insertion). If the single
individual device is used, additional components are necessary for insertion.
• Initial and ongoing training is needed to maximize insertion success and minimize complications.7
• Medications delivered via endotracheal tube cannot be used with a Combitube in the esophageal position.
Medications may not reach the alveolar surfaces of the lung for absorption.
• The Combitube is intended for use up to 8 hours only.13
EQUIPMENT
• Combitube, of the appropriate size for the patient’s height
• Large (100-mL) Luer-tip syringe
• Small (20-mL) Luer-tip syringe
• Water-soluble lubricant
• Mouth-to-mask or self-inflating manual resuscitation bag-valve-mask device and mask attached to a high-flow oxygen
source
• Oxygen source and tubing
• Gloves, mask, gown, and eye protection
• Suction equipment (suction canister with control head, tracheal suction catheters, Yankauer suction tip)
• Fluid deflector elbow
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure adequate ventilation and oxygenation with either a mouth-to-mask or a self-inflating manual resuscitation bag-
valve-mask device. Rationale: The patient is nonresponsive and unable to maintain adequate ventilation without
assisted ventilation before the Combitube insertion.
• Ensure that the suction equipment is assembled and in working order. Rationale: The patient may regurgitate
during insertion or while the Combitube is in place and need oropharyngeal or tracheal suctioning or both.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
Procedure for Combitube Insertion
References
1. American Heart Association. ACLS Resource Text (ACLS). Dallas: AHA; 2008.
2. Calkins, T, et al. Success and complication rates with -prehospital placement of an esophageal-tracheal
Combitube as a rescue airway. Prehosp Disaster Med. 2006; 21(2 Suppl 2):97–100.
3. Frass, M, Combitube retrieved June 22, 2009. Internet J Anesthesiol. 2001; 5(2). www.ispub.com
4. Frass, M, et al. Evaluation of esophageal Combitube in -cardiopulmonary resuscitation. Crit Care Med. 1987;
15:609–611.
5. Kayhan, D, et al, Which is responsible for hemodynamic response due to laryngoscopy and endotracheal
intubation. Eur J -Anaesthesiol. Catecholamines, vasopression or angiotensin. 2005; 22(10):780–785.
6. Keller, C, et al. The influence of cuff volume and anatomic location on pharyngeal, esophageal, and tracheal
mucosal pressures with the esophageal tracheal Combitube. Anesthesiology. 2002; 96:1074–1077.
7. Kory, P, et al, Initial airway management skills of senior residents. Simulation training compared with traditional
training. Chest. 2007; 132(6):1927–1931.
8. Lavery, G, McCloskey, B, et al. The difficult airway in adult critical care. Crit Care Med. 2008; 39(7):2163–2173.
9. Mace, SE, Challenges and advantages in intubation. Rapid sequence intubation. Emerg Med Clin North Am.
2008; 4(26):1043–1068.
10. Oczenski, W, et al. Hemodynamic and catecholamine stress responses to insertion of the Combitube, laryngeal
mask airway, and tracheal intubation. Anesth Analg. 1999; 88(6):1389–1394.
11. Rich, J, Thierbach, A, Frass, M. The Combitube, self-inflating bulb, and colorimetric carbon dioxide detector to
advance airway management in the first echelon of the battlefield. Mil Med. 2006; 171(5):389–395.
12. Tyco, Hare. Combitube, Mansfi eld, MA, 2005,Tyco. www.nellcor.com/Serv/Manuals.aspx?ID=259
www.nellcor.com/_catalog/pdf/sns/dfu/10000643b_dfu_combitube.pdf, June 19, 2009. [Text available at. Linked
from, retrieved].
13. Tyco Healthcare, Combitube quick guide Mansfield, MA, 2000. Tyco. www.nellcor.com/prod/Product.aspx?
S1=AIR&S2=&id=259 Text available at. www.nellcor.com/_Catalog/PDF/Product/Combitube%20QRG.pdf, June
19, 2009 [Linked from, retrieved].
14. Vezina, M, et al. Complications associated with esophageal-tracheal Combitube in the pre-hospital setting. Can J
Anaesth. 2007; 54(2):124–128.
Additional Readings
Agro, F, et al, Current status of the Combitube. a review of the literature. J Clin Anesth 2002; 14:307–314.
Foley, LJ, Oc hroc h EA. Bridges to establish an emergenc y -airway and alternate intubating tec hniques. Crit Ca re Clin. 2000; 16:429–444.
Gaitini, LA, Vaida, S J, Agro, F. The esophageal-trac heal -Combitube. Anesthesiol Clin North Am. 2002; 20:893–906.
Idris, AH, Gabrielli, A. Advanc es in airway management. Emerg Med Clin North Am. 2002; 20:843–857.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 2
PURPOSE:
Endotracheal intubation is performed to establish and maintain a patent airway, facilitate oxygenation and
ventilation, reduce the risk of aspiration, and assist with the clearance of secretions.
• Two types of laryngoscope blades exist: straight and curved. The straight (Miller) blade is designed so that the tip
extends below the epiglottis, to lift and expose the glottic opening. The straight blade is recommended for use in
obese patients, pediatric patients, and patients with short necks because their tracheas may be located more
anteriorly. When a curved (Macintosh) blade is used, the tip is advanced into the vallecula (the space between the
epiglottis and the base of the tongue), to expose the glottic opening.
• Laryngoscope blades are available with fiberoptic light delivery systems. These systems provide a brighter light than
bulbs, which can become scratched or covered with secretions.
• Endotracheal tube size reflects the size of the internal diameter of the tube. Tubes range in size from 2.5 mm for
neonates to 9 mm for large adults. Endotracheal tubes that range in size from 7 to 7.5 mm are used for average-sized
adult women, whereas endotracheal tubes that range in size from 8 to 9 mm are used for average-sized adult men
(Fig. 2-2).8,9,12 The tube with the largest clinically acceptable internal diameter should be used to minimize airway
resistance and assist in suctioning.4
FIGURE 2-2 Parts of the endotracheal tube (soft-cuffed tube by Smiths Industries Medical Systems, Co, Valencia, Calif). (From Kersten LD: Comprehensive
respiratory nursing, Philadelphia, 1989, Saunders, 637.)
• Endotracheal intubation can be done via nasal or oral routes. The skill of the practitioner who performs the intubation
and the patient’s clinical condition determine the route used.
• Nasal intubation is relatively contraindicated in trauma patients with facial fractures or suspected fractures at the base
of the skull and after cranial surgeries, such as transnasal hypophysectomy.
• Improper intubation technique may result in trauma to the teeth, soft tissues of the mouth or nose, vocal cords, and
posterior pharynx.
• In patients with suspected spinal cord injuries, in-line cervical immobilization of the head must be maintained during
endotracheal intubation.
• Primary and secondary confirmation of endotracheal intubation should be performed.1,4
Primary confirmation of proper endotracheal tube placement includes visualization of the tube passing through the
vocal cords, absence of gurgling over the epigastric area, auscultation of bilateral breath sounds, bilateral chest rise
and fall during ventilation, and mist in the tube.
Secondary confirmation of proper endotracheal tube placement is necessary to protect against unrecognized
esophageal intubation. Methods include use of disposable end-tidal carbon dioxide (CO2 ) detectors, continuous
end-tidal CO2 monitors, and esophageal detection devices.
• End-tidal CO2 (PetCO2 ) monitoring devices have been shown to be reliable indicators of expired CO2 in patients with
perfusing rhythms.1,5,11,13,15 During cardiac arrest (nonperfusing rhythms), low pulmonary blood flow may cause
insufficient expired CO2 .14 CO2 detected with an end-tidal CO2 detector is a reliable indicator of proper tube
placement.6 If CO2 is not detected, use of an esophageal detector device is recommended.1,3,11,15
• Disposable end-tidal CO2 detectors are chemically treated with a nontoxic indicator that changes color in the presence
of CO2 and indicates that the endotracheal tube has been placed successfully into the trachea.
• Continuous end-tidal CO2 monitors may be used to confirm proper endotracheal tube placement after intubation
attempts and allow for the detection of future tube dislodgment.
• Esophageal detector devices work by creating suction at the end of the endotracheal tube with compressing a flexible
bulb or pulling back on a syringe plunger. When the tube is placed correctly in the trachea, air allows for reexpansion
of the bulb or movement of the syringe plunger. If the tube is located in the esophagus, no movement of the syringe
plunger or reexpansion of the bulb is seen. These devices may be misleading in patients who are morbidly obese,
patients in status asthmaticus, patients late in pregnancy, or patients with large amounts of tracheal secretions.1
• Double-lumen endotracheal tubes are used for independent lung ventilation in situations with bleeding of one lung or
a large air leak that would impair ventilation of the good lung.
• The endotracheal tube also provides a route for the administration of emergency medications (e.g., lidocaine,
epinephrine, atropine, and naloxone) when no other routes of administration are available.4
EQUIPMENT
• Personal protective equipment, including eye protection
• Endotracheal tube with intact cuff and 15-mm connector (women, 7-mm to 7.5-mm tube; men, 8-mm to 9-mm tube)
• Laryngoscope handle with fresh batteries
• Laryngoscope blades (straight and curved)
• Spare bulb for laryngoscope blades
• Flexible stylet
• Self-inflating manual resuscitation bag-valve-mask device with face mask connected to supplemental oxygen (≥15
L/min)
• Oxygen source and connecting tubes
• Swivel adapter (for attachment to resuscitation bag or ventilator)
• Luer-tip 10-mL syringe for cuff inflation
• Water-soluble lubricant
• Rigid pharyngeal suction-tip (Yankauer) catheter
• Suction apparatus (portable or wall)
• Suction catheters
• Bite-block or oropharyngeal airway
• Endotracheal tube–securing apparatus or appropriate tape
Commercially available endotracheal tube holder
Adhesive tape (6 to 8 inches long)
Twill tape (cut into 30-inch lengths)
• Stethoscope
• Monitoring equipment: Continuous oxygen saturation and cardiac rhythm
• Secondary confirmation device: Disposable end-tidal CO2 detector, continuous end-tidal CO2 monitoring device, or
esophageal detection device
• Drugs for intubation as indicated (sedation, paralyzing agents, lidocaine, atropine)
Additional equipment (to have available depending on patient need or practitioner preference) includes the following:
• Anesthetic spray (nasal approach)
• Local anesthetic jelly (nasal approach)
• Magill forceps (to remove foreign bodies obstructing the airway)
• Ventilator
Patient Preparation
• Perform a pre-procedure verification and time out, if non-emergent. Rational: Ensures patient safety.
• Ensure that the patient understands preprocedural teaching, if appropriate. Answer questions as they arise, and
reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and
reinforced.
• Before intubation, initiate intravenous or intraosseous access. Rationale: Readily available intravenous or
intraosseous access may be necessary if the patient needs to be sedated or paralyzed or needs other medications
because of a negative response to the intubation procedure.
• Position the patient appropriately.
Positioning of the nontrauma patient is as follows: Place the patient supine with the head in the sniffing position, in
which the head is extended and the neck is flexed. Placement of a small towel under the occiput elevates it several
inches, allowing for proper flexion of the neck (Fig. 2-3). Rationale: Placement of the head in the sniffing position
allows for visualization of the larynx and vocal cords by aligning the axes of the mouth, pharynx, and trachea.
FIGURE 2-3 Neck hyperextension in the sniffing position aligns the axis of the mouth, pharynx, and trachea before endotracheal intubation. (From Kersten LD:
Comprehensive respiratory nursing, Philadelphia, 1989, Saunders, 642.)
Positioning of the trauma patient is as follows: Manual in-line cervical spinal immobilization must be maintained
during the entire process of intubation. Rationale: Because cervical spinal cord injury must be suspected in all
trauma patients until proved otherwise, this position helps prevent secondary injury should a cervical spine injury
be present.
• Premedicate as indicated. Rationale: Appropriate premedication allows for more controlled intubation, reducing
the incidence of insertion trauma, aspiration, laryngospasm, and improper tube placement.
• As appropriate, notify the respiratory therapy department of impending intubation so that a ventilator can be set up.
Rationale: The ventilator is set up before intubation.
Procedure for Performing Endotracheal Intubation
FIGURE 2-4 Technique of orotracheal intubation. The laryngoscope blade is inserted into the oral cavity from the right, pushing the tongue to the left as it is
introduced.
FIGURE 2-5 The blade is advanced into oropharynx, and the laryngoscope is lifted to expose the epiglottis.
FIGURE 2-6 The tip of the blade is placed in the vallecula, and the laryngoscope is lifted further to expose the glottis. The tube is inserted through the right
side of the mouth.
FIGURE 2-7 The endotracheal tube is passed through the vocal cords. (From Flynn JM, Bruce NP: Introduction to critical care skills, St Louis, 1993, Mosby, 56.)
FIGURE 2-8 The tube is advanced through the vocal cords into the trachea.
FIGURE 2-9 The tube is positioned so that the cuff is below the vocal cords, and the laryngoscope is removed.
FIGURE 2-10 Methods of securing adhesive tape. Example protocol for securing the endotracheal tube w ith adhesive tape. 1, Clean the patient’s skin w ith
mild soap and w ater. 2, Remove oil from the skin w ith alcohol and allow to dry. 3, Apply a skin adhesive product to enhance tape adherence. (When tape is
removed, an adhesive remover is necessary.) 4, Place a hydrocolloid membrane over the cheeks to protect friable skin. 5, Secure w ith adhesive tape as
show n. (From Henneman E, Ellstrom K, St John RE: AACN protocols for practice: care of the mechanically ventilated patient series, Aliso Viejo, CA, 1999, American Association of
Critical-Care Nurses, 56.)
References
1. American Heart Association, Guidelines 2005 American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care. adjuncts for airway control and ventilation. Circulation. 2005;
112((Suppl) IV):51–57.
2. Barnason, S, et al. Comparison of two endotracheal tube securement techniques on unplanned extubation,
oral mucosa, and facial skin integrity. Heart Lung. 1998; 27:409–417.
3. Bozeman, WP, et al. Esophageal detector device versus detection of end-tidal carbon dioxide level in
emergency intubation. Ann Emerg Med. 1996; 27:595–599.
4. Cummins RO, ed.. Airway, airway adjuncts, oxygenation, and ventilation. ACLS: principles and practice.
American Heart Association: Dallas, 2003:135–180.
5. Goldberg, JS, et al. Colorimetric end-tidal carbon dioxide monitoring for tracheal intubation. Anesth Analg.
1990; 70:191–194.
6. Hayden, SR, et al. Colorimetric end-tidal CO2 detector for verification of endotracheal tube placement in out-
of-hospital cardiac arrest. Acad Emerg Med. 1995; 2:499–502.
7. Hendey, GW, et al. The esophageal detector bulb in the aeromedical setting. J Emerg Med. 2002; 23:51–55.
8. Henneman, E, Ellstrom, E, St John RE, Airway management. AACN protocols for practice: care of the
mechanically ventilated patient series. American Association of Critical-Care Nurses, Aliso Viejo,CA, 1999.
9. Holleran, RS, Air and surface patient transport. principles and practice. ed 3. Mosby, St Louis, 2003.
10. Kasper, CL, et al. The self-inflating bulb to detect esophageal intubation during emergency airway
management. Anesthesiology. 1998; 88:898–902.
11. Schaller, RJ, et al, Comparison of a colorimetric end-tidal CO2 detector and an esophageal aspiration device for
verifying endotracheal tube placement in the prehospital setting. a six-month experience. Prehosp Disaster Med
1997; 12:57–63.
12. Stewart, C. Tracheal intubation. In: Stewart C, ed. Advanced airway management. New Jersey: Prentice Hall;
2002:76–113.
13. Takeda, T, et al. The assessment of three methods to verify tracheal tube placement in the emergency setting.
Resuscitation. 2003; 56:153–157.
14. Varon, AJ, et al. Clinical utility of a colorimetricend-tidal CO2 detector in cardiopulmonary resuscitation and
emergency intubation. J Clin Monit. 1991; 7:289–293.
15. Zaleski, L, et al. The esophageal detector device. Does it work. Anesthesiology. 1993; 79:244–247.
Additional Readings
Committee on Trauma, Americ an College of S urgeons. advanc ed trauma life support manual. Americ an College of S urgeons, Chic ago, 2004.
Ellis, DY, Harris, T, Zideman, D, Cric oid pressure in the -emergenc y department rapid sequenc e trac heal -intubation. a risk-benefit analysis. Ann Emerg Med 2007;
50:653–656.
Emergenc y Nurses Assoc iation, Trauma nursing c ore c ourse. provider manual. ed 6. Emergenc y Nurses Assoc iation, Des Plaines, IL, 2007.
National Assoc iation of Emergenc y Tec hnic ians, PHTLS . basic and advanc ed prehospital trauma life support. ed 5. Mosby, S t Louis, 2003.
Roberts JR, Hedges JR, eds. Clinic al proc edures in emergenc y medic ine, ed 4, Philadelphia: S aunders, 2004.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 3
PURPOSE:
Endotracheal intubation is performed to establish and maintain a patent airway, facilitate oxygenation and
ventilation, reduce the risk of aspiration, and assist with the clearance of secretions.
EQUIPMENT
• Personal protective equipment, including eye protection
• Endotracheal tube with intact cuff and 15-mm connector (women, 7-mm to 7.5-mm tube; men, 8-mm to 9-mm tube)
• Laryngoscope handle with fresh batteries
• Laryngoscope blades (straight and curved)
• Spare bulb for laryngoscope blades
• Flexible stylet
• Self-inflating manual resuscitation bag-valve-mask device connected to supplemental oxygen (≥15 L/min)
• Oxygen source and connecting tubes
• Swivel adapter (for attachment to resuscitation bag or ventilator)
• Luer-tip 10-mL syringe for cuff inflation
• Water-soluble lubricant
• Rigid pharyngeal suction-tip (Yankauer) catheter
• Suction apparatus (portable or wall)
• Suction catheters
• Bite-block or oropharyngeal airway
• Endotracheal tube–securing apparatus or appropriate tape
Commercially available endotracheal tube holder
Adhesive tape (6 to 8 inches long)
Twill tape (cut into 30-inch lengths)
• Stethoscope
• Monitoring equipment: continuous oxygen saturation and cardiac rhythm
• Secondary confirmation device: Disposable end-tidal CO2 detector, continuous end-tidal CO2 monitoring device, or
esophageal detection device
• Drugs for intubation as indicated (sedation, paralyzing agents, lidocaine, atropine)
• Additional equipment, to have available as needed, includes the following:
Anesthetic spray (nasal approach)
Local anesthetic jelly (nasal approach)
Magill forceps (to remove foreign bodies obstructing the airway)
Ventilator
Patient Preparation
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure that the patient understands preprocedural teachings, if appropriate. Answer questions as they arise, and
reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and
reinforced.
• Before intubation, initiate intravenous or intraosseous access. Rationale: Readily available intravenous or
intraosseous access may be necessary if the patient needs to be sedated or paralyzed or needs other medications
because of a negative response to the intubation procedure.
• Position the patient appropriately.
Positioning of the nontrauma patient is as follows: Place the patient supine with the head in the sniffing position, in
which the head is extended and the neck is flexed. Placement of a small towel under the occiput elevates it several
inches, allowing for proper flexion of the neck (see Fig. 2-3). Rationale: Placement of the head in the sniffing
position allows for visualization of the larynx and vocal cords by aligning the axes of the mouth, pharynx, and
trachea.
Positioning of the trauma patient is as follows: Manual in-line cervical spinal immobilization must be maintained
during the entire process of intubation. Rationale: Because cervical spinal cord injury must be suspected in all
trauma patients until proved otherwise, this position helps prevent secondary injury should a cervical spine injury
be present.
• Premedicate as indicated. Rationale: Appropriate premedication allows for more controlled intubation, reducing
the incidence of insertion trauma, aspiration, laryngospasm, and improper tube placement.
• As appropriate, notify the respiratory therapy department of impending intubation so that a ventilator can be set up.
Rationale: Ventilator is set up before intubation.
Procedure for Performing Endotracheal Intubation
References
1. American Heart Association, Guidelines 2005 American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care. adjuncts for airway control and ventilation. Circulation. 2005;
112((Suppl) IV):51–57.
2. Barnason, S, et al. Comparison of two endotracheal tube securement techniques on unplanned extubation,
oral -mucosa, and facial skin integrity. Heart Lung. 1998; 27:409–417.
3. Bozeman, WP, et al. Esophageal detector device versus -detection of end-tidal carbon dioxide level in
emergency intubation. Ann Emerg Med. 1996; 27:595–599.
4. Cummins RO, ed.. Airway, airway adjuncts, oxygenation, and ventilation. ACLS: principles and practice.
American Heart Association: Dallas, 2003:135–180.
5. Goldberg, JS, et al. Colorimetric end-tidal carbon dioxide monitoring for tracheal intubation. Anesth Analg.
1990; 70:191–194.
6. Hayden, SR, et al. Colorimetric end-tidal CO2 detector -for verification of endotracheal tube placement in
out-of-hospital cardiac arrest. Acad Emerg Med. 1995; 2:499–502.
7. Hendey, GW, et al. The esophageal detector bulb in the aeromedical setting. J Emerg Med. 2002; 23:51–55.
8. Henneman, E, Ellstrom, E, St John RE, Airway management. In AACN protocols for practice: care of the
mechanically ventilated patient series. American Association of Critical-Care Nurses, Aliso Viejo, CA, 1999.
9. Holleran, RS, Air and surface patient transport. principles and practice. ed 3. Mosby, St Louis, 2003.
10. Kasper, CL, et al. The self-inflating bulb to detect esophageal intubation during emergency airway
management. Anesthesiology. 1998; 88:898–902.
11. Schaller, RJ, et al, Comparison of a colorimetric end-tidal CO2 detector and an esophageal aspiration device for
verifying endotracheal tube placement in the prehospital setting. a six-month experience. Prehosp Disaster Med
1997; 12:57–63.
12. Stewart, C. Tracheal intubation. In: Stewart C, ed. Advanced airway management. NJ: Prentice Hall; 2002:76–
113.
13. Takeda, T, et al. The assessment of three methods to verify tracheal tube placement in the emergency setting.
Resuscitation. 2003; 56:153–157.
14. Varon, AJ, et al. Clinical utility of a colorimetricend-tidal CO2 detector in cardiopulmonary resuscitation and
emergency intubation. J Clin Monit. 1991; 7:289–293.
15. Zaleski, L, et al, The esophageal detector device. does it work. Anesthesiology 1993; 79:244–247.
Additional Readings
Committee on Trauma, Americ an College of S urgeons. advanc ed trauma life support manual. Americ an College of S urgeons, Chic ago, 2004.
Ellis, DY, Harris, T, Zideman, D, Cric oid pressure in the -emergenc y department rapid sequenc e trac heal intubation. a risk-benefit analysis. Ann Emerg Med 2007;
50:653–656.
Emergenc y Nurses Assoc iation, Trauma nursing c ore c ourse. provider manual. ed 6. Emergenc y Nurses Assoc iation, Des Plaines, IL, 2007.
National Assoc iation of Emergenc y Tec hnic ians, PHTLS . basic and advanc ed prehospital trauma life support. ed 5. Mosby, S t Louis, 2003.
Roberts JR, Hedges JR, eds. Clinic al proc edures in emergenc y medic ine, ed 4, Philadelphia: S aunders, 2004.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 4
PURPOSE:
Endotracheal tube and oral care is performed to prevent buccal, oropharyngeal, and tracheal trauma from the
tube and cuff; to provide oral hygiene; to promote ventilation; and to decrease the risk of ventilator-associated
pneumonia.
EQUIPMENT
• Goggles or glasses and mask
• Bite-block or oral airway if needed
• Adhesive or twill tape; commercial endotracheal tube holder (design must ensure ability to provide oral care and
suctioning)
• 2 × 2 Gauze or cotton swab for cleaning around the nares
• Normal saline solution
• Soft pediatric/adult toothbrush or suction toothbrush
• Toothettes/oral swab/oral suction swab
• Oral cleansing solution (e.g., 1.5% H2 O2,3,18,31,44,47 chlorhexidine,3,6,9,16,22,23,26,34,52 cetylpyridinium chloride [CPC],3,30,43,50
toothpaste10,24,40 )
Additional equipment, to have available as needed, includes the following:
• Closed-suction setup with a catheter of appropriate size (Table 4-1)
TABLE 4-1
Guidelines for Catheter Size for Endotracheal and Tracheostomy Tube Suctioning*
*This guide should be used as an estimate only. Actual sizes depend on the size and individual needs of the patient.
(From St John RE, Seckel MA: Airway management. In AACN protocols for practice: care of the mechanically ventilated patient series, ed 2, Aliso Viejo, CA, 2002,
American Association of Critical-Care Nurses.)
• Sterile saline solution lavage containers for cleansing the closed suction system after use (5 to 10 mL)
• Suction catheter for oral and nasal suctioning (single-use Yankauer, covered Yankauer, disposable oral saliva ejector)
• Two sources of suction or a bifurcated connection device attached to a single suction source
• Connecting tube (4 to 6 ft)
• Nonsterile gloves
• Stethoscope
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise and reinforce
information as needed. Rationale: This process evaluates and reinforces understanding of previously taught
information.
• Maintain the patient in a semi-Fowler’s (≥30 degrees) position during mechanical ventilation to reduce the risk of
aspiration.13,36,37,51,53 Assist the patient to a high Fowler’s position or the most comfortable position for both the patient
and nurse before performing the care. Rationale: This position promotes comfort and reduces physical strain and
maintains head of bed elevation to reduce risk of aspiration.13,20,36,37,51,53
Procedure for Endotracheal Tube and Oral Care
References
1. Berry, AM, Davidson, PM, et al. Systematic literature review of oral hygiene practices for intensive care patients
receiving mechanical ventilation. Am J Crit Care. 2007; 16(6):552–563.
2. Carlson, J, Mayrose, J, et al, Extubation force. tape versus endotracheal tube holders. Ann Emerg Med. 2007;
50(6):686–691.
3. Chan, EY, et al, Oral decontamination for prevention of pneumonia in mechanically ventilated adults. systematic
review and meta-analysis. BMJ 2007; 334:889–893.
4. Chao, YF, et al, Removal of oral secretion prior to position change can reduce the incidence of ventilator-
associated pneumonia for adult ICU patients. a clinical controlled trial study. J Clin Nurs. 2009; 18(1):22–28.
5. Chendrasekhar, A, Timberlake, GA. Endotracheal tube cuff pressure threshold for prevention of nosocomial
pneumonia. J Applied Res. 2003; 3(3):311–314.
6. Chlebicki, MP, Safdar, N, Topical chlorhexidine for prevention of ventilator-associated pneumonia. a meta-
analysis. Crit Care Med. 2007; 35(2):595–602.
7. Cummins RO, ed.. Adjuncts for airway control, oxygenation, and ventilation. ACLS : principles and practice.
American Heart Association: Dallas, 2003:167.
8. De Pew CL, et al, Subglottic secretion drainage. a literature review. AACN Adv Crit Care. 2007; 18(4):366–379.
9. DeRiso, AJ, II., et al. Chlorhexidine gluconate 0. 12% oral rinse reduces the incidence of total nosocomial
respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest.
1996; 109:1556–15161.
10. DeWalt, EM. Effect of timed hygienic measures on oral mucosa in a group of elderly subjects. Nurs Res. 1975;
24:104–108.
11. Dezfulian, C, et al, Subglottic secretion drainage for preventing ventilator-associated pneumonia. a meta-analysis.
Am J Med. 2005; 118(1):11–18.
12. Dragoumanis, CK, et al. Investigating the failure to aspirate subglottic secretions with Evac endotracheal tube.
Anesth Analg. 2007; 105:1083–1085.
13. Drakulovic, MB, et al, Supine body position as a risk factor for nosocomial pneumonia in mechanically
ventilated patients. a randomized trial. Lancet 1999; 354:1851–1858.
14. El-Solh AA, et al, Colonization of dental plaque. a reservoir of respiratory pathogens for hospital acquired
pneumonia in institutionalized elders. Chest 2004; 126:1575–1582.
15. Ferrer M, et al, Maintenance of tracheal tube cuff pressure. where are the limits [commentary]. Crit Care 2008;
12:106–107.
16. Ferretti, GA, et al. Chlorhexidine for prophylaxis against oral infections and associated complications in
patients receiving bone marrow transplants. J Am Dent Assoc. 1987; 114:461–467.
17. Frost, P, Wise, MP, Tracheotomy and ventilator-associated pneumonia. the importance of oral care. Eur Respir J.
2008; 31(1):221–222.
18. Garcia, R, A review of the possible role of oral and dental colonization on the occurrence of healthcare-associated
pneumonia. underappreciated risk in a call for interventions. Am J Infect Control. 2005; 33(9):527–541.
19. Garrouste-Orgeas M, et al, Oropharyngeal or gastric colonization and nosocomial pneumonia in adult
intensive care unit patients. a prospective study based on genomic DNA analysis. Am J Respir Crit Care Med
1997; 156:1647–1655.
20. Gastmeier, P, Geffers, C, Prevention of ventilator-associated pneumonia. analysis of studies published since
2004. J Hosp Infect. 2007; 67(1):1–8.
21. Grap, MJ, et al, Oral care interventions in critical care. frequency and documentation. Am J Crit Care 2003;
12:113–119.
22. Grap, MJ, et al, Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in
mechanically ventilated patients. a pilot study. Heart Lung 2004; 33:83–91.
23. Houston, S, et al. Effectiveness of 0. 12% chlorhexidine gluconate oral rinse in reducing prevalence of
nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care. 2002; 11:567–570.
24. Ishikawa, A, Yoneyama, T, et al. Professional oral health care reduces the number of oropharyngeal bacteria. J
Dent Res. 2008; 87(6):594–598.
25. Kaplow, R, Bookbinder, M. A comparison of four endotracheal tube holders. Heart Lung. 1994; 23(1):59–66.
26. Koeman, M, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator associated
pneumonia. Am J Respir Crit Care Med. 2006; 173:1348–1355.
27. Labeau, S, Vandijck, D, et al, Evidence-based guidelines for the prevention of ventilator-associated pneumonia .
results of a knowledge test among European intensive care nurses. J Hosp Infect. 2008; 70(2):180–185.
28. Lansford, T, Moncure, M, et al. Efficacy of a pneumonia prevention protocol in the reduction of ventilator-
associated pneumonia in trauma patients. Surg Infect (Larchmt). 2007; 8(5):10–505.
29. Lorente, L, et al. Evidence on measures for the prevention of ventilator-associated pneumonia. Eur Respir J. 2007;
30:1193–1207.
30. Mankodi, S, et al. A 6- month clinical trial to study the -effects of a cetylpyridinium chloride mouth rinse on
gingivitis and plaque. Am J Dent. 2005; 18:9A–14A.
31. Marshall, MV, Cancro, LP, Fischman, SL, Hydrogen peroxide. a review of its use in dentistry. J Periodontol
1995; 66:786–796.
32. Mori, H, et al. Oral care reduces incidence of ventilator -associated pneumonia in ICU populations. Intensive Care
Med. 2006; 32:230–236.
33. Munro, CL, Grap, MJ, Oral health and care in the intensive care unit. state of the science. Am J Crit Care 2004;
13:25–33.
34. Munro, CL, et al, Chlorhexidine reduces ventilator associated pneumonia (VAP) in mechanically ventilated ICU
adults. Crit Care Med 24 2006; 12:A1 [(suppl)].
35. Murdoch, E, Holdgate, A. A comparison of tape-tying versus a tube-holding device for securing endotracheal
tubes in adults. Anaesth Intensive Care. 2007; 35(5):730–735.
36. Muscedere, J, et al, Comprehensive evidence-based clinical practice guidelines for ventilator associated
pneumonia. prevention. J Crit Care 2008; 23:126–137.
37. Niederman, MS, Craven, DE, et al. Guidelines for the management of adults with hospital- acquired, ventilator- -
associated and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005; 171:388–416.
38. Paju, S, Scannapieco, FA. Oral biofilms, periodontitis, and pulmonary infections. Oral Dis. 2007; 13(6):508–512.
39. Papadimos, TJ, Hensley, SJ, et al. Implementation of the “FASTHUG” concept decreases the incidence of
ventilator-associated pneumonia in a surgical intensive care unit. Patient Saf Surg. 2008; 2:3.
40. Pearson, LS, Hutton, JL. A controlled trial to compare the ability of foam swabs and toothbrushes to remove
dental plaque. J Adv Nurs. 2002; 39:480–489.
41. Safdar, N, Dezfulian, C, et al, Clinical and economic consequences of ventilator-associated pneumonia. a
systematic review. Crit Care Med. 2005; 33(10):2184–2193.
42. Scannapieco, FA, Pneumonia in nonambulatory patients. the role of oral bacteria and oral hygiene. J Am Dent -
Assoc 2006; 137:21S–25S [(Suppl)].
43. Schiffner, U, Plaque and gingivitis in the elderly. a randomized, single blinded clinical trial on the outcome of
intensified mechanical or anti-bacterial oral hygiene measures. J Clin Periodontol 2007; 34:1068–1073.
44. Schleder, B, Stott, K, Lloyd, RC. The effect of a comprehensive oral care protocol on patients at risk for
ventilator-associated pneumonia. J Advocate Health Care. 2002; 4:27–30.
45. Shibly, O, et al. Clinical evaluation of a hydrogen peroxide mouth rinse, sodium chlorhexidine, for
prophylaxis against oral infections and associated bicarbonate dentifrice, and mouth moisturizer on oral health. J
Clin Dent. 1997; 8:145–149.
46. Shorri, A, O’Malley, P, Continuous subglottic suctioning for the prevention of VAP. potential economic
impact. Chest 2001; 119:228–238.
47. Simmons-Trau D, et al. Reducing VAP with 6 sigma. Nurs Manage. 2004; 35(6):41–45.
48. Sole, ML, Poalillo, FE, et al, Bacterial growth in secretions and on suctioning equipment of orally intubated
patients. a pilot study. Am J Crit Care. 2002; 11(2):141–149.
49. Sole, ML, et al. A multisite survey of suctioning techniques and airway management practices. Am J Crit Care.
2003; 12:220–232.
50. Stookey, GK, et al. A 6-month clinical study assessing the safety and efficacy of two cetylpyridinium chloride
mouth rinses. Am J Dent. 2005; 18:24A–28.
51. Tablan, OC, Anderson, LJ, et al, Guidelines for preventing health-care-associated pneumonia, 2003.
recommendations of CDC and the Healthcare Infection Control Practices -Advisory Committee. MMWR
Recomm Rep. 2004; 53(RR-3):1–36.
52. Tantipong, H, Morkchareonpong, C, et al. Randomized controlled trial and meta-analysis of oral decontamination
with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp
Epidemiol. 2008; 29(2):131–136.
53. Torres, A, et al, Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation. the effect
of body position. Ann Intern Med, 1992; 116:540–543.
54. Vollman, KM. Ventilator associated pneumonia and pressure ulcer prevention as targets for quality improvement
in the ICU. Crit Care Nurs Clin North Am. 2006; 18:453–467.
55. Westwell, S. Implementing a ventilator care bundle in an adult intensive care unit. Nurs Crit Care. 2008;
13(4):203–207.
P R OC E D UR E 5
Extubation/Decannulation (Perform)
Kirsten N. S killings and Bonnie L. Curtis
PURPOSE:
The purpose of extubation and decannulation is to remove the artificial airway to allow the patient to breathe
independently.
EQUIPMENT
• Suctioning equipment
• Personal protective equipment
• Sterile suction catheter or suction kit
• Self-inflating manual resuscitation bag-valve-device connected to 100% oxygen source
• Oxygen source and tubing
• Scissors
• Supplemental oxygen with aerosol
• 10-mL syringe
• Rigid pharyngeal suction-tip (Yankauer) catheter
• Sterile dressing for tracheal stoma
Additional equipment, to have available as needed, includes the following:
• Endotracheal intubation supplies
• Emergency cart
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This process evaluates and reinforces understanding of previously taught
information.
• Place patient in semi-Fowler’s position. Rationale: Respiratory muscles are more effective in an upright position
versus a prone position. This position facilitates coughing and minimizes the risk of vomiting and consequent
aspiration.
Procedure for Performing Extubation and Decannulation
References
1. O’Meade, M, Guyatt, G, Cook, D, Weaning from mechanical ventilation. the evidence from clinical research.
Respir Care 2001; 12:78–83.
2. Pierce, L, Airway maintenance. In Management of the -mechanically ventilated patient. ed 2. Saunders, St Louis,
2007.
3. Scales, K, Pilsworth, J. A practical guide to extubation. Nurs Standard. 2007; 22(2):44–48.
4. St John RE, Seckel, MA. Airway management. In Burns SM, ed. : AACN protocols for practice: care of
mechanically ventilated patients, ed 2, Sudbury, MA: Jones and Bartlett, 2007.
5. Twibel, R, Siela, D, Mahmoodi, M. Subjective perceptions in physiological variables during weaning from
mechanical ventilation. Am J Crit Care. 2003; 12:101–112.
Additional Readings
Americ an Assoc iation for Respiratory Care, Clinic al prac tic e guideline. removal of the endotrac heal tube. Respiratory Care. 2007; 52(1):81–93.
Burns, S M, Weaning from mec hanic al ventilationBurns S M, ed.. AACN protoc ols for prac tic e. c are of -mec hanic ally ventilated patients. ed 2. Jones and Bartlett
Publishers, S udbury, MA, 2007:97–160.
Ead, H. Post anesthesia trac heal extubation. CACCN. 2004; 15(3):20–25.
Henneman, E, Liberating patients from mec hanic al ventilation. a team approac h. Crit Care Nurse 2001; 21:25–33.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 6
Extubation/Decannulation (Assist)
Kirsten N. S killings and Bonnie L. Curtis
PURPOSE:
The purpose of extubation and decannulation is to remove the artificial airway to allow the patient to breathe
independently.
EQUIPMENT
• Suctioning equipment
• Personal protective equipment
• Sterile suction catheter or suction kit
• Self-inflating manual resuscitation bag-valve-device connected to 100% oxygen source
• Oxygen source and tubing
• Scissors
• Supplemental oxygen with aerosol
• 10-mL syringe
• Rigid pharyngeal suction-tip (Yankauer) catheter
• Sterile dressing for tracheal stoma
Additional equipment, to have available as needed, includes the following:
• Endotracheal intubation supplies
• Emergency cart
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This process evaluates and reinforces understanding of previously taught
information.
• Place the patient in a semi-Fowler’s position. Rationale: Respiratory muscles are more effective in an upright
position versus a supine position. This position facilitates coughing and minimizes the risk of vomiting and
consequent aspiration.
Procedure for Assisting with Extubation and Decannulation
References
1. O’Meade, M, Guyatt, G, Cook, D, Weaning from mechanical ventilation. the evidence from clinical research.
Respir Care 2001; 12:78–83.
2. Pierce, L, Airway maintenance. In Management of the mechanically ventilated patient. ed 2. Saunders, St Louis,
2007.
3. Scales, K, Pilsworth, J. A practical guide to extubation. Nurs Stand. 2007; 22(2):44–48.
4. St John, RE, Seckel, MA, Airway managementBurns SM, ed.. AACN protocols for practice . care of mechanically
ventilated patients. ed 2. Jones and Bartlett Publishers, Sudbury, MA, 2007:1–57.
5. Twibel, R, Siela, D, Mahmoodi, M. Subjective perceptions in physiological variables during weaning from
mechanical ventilation. Am J Crit Care. 2003; 12:12–101.
Additional Readings
Americ an Assoc iation for Respiratory Care, Clinic al prac tic e guideline. removal of the endotrac heal tube. Respir Care. 2007; 52(1):81–93.
Burns, S M, Weaning from mec hanic al ventilationBurns S M, ed.. AACN protoc ols for prac tic e. c are of mec hanic ally ventilated patients. ed 2. Jones and Bartlett
Publishers, S udbury, MA, 2007:97–160.
Ead, H, Post anesthesia trac heal extubation . CACCN. 2004; 15(3):20–25.
Henneman, E. Liberating patients from mec hanic al ventilation. a team approac h. Crit Care Nurse 2001; 21:25–33.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 7
PURPOSE:
A laryngeal mask airway may be used to provide an emergency airway during resuscitation of a profoundly
unconscious patient who needs artificial ventilation when endotracheal intubation is not readily available or has
failed in establishing an airway.1
FIGURE 7-1 Components of the laryngeal mask airw ay. (From The Laryngeal Mask Company Limited: Instruction manual: LMA-Classic, San Diego, 2005, LMA.)
An airway tube connects the mask and the 15-mm male adapter.
The mask’s cuff, when inflated, conforms to the contours of the hypopharynx, with the opening of the air tube
positioned directly over the laryngeal opening. Two aperture bars cross the opening where the tube exits into the
mask.
An inflation line is fitted with a valve and a pilot balloon that leads to the mask’s cuff.
• The final placement of an LMA in the airway should be understood (Fig. 7-2).
FIGURE 7-2 Dorsal view of the laryngeal mask airw ay show ing position in relation to pharyngeal anatomy. (From The Laryngeal Mask Company Limited: Instruction
manual: LMA-Classic, San Diego, 2005, LMA.)
• The ability to ventilate an unconscious patient adequately with a mouth-to-mask or bag-valve-mask device is
necessary.
• An understanding of the limitations of the LMA is needed. Limitations are as follows:
The LMA does not protect the airway from aspiration of stomach contents, and the risks of insertion and aspiration
must be weighed against the need to establish an airway.12
v
The presence of a nasogastric tube may make regurgitation more likely because of its effect on the esophageal
sphincter tone and may also prevent the LMA from properly sealing the hypopharynx.12,13
The LMA should not be used on patients who need high ventilator pressures (e.g., patients with pulmonary fibrosis,
significant obesity) because the LMA provides a low-pressure seal.12
The LMA should not be used in an emergency situation in which the patient is not profoundly unconscious and
may resist insertion of the device.12
The LMA should be used with caution in patients with oropharyngeal trauma, only when all other means of
establishing an airway fail1 and when the risks of insertion are weighed against the need to establish an airway.
The LMA can cause local irritation that leads to coughing and pressure lesions, which may cause 12th cranial nerve
palsy.2
• There are no absolute contraindications to the LMA if the alternative is loss of the airway with its associated
complications.6
• The LMA may provide a more viable means of ventilation than a self-inflating manual resuscitation bag-valve-mask
device in patients with a beard or without teeth.11
• Initial and ongoing training is necessary to maximize insertion success and minimize complications.8,11
• This procedure refers specifically to the LMA-Unique, a disposable model of the nondisposable LMA-Classic. Other
types of LMA devices are available and provide additional features, such as endotracheal intubation through the LMA
or gastric suctioning.
• The LMA-Unique is latex-free.7,12
EQUIPMENT
• Two LMA-Unique devices of the appropriate size for patient weight3
Weight ranges listed for LMA-Unique sizes are only approximations; the size used may need to be adjusted for
individual body habitus variations (i.e., patients who are short and obese may need a smaller size). Emerging
clinical data suggest that use of a larger size provides an effective seal without associated higher pharyngeal
pressures.3,7
Size 3, 30 to 50 kg
Size 4, 50 to 70 kg
Size 5, 70 to 100 kg
Size 6, ≥100 kg
• 60-mL Luer-tip syringe
• Water-soluble lubricant
• Gloves, mask, and eye protection
• Suction equipment (suction canister with control head, tracheal suction catheters, Yankauer suction tip)
• Mouth-to-mask or self-inflating manual resuscitation bag-valve-mask device, with peak pressure manometer, attached
to a high-flow oxygen source
• Bite-block, at least 3 cm thick
• Tape or commercially available tube-securing device
Patient Preparation
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure adequate ventilation and oxygenation with either a mouth-to-mask or bag-valve-mask device. Rationale:
The patient is nonresponsive and apneic without assisted ventilation before the LMA insertion.
• Ensure that the suction equipment is assembled and in working order. Rationale: The patient may regurgitate
during the insertion or while the LMA is in place and need oropharyngeal or tracheal suctioning.
• Anything that is not permanently affixed in the patient’s mouth (e.g., dentures, partials, jewelry) should be removed.
Rationale: Inadvertent dislodgment and aspiration might occur with the placement of the LMA.
Procedure for Laryngeal Mask Airway (LMA-Unique) Insertion
Table 7-1
Test Cuff Inflation Volumes
(From The Laryngeal Mask Company Limited: Instruction manual: LMA-Classic, San Diego, 2005, LMA.)
Table 7-2
Maximal Cuff Inflation Volumes
6 50 mL
(From The Laryngeal Mask Company Limited:Instruction manual: LMA-Classic, San Diego, 2005, LMA.)
FIGURE 7-3 Method for deflating the laryngeal mask airw ay cuff. (From The Laryngeal Mask Company Limited: Instruction manual: LMA-Classic, San Diego, 2005, LMA.)
FIGURE 7-4 Laryngeal mask airw ay cuff properly deflated for insertion. (From The Laryngeal Mask Company Limited: Instruction manual: LMA-Classic, San Diego, 2005,
LMA.)
FIGURE 7-5 A, Method for holding the LMA for insertion. B, With the head extended and the neck flexed, the caregiver carefully flattens the LMA tip against
the hard palate. C, To facilitate LMA introduction into the oral cavity, the caregiver gently presses the middle finger dow n on the jaw . D, The index finger
pushes the LMA in the cranial direction follow ing the contours of the hard and soft palates. E, Maintaining pressure w ith the finger in the tube in the cranial
direction, the caregiver advances the LMA until definite resistance is felt at the base of the hypopharynx. Note the flexion of the w rist. F, The caregiver
gently maintains cranial pressure w ith the nondominant hand w hile removing the index finger. (From The Laryngeal Mask Company Limited: Instruction manual: LMA-
Classic, San Diego, 2005, LMA.)
FIGURE 7-6 A, Method for holding the LMA for thumb insertion. B, With the fingers extended, press the thumb along the posterior pharynx. C, Advance the
thumb to its fullest extent. D, Press LMA gently into place w ith the nondominant hand w hile removing the thumb. (From The Laryngeal Mask Company Limited:
Instruction manual: LMA-Classic, San Diego, 2005, LMA.)
FIGURE 7-7 Inflation w ithout holding the tube allow s the mask to seat itself optimally. (From The Laryngeal Mask Company Limited: Instruction manual: LMA-Classic, San
Diego, 2005, LMA.)
FIGURE 7-8 The bite-block and airw ay tube are taped together w ith the tube taped dow nw ard against the chin. (From The Laryngeal Mask Company
Limited:Instruction manual: LMA-Classic, San Diego, 2005, LMA.)
References
1. American Heart Association. Advanced cardiac life support (ACLS). Dallas: AHA; 2006.
2. Birnbaumer, D, Pollack, C, Jr. Troubleshooting and managing the difficult airway. Semin Respir Crit Care Med.
2002; 23(1):3–9.
3. Brimacombe, J, Berry, A, Insertion of the laryngeal mask airway. a prospective study of four techniques.
Anaesth Intensive Care 1993; 21:89–92.
4. Duk-Kyung, K, et al. A heated humidifier does not reduce laryngo-pharyngeal complaints after brief laryngeal
mask anesthesia. Can J Anesthesia. 2007; 54:134–140.
5. Hand, H, Cardiopulmonary resuscitation. the laryngeal mask airway. Emerg Nurse 2002; 10:31–37.
6. Idris, AH, Gabrielli, A. Advances in airway management. Emerg Med Clin North Am. 2002; 20:843–857.
7. LMA, Inc. LMA. www.lmana.com/faqs.php#faq06, 2008. [retrieved February 25, 2009. from].
8. Lopez, AM, et al. A clinical evaluation of four disposable laryngeal masks in adult patients. J Clin Anesth. 2008;
20(7):508–513.
9. Ocker, H. A comparison of the laryngeal tube with the laryngeal mask airway during routine surgical
procedures. Anesth Analg. 2002; 95(4):1094–1097.
10. Radu, AD, et al, Pharyngo-laryngeal discomfort after breast surgery. comparison between orotracheal intubation
and laryngeal mask. Breast. 2008; 17(4):407–411.
11. Shuster, M, Nolan, J, Barnes, TA. Airway and ventilation management. Emerg Cardiovasc Care. 2002; 20:23–
35.
12. The Laryngeal Mask Company Limited. LMA instruction manual. San Diego: LMA; 2005.
13. Ulrich-Pur H, et al. Comparison of mucosal pressures induced by cuffs of different airway devices. Anesthesiology.
2006; 104(5):933–938.
Additional Readings
Bogetz, MS . Using the laryngeal mask airway to manage the diffic ult airway. Anesthesiol Clin North Am. 2002; 20:863–870.
Burns, S M. S afely c aring for patients with a laryngeal mask airway. Crit Ca re Nurse. 2001; 21:72–74.
Gabrielli, A, et al. Alternative ventilation strategies in c ardiopulmonary resusc itation. Curr Opin Crit Ca re. 2002; 8:199–211.
Maltby, JR, Loken, RG, Watson, NC, The laryngeal mask -airway. c linic al appraisal in 250 patients. Can J Anesth 1990; 37:509–513.
Nolan, JD, Prehospital and resusc itative airway c are. should the gold standard be reassessed. Curr Opin Crit Care 2001; 7:413–421.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 8
PURPOSE:
Surgical cricothyrotomy is an emergent procedure creating an opening in the cricothyroid membrane to facilitate
placement of an endotracheal or tracheostomy tube and provide effective oxygenation and ventilation.
Contraindications
Absolute
• Airway can be managed effectively with self-inflating manual resuscitation bag-valve-mask device, intubation, or
rescue airway (Combitube, LMA, or King Airway).
• Complete transection of trachea
• Laryngotracheal disruption with retraction of distal trachea
• Fractured larynx
Relative
• Inability to identify anatomic landmarks
• Bleeding diathesis
• Children less than 12 years of age5,6
In young children, the airway is funnel-shaped with the narrowest portion at the cricoid ring rather than the vocal
cords as in adults. This narrowing increases the risk of development of subglo ic stenosis after cricothyrotomy.
Percutaneous transtracheal ventilation via needle cricothyrotomy is the method of choice for surgical airway
management in young children.6
EQUIPMENT
• Personal protective equipment (face mask, eye protection, gown, sterile gloves)
• Sterile surgical drape
• Skin antiseptic
• No. 10 or 11 blade scalpel
• 4 × 4 gauze sponges
• Suction device and suction catheter
• Curved hemostats
• Tracheal (Trousseau) dilator or nasal speculum
• 5.0 to 6.0 cuffed endotracheal tube or no. 4 tracheos- tomy tube
• 10-mL syringe
• Cloth tracheostomy ties
• Self-inflating manual resuscitation bag-valve-mask device with oxygen source
• Oxygen source and tubing
• Stethoscope
Additional equipment, to have available as needed, includes the following:
• Commercially prepared kit such as the Melker Emergency Cricothyrotomy Catheter (Cook Medical, Inc,
Bloomington, Ind; www.cookmedical.com), which uses a specially designed airway and a modified Seldinger
technique for insertion
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Position the patient supine and maintain cervical spine stabilization if indicated. Rationale: Patients who need
emergent surgical cricothyrotomy often have traumatic injuries that necessitate cervical spine stabilization.
• Continue attempts to ventilate and oxygenate the patient with a self-inflating manual resuscitation bag-valve-mask
device if the patient is apneic or respiratory efforts are inadequate. Rationale: This action can prevent further
hypoxia and hypercarbia.
Procedure for Surgical Cricothyrotomy
FIGURE 8-1 Anatomy of neck and location of cricothyroid membrane. (Adapted from Patton KT, Thibodeau GA: Mosby’ s handbook of anatomy and physiology, St Louis,
2000, Elsevier.)
FIGURE 8-2 Surgical cricothyrotomy. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 8, St Louis, 2009, Elsevier.)
References
1. American College of Surgeons, Airway and ventilatory management. advanced trauma life support. ed 7.
ACS, Chicago, 2004.
2. American Heart Association, Airway, airway adjuncts, -oxygenation and ventilation. advanced cardiac life -
supportprinciples and practice. AHA, Dallas, 2006.
3. McGill, J, Clinton, JE, Ruiz, E. Cricothyrotomy in the emergency department. Ann Emerg Med. 1982; 11:361–
364.
4. Northwest, MedStar, Critical Care Air Medical Transport Service, Surgical cricothyrotomy. protocol and
procedure book. Northwest MedStar, Spokane, WA, 2008:133–134.
5. Sanders, MJ. Mosby’s paramedic textbook, ed 2. St Louis: Mosby; 2001.
6. Tintinalli, JE, Kelen, GD, Stapczynski, JS, Emergency -medicine. a comprehensive study guide. ed 6.
McGraw-Hill, New York, 2004.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 9
PURPOSE:
Surgical cricothyrotomy is an emergent procedure creating an opening in the cricothyroid membrane to facilitate
placement of an endotracheal or tracheostomy tube and provide effective oxygenation and ventilation.
Contraindications
Absolute
• Airway can be managed effectively with self-inflating manual resuscitation bag-valve-mask device or rescue airway
(Combitube, LMA, or King Airway).
• Complete transection of trachea
• Laryngotracheal disruption with retraction of distal trachea
• Fractured larynx
Relative
• Inability to identify anatomic landmarks
• Bleeding diathesis
• Children less than 12 years of age5,6
In young children, the airway is funnel-shaped with the narrowest portion at the cricoid ring rather than the vocal
cords as in adults. This narrowing increases the risk of development of subglo ic stenosis after cricothyrotomy.
Percutaneous transtracheal ventilation via needle cricothyrotomy is the method of choice for surgical airway
management in young children.6
EQUIPMENT
EQUIPMENT
• Personal protective equipment (face mask, eye protection, gown, sterile gloves)
• Sterile surgical drape
• Skin antiseptic
• No. 10 or 11 blade scalpel
• 4 × 4 gauze sponges
• Suction device and suction catheter
• Curved hemostats
• Tracheal (Trousseau) dilator or nasal speculum
• 5.0 to 6.0 cuffed endotracheal tube or no. 4 tracheostomy tube
• 10-mL syringe
• Cloth tracheostomy ties
• Self-inflating manual resuscitation bag-valve-mask device with oxygen source
• Oxygen source and tubing
• Stethoscope
Additional equipment, to have available as needed, includes the following:
• Commercially prepared kit such as the Melker Emergency Cricothyrotomy Catheter (Cook Medical, Inc,
Bloomington, Ind; www.cookmedical.com), which uses a specially designed airway and a modified Seldinger
technique for insertion
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Position the patient supine and maintain cervical spine stabilization if indicated. Rationale: Patients who need
emergent surgical cricothyrotomy often have traumatic injuries that require cervical spine stabilization.
• Continue attempts to ventilate and oxygenate the patient with a self-inflating manual resuscitation bag-valve-mask
device if patient is apneic or respiratory efforts are inadequate. Rationale: This action can prevent further hypoxia
and hypercarbia.
Procedure for Assisting with Surgical Cricothyrotomy
References
1. American College of Surgeons, Airway and ventilatory management. advanced trauma life support. ed 7.
ACS, Chicago, 2004.
2. American Heart Association, Airway, airway adjuncts, -oxygenation and ventilation. advanced cardiac life -
supportprinciples and practice. AHA, Dallas, 2006.
3. McGill, J, Clinton, JE, Ruiz, E. Cricothyrotomy in the emergency department. Ann Emerg Med. 1982; 11:361–
364.
4. Northwest, MedStar. Critical Care Air Medical Transport Service. In: Surgical cricothyrotomy: protocol and
procedure book. Spokane, WA: Northwest MedStar; 2008:133–134.
5. Sanders, MJ. Mosby’s paramedic textbook, ed 2. St Louis: Mosby; 2001.
6. Tintinalli, JE, Kelen, GD, Stapczynski, JS, Emergency -medicine. a comprehensive study guide. ed 6. McGraw-
Hill, New York, 2004.
P R OC E D UR E 1 0
PURPOSE:
Nasopharyngeal airways are used to maintain a patent airway to the hypopharynx and to facilitate the removal of
tracheobronchial secretions by directing the catheter and by averting tissue trauma that is associated with
repeated suction attempts.4
FIGURE 10-1 Nasopharyngeal airw ay. A, Airw ay parts. B, Proper placement. (From Eubanks DH, Bone RC: Comprehensive respiratory care: a learning system, St Louis,
1990, Mosby, 518.)
• The nasopharyngeal airway has three parts: the flange, cannula, and bevel or tip. The flange is the wide trumpet-like
end that prevents further slippage into the airway. The hollow shaft of the cannula permits airflow into the
hypopharynx. The bevel or tip is the opening at the distal end of the tube. When properly inserted, and the correct
size, the tip can be seen resting posterior to the base of the tongue.
• The external diameter of the nasopharyngeal airway should be slightly smaller than the patient’s external nares
opening. The length of the nasopharyngeal airway is determined by measuring the distance between the naris and the
tragus of the ear (Fig. 10-2).2 Improperly sized nasopharyngeal airways may result in increased airway resistance,
limited airflow (if the airway is too small), kinking and mucosal trauma, gagging, vomiting, and gastric distention (if
the airway is too large). Some manufacturers provide nasopharyngeal airways shaped specifically for the right and left
nares.
FIGURE 10-2 A, Estimating nasopharyngeal airw ay size. B, Nasopharyngeal position after insertion. (From Eubanks DH, Bone RC: Comprehensive respiratory care: a
learning system, St Louis, 1990, Mosby, 552.)
• The advantages of the nasopharyngeal airway include increased comfort and tolerance in a conscious patient, stable
airway positioning for long periods, decreased incidence of gag reflex stimulation, and minimal incidence of mucosal
trauma during frequent suctioning.
• Nasopharyngeal airways are especially useful for relieving airway obstruction associated with mandibular-type injuries
that result in jaw immobility or soft tissue obstruction. Examples of these injuries include jaw wiring, trismus, pain,
edema, jaw spasms, and mechanical impairment such as temporomandibular joint fractures and zygomatic fractures.
In selected patient situations, a nasopharyngeal airway may be used to facilitate the passage of a fiberoptic
bronchoscope and to tamponade small bleeding blood vessels in the nasal mucosa.
• Insertion of the nasopharyngeal airway in an alert patient may stimulate the gag reflex and cause retching and
vomiting.
• The nasopharyngeal airway is used most commonly in the postanesthesia recovery period to facilitate pulmonary
toilets and in situations in which the patient is semiconscious.
• Contraindications to use of a nasopharyngeal airway are as follows:
Patients undergoing anticoagulation or antiplatelet therapy
Patients prone to epistaxis
Patients with obstructed nasal passageways
Patients with facial or head trauma when basilar skull fracture or cranial vault communication is suspected
EQUIPMENT
• Appropriately sized nasal airway (Table 10-1)
TABLE 10-1
Nasopharyngeal Airway Sizing
(From Cummins RO, editor: Airway, airway adjuncts, oxygenation, and ventilation. In ACLS: principles and practice, Dallas, 2003, American Heart Association, 145-
146.)
• Nonsterile gloves
• Water-soluble lubricant
• Suction equipment
• Flashlight
• Tongue depressor
PATIENT AND FAMILY EDUCATION
• Explain the purpose of the airway and the necessity of the procedure to conscious patients or to the family of an
unconscious patient. Rationale: Communication and explanation regarding therapy are cited as important needs of
patients and families to relieve anxiety and encourage communication.
• Explain the patient’s role in assisting with insertion of the airway. Rationale: Patient cooperation is elicited, and tube
insertion is facilitated.
• Discuss the sensory experiences associated with nasal airway insertion, including the presence of an airway in the nose
and possible gagging. Rationale: Knowledge of anticipated sensory experiences reduces anxiety and distress.
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This step evaluates and reinforces understanding of previously taught
information.
• Position the patient. Unless contraindicated, a supine or high Fowler’s position is acceptable. Rationale: This
positioning promotes patient and nurse comfort and provides easy access to the external nares.
Procedure for Nasopharyngeal Airway Insertion
References
1. American Association of Respiratory Care and Clinical Practice Guidelines, Nasotracheal suctioning, revision
and update. 2004. American Association of Respiratory Care: Irving, TX.
2. Cummins, RO. Airway, airway adjuncts, oxygenation, and ventilation. In: In ACLS: principles and practice. Dallas:
American Heart Association; 2006:145–146.
3. Eubanks, DH, Bone, RC, Comprehensive respiratory care. a learning system. Mosby, St Louis, 1990:491–495.
4. Pierce, LNB. Management of the mechanically ventilated patient, ed 2. St Louis: Saunders; 2007.
Additional Readings
Roberts, K, Whalley, H, Bleetman, A, The nasopharyngeal airway. dispelling myths and establishing the fac ts. J Emerg Med 2005; 22:394–396.
S t. John RE, S ec kel, MA, Airway managementBurns S M, ed.. AACN protoc ols for prac tic e. c are of the mec hanic ally ventilated patient. ed 2. 2007. Jones and
Bartlett Publishers: S udbury, MA.
P R OC E D UR E 11
PURPOSE:
Oropharyngeal airways are inserted to relieve airway obstruction, provide short-term maintenance of an airway,
and facilitate removal of tracheobronchial secretions.
FIGURE 11-1 Oropharyngeal airw ays. A, Guedel airw ay. B, Berman airw ay. C, Properly inserted oropharyngeal tube. (From Eubanks DH, Bone RC:
Comprehensive respiratory care: a learning system, St Louis, 1990, Mosby, 518.)
• The Guedel airway is tubular with a flattened-oval inner diameter. A suction catheter passes through the central lumen
or channel.
• The Berman airway has a channel on either side that guides the catheter along the edge of the airway into the
pharyngeal space.
• Oral airways are manufactured in a variety of lengths and widths for adults, children, and infants. Sizing depends on
the age and size of the patient (Table 11-1). An alternative method used to select the size of an oral airway is to
measure the airway by placing the flange alongside the patient’s lips and the oral airway tip alongside the angle of the
jaw (Fig. 11-2). Improperly sized airways can cause airway obstruction (if they are too small) and tongue displacement
against the oropharynx (if they are too large).
TABLE 11-1
Oral Airway Sizes
Size of Patient Diameter of Oral Airw ay (mm) Size of Oral Airw ay (Guedel)
From Cummins RO, editor: Airway, airway adjuncts, oxygenation, and ventilation. In ACLS: principles and practice, Dallas, 2003, American Heart Association, 145.
FIGURE 11-2 Alternative method for selecting size of an oropharyngeal airw ay. (From Eubanks DH, Bone RC: Comprehensive respiratory care: a learning system, St
Louis, 1990, Mosby, 552.)
• Oropharyngeal airways are used most commonly in unconscious patients because they may stimulate vomiting in a
conscious or semiconscious patient.2
• Oral airways facilitate suctioning of the pharynx and prevent patients from biting their tongues, grinding their teeth,
or occluding their endotracheal or oral gastric tubes. In addition, an oropharyngeal airway may be used in
conjunction with an oral endotracheal tube to facilitate artificial ventilation, acting as a bite-block and preventing
damage to the endotracheal tube, tongue, and soft tissues of the mouth.
• Improper or rough insertion techniques can result in tooth damage or loss and lacerations to the roof of the mouth.
Improper lip, oral, and airway care can result in pressure sores, cracked lips, and stomatitis.
• Oropharyngeal airway placement should never be attempted in a patient who is actively seizing.
EQUIPMENT
• Appropriately sized oral airway
• Nonsterile gloves
• Tongue depressor
• Tape
Additional equipment, to have available as needed, includes the following:
• Goggles, glasses, or face mask
• Suction equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that patient and family understand preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This step evaluates and reinforces understanding of previously taught
information.
• Position the patient. A semi-Fowler’s or supine position is preferred for a conscious patient. Rationale: This
positioning promotes patient and nurse comfort and provides easy access to the oral cavity.
• Hyperextend the patient’s neck with the head-tilt chin-lift technique or the jaw-thrust technique for opening the
airway of the unconscious patient. Maintain cervical stabilization in a trauma patient, using the jaw-thrust technique
only. Rationale: Opening the airway can prevent obstructions that result from posterior displacement of the tongue
and epiglottis.
Procedure for Oropharyngeal Airway Insertion
FIGURE 11-3 Crossed-finger technique for opening the mouth. (From Eubanks DH, Bone RC: Comprehensive respiratory care: a learning system, St Louis, 1990, Mosby,
631.)
FIGURE 11-4 Insertion of an oropharyngeal airw ay. A, Advance airw ay w ith curved end up. B, Rotate airw ay 180 degrees. (From Eubanks DH, Bone RC:
Comprehensive respiratory care: a learning system, St Louis, 1990, Mosby, 551.)
References
1. Cummins RO, ed.. Airway, airway adjuncts, oxygenation, and ventilation. In ACLS: principles and practice,.
American Heart Association: Dallas, 2006:145–146.
2. Dulak, S. Placing an oropharyngeal airway. RN. 2005; 68(2):20.
3. Pierce, L. Management of the mechanically ventilated -patient,. St Louis: Saunders; 2007.
Additional Reading
S t John, R, S ec kel MBurns S M, ed.. Airway management. Care of mec hanic ally ventilated patients. 2ed. Jones and Bartlett, S udbury, MA, 2007.
P R OC E D UR E 1 2
PURPOSE:
Endotracheal or tracheostomy tube suctioning is performed to maintain the patency of the artificial airway and to
improve gas exchange, decrease airway resistance, and reduce infection risk by removing secretions from the
trachea and main-stem bronchi. Suctioning also may be performed to obtain samples of tracheal secretions for
laboratory analysis.
EQUIPMENT
• Open technique
Suction catheter of appropriate size (Table 12-1)
Table 12-1
Guideline for Catheter Size for Endotracheal and Tracheostomy Tube Suctioning*
*This guide should be used as an estimate only. Actual sizes depend on the size and individual needs of the patient. Alw ays follow manufacturer’s guidelines.
Adapted from St John RE, Seckel M: Airway management. In AACN protocols for practice: care of the mechanically ventilated patient series, Sudbury, MA, 2007,
Jones & Bartlett Publishers, 41.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Assist the patient in achieving a position that is comfortable for the patient and nurse, generally semi-Fowler’s or
Fowler’s, with the bed elevated to the nurse’s waist level. Rationale: This positioning promotes comfort,
oxygenation, and ventilation and reduces strain.
• Secure additional personnel to assist with the self-inflating manual resuscitation bag-valve-device to provide
hyperoxygenation (open-suction technique only). Rationale: Two hands are necessary to inflate the self-inflating
manual resuscitation bag-valve-device for adult tidal volume levels (>600 mL).
Procedure for Endotracheal or Tracheostomy Tube Suctioning
References
References
1. AARC Clinical Practice Guideline. Endotracheal suctioning of mechanically ventilated adults and children
with artificial airways. Respir Care. 1993; 38:500–504.
2. AACN Practice Alert. Oral care in the critically ill.
www.aacn.org/WD/Practice/Docs/Oral_Care_in_the_Critically_Ill.pdf, 2006. [retrieved August 9, 2008, from].
3. Akgul, S, Akyolcu, N. Effects of normal saline on endotracheal suctioning. J Clin Nurs. 2002; 11:826–830.
4. Arroyo-Novoa, CM, et al, Pain related to tracheal suctioning in awake acutely and critically ill adults. a descriptive
study. Intensive Crit Care Nurs 2007; 24:20–27.
5. Bourgault, AM, et al. Effects of endotracheal tube suctioning on arterial oxygen tension and heart rate variability.
Biol Res Nurs. 2006; 7:268–278.
6. Celik, SA, Kanan, N, A current conflict. use of isotonic sodium chloride solution on endotracheal suctioning in
critically ill patients. Dimens Crit Care Nurs 2006; 25:11–14.
7. Centers for Disease Control and Prevention, Guidelines for prevention of health-care-associated pneumonia,
2003 . Recommendations of CDC and the Healthcare infection Control Practices Advisory Committee. MMWR.
2004; 53(No. RR-3):1–35.
8. Czarnik, R, et al. Differential effects of continuous versus intermittent suction on tracheal tissue. Heart Lung.
1991; 20:144–151.
9. Ellstrom, K. The pulmonary system. In: Alspach J, ed. Core curriculum for critical care nursing. ed 6. St Louis:
Elsevier; 2006:45–183.
10. Glass, C, et al. Nurse performance of hyperoxygenation. Heart Lung. 1991; 20:299.
11. Glass, C, et al. Nurses’ ability to achieve hyperinflation and hyperoxygenation with a manual resuscitation bag
during endotracheal suctioning. Heart Lung. 1993; 22:158–165.
12. Grap, MJ, et al, Endotracheal suctioning. ventilator versus manual delivery of hyperoxygenation breaths. Am J
Crit Care 1996; 5:192–197.
13. Hess, D, Goff, G, The effects of two-hand versus one-hand ventilation on volumes delivered during bag-valve
ventilation at various resistances and compliances. Joanna Briggs Institute for Evidence Based Nursing and
Midwifery. Tracheal suctioning of adults with an artificial airway. Respir Care 1987; 32:1025–1028.
14. Joanna Briggs Institute for Evidence Based Nursing and Midwifery. Tracheal suctioning of adults with an
artificial airway. Best Practice. 2000; 4:1–6.
15. Jongerden, IP, et al, Open and closed endotracheal suction systems in mechanically ventilated intensive care
patients. a meta-analysis. Crit Care Med 2007; 35:70–260.
16. Kirimili, B, King, J, Pfaeffle, H. Evaluation of tracheal bronchial suction techniques. J Cardiovasc Surg. 1970;
59:340–344.
17. Kleiber, C, Krutzfield, N, Rose, E. Acute histologic changes in the tracheobronchial tree associated with
different suction catheter insertion techniques. Heart Lung. 1988; 17:10–14.
18. Klockare, M, et al, Comparison between direct humidification and nebulization of the respiratory track at
mechanical ventilation. distribution of saline solution studied by gamma camera. J Clin Nurs 2006; 15:301–307.
19. Kubota, Y, et al. Is a straight catheter necessary for selective bronchial suctioning in the adult. Crit Care Med. 1986;
14:755–756.
20. Kuzenski, B. Effect of negative pressure on tracheobronchial trauma. Nurs Res. 1978; 27:260–263.
21. Lasocki, S, et al, Open and closed-circuit endotracheal suctioning in acute lung injury. efficiency and effects on
gas exchange. Anesthesiology 2006; 104:39–47.
22. McCauley, C, Boller, L. Bradycardiac responses to endotracheal suctioning. Crit Care Med. 1986; 16:1165–
1166.
23. Ogburn-Russell, L. The effect of continuous and intermittent suctioning on the tracheal mucosa of dogs. Heart
Lung. 1987; 16:297.
24. Oh, H, Seo, W. A meta-analysis of the effects of various interventions in preventing endotracheal suctioning
induced hypoxemia. J Clin Nurs. 2003; 12:912–924.
25. Puntillo, KA, et al, Patients’ perceptions and responses to procedural pain. results from the Thunder Project II.
Am J Crit Care 2001; 10:238–251.
26. Rauen, CA, et al, Seven evidence-based practice habits. putting some sacred cows out to pasture. Crit Care Nurse
2008; 28:98–124.
27. Ridling, DA, Martin, LD, Bratton, SL. Endotracheal suctioning with and without instillation of isotonic sodium
chloride solutions in critically ill children. Am J Crit Care. 2003; 12:212–219.
28. Rutula, W, Stiegel, M, Sarubbi, F. A potential infection hazard associated with the use of disposable saline
vials. Infect Control. 1984; 5:170–172.
29. St John, RE. Airway and ventilator management. In: Chulay M, Burns S, eds. AACN essentials of critical care
nursing. ed 2. New York: McGraw-Hill Publishing; 2006:111–143.
30. St John, RE, Seckel, MA. Airway management. In: Burns SM, ed. AACN protocol for practice: care of mechanically
ventilated patients. ed 2. Sudbury, MA: Jones and Bartlett Publishers; 2006:1–57.
31. Subirana, M, et al. Closed tracheal suction systems versus open tracheal systems for mechanically ventilated adult
patients. Cochrane Database Syst Rev. 4, 2007. [CD004581].
32. Wynne, R, Botti, M, Parztz, J. Preoxygenation for tracheal suctioning in ventilated adults (protocol). Cochrane
Database Syst Rev. (4):2004. [CD005142].
Additional Readings
Kerr, M, et al. Effec t of endotrac heal suc tioning on c erebral oxygenation in traumatic brain-injured patients. Crit Ca re Med. 1999; 27:2776–2781.
Labarc a, J, et al. A multistate outbreak of Ralstonia pic kettii c olonization assoc iated with an intrinsic ally c ontaminated respiratory c are solution. Clin Infect Dis. 1999;
29:1281–1286.
Paul-Allen, J, Ostrow, C. S urvey of nursing prac tic es with c losed-system suc tioning. Am J Crit Ca re. 2000; 9:9–19.
Pierc e, LN. Management of the mec hanic ally ventilated -patient, ed 2. S t Louis: Elsevier, 2007.
S ole, M, Byers, JF, Ludy, JE, et al. A multisite survey of -suc tioning tec hniques and airway management prac tic es. Am J Crit Ca re. 2002; 11:220–232.
P R OC E D UR E 1 3
PURPOSE:
The tracheal tube cuff helps stabilize the endotracheal or tracheal tube and maintains an adequate airway seal so
that air moves through the tube into the lungs. The cuff also may decrease the risk of aspiration of large food
particles, but it does not protect against aspiration of liquid.
• High-volume low-pressure cuffs allow a large surface area to come into contact with the tracheal wall, distributing the
pressure over a much greater area. The older cuff design (low-volume high-pressure) may require 40 mm Hg (54.4
cm H2 O) to obtain an effective seal and is undesirable.
• The amount of pressure and volume necessary to obtain a seal and prevent mucosal damage depends on tube size and
design, cuff configuration, mode of ventilation, and the patient’s arterial blood pressure.
• A variety of devices are available to measure cuff pressures, including bedside sphygmomanometers, special aneroid
cuff manometers, and electronic cuff pressure devices. Ideally, the cuff pressures should be between 20 and 25 mm
Hg and still meet the goals of cuff use. Tracheal capillary perfusion pressure is 25 to 35 mm Hg for patients with
normotensive conditions. Lower cuff pressures are associated with less mucosal damage but also are associated with
silent aspiration, which has been shown to be more prevalent at cuff pressures less than 20 mm Hg.1,6,8
• Two techniques, minimal leak technique (MLT) and minimal occlusion volume (MOV), are used to inflate and
monitor air in the cuff.
The MLT involves air inflation of the tube cuff until any leak stops; then, a small amount of air is removed slowly
until a small leak is heard on inspiration. Problems with this technique include difficulty maintaining positive end
expiratory pressure (PEEP), aspiration around the cuff, and increased movement of the tube in the trachea during
cuff deflation.2,4,5,7,8 Aspiration may be prevented with deep pharyngeal suctioning before use of the MLT.
The MOV consists of injection of air into the cuff until no leak is heard, then withdrawal of the air until a small leak
is heard on inspiration, and then addition of more air until no leak is heard on inspiration.2,4,5,7,8
• Each technique has distinct advantages. MLT decreases tracheal mucosal injury and assists in mobilizing secretions
forward into the pharynx. MOV is used if the patient needs a seal to provide adequate ventilation or is at risk for
aspiration.4,8
• Although rare since the use of high-volume low-pressure devices became common, the adverse effects of tracheal tube
cuff inflation include tracheal stenosis, necrosis, tracheoesophageal fistulas, and tracheomalacia. These complications
may be more likely to occur in conditions that adversely affect tissue response to mucosal injury, such as hypotension.
Two major mechanisms are mainly responsible for airway damage: tube movement and pressure. Duration of
intubation also plays a significant role.4,8
• Routine cuff deflation is unnecessary and is no longer recommended.4
• Unintentional extubation and tube manipulation can occur with ineffective patient restraint or sedation, inadequate
securing of the tube, incorrect tube size and length, improper support or respiratory underinflation of endotracheal
cuff, and prolonged intubation.4
EQUIPMENT
• 10-mL syringe
• Pressure manometer with extension line or specially designed manometer to measure cuff pressures
• Three-way stopcock
• Stethoscope
• Self-inflating manual resuscitation bag-valve device
• Oxygen source and tubing
Additional equipment (for cuff inflation with faulty inflating device) includes the following:
• Scissors
• Padded hemostats
• Short 18-gauge or 23-gauge blunt needle
• Tongue depressor
• Tape (1 inch wide)
• Reintubation equipment, in case of accidental extubation
• Suction supplies (see Procedure 12)
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Place patient in semi-Fowler’s position. Rationale: This positioning promotes general relaxation, oxygenation, and
ventilation. It also reduces stimulation of the gag reflex and risk of aspiration.
Procedure for Tracheal Tube Cuff Care
FIGURE 13-2 Measuring cuff pressure w ith a homemade pressure monitor. (From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990,
Mosby.)
FIGURE 13-3 Attachments for emergency cuff inflation for faulty inflation line. (From Sills J: An emergency cuff inflation technique, Respir Care 31:200, 1986.)
References
1. Hess, D. Tracheostomy tubes and related appliances. Respir Care. 2005; 50(4):497–509.
2. MacIntyre, N, Branson, R. Mechanical ventilation,, ed 2. Philadelphia: Saunders; 2009.
3. Morris, L, Zoumalan, R, Roccaforte, D, et al, Monitoring -tracheal tube cuff pressures in the intensive care unit. a
comparison of digital palpation and manometry. Ann Otol Rhinol Laryngol. 2007; 116(9):639–642.
4. Pierce, L, Airway maintenance. Management of the mechanically ventilated patient. ed 2. Saunders, St Louis, 2007.
5. Plambeck, A, Adult ventilation management. Corexcel. www.corexcel.com/courses/vent.htm, 2004 [retrieved
April 22, 2004].
6. Roman, M. Tracheostomy tubes. Medsurg Nurs. 2005; 14(2):143–145.
7. St John R, Protocols for practice. airway management. Crit Care Nurse. 2004; 24(2):93–96.
8. Urden, L, Stacy, K, Lough, M, et al, Thelan’s critical -care nursing. diagnosis and management. Mosby, St Louis,
2005.
Additional Reading
Winn, M, Right, K, Trac heostomy. a guide to nursing c are. Austr Nurs J. 2005; 13(5):1–4.
P R OC E D UR E 1 4
PURPOSE:
Tracheostomy tube care is performed to maintain airway patency and decrease infection risk by removing
secretions that accumulate within the inner cannula.
FIGURE 14-1 Sites for tracheostomy insertion. (From Serra A: Tracheostomy care, Nurs Stand 14:42,45-52, 2000.)
FIGURE 14-2 A tracheostomy (sometimes called a tracheotomy) is created surgically by making an opening through the skin of the neck into the trachea.
(Serra A: Tracheostomy care, Nurs Stand 14:42,45-52, 2000.)
• Tracheostomy tubes have a variety of parts (Fig. 14-3) and are available in various sizes and styles from several
manufacturers. The tubes can be metal or plastic, with standard or extra length. Clinicians who care for patients with
tracheostomy tubes must understand the differences and select a tube that appropriately fits the patient and clinical
condition. A tracheostomy tube is shorter than but similar in diameter to an endotracheal tube and has a squared-off
distal tip for maximization of airflow. The outer cannula forms the body of a tracheostomy tube with a cuff. The neck
flange, attached to the outer cannula, assists in stabilizing the tube in the trachea and provides the small holes
necessary for proper securing of the tube. Some tracheostomy setups have an inner cannula inserted into the outer
cannula. The inner cannula is removable for easy cleaning without airway compromise. The cuff is a balloon inflated
with air to maintain a seal around the tube. As the air flows through the one-way inflation valve, the pilot balloon
inflates, which indicates the volume of air present in the cuff.
FIGURE 14-3 Parts of a tracheostomy tube. (From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby, 570.)
• A cuffed tube is appropriate for use in patients who need mechanical ventilation or for whom aspiration is a problem.
The cuff limits aspiration of oral and gastric secretions. Uncuffed tubes are commonly used in children, in adults with
laryngectomies, and during decannulation of the tracheostomy. A fenestrated tracheostomy tube has an opening in
the curvature of the posterior wall of the outer cannula. The matching fenestrated inner cannula is inserted into the
outer cannula. Fenestrated tracheostomy tubes are useful for patients with smaller tracheas and during weaning.12
With cuff deflation, options for speech are finger occlusion technique, placement of a speaking valve (Passy-Muir
valve), or capping of the outer cannula; all permit air to flow through the upper airway and tracheostomy opening.
Foam cuff tracheostomy tubes consist of a high-volume cuff and are composed of polyurethane foam covered with a
silicone sheath. Despite the long availability of this type of tracheostomy tube, it is not commonly used and is usually
reserved for patients who already have tracheal injury related to the cuff.
• A tracheotomy is performed as either an elective procedure or an emergency procedure for a variety of reasons (Table
14-1). Most often, the procedure is elective and performed in the operating room with sterile conditions. An
emergency tracheotomy is performed at the bedside with aseptic technique or before arrival in the critical care unit
when swelling, injury, or other upper airway obstruction prevents intubation with an endotracheal tube.
Percutaneous tracheotomies also are performed at the bedside. Minimally invasive percutaneous tracheotomy was
introduced recently as an alternative to the traditional surgical technique. It has gained widespread acceptance in the
past decade.5,8 This procedure consists of passing a needle into the trachea, placing a J-tipped guidewire, progressively
dilating the trachea, and placing the tracheostomy tube. The percutaneous procedure has achieved outcomes
comparable with outcomes with the surgical technique.1,3
Table 14-1
Indications for Tracheostomy
Bypass acute upper airway obstruction
Prolonged need for artificial airway
Prophylaxis for anticipated airway problems
Reduction of anatomic dead space
Prevention of pulmonary aspiration
Retained tracheobronchial secretions
Chronic upper airway obstruction
• Protocols for emergency tracheotomy vary among institutions. Often, nurses at the bedside take an active role in
assisting with tracheotomy and insertion of a tracheostomy tube; however, some institutions have surgical personnel
at the bedside to assist with the procedure.
• During insertion, the obturator replaces the inner cannula. Its smooth surface protrudes from the outer cannula and
minimizes tracheal trauma. When the tracheostomy tube is inserted, the obturator is removed and replaced with the
inner cannula, which locks in place. The same size sterile tracheostomy tube should be available at the bedside for
easy access in case of accidental decannulation.
•
The decision for a tracheotomy in patients with long-term mechanical ventilation is made on the basis of the team’s
projection regarding length of time that mechanical ventilation or an artificial airway is required. A tracheostomy tube
is the preferred method of airway maintenance in a patient who needs intubation for more than 14 to 21 days. Each
case must be reviewed individually.1,3,10,13,14 Better predictors are needed to further identify patients who can benefit
from tracheotomy early in the course of mechanical ventilation.8
• When compared with endotracheal tubes, tracheostomy tubes provide added benefits to patients, including the
following:
Prevention of further laryngeal injury from the translaryngeal tube
Improved patient comfort, acceptance, and toleration
Ease of oral care
Decreased work of breathing because of less airflow resistance
Facilitation of weaning from mechanical ventilation
Decreased requirement for sedation
Provision of a speech mechanism
Enhanced communication
Greater patient mobility
Facilitation of removal of secretions
Reduced risk of unintentional airway loss
• A tracheostomy tube is viewed by the body as foreign material. The body responds by increasing mucus production.
Also, ciliary movement is impaired, which limits the forward movement of the mucociliary escalator. Because the
tracheostomy bypasses the upper airway and its protective and hydrating mechanisms, patients are at increased risk
of infection. Lack of hydration by the upper airway can lead to thick mucus, which increases the risk of airway
obstruction. Tracheostomy patients should receive continuous humidified air or oxygen for this reason.1,4
• The tracheostomy tube creates a more stable airway, making transfer out of the critical care unit feasible when overall
patient condition warrants. Also, care of the patient, such as suctioning, oral care, and ability to meet nutritional
needs, is simplified.
• A stoma less than 48 hours old has not fully formed a tracheostomy tract. If the tracheostomy tube is accidentally
dislodged, the tracheostomy may close and compromise the patient’s airway.
• A small amount of bleeding is expected for the first few days after a tracheotomy. Bright frank bleeding or constant
oozing is not expected and should be brought to the attention of the physician or advanced practice nurse.
• Consideration should be given to obtaining assistance with tracheostomy care, especially when tracheal ties are
changed or a patient is agitated. An extra pair of hands can minimize the risk for accidental dislodgment.
EQUIPMENT
S ome institutions may use tracheostomy care kits for cleaning a nondisposable inner cannula. Others may use disposable
inner cannulas, in which case the following equipment is needed:
• Personal protective equipment
• Sterile normal saline solution (NS) or water
• Sterile cotton swabs
• Sterile 4 × 4 gauze pads
• Commericial tracheostomy tube holder
• Sterile precut tracheostomy dressing
• Sterile disposable inner cannula of the same size
• Suction supplies
• Self-inflating manual resuscitation bag-valve-device and mask
Additional equipment (to have available based on patient need) includes the following:
• Second practitioner (if changing tracheal ties)
• Extra sterile tracheostomy kit at bedside
Patient Preparation
• Verify the correct patient with two identifiers. Rationale:. Prior to performing a procedure, the nurse should ensure
the correct identification of the patient for the intended intervention.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
Procedure for Tracheostomy Tube Care
FIGURE 14-4 Placement of tracheostomy tw ill tape. A, Face plate w ith threading of tw ill tape (for prevention of decannulation, an additional person needs to
stabilize face plate). B, Advancing of the tw ill tape around the back of the neck and looping through the other side of face plate. C, Doubling of the tw ill tape
and securing in a knot.
References
1. Billau, C. Suctioning. In: Russell C, Matta B, eds. Tracheostomy a multiprofessional handbook. Cambridge:
Cambridge University Press; 2004:157–171.
2. Buchfa, VL, Fries, CM, Repiratory care in nursing procedures. ed 3. Springhouse Corp, Springhouse, PA,
2000:449–455.
3. Burns, SM, et al. Are frequent inner cannula changes necessary? A pilot study. Heart Lung. 1998; 27:58–62.
4. Henneman, E, Ellstrom, K, St John RE, Airway management. In AACN protocols for practice: care of the
mechanically ventilated patient series. American Association of Critical-Care Nurses, Aliso Viejo, CA, 1999.
5. Hess, D. Tracheostomy tubes and related appliances. Respir Care. 2005; 50(4):497–509.
6. Hubmayr, RD, Burchardi, H, Elliot, M, et al. American Thoracic Society Assembly on Critical Care, European
Respiratory Society, European Society of Intensive Care Medicine, Societe de Reanimation de Langue Francaise.
Statement of the 4th International Consensus Conference in Critical Care on ICU-Acquired Pneumonia, Chicago,
Illinois, May 2002. Intensive Care Med. 2002; 28:1521–1536.
7. McCloskey, J, Bulechek, G. Nursing interventions classification, ed 3. St Louis: Mosby; 2002.
8. Mittendorf, EA, et al. Early and late outcome of bedside percutaneous tracheostomy in the intensive care unit.
Am Surg. 2002; 68:342–346.
9. Potter, P, Perry, A, Fundamentals of nursing. Mosby, St Louis, 2009:946–950.
10. Rana, S, Pendem, S, Pogodzinski, M, et al. Tracheostomy in critically ill patients. Mayo Clini Proce. 2005;
80(12):1632–1638.
11. Rankin, N. What is optimum humidity. Respir Care Clin North Am. 1998; 4:321–328.
12. Roman, M. Tracheostomy tubes. Medsurg Nurs. 2005; 14(2):143–145.
13. Russell, C. Providing the nurse with a guide to tracheostomy care and management. Br J Nurs. 2005; 14(8):428–
433.
14. St John R, Protocols for practice. airway management. Crit Care Nurs. 2004; 24(2):93–96.
15. Seay, S, Gay, S, Strauss, M. Tracheostomy emergencies. Am J Nursing. 2002; 102(3):59–61.
16. Tolentino, AF, Ruppert, SD, Shiao, SY : Evidence-basedpractice: Use of the ventilator bundle to prevent
ventilatorassociated pneumonia, Am J Crit Care, 16( 1): 20- 2007
17. Trundle, C, Brooks, R, Infection control issues in the care of a patient with a tracheostomy. In Tracheostomy a
multiprofessional handbook. Cambridge University Press, Cambridge, 2004:343–360.
18. Winn, M, Right, K, Tracheostomy. a guide to nursing care. Austr Nurs. 2005; 13(5):1–4.
Additional Readings
Plambec k, A. Adult ventilation management, Corexc el, Inc . www.c orexc el.c om/c ourses/vent.htm, 2004. [retrieved 10/28/09, from].
S t John R, S ec kel, M, Airway managementBurns S , ed.. Care of the mec hanic ally ventilated patients. MA. ed 2. Jones and Bartlett, S udbury, 2007.
S erra, A. Trac heostomy c are. Nurs Sta nd. 2000; 14:42,45–52.
Tamburri, LM. Care of the patient with a trac heostomy. Orthop Nurs. 2000; 19:49–58.
Thompson, J, Mc Farland G, Hirsc h J, et al. Ear, nose and throat. Mosby’s clinica l nursing. 2002; 627–630.
SECTION TWO
Special Pulmonary Procedures
P R OC E D UR E 1 5
PURPOSE:
End-tidal carbon dioxide provides a noninvasive continuous measurement of ventilation12 or inhaled and
exhaled carbon dioxide concentration commonly referred to as capnography. A capnograph depicts this
measurement as a graphic picture or waveform tracing of each respiratory cycle. The partial pressure of end-
tidal CO2 is assumed to represent alveolar gas, which under normal ventilation/perfusion matching in the lungs
closely parallels arterial levels of CO2.
FIGURE 15-1 Essentials of the normal capnographic w aveform. (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
A zero baseline represents the completion of inspiration and the beginning of exhalation of CO2 -free gas from
anatomic dead space. This gas comes from the large airways, oropharynx, and nasopharynx (see Fig. 15-1, A-B).
A rapid sharp upstroke occurs as the gas from the intermediate airways, containing a mixture of fresh gas and CO2 ,
begins to be exhaled from the lungs (see Fig. 15-1, B-C).
A nearly flat alveolar plateau occurs as exhaled flow velocity slows and mixed gas is displaced by alveolar gas (Fig.
15-1, C-D). Alveolar exhalation of CO2 is nearing completion.
A distance end-tidal point most closely reflects the maximal concentration of exhaled CO2 and the end of exhalation
(Fig. 15-1, D).
A rapid down stroke occurs as the patient begins the inspiration of gas that is essentially devoid of CO2 (see Fig. 15-
1, D-E).
The positively deflected limb occurs with exhalation, whereas the negatively deflected limb occurs with inhalation.
This is opposite from other respiratory waveforms, including the respirogram, spirogram, and flow-volume loop.
The capnogram deviates from normal whenever physiologic or mechanical disruption of the breath occurs.
EQUIPMENT
• Personal protective equipment, including goggles, mask, and gloves
• Capnograph
• Airway adapter PetCO2 nasal cannula
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
Procedure for Continuous End-Tidal Carbon Dioxide Monitoring
FIGURE 15-2 Gradually increasing PetCO2. (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
FIGURE 15-3 Gradual increase in baseline and PetCO2. (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
FIGURE 15-4 Exponential fall in PetCO2. (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
FIGURE 15-5 Decreased PetCO2, (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
FIGURE 15-6 Sudden decrease in PetCO2 values. (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
FIGURE 15-7 Sudden decrease in PetCO2, to near zero. (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
FIGURE 15-8 Low PetCO2, w ithout alveolar plateau. (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO, part of Covidien.)
References
1. AARC, AARC clinical practice guideline. capnography/capnometry during mechanical ventilation—2003
revision and update. Respir Care 2003; 48:534–538.
2. Ahrens, T, et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac
arrest. Am J Crit Care. 2001; 10:391–398.
3. Burton, JH, Harrah, JD, Germann, CA, et al. Does end-tidal carbon dioxide monitoring detect respiratory events
prior to current sedation montoring practices. Acad Emerg Med. 2006; 13(5):500–504.
4. Davis, DP, et al, The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in
patients with head injury after paramedic rapid sequence intubation . J Trauma Inj Infect Crit Care. 2004;
56(4):808–814.
5. Delorio, NM. Continuous end-tidal carbon dioxide monitoring for confirmation of endotracheal tube placement
is neither widely available nor consistently applied by emergency physicians. Emerg Med J. 2005; 22:490–493.
6. Eisenbacher, S, Heard, L. Capnography in the gastroenterology lab. Gastroenterol Nurs. 2005; 28(2):99–106.
7. Erasmus, PD. The use of end-tidal carbon dioxide monitoring to confirm endotracheal tube placement in
adult and paedratic intensive care units in Australia and New Zealand. Anaesth Intensive Care. 2004; 32(5):672–
675.
8. Hutchison, R, Rodriguez, L. Capnography and respiratory depression. Am J Nursing. 2008; 108(2):35–39.
9. La-Valle TL, Perry, AG, Capnography. assessing end-tidal CO2 levels. Dimensions Crit Care Nurs 1995;
14:70–77.
10. Martin, S, Wilson, M, Monitoring gaseous exchange. implications for nursing care. Aust Crit Care 2002; 15:8–
13.
11. Maslow, A, et al. Monitoring end-tidal carbon dioxide during weaning from cardiopulmonary bypass in
patients without significant lung disease. Anesth Analg. 2001; 92:306–313.
12. Miner, JR, Krauss, B, Procedural sedation and analgesia research. state of the art. Acad Emerg Med. 2007;
14(2):170–178.
13. Rose, L, Presneill, JJ, Cade, JF. Update in computer-driven weaning from mechanical ventilation. Anaesth Intensive
Care. 2007; 35(2):213–221.
14. Silvestri, S, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on
the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg
Med. 2005; 45(5):497–503.
15. St John R. End-tidal carbon dioxide monitoring. Crit Care Nurse. 2003; 23:83–88.
Additional Readings
Gravenstein, JS , Jaffe, MB, Paulus, DA Capnography. c linic al aspec ts. Cambridge University Press, United Kingdom, 2004.
Pierc e, LNBMec hanic al ventilation and intensive respiratory c are. Philadelphia: S aunders, 1995.
P R OC E D UR E 1 6
PURPOSE:
Venous oxygen saturation monitoring is performed to measure the oxygen saturation of the venous blood. The
value can be obtained either from the superior vena cava or from the pulmonary artery. Continuous assessment
of the balance between a patient’s oxygen delivery and oxygen consumption can be monitored with a specialized
fiberoptic central venous or pulmonary artery catheter and an associated computer or module.
Table 16-1
Common Conditions and Activities That Affect Venous Oxygen Saturation Values
Decreased Central and Mixed Venous Oxygen Saturation
Decreased Oxygen Delivery
Decreased cardiac output
Decreased hemoglobin
Decreased arterial oxygen saturation
Decreased arterial partial pressure of oxygen
Increased Oxygen Consumption
Fever
Pain
Shivering
Seizures
Increased work of breathing
Agitation
Infection and sepsis
Vasoactive and beta-agonist medications
Multiple organ failure
Burns
Head injury
Increased musculoskeletal activities
Numerous nursing procedures (e.g., dressing changes, suctioning, turning, and chest physiotherapy)
Increased Central and Mixed Venous Oxygen Saturation
Increased Oxygen Delivery
Increased cardiac output
Increased hemoglobin
Increased arterial oxygen saturation
Increased arterial partial pressure of oxygen
Decreased Oxygen Consumption
Hypothermia
Hypothyroidism
Pharmacologic paralysis and sedation
Anesthesia
Cellular dysfunction
Decreased work of breathing
Decreased musculoskeletal activities
• S VO2 does not correlate directly with any of the determinants of oxygen delivery or oxygen consumption. Because a
critically ill patient is in a dynamic state with rapidly changing oxygen demand and oxygen consumption, S VO2 must
be viewed in the light of these changing determinants and considered an index of oxygen balance.1,2,6,8,13
• A normal S VO2 generally is considered to be 60% to 80%,2,8 and a clinically significant change in S VO2 (5% to 10%) can
be an early indicator of physiologic instability.2,8 S VO2 values of less than 60% may result from either inadequate
oxygen delivery or excess oxygen consumption. S VO2 monitoring is used in critically ill patients for earlier detection of
oxygenation instability than that obtained through traditional PA monitoring.2,6,8,13
• The percent of venous oxygen saturation as measured in the superior vena cava (ScVO2 ) reflects the mixing of venous
blood from the superior half of the body. It does not include blood from the IVC and coronary sinus. ScVO2 , right
atrium (RA), and S VO2 do not correlate absolutely. ScVO2 does trend with S VO2 in a variety of hemodynamic states. In
normal conditions, ScVO2 is slightly less than the RA oxygen saturation and lower than S VO2 . In septic or shock states,
ScVO2 is higher than S VO2 , with a difference that ranges from 5% to 7% and up to 18% in severe shock. This
difference is in part because of a redistribution of blood flow caused by the various pathophysiologies. Therefore,
ScVO2 overestimates S VO2 in shock conditions; a low ScVO2 likely indicates an even lower S VO2 .4,9-11
• Small French size and shorter oximetry catheters have pediatric patient applications for assessment of venous
saturation.9
• Some common proper setup and maintenance steps for the catheters and bedside computer or module are necessary
for accurate monitoring of both ScVO2 and S VO2 .
• Continuous venous saturation monitoring is performed with a three-component system (Fig. 16-1)2,5-7 :
FIGURE 16-1 Oximetry system w ith reflectance spectrophotometry. (From Edwards Lifesciences LLC: Understanding mixed venous oxygen saturation [SVO2]
monitoring using the Swan Ganz TD System, ed 2, Irvine, CA, 2002, Edwards Lifesciences.)
A fiberoptic central venous (CV) or PA catheter contains two fiberoptic filaments that exit at the distal lumen. One
filament serves as a sending fiber for the emission of light; the other serves as a receiving fiber for the light reflected
back from the blood in the vessel (Fig. 16-2).
FIGURE 16-2 Oximetry catheters. A, Small French size for pediatric applications. B, Central venous catheter. C, Pulmonary artery catheter. (From Edwards
Lifesciences LLC, Irvine, CA, 2008.)
The optic module houses the light-emitting diodes (LEDs), which transmit various wavelengths of light, and a
photodetector, which receives light back. The light wavelengths are shone through a blood sample. Desaturated
hemoglobins, saturated hemoglobins (oxyhemoglobin), and dyshemoglobins (carboxyhemoglobin,
methemoglobin) have different light absorption characteristics. The ratio of hemoglobin to oxyhemoglobin is
determined and reported as a percentage value.2,5,7 All previous patient data, including calibration of saturation
values and patient identification information, are stored in this component. This module should not be
disconnected. If the module must be disconnected, refer to the manufacturer’s instructions for a disconnection
procedure that does not result in memory loss.
An oximeter computer, which can be a stand-alone unit or a module for a bedside monitoring system, has a
microprocessor that converts the light information from the optic module into an electrical display, updated every
few seconds for continuous monitoring. This information is displayed as a continuous graphic trend, a numeric
display, or both, depending on the manufacturer.
Proper calibration of the monitor and catheter ensures accuracy of venous saturation values. The two types of
calibration are in vitro, in which the catheter and optics module are calibrated before insertion; and in vivo, where
the venous saturation value is compared with a laboratory co-oximeter value from a blood sample. Follow
manufacturer recommendations for performing calibration procedures. Daily in vivo calibrations are
recommended. In addition, proper blood sampling techniques from the distal port of the PA catheter are necessary
for ensuring accurate values for calibration.2,5,7,8
EQUIPMENT
• Fiberoptic PA catheter for S VO2 (various sizes, 4 Fr to 8 Fr; various lumens, 2 Fr to 7 Fr; various lengths, 25 to 110 cm)
• Fiberoptic CV catheter for ScVO2 (various sizes for pediatric to adult use, 4.5 Fr to 8.5 Fr; various lengths, 5 to 20 cm;
single, double, or triple lumen)
• Fiberoptic probe for ScVO2
• Optic module
• Oximeter computer or bedside monitoring system module
• Equipment required for CV monitoring (see Procedure 70) or PA catheterization and pressure monitoring (see
Procedure 73)
Additional equipment (to have available depending on patient need) includes the following:
• Printer
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Answer patient questions as they arise, and reinforce information as needed. Rationale: This communication
evaluates and reinforces understanding of previously taught information.
Procedure for Continuous Mixed Venous Oxygen Saturation Monitoring
References
1. Bishop, MH, et al, Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and
oxygen consumption as resuscitation endpoints in severe trauma . J Trauma 1995; 38:780–787.
2. Darovic, GO. Handbook hemodynamic monitoring, ed 2. St Louis: Saunders; 2004.
3. Dellinger, RP, Levy, MM, Carlet, JM, et al, Surviving sepsis campaign . international guidelines for the
management of severe sepsis and septic shock. Crit Care Med 2008; 36:296–327.
4. Edwards, JD, Mayall, RM. Importance of the sampling site for measurement of mixed venous oxygen
saturation in shock. Crit Care Med. 1998; 26:1356–1360.
5. Edwards Lifesciences LLC, Vigilance. continuous cardiac output and Svo2 monitoring system. Operations
manual. Edwards Lifesciences: Irvine, CA, 2003.
6. Headley, JM. Strategies to optimize the cardiorespiratory status of the critically ill. AACN Clin Issues Crit Care
Nurs. 1995; 6:121–134.
7. Hospira, Inc. Q2Plus SO2 /CO computer (system operating manual. North Chicago: Hospira; 2004.
8. Jesurum, JT, Svo2 monitoring. AACN protocols for practice . hemodynamic monitoring. American
Association of Critical-Care Nurses: Aliso Viejo, CA, 1998.
9. Liakopoulos, OJ, Ho, JK, Yezbick, A, et al. An experimental and clinical evaluation of a novel central venous
catheter with integrated oximetry for pediatric patients undergoing cardiac surgery. Anesth Analg. 2007;
I105(6):1598–1604.
10. Reinhart, K, Kuhn H-J, Hartog, C, et al, Continuous central venous and pulmonary artery oxygen saturation
monitoring in the critically ill. Intensive Care Med. 2004; 30:1572–1578.
11. Rivers, EP, Cobra, V, Whitmill, M, Early goal-directed therapy in severe sepsis and septic shock. a contempory
review of the literature. Curr Opin Anesthesiol 2008; 21:128–140.
12. Vedrinne, C, et al. Predictive factors for usefulness of fiberoptic pulmonary artery catheter for continuous
oxygen saturation in mixed venous blood monitoring in cardiac surgery. Anesth Analg. 1997; 85:2–10.
13. White, KM. Using continuous Svo2 to assess oxygen supply/demand balance in the critically ill patient. AACN
Clin Issues Crit Care Nurs. 1993; 4:134–147.
Additional Readings
AACN. S evere sepsis. from www.aac n.org/WD/Prac tic e/Doc s/S evere_S epsis_04-2006.pdf. [ac c essed].
AACN. Pulmonary artery pressure measurement. www.aac n.org/WD/Prac tic e/Doc s/PAP_Measurement_05-2004.pdf. [ac c essed].
Antonelli M, Levy, M, Andrews, PJD, et al. Hemodynamic monitoring in shoc k and implic ation for management, International Consensus Conferenc e, Paris,
Franc e 27-28 April 2006. Intensive Ca re Med. 2007; 33(4):1–16.
Carc illo, JA, Fields, AI, Americ an College of Critic al Care Medic ine Task Forc e Committee Members. Clinic al -prac tic e parameters for hemodynamic support of
paediatric and neonatal patients in septic shoc k. Crit Care Med 2002; 30:1365–1378.
De Oliveira, CF, de Oliveira, DS F, Moura, JDGet al. ACCM/PALS haemodynamic support guidelines for paediatric septic shoc k. an outc omes c omparison with
and without monitoring c entral venous oxygen saturation. Intensive Care Med. 2008; 34(6):1065–1075.
Edwards Lifesc ienc es LLC. Understanding c ontinuous mixed venous oxygen saturation (S vo2) monitoring with the S wan-Ganz oximetry TD system. ed 2, Irvine,
CA: Edwards Lifesc ienc es; 2002.
Goodric h, C. Continuous c entral venous oximetry monitoring. Crit Ca re Nurs Clin North Am. 2006; 18:203–209.
Kec keisen, M Pulmonary artery pressure monitoring. In AACN protoc ols for prac tic e. hemodynamic monitoring. Americ an Assoc iation of Critic al-Care Nurses,
Aliso Viejo, CA, 1998.
Rivers, EP, Ander, DS , Powell, D. Central venous oxygen saturation monitoring in the c ritic ally ill. Curr Opin Ca re. 2001; 7(3):204–211.
P R OC E D UR E 1 7
PURPOSE:
Pulse oximetry is a noninvasive monitoring technique used to estimate the measurement of arterial oxygen
saturation of hemoglobin.
FIGURE 17-1 A sensor device that contains a light source and a photodetector is placed around a pulsating arteriolar bed, such as the finger, great toe,
nose, or earlobe. Red and infrared w avelengths of light are used to determine arterial saturation. (Reprinted by permission of Nellcor Puritan Bennett LLC, Boulder, CO,
part of Covidien.)
• Oxygen saturation values obtained with pulse oximetry (SpO2 ) represent one part of a complete assessment of a
patient’s oxygenation status and are not a substitute for measurement of arterial saturation of oxygen (SaO2 ) or of
ventilation (as measured with arterial partial pressure of carbon dioxide [PaCO2 ]).
• The accuracy of SpO2 , measurements requires consideration of many physiologic variables. Patient variables include
the following:
Hemoglobin level
Presence of dyshemoglobinemias (i.e., carboxyhemoglobinemia after carbon monoxide exposure)
Arterial blood flow to the vascular bed
Temperature of the digit or the area where the oximetry sensor is located
Patient’s oxygenation ability
Fraction of inspired oxygen (percentage of inspired oxygen)
Evidence of ventilation-perfusion mismatch
Amount of ambient light seen with the sensor
Venous return at the sensor location
• A complete assessment of oxygenation includes evaluation of oxygen content and delivery, which includes the
following parameters: arterial partial pressure of oxygen (PaO2 ), SaO2 hemoglobin, cardiac output, and, when
available, mixed venous oxygen saturation.
• Normal oxygen saturation values are approximately 97% to 99% in a healthy individual breathing room air. An
oxygen saturation value of 95% is clinically accepted in a patient with a normal hemoglobin level. With a normal
blood pH and body temperature, an oxygen saturation value of 90% is generally equated with a PaO2 of 60 mm Hg.
• Tissue oxygenation is not reflected by arterial or oxygen saturation obtained with pulse oximetry.
• The affinity of hemoglobin with oxygen may impair or enhance oxygen release at the tissue level.
Oxygen is more readily released to the tissues when pH is decreased (acidosis), body temperature is increased,
PaCO2 , is increased, and 2,3-diphosphoglycerate levels (a by-product of glucose metabolism that facilitates the
dissociation of oxygen from the hemoglobin molecule to tissue) are increased (decreased oxygen affinity).
When hemoglobin has greater affinity for oxygen, less is available to the tissues (increased oxygen affinity).
Conditions such as increased pH (alkalosis), decreased temperature, decreased PaCO2 , and decreased 2,3-
diphosphoglycerate (as found in stored blood products) increase oxygen binding to the hemoglobin and limit its
release to the tissue.
• Oxygen saturation values may vary with the amount of oxygen usage or uptake by the tissues. In some patients, a
difference is seen in SpO2 values at rest compared with values during activity, such as ambulation or positioning.
• Oxygen saturation does not directly reflect the patient’s ability to ventilate. The true measure of ventilation is
determination of the PaCO2 in arterial blood. Use of SpO2 in a patient with obstructive pulmonary disease may result
in erroneous clinical assessments of condition. As the degree of lung disease increases, the patient’s drive to breathe
may shift from an increased carbon dioxide stimulus to a hypoxic stimulus. Enhancing the patient’s oxygenation and
increasing the SpO2 may limit the ability to ventilate. The normal baseline SpO2 for a patient with known severe
restrictive disease and more definitive methods of determination of the effectiveness of ventilation must be assessed
before consideration of interventions that enhance oxygenation.
• Any discoloration of the nail bed or obstruction of the nail bed can potentially affect the transmission of light through
the digit. The impact of dark nail polish, such as blue, green, brown, or black colors,4,5,11,17 has been reported to limit
the transmission of light and thus impact the SpO2 , although a recent study showed that fingernail polish does not
cause a clinically significant change in the pulse oximeter readings in healthy individuals.15 If the nail polish cannot be
removed and is believed to be affecting the accuracy of the reading, the sensor can be placed in a lateral side-to-side
position on the finger to obtain readings if no other method of sampling the arterial bed is available.5,15 Bruising under
the nail can limit the transmission of light and result in an artificially decreased SpO2 value. Pulse oximetry has not
been shown to be affected by the presence of an elevated bilirubin.2 The presence of acrylic fingernails may impair the
accuracy of the pulse oximetry reading, and removal of the nail covering may be necessary to ensure accurate
measurement,9 although unpolished acrylic nails have been proven not to affect pulse oximetry readings.14
• Standard pulse oximeters use two wavelengths and are unable to differentiate between oxygen and carbon monoxide
bound to hemoglobin and falsely elevated SpO2 measurements. Standard pulse oximetry equipment should never be
used in suspected cases of carbon monoxide exposure. However, recent technology advancements in pulse oximetry
have included the introduction of a monitor system that uses up to 12 wavelengths with a digit-based pulse oximeter
sensor and that allows for measurement estimates of certain, dyshemoglobinemias (i.e., carboxyhemoglobinemia).12
An arterial blood gas always should be obtained to determine the accurate oxygen saturation and, if a CO oximeter is
available, measurement of carboxyhemoglobin and methemoglobin.3
• Dark skin has been suggested to possibly affect the ability of the pulse oximeter to detect arterial pulsations. One
study found more frequent differences between the SpO2 and SaO2 in black patients when compared with lighter
skinned patients10 ; another study did not find a significant difference.13
• Certain dyes used intravenously may interfere with the accuracy of measurements, although as a result of rapid
clearance, the impact is limited. Dyes include methylene blue, indigo carmine, indocyanine green, and fluorescein.8
• A pulse oximeter should not be used as a predictive indicator of the actual arterial blood gas saturation.
• A pulse oximeter should never be used during a cardiac arrest situation because of the extreme limitations of blood
flow during cardiopulmonary resuscitation and the pharmacologic action of vasoactive agents administered during
the resuscitation effort.
• Low perfusion states such as hypotension, vasoconstriction, hypothermia, or administration of vasoconstrictive agents
limit the ability of the oximeter to distinguish the true pulsatile wave form from background noise.
• In vasoconstrictive states, oxygen saturation may be measured with a finger probe, but in patients with significant
shifts in hemodynamic stability, the ear or forehead has been shown to be reasonably resistant to the vasoconstrictive
effects of the sympathetic nervous system.1,16
• Forehead sensors used in patients placed in Trendelenburg’s position may require up to 20 mm Hg external pressure
to achieve accurate readings, which may be accomplished with an appropriately applied headband.1
EQUIPMENT
• Oxygen saturation monitor
• Oxygen saturation cable and sensor, which may be disposable or nondisposable
• Manufacturer’s recommended germicidal agent for cleaning the nondisposable sensor (used for cleaning between
patients)
Patient Preparation
• Verify the correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure
the correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
Procedure for Oxygen Saturation Monitoring with Pulse Oximetry
FIGURE 17-2 Sensor types and sensor sites for pulse oximetry monitoring. Use “w rap” or “clip” style sensors on the fingers (including thumb), great toe,
and nose. The w indow s for the light source and photodetector must be placed directly opposite each other on each side of the arteriolar bed to ensure
accuracy of SpO2 measurements. Choice of the correct size of the sensor helps decrease the incidence of excess ambient light interference and optical
shunting. “Clip” style sensors are appropriate for fingers (except the thumb) and the earlobe. Ensuring that the arteriolar bed is w ell w ithin the clip w ith the
w indow s directly opposite each other decreases the possibility of excess ambient light interference and optical shunting. (Reprinted by permission of Nellcor
Puritan Bennett LLC, Boulder, CO, part of Covidien.)
References
1. Agashe, GS, Coakley, J, Mannheimer, PD. Forehead pulse oximetry. Anesthesiology. 2006; 105:1111–1115.
2. Awad, AA, et al. Different responses of ear and finger pulse oximeter wave form to cold pressor test. Anesth
Analg. 2001; 92:1483–1486.
3. Barker, SJ, et al, Measurement of carboxyhemoglobin and methemoglobin by pulse oximetry . Anesthesiology .
2006; 105:892–897.
4. Chan, MM. What is the effect of fingernail polish on pulse oximetry. Chest. 2003; 123:2163–2164.
5. Grap, MJ. Pulse oximetry. Crit Care Nurse. 1998; 18:94–99.
6. Grap, MJ, Pulse oximetry. AACN protocols for practice . technology series. American Association of Critical-Care
Nurses: Aliso Viejo, CA, 2005.
7. Hanowell, L, Eisele, JH, Downs, D. Ambient light affects pulse oximeters. Anesthesiology. 1987; 67:864–865.
8. Hedges, J, Baker, WE, Lanoix, R, et al, Pulse oximetry. Roberts . clinical procedures in emergency medicine.
ed 4. PA Saunders, Philadelphia, 2004:32–36.
9. Hinkelbein, J, Koehler, H, Genzwuerker, HV, et al, Artificial acrylic finger nails may alter pulse oximetry
measurement . Resuscitation 2006; 74:75–82.
10. Jubran, A. Reliability of pulse oximetry in titrating supplemental oxygen therapy in ventilator-dependent
patients. Chest,. 1990; 97:1420–1425.
11. Kelleher, JF. Pulse oximetry. J Clin Monit. 1989; 5:37–62.
12. Masimo, Rainbow SET Pulse CO-Oximetery. http://www.masimo.com/Rainbow/about.htm., 2008 [retrieved
March 21, 2009, from].
13. McConnell, EA, Performing pulse oximetry . Nursing 1999; 99:11–17.
14. Peters, SM. The effect of acrylic nails on the measurement of oxygen saturation as determined by pulse
oximetry. AANAJ. 1997; 65:361–363.
15. Rodden, AM, Spicer, L, Diaz, VA, et al. Does fingernail polish affect pulse oximeter readings. Intensive Crit Care
Nurs. 2007; 23:51–55.
16. Schallom, L. Comparison of forehead and digit oximetry in surgical/trauma patients at risk of decreased
peripheral perfusion. Heart Lung. 2007; 36:188–194.
17. Szarlarski, NL, Cohen, NH. Use of pulse oximetry in critically ill adults. Heart Lung. 1989; 18:444–453.
18. Zablocki, AD, Rasch, DK, A simple method to prevent interference with pulse oximetry by infrared heating .
Anesth Analg . 1987; 66:915.
Additional Readings
Bianc hi, J, et al, Pulse oximetry index. a simple arterial assessment for patients with venous disease. J Wound Care 2008; 17:253–260.
Clark, AP, Legal lessons. “But his O 2 sat was normal. Clin Nurse S pec ialist 2002; 16:162–163.
Giuliano, KK, et al. New-generation pulse oximetry in the c are of c ritic ally ill patients. Am J Crit Ca re. 2005; 14:26–39.
Witting, MD, S c harf, S M, Diagnostic room-air pulse oximetry. effec ts of smoking, rac e, and sex. Am J Emerg Med 2008; 26:131–136.
P R OC E D UR E 1 8
Pronation Therapy
Kathleen M. Vollman and Jan Powers
PURPOSE:
The prone position may be indicated in patients in whom conventional ventilator strategies have not been
successful in recruiting alveoli and who continue to need maximal ventilator support with marginal oxygenation.
The prone position is used in an attempt to improve oxygenation in patients with acute lung injury or acute
respiratory distress syndrome. The position also may be used for mobilization of secretions as a postural
drainage technique, posterior wound management that allows excellent visualization and management of the
site, relief of pressure in the sacral region, positioning for operative or diagnostic procedures, and therapeutic
sleep for critically ill patients who normally sleep on the abdomen at home.
In zone 1, near the apex, alveolar pressure exceeds arterial pressure, creating little or no flow.
In zone 2, the pulmonary artery pressure exceeds alveolar pressure, which exceeds the venous pressure. Blood flow
in this area occurs based on the differences in pressure between the arterial and alveolar bed.
In zone 3, the arterial pressure is greater than the venous pressure, which is greater than the alveolar pressure. In
this zone, the influence of the alveolar pressure on blood flow is reduced, resulting in freedom of flow in this
region.35,36
• In supine and lateral positions, apical region blood flow changes. No real change is seen in basilar units, but a greater
dependent versus nondependent blood flow occurs. In the prone position, a marked reduction occurs, however, in
the gravitational perfusion gradient, which suggests no gravity-dependent benefit to flow in the prone position.21
• On the basis of the current available data as outlined here, changes in oxygenation seem to be related to differences in
the regional inflation/ventilation of the lung while prone and are not related to a redistribution of blood flow.6,17,23
• Suggested criteria for use of the prone position include:
Consider use of the prone position for patients with ARDS who need potentially injurious levels of FiO2 or plateau
pressure, provided they are not put at risk from positional changes6
PaO2 /FiO2 ratio less than 200 on a FiO2 greater than 50% with sufficient positive end-expiratory pressure used to
recruit alveoli
• Contraindications and precautions to manual pronation therapy include the following3,7,23,26,31,32 :
Patient unable to tolerate a head-down position
Increased intracranial pressure
Unstable spine (unless Stryker Frame [Stryker Medical], Kalamazoo, MI used)
Patient with hemodynamically unstable condition (as defined by a systolic blood pressure less than 90 mm Hg) with
fluid and vasoactive support in place
With use of a support frame, patient weight greater than 135 kg
Weight 160 kg or greater (weigh the risk/benefit ratio for the patient and staff)
Extracorporeal membrane oxygenator cannula placement problems
Open chest or unstable chest wall
Bronchopleural fistula
Unstable pelvis
Facial trauma
Grossly distended abdomen or ischemic bowel
Pregnancy
Bifurcated endotracheal tube
• Absolute contraindications for use of Automated Prone Positioning RotoProne™ Therapy System (KCI Licensing,
Inc.) include:
Unstable cervical, thoracic, lumbar, pelvic, skull, or facial fractures
Cervical or skeletal traction
Uncontrolled intracranial pressure (ICP)
Patient weight less than 40 kg (88 lb)
Patient weight more than 159 kg (350 lb)
Patient height in excess of 6 ft 6 inches
• Relative contraindications for use of Automated Prone Positioning RotoProne™ Therapy System (must weigh risk and
benefits) include:
Hemodynamic instability
Severe agitation
Wounds at risk of dehiscence
Patients in prone position with open sternal wound or thoracic postsurgical incision
Open abdomen
Intolerance to face-down position
Any implant that potentially increases risk of skin breakdown, including, but not limited to, breast implants or
penile prosthesis
Pregnancy
• The use of the prone position is discontinued when the patient no longer shows a positive response to the position
change or mechanical ventilation support has been optimized. The literature has not clearly identified when the use of
prone positioning should be discontinued. One suggestion for discontinuation is when the patient’s PaO2 /FiO2 ratio is
greater than 200 on less than 50% FiO2 and less than or equal to 10 cm of H2 O of positive end-expiratory pressure.
With use of the RotoProne™ Therapy System Surface, weaning from the prone position is recommended. Increase
supine time while decreasing time in the prone position until the patient is able to tolerate 24 hours in the supine
position with no decrease in oxygenation response. The patient can then be taken off the RotoProne and placed on an
appropriate surface to achieve patient goals.
EQUIPMENT
• Pillows or foam blocks
• Four or five staff members
• Lift sheets
or
• Vollman Prone Positioner (VPP; Hill-Rom, Inc, Batesville, IN; Fig. 18-2): weight limit per manufacturer’s
recommendation, 300 1b
FIGURE 18-2 Diagram of Vollman Prone Positioner. (From Hill-Rom, Inc, San Antonio, TX)
FIGURE 18-3 RotoProne™ Therapy System (Courtesy of KCI Licensing, Inc., 2008.)
• Stryker Frame for use in patients with unstable spines, if available: weight limit per manufacturer’s recommendations
• Capnography monitor
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teachings. Answer questions as they arise and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Assess patient’s mental condition. Rationale: Assessment of agitation with a reliable and valid scale and provide
appropriate management before, during, and after the turn are key to accomplishing a safe procedure.
• Turn off the tube feeding 1 hour before the prone position turn. Rationale: This action assists with gastric emptying
and reduces the risk of aspiration during the turning procedure.35 Enteral feeding can be continued during prone
position29 ; use of prokinetic agents or transpyloric feedings is recommended to prevent complications associated with
vomiting.25
• Before positioning the patient prone, the following care activities should be performed:
Remove electrocardiogram leads from the anterior chest wall.
Perform eye care, including lubrication and taping of the eyelids closed in a horizontal fashion.
Ensure the tongue is inside the patient’s mouth. If the tongue is swollen or protruding, insert a bite-block.
Ensure the tape or ties of the endotracheal tube or tracheotomy tube are secure. Changing of the ties may be
necessary on return to the supine position if they are not secure. If adhesive tape is used to secure the endotracheal
tube, consider double taping or wrapping completely around the head because increased salivary drainage occurs
in the prone position and may loosen the adhesive.26,32 Commercial endotracheal tube (ETT) securement devices are
not recommended for use during prone positioning because of possibility of increased skin breakdown and
breakdown of adhesive from increased salivary drainage.16
If a wound dressing on the anterior body is due to be changed during the prone position sequence, perform the
dressing change before the turn. If saturated on return from the prone position, the dressing needs to be changed.
Empty ileostomy/colostomy bags before positioning. Placement of the drainage bag to gravity drainage and padding
around the stoma to prevent pressure directly on stoma are recommended.
Capnography monitoring is suggested to help ensure proper positioning of the tube during the turning procedure
and in the prone position.
• Rationale: These activities prevent areas of pressure and potential skin breakdown; avoid complications related to
injury or accidental extubation; and promote the delivery of comprehensive care before, during, and after the
pronation therapy.26,31,32,34
Procedure for Manual Pronation Therapy
FIGURE 18-4 Positioning of ventilator tubing. (From Hill-Rom, Inc., San Antonio, TX)
FIGURE 18-5 Turning patient prone on Vollman Prone Positioner.
FIGURE 18-6 Patient lying prone on Vollman Prone Positioner. (From Hill-Rom, Inc., San Antonio, TX)
FIGURE 18-7 Patient returning to supine position. (From Hill-Rom, Inc., San Antonio, TX)
References
1. Abroung, F, et al, The effect of prone positioning in acute respiratory distress syndrome or acute lung injury. a
meta-analysisareas of uncertainty and recommendations for research. Intensive Care Med. 2008; 34(6):1002–
1011.
2. Alsaghir, AH, Martian, CM, Effect of prone positioning in patients with acute respiratory distress syndrome. a
meta-analysis. Crit Care Med 2008; 36:603–609.
3. Chatte, G, et al. Prone position in mechanically ventilated patients with severe acute respiratory failure. Am J
Respir Crit Care Med. 1997; 155:473–478.
4. Curley, MA, et al, Effect of prone positioning on clinical outcomes in children with acute lung injury. a
randomized controlled trial. JAMA 2005; 294:229–237.
5. Curley, MAQ, Prone positioning of patients with acute respiratory distress syndrome. a systematic review.
Am J Crit Care 1999; 8:397–405.
6. Dellinger, PR, et al, Surviving sepsis campaign. international guidelines for management of severe sepsis and
septic shock2008. Crit Care Med 2008; 36:296–327.
7. Fridrich, P, et al. The effects of long-term prone positioning in patients with trauma induced adult respiratory
distress syndrome. Anesth Analg. 1996; 83:1206–1211.
8. Froese, AB, Bryan, AC. Effects of anesthesia and paralysis on diaphragmatic mechanics in man. Anesthesiology.
1974; 41:242–255.
9. Gattinoni, L, et al. Body position changes redistribute lung computed tomographic density in patients with
acute respiratory failure. Anesthesiology. 1991; 74:15–23.
10. Gattinoni, L, et al. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J
Med. 2001; 345:568–573.
11. Gattinoni, L, et al. Relationships between lung computed tomographic density, gas exchange and PEEP in
acute respiratory failure. Anesthesiology. 1988; 69:824–832.
12. Goldhill, DR, Imhoff, M, McLean, B, et al, Rotational bed therapy to prevent and treat respiratory complications.
a review and meta analysis. Am J Crit Care 2007; 16:50–62.
13. Guerin, C, et al, Effects of systematic prone positioning in hypoxemic acute respiratory failure. a randomized
controlled trial. JAMA 2004; 292:2379–2387.
14. Harcomb, C. Nursing patient with ARDS in prone position. Nurs Stand. 2004; 18(19):33–39.
15. Kaneko, K, et al. Regional distribution of ventilation and perfusion as a function of body position. J Appl Physiol.
1966; 21:767–777.
16. Laux, L, McGonigal, M, Thieret, T, et al. Use of prone positioning in a patient with acute respiratory distress
syndrome. Crit Care Nurs Q. 2008; 31(2):178–183.
17. Malbouisson, LM, et al. Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory
distress syndrome. Am J Respir Crit Care Med. 2005; 161:2005–2012.
18. Mancebo, J, et al. A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome.
Am J Respir Crit Care Med. 2006; 173:1233–1239.
19. Marklew, A. Body positioning and its effect on oxygenation—a literature review. Nurs Crit Care. 2006; 11(1):16–
22.
20. Murray, TA, Patterson, LA. Prone positioning of trauma patients with acute respiratory distress syndrome and
open abdominal incisions. Crit Care Nurse. 2002; 22:52–56.
21. Mutoh, T, et al. Prone position alters the effect of volume overload on regional pleural pressures and improves
hypoxemia in pigs in vivo. Am Rev Respir Dis. 1992; 146:300–306.
22. Papazian, L, et al. Comparison of prone positioning and high frequency oscillatory ventilation of patients with
acute respiratory distress syndrome. Crit Care Med. 2005; 33:2162–2171.
23. Pappert, D, et al. Influence of positioning on ventilation-perfusion relationships in severe adult respiratory
distress syndrome. Chest. 1994; 106:1511–1516.
24. Pelosi, P, Brazzi, L, Gattinoni, L. Prone position in ARDS. Eur Respir J. 2002; 20:1017–1028.
25. Reignier, J, Thenoz-Jost, N, Fiancette, M, et al. Early enteral nutrition in mechanically ventilated patients in the
prone position. Crit Care Med. 2004; 32(1):94–99.
26. Rowe, C. Development of clinical guidelines for prone positioning in critically ill adults. Nurs Crit Care. 2004;
9(2):50–57.
27. Sebat, F, Johnson, D, Shoffner, D, et al. Benefits, complications of prone position and utility of automated proning
bed in the treatment of acute lung injury (ALI). Chest. 2007; 132(4):572S.
28. Sud, S, et al, Effect of mechanical ventilation in the prone position on clinical outcomes in patients with acute
respiratory failure. a systematic review and meta-analysis. CMAJ. 2008; 178(9):1153–1161.
29. Van der Voort, PH, Zandstra, DF, Enteral feeding in the critically ill. comparison between supine and prone
positionsa prospective crossover study in mechanically ventilated patients. Crit Care. 2001; 5(4):216–220.
30. Voggenreiter, G, et al, Prone positioning improves oxygenation in post traumatic lung injury. a prospective
randomized trial. J Trauma 2005; 59:333–341.
31. Vollman, KM. The effect of suspended prone positioning on PaO2 and A-a gradients in adult patients with acute
respiratory failure. California State University: Master’s Thesis, Long Beach; 1989.
32. Vollman, KM, Prone positioning in the ARDS patient. the art and science. Crit Care Nurs Clin North Am.
2004; 16(3):319–336.
33. Vollman, KM. What are the practice guidelines for prone positioning of acutely ill patients? Specifically, what
are the recommendations related to hemodynamic monitoring and tube feeding? Crit Care Nurse. 2001; 21:84–
86.
34. Vollman, KM, Bander, JJ. Improved oxygenation utilizing a prone positioner in patients with acute respiratory
distress syndrome. Intensive Care Med. 1996; 22:1105–1111.
35. West, JB, Respiratory physiology. the essentials. ed 3. Williams & Wilkins, Baltimore, 1985.
36. West, JB, Dollery, CT, Naimark, A, Distribution of blood flow in isolated lung. relation to vascular and alveolar
pressures. J Appl Physiol 1964; 19:713–724.
37. Winslow, EH, et al. Effects of a lateral turn on mixed venous oxygen saturation and heart rate in critically ill
adults. Heart Lung. 1990; 19:555–561.
SECTION THREE
Thoracic Cavity Management
P R OC E D UR E 1 9
Autotransfusion
Robin M. Beard
PURPOSE:
Autotransfusion is the collection and filtration of blood from an active bleeding site and reinfusion of that
(autologous) blood into the same patient for the maintenance of blood volume.
EQUIPMENT
• Personal protective equipment
• Autotransfusion collection system
• Autotransfusion system replacement bag
• Blood administration set
• 40-µm microemboli filter
• Normal saline (NS) intravenous (IV) solution
Patient Preparation
• Verify correct patient using two identifiers. Rationale: Prior to performing a procedure the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
Procedure for Autotransfusion
References
1. American Association of Blood Banks, Guidelines for blood recovery and reinfusion in surgery and trauma .
American Association of Blood Banks, Bethesda, MD, 1997.
2. American Association of Blood Banks. Technical manual, ed 16. Bethesda, MD: American Association of Blood
Banks; 2008.
3. Purcell, TB. Autotransfusion. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. ed 4.
Philadelphia: Saunders; 2004:410–426.
Additional Readings
Americ an Assoc iation of Blood Banks Guidanc e for standards for perioperative autologous blood c ollec tion and administration. Americ an Assoc iation of Blood
Banks, Bethesda, MD, 2002.
Brown, M, Whalen, PK, Red blood c ell transfusion in c ritic ally ill patients. emerging risks and alternatives. Crit Care Nurse 2000; 1–14. [(S uppl)].
Cross, MH, Autotransfusion in c ardiac surgery . Perfusion 2001; 16:391–400.
Dial, S , Nguyen, D, Menzies, D, Autotransfusion of shed mediastinal blood. a risk fac tor for mediastinitis after c ardiac surgery? Results of a c luster investigation.
Chest. 2003; 124(5):1847–1851.
Ley, S J, Intraoperative and postoperative blood salvage . AACN Clin Issues 1996; 7:238–248.
Oeltjen, AM, S antrac h PJ, Autologous transfusion tec hniques. J Intra ven Nurs . 1997; 20:305–310.
S irvinskas, E, Veikutiene, A, Benetis, R, et al. Influenc e of early re-infusion of autologous shed mediastinal blood on c linic al outc ome after c ardiac surgery.
Perfusion. 2007; 22(5):345–352.
Weniger, J, von der Emde J, S c hric ker, K, et al. Autotransfusion of drainage blood after heart surgery. La ngenbecks Archiv Für Chirurgie. 1980; 351(4):229–241.
[(author’s transl)].
P R OC E D UR E 2 0
PURPOSE:
Chest tubes are placed for the removal or drainage of air, blood, or fluid from the intrapleural or mediastinal
space. They also are used to introduce sclerosing agents into the pleural space to prevent a reaccumulation of
fluid.
FIGURE 20-1 Standard sites for tube thoracostomy. A, The second intercostal space, midclavicular line. B, The fourth or fifth intercostal space, midaxillary
line. Most clinicians prefer midaxillary line placement for all chest tubes, regardless of pathology. Placement of the tube too far posteriorly does not allow the
patient to lie dow n comfortably. (From Roberts JR, Hedges JR, editors: Clinicals in emergency medicine, ed 4, Philadelphia, 2004, Saunders.)
When the tube is in place, the tube is sutured to the skin to prevent displacement, and an occlusive dressing is
applied (see Fig. 21-1). The chest tube also is connected to a chest drainage system (see Procedure 24) to remove air
and fluid from the pleural space, which facilitates reexpansion of the collapsed lung. All connection points are
secured with tape or zip ties (Parham-Martin bands) to ensure that the system remains airtight (see Fig. 21-2).
The water-seal chamber should bubble gently immediately on insertion of the chest tube during expiration and with
coughing. Continuous bubbling in this chamber indicates a leak within the patient or in the chest drainage system.
Fluctuations in the water level in the water-seal chamber of 5 to 10 cm, rising during inhalation and falling during
expiration, should be observed with spontaneous respirations. If the patient is on mechanical ventilation, the
pattern of fluctuation is just the opposite. Any suction applied must be disconnected temporarily to assess correctly
for fluctuations in the water-seal chamber.
Mediastinal tubes generally are placed in the operating room by a surgeon after cardiac surgery.
EQUIPMENT
• Antiseptic solution or swab packets
• Caps, masks, sterile gloves, gowns, drapes
• Protective eyewear (goggles)
• Local anesthetic: 1% lidocaine solution (without epinephrine)
• Tube thoracotomy insertion tray
Sterile towels, 4 × 4 sterile gauze
Scalpel with no. 10 blade
Two Kelly clamps, curved clamps
Needle holder
Monofilament or silk suture material with cutting needle
• Sterile basin or medicine cup
• Suture scissors
• Two hemostats
• 10-mL syringe with 20-gauge 1½-inch needle
• 5-mL syringe with 25-gauge 1-inch needle
• Thoracotomy tubes (12F to 40F, as appropriate)
• Closed chest drainage system
• Suction source
• Suction connector and connecting tubing (usually 6 feet for each tube)
• 1-inch adhesive tape or zip ties (Parham-Martin bands)
• Dressing materials
4 × 4 gauze pads
Slit drain sponges
Petrolatum gauze
Tape
Commercial securing device
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands pre-procedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Obtain informed consent if circumstances allow. Rationale: Invasive procedures, unless performed with implied
consent in a life-threatening situation, require written consent of the patient or significant other.
• Determine the insertion site and mark the skin with an indelible marker. Rationale: The insertion site is determined
by the indication for the chest tube. For air, use the second intercostal space; for fluid, use the fifth or sixth intercostal
space.
• Determine the size of chest tube needed. Rationale: Evacuation of air necessitates a smaller tube; evacuation of fluid
necessitates larger tubes.
• Assist the patient to the lateral, supine (for pneumothorax), or semi-Fowler’s position (for hemothorax).6 Rationale:
This positioning enhances accessibility to the insertion site for positioning of the chest tube.
• Administer prescribed analgesics or sedatives as needed; follow institutional policy for moderate or procedural
sedation. Rationale: Analgesics and sedatives reduce the discomfort and anxiety experienced and facilitate patient
cooperation.
• Administer oxygen and monitor pulse oximeter or end-tidal carbon dioxide level. Rationale: Real-time assessment
of patient’s respiratory status during the procedure is provided.
• Ensure patient has a patent intravenous (IV) access. Rationale: This access provides a route for analgesic, sedation,
and emergency medications.
Procedure for Performing Chest Tube Placement
FIGURE 20-2 Insertion of a chest tube can be relatively painless w ith proper infiltration of the skin and pleura w ith local anesthetic. The liberal use of
buffered 1% lidocaine w ithout epinephrine (maximal lidocaine dose, 5 mg/kg) is recommended. (From Roberts JR, Hedges JR, editors: Clinicals in emergency medicine,
ed 4, Philadelphia, 2004, Saunders.)
FIGURE 20-3 Transverse skin incision is made directly over the inferior aspect of the anesthetized rib dow n to the subcutaneous tissue. (From Dumire SM,
Paris PM: Atlas of emergency procedures, Philadelphia, 1994, Saunders.)
FIGURE 20-4 Blunt dissection is accomplished w ith forcing a closed clamp through the incision and using an opening-and-spreading maneuver to create a
tunnel to the pleura. ICS, Intercostal space.
FIGURE 20-5 Just over the superior portion of the rib, close the clamp and push w ith steady pressure into the pleura. (From Dumire SM, Paris PM: Atlas of
emergency procedures, Philadelphia, 1994, Saunders.)
FIGURE 20-6 The tube is grasped w ith the curved clamp, w ith the tube tip protruding from the jaw s. (From Roberts JR, Hedges JR, editors: Clinicals in emergency
medicine, ed 4, Philadelphia, 2004, Saunders.)
FIGURE 20-7 A “stay” suture is placed first next to the tube to close the skin incision. A, The knot is tied securely, and the ends, w hich subsequently are
w rapped around the chest tube, are left long. B, The ends of the suture are w ound tw ice about the tube, tightly enough to indent the tube slightly, and are
tied securely. (From Roberts JR, Hedges JR, editors: Clinicals in emergency medicine, ed 4, Philadelphia, 2004, Saunders.)
References
1. Buchman, TG, Hall, BL, Bowling, WM, et al. Thoracic trauma. In: Tininalli JE, Kelen DG, Stapczynski JS, eds.
Emergency medicine: a comprehensive guide. ed 6. New York: McGraw-Hill; 2004:1595–1612.
2. Dev, SP, Nascimiento, B, Simone, C, et al. Chest-tube -insertion. N Engl J Med. 2007; 357:e15.
3. Irwin, RS, Rippe, JM. Intensive care medicine. Philadelphia: Wolters Kluwer/Lippincott & -Williams & Wilkins;
2008.
4. Laws, D, Neville, E, Duffy, J, BTS guidelines for insertion of a chest drain. Suppl II. Thorax 2003; 58:ii53–ii59.
5. May, G, Bartram, T. The use of intrapleural anaesthetic to reduce the pain of chest drain insertion. Emerg Med J.
2007; 24:300–301.
6. Roberts. Clinical procedures in emergency medicine, ed 4. Philadelphia: Saunders; 2004.
7. Sullivan, B. Nursing management of patients with a chest drain. Br J Nurs. 2008; 17(6):388–393.
8. Thompson, JM, McFarland, GK, Hirsh, JE, et al. Mosby’s clinical nursing,, ed 5. St Louis: Mosby; 2002.
Additional Readings
Argall, J. S eldinger tec hnique c hest drains and c omplic ation rate. Emerg Med J. 2003; 20:169–170.
Charnoc kY, Evans, D, Nursing management of c hest drains. a systematic review. Aust Crit Care 2001; 14:156–160.
Coughlin, AM, Parc hinsky, C. Go with the flow of c hest tube therapy. Nursing. 2006; 36:36–42.
Ellis, H. The applied anatomy of c hest drain insertion. Br J Hosp Med (London). 2007; 68:M44–45.
Frankel, TL, Hill, PC, S tamou, S C, et al. S ilastic drains vs c onventional c hest tubes after c oronary artery bypass. Chest. 2003; 124:108–113.
Gareeboo, S , S ingh, S , Tube thorac ostomy. how to insert a c hest drain. Br J Hosp Med (London) 2006; 67:M16–18.
Lehwaldt, D, Timmins, F, Nurses’ knowledge of c hest drain c are. an exploratory desc riptive survey. Nurs Crit Care 2005; 10:192–200.
Zgoda, MA, Lunn, W, Ashiku, S , et al, Minimally invasive -tec hniques. direc t visual guidanc e for c hest tube -plac ement through a single-port thorac osc opya -
novel tec hnique. Chest 2005; 127:1805–1807.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 2 1
PURPOSE:
Chest tubes are placed for the removal or drainage of air, blood, or fluid from the intrapleural or mediastinal
space. They also are used to introduce sclerosing agents into the pleural space to prevent a reaccumulation of
fluid.
FIGURE 21-1 Occlusive chest tube dressing. (From Kersten LD: Comprehensive respiratory nursing, Philadelphia, 1989, Saunders.)
FIGURE 21-2 The securing of connection points. A, Tape. B, Parham-Martin bands. (From Kersten LD: Comprehensive respiratory nursing, Philadelphia, 1989,
Saunders.)w
• The water-seal chamber should bubble gently immediately on insertion of the chest tube during expiration and with
coughing. Continuous bubbling in this chamber indicates a leak within the patient or in the chest drainage system.
Fluctuations in the water level in the water-seal chamber of 5 to 10 cm, rising during inhalation and falling during
expiration, should be observed with spontaneous respirations. If the patient is on mechanical ventilation, the pattern
of fluctuation is just the opposite. Any suction applied must be disconnected temporarily to assess correctly for
fluctuations in the water-seal chamber.
• Mediastinal tubes generally are placed in the operating room by a surgeon after cardiac surgery.
EQUIPMENT
• Antiseptic solution or antiseptic swab packets
• Caps, masks, sterile gloves, gowns, drapes
• Protective eyewear (goggles)
• Local anesthetic: 1% lidocaine solution (without epinephrine)
• Tube thoracotomy tray
Sterile towels, 4 × 4 sterile gauze
Scalpel with no. 10 blade
Two Kelly clamps, curved clamps
Needle holder
Monofilament or silk suture material with cutting needle
Sterile basin or medicine cup
Suture scissors
Two hemostats
10-mL syringe with 20-gauge, 1½-inch needle
5-mL syringe with 25-gauge, 1-inch needle
• Thoracotomy tubes (12F to 40F, as appropriate)
• Closed chest drainage system
• Suction source
• Suction connector and connecting tubing (usually 6 feet for each tube)
• Y connector
• 1-inch adhesive tape or zip ties (Parham-Martin bands)
• Dressing materials
4 × 4 gauze pads
Slit drain sponges
Petrolatum gauze
Tape
• Commercial securing device
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Obtain consent if circumstances allow. Rationale: Invasive procedures, unless performed with implied consent in a
life-threatening situation, require written consent of the patient or significant other.
• Insure that the practitioner inserting the chest tube has identified the insertion site and marked the skin with an
indelible marker. Rationale: The insertion site is identified by the practitioner inserting the chest tube, who marks
it with an indelible marker, and determined by the indication for the chest tube. For air, the second intercostal space
is used; for fluid, the fifth or sixth intercostal space is used.
• Consult with the practitioner for the appropriate size chest tube to be inserted. Rationale: Evacuation of air
necessitates a smaller tube; evacuation of fluid necessitates larger tubes.
• Assist the patient to the lateral, supine (for pneumothorax), or semi-Fowler’s position (for hemothorax).6 Rationale:
This positioning enhances accessibility to the insertion site for positioning of the chest tube.
• Administer prescribed analgesics or sedatives as needed; follow institutional policy for moderate or procedural
sedation. Rationale: Analgesics and sedatives reduce the discomfort and anxiety experienced and facilitate patient
cooperation.
• Administer oxygen and monitor pulse oximeter or end-tidal carbon dioxide level. Rationale: Real-time assessment
of patient’s respiratory status during the procedure is provided.
• Ensure patient has a patent intravenous (IV) access. Rationale: This access provides a route for analgesic, sedation,
and emergency medications.
Procedure for Assisting With Chest Tube Placement
References
1. Buchman, TG, Hall, BL, Bowling, WM, et al, Thoracic traumaTininalli JE, Kelen DG, Stapczynski JS, eds..
Emergency medicine. a comprehensive guide. ed 6. McGraw-Hill, New York, 2004:1595–1612.
2. Dev, SP, Nascimiento, B, Simone, C, et al. Chest-tube -insertion. N Engl J Med. 2007; 357:e15.
3. Irwin, RS, Rippe, JM. Intensive care medicine,. Philadelphia: Wolters Kluwer/Lippincott and -Williams & Wilkins;
2008.
4. Laws, D, Neville, E, Duffy, J. BTS guidelines for insertion of a chest drain. Thorax. 2003; 58(Suppl II):ii53–ii59.
5. May, G, Bartram, T. The use of intrapleural anaesthetic to reduce the pain of chest drain insertion. Emerg Med J.
2007; 24:300–301.
6. Roberts, JR. Clinical procedures in emergency medicine, ed 4. Philadelphia: Saunders; 2004.
7. Sullivan, B. Nursing management of patients with a chest drain. Br J Nurs. 2008; 17(6):388–393.
8. Thompson, JM, McFarland, GK, Hirsh, JE, et al. Mosby’s clinical nursing, ed 5. St Louis: Mosby; 2002.
Additional Readings
Argall, J. S eldinger tec hnique c hest drains and c omplic ation rate. Emerg Med J. 2003; 20:169–170.
Charnoc k, Y, Evans, D, Nursing management of c hest drains. a systematic review. Aust Crit Care 2001; 14:156–160.
Coughlin, AM, Parc hinsky, C. Go with the flow of c hest tube therapy. Nursing. 2006; 36:36–42.
Ellis, H. The applied anatomy of c hest drain insertion. Br J Hosp Med (London). 2007; 68:M44–45.
Frankel, TL, Hill, PC, S tamou, S C, et al. S ilastic drains vs c onventional c hest tubes after c oronary artery bypass. Chest. 2003; 124:108–113.
Gareeboo, S , S ingh, S , Tube thorac ostomy. how to insert a c hest drain. Br J Hosp Med (London) 2006; 67:M16–18.
Lehwaldt, D, Timmins, F, Nurses’ knowledge of c hest drain c are. an exploratory desc riptive survey. Nurs Crit Care 2005; 10:192–200.
Zgoda, MA, Lunn, W, Ashiku, S , et al, Minimally invasive tec hniques. direc t visual guidanc e for c hest tube plac ement through a single-port thorac osc opya novel
tec hnique. Chest 2005; 127:1805–1807.
P R OC E D UR E 2 2
PURPOSE:
Chest tube removal is performed to discontinue a chest tube when it is no longer needed for the removal or
drainage of air, blood, or fluid from the intrapleural or mediastinal space.
FIGURE 22-1 Purse-string suture. Removing the chest tube. A, First throw of a knot in the mattress suture. B, Removal of the chest tube and tying of purse-
string suture. (From Leonar S, Nikaidoh H: Thoracentesis and chest tube insertion. In Levin D, Morriss F, editors: Essentials of pediatric intensive care, St Louis, 1990, Quality
Medical Publishing.)
• A primary goal of chest tube removal is removal of tubes without introduction of air or contaminants into the pleural
space.
EQUIPMENT
• Suture removal set
• Antiseptic swabs (povidone-iodine, chlorhexidine gluconate with alcohol, etc)6
• Petrolatum gauze, as per hospital protocol
• Rubber-tipped Kelly clamps (two per chest tube) or disposable umbilical clamps
• Wide occlusive tape (2-inch)
• Elastic closure device, such as Steri-Strips (3M, St. Paul, MN)
• Dry 4 × 4 gauze sponges (two to four)
• Waterproof pad
• Personal protective equipment (goggles, sterile and nonsterile gloves, mask, gown)
Additional equipment (to have available depending on patient need) includes the following:
• Specimen collection cup (if catheter tip is to be sent to the laboratory for analysis)
• Scissors
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information. Anticipatory preparation may prepare patients for a better experience.15,19,20
• Administer premedication of adequate analgesics at least 20 minutes before the procedure. Alternatively, subfascial
lidocaine may be injected into the chest tube tract. Slow deep-breathing relaxation exercises in addition to opioids
have also been shown to further diminish pain sensation.8 Rationale: Intravenous morphine 4 mg 20 minutes
before or ketorolac 30 mg 60 minutes before the procedure have been shown to have substantial relief of pain without
excessive analgesia.16 Pain medication and relaxation exercises reduce the discomfort and anxiety experienced, which
facilitates patient cooperation.8,15,16
• Time the removal procedure to occur at peak analgesic effect. Rationale: This timing increases patient cooperation
and decreases anxiety.16
• Place the patient in the semi-Fowler’s position. Alternatively, place the patient on the unaffected side with the
waterproof pad underneath the site. Rationale: This position enhances accessibility to the insertion site of the chest
tube and protects the bed from drainage.
Procedure for Performing Chest Tube Removal
References
1. Abramov, D, et al. Timing of chest tube removal after coronary artery bypass surgery. J Card Surg. 2005; 20:142–
146.
2. Bell, RL, et al, Chest tube removal. end-inspiration or end-expiration. J Trauma 2001; 50:674–677.
3. Bjessmo, S, et al, Comparison of three different chest drainages after coronary artery bypass surgery. a
randomised trial in 150 patients. Eur J Cardiothorac Surg 2007; 31:372–375.
4. Bruce, EA, Howard, RF, Franck, LS, Chest drain removal pain and its management. a literature review. J Clin
Nurs 2008; 15:145–154.
5. Cerfolio, RJ, Bryant, AS. Results of a prospective algorithm to remove chest tubes after pulmonary resection with
high output. J Thorac Cardiovasc Surg. 2008; 135(2):269–273.
6. Digison, MB. A review of anti-septic agents for pre-operative skin preparation. Plast Surg Nurs. 2007; 27(4):185–
189.
7. Frankel, TL, et al. Silastic drains vs conventional chest tubes after coronary artery bypass. Chest. 2003;
124:108–113.
8. Friesner, SA, Curry, DM, Moddeman, GR, Comparison of two pain-management strategies during chest tube
removal. relaxation exercise with opioids and opioids alone. Heart Lung. 2006; 35(4):269–276.
9. Gercekoglu, H, et al. Effect of timing of chest tube removal on development of pericardial effusion following
cardiac surgery. J Card Surg. 2003; 18(3):217–224.
10. Hendrikse, KA, et al. Low value of routine chest radiographs in a mixed medical surgical ICU. Chest. 2007;
132(3):823–828.
11. Khan, T, et al. Is routine chest radiograph following mediastinal drain removal after cardiac surgery useful. Eur J
Cardiothorac Surg. 2008; 34(3):542–544.
12. Laws, D, Neville, E, Duffy, J. British Thoracic Society guidelines for the insertion of a chest drain. Thorax. 2003;
58(Suppl II):ii53–ii59.
13. Martino, K, et al. Prospective randomized trial of thoracostomy removal algorithms. J Trauma. 1999; 46:369–
371.
14. Mimnaugh, L, et al. Sensations experienced during removal of tubes in acute postoperative patients. Appl Nurs
Res. 1999; 12:78–85.
15. Puntillo, K, et al, Patients’ perceptions and responses to procedural pain. results from Thunder Project II. Am J
Crit Care 2001; 10:238–251.
16. Puntillo, K, Ley, SJ. Appropriately timed analgesics control pain due to chest tube removal. Am J Crit Care.
2004; 13:292–304.
17. Sakopoulos, AG, et al. Efficacy of Blake drains for mediastinal and pleural drainage following cardiac operations. J
Card Surg. 2005; 20(6):574–577.
18. Sullivan, B. Nursing management of patients with a chest drain. Br J Nurs. 2008; 17(6):388–393.
19. Suls, J, Wan, CK, Effects of sensory and procedural information on coping with stressful medical procedures
and pain. a meta-analysis. J Consult Clin Psychol 1989; 57:372–379.
20. Summer, GH, Puntillo, K. Management of surgical and procedural pain in a critical care setting. Crit Care Nurs
Clin North Am. 2001; 13:233–242.
21. Younes, RN, et al. When to remove a chest tube? A randomized study with subsequent prospective
consecutive validation. J Am Coll Surg. 2002; 195(5):658–662.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 2 3
PURPOSE:
Chest tube removal is performed to discontinue a chest tube when it is no longer needed for the removal or
drainage of air, blood, or fluid from the intrapleural or mediastinal space.
EQUIPMENT
• Suture removal set
• Antiseptic swabs (povidone-iodine, chlorhexidine gluconate with alcohol, etc)6
• Petrolatum gauze, per hospital policy
• Rubber-tipped Kelly clamps (two per chest tube) or disposable umbilical clamps
• Wide occlusive tape (2-inch)
• Elastic closure device, such as Steri-Strips (3M, St. Paul, MN)
• Dry 4 × 4 gauze sponges (two to four)
• Waterproof pad
• Personal protective equipment (goggles, sterile and nonsterile gloves, mask, gown)
Additional equipment (to have available depending on patient need) includes the following:
• Specimen collection cup (if catheter tip is to be sent to the laboratory for analysis)
• Scissors
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information. Anticipatory preparation may prepare patients for a better experience.15,19,20
• Administer premedication of adequate analgesics at least 20 minutes before procedure. Alternatively, subfascial
lidocaine may be injected into the chest tube tract. Slow deep-breathing relaxation exercises in addition to opioids
have also been shown to further diminish pain sensation.8 Rationale: Intravenous morphine 4 mg 20 minutes
before or ketorolac 30 mg 60 minutes before the procedure have been shown to have substantial relief of pain without
excessive analgesia.16 Pain medication and relaxation exercises reduce the discomfort and anxiety experienced and
facilitate patient cooperation.8,15,16
• Time the removal procedure to occur at peak analgesic effect. Rationale: This timing increases patient cooperation
and decreases anxiety.16
• Place the patient in the semi-Fowler’s position. Alternatively, place the patient on the unaffected side with the
waterproof pad underneath the site. Rationale: This position enhances accessibility to the insertion site of the chest
tube and protects the bed from drainage.
Procedure for Performing Chest Tube Removal
References
1. Abramov, D, et al. Timing of chest tube removal after coronary artery bypass surgery. J Card Surg. 2005; 20:142–
146.
2. Bell, RL, et al, Chest tube removal. end-inspiration or end-expiration. J Trauma 2001; 50:674–677.
3. Bjessmo, S, et al, Comparison of three different chest drainages after coronary artery bypass surgery. a
randomised trial in 150 patients. Eur J Cardiothorac Surg 2007; 31:372–375.
4. Bruce, EA, Howard, RF, Franck, LS, Chest drain removal pain and its management. a literature review. J Clin
Nurs 2008; 15:145–154.
5. Cerfolio, RJ, Bryant, AS. Results of a prospective algorithm to remove chest tubes after pulmonary resection with
high output. J Thorac Cardiovasc Surg. 2008; 135(2):269–273.
6. Digison, MB. A review of anti-septic agents for pre-operative skin preparation. Plast Surg Nurs. 2007; 27(4):185–
189.
7. Frankel, TL, et al. Silastic drains vs conventional chest tubes after coronary artery bypass. Chest. 2003;
124:108–113.
8. Friesner, SA, Curry, DM, Moddeman, GR, Comparison of two pain-management strategies during chest tube
removal. relaxation exercise with opioids and opioids alone. Heart Lung. 2006; 35(4):269–276.
9. Gercekoglu, H, et al. Effect of timing of chest tube removal on development of pericardial effusion following
cardiac surgery. J Card Surg. 2003; 18(3):217–224.
10. Hendrikse, KA, et al. Low value of routine chest radiographs in a mixed medical surgical ICU. Chest. 2007;
132(3):823–828.
11. Khan, T, et al. Is routine chest x-ray following mediastinal drain removal after cardiac surgery useful. Eur J
Cardiothorac Surg. 2008; 34(3):542–544.
12. Laws, D, Neville, E, Duffy, J. British Thoracic Society guidelines for the insertion of a chest drain. Thorax. 2003;
58(Suppl II):ii53–ii59.
13. Martino, K, et al. Prospective randomized trial of thoracostomy removal algorithms. J Trauma. 1999; 46:369–
371.
14. Mimnaugh, L, et al. Sensations experienced during removal of tubes in acute postoperative patients. Appl Nurs
Res. 1999; 12:78–85.
15. Puntillo, K, et al, Patients’ perceptions and responses to procedural pain. results from Thunder Project I. Am J
Crit Care 2001; 10:238–251.
16. Puntillo, K, Ley, SJ. Appropriately timed analgesics control pain due to chest tube removal. Am J Crit Care.
2004; 13:292–304.
17. Sakopoulos, AG, et al. Efficacy of Blake drains for mediastinal and pleural drainage following cardiac operations. J
Card Surg. 2005; 20(6):574–577.
18. Sullivan, B. Nursing management of patients with a chest drain. Br J Nurs. 2008; 17(6):388–393.
19. Suls, J, Wan, CK, Effects of sensory and procedural information on coping with stressful medical procedures
and pain. a meta-analysis. J Consult Clin Psychol 1989; 57:372–379.
20. Summer, GH, Puntillo, K. Management of surgical and procedural pain in a critical care setting. Crit Care Nurs
Clin North Am. 2001; 13:233–242.
21. Younes, RN, et al. When to remove a chest tube? A randomized study with subsequent prospective
consecutive validation. J Am Coll Surg. 2002; 195(5):658–662.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 2 4
PURPOSE:
Closed chest drainage systems are used to facilitate the evacuation of fluid, blood, and air from the pleural
space, the mediastinum, or both; to restore negative pressure to the pleural space; and to promote reexpansion
of a collapsed lung.
Table 24-1
Table 24-1
Pressure Conversion Chart*
cm H2O mm Hg
20 15
25 18
30 22
35 26
40 30
45 33
50 37
60 44
• Disposable CDSs:
Correlate to the three-bottle drainage system, with collection, water-seal, and suction control chambers positioned
side by side in a molded plastic disposable unit (Fig. 24-1). These include the Pleur-Evac, Thora-Klex, Argyle, and
Atrium systems.
FIGURE 24-1 Disposable system correlates w ith three-bottle system. (From Luce JM, Tyler ML, Pierson DJ: Intensive respiratory care, Philadelphia, 1984, Saunders.)
Are equipped with a positive-pressure relief valve used to prevent a tension pneumothorax if the suction tubing
becomes accidentally occluded or if the suction source fails. In addition, automatic and manual pressure relief
valves vent excessive negative pressure, such as may occur during deep inspiration or with milking of the chest
tube.
May have replaceable collection chambers, which can be removed when filled and replaced with a new one without
changing the entire unit.
Often have latex-free tubing.
Have self-sealing ports or collection tubes for aspiration of drainage samples and removal of excess chamber fluid
levels.
• Some systems have accessories that may be used to convert them to an autotransfusion unit.
• Some CDSs use dry suction with a traditional water-seal and either a regulator or a restricted orifice mechanism.
Although water is added to the water-seal chamber, water does not need to be added to the suction chamber. Instead,
the suction source (usually a wall regulator) is increased until an indicator appears.
• Some CDSs are waterless, referred to as dry-dry drains, and have a one-way valve, which eliminates the need to fill
any chambers (except an air-leak indicator zone, as needed). A valve opens on expiration and allows patient air to exit,
then closes to prevent atmospheric air from entering during inspiration. This one-way valve feature allows the system
to be used in the vertical or horizontal position without loss of the seal. These systems are safe if accidentally tipped.
The amount of suction delivered is regulated with an adjustable dial.
• Advantages of dry suction are ease of setup; ease of application if higher, more precise levels of suction are needed;
and a quiet system.
• Some clinicians suggest use of the Emerson pump (Fig. 24-2) for patients with large bronchopleural air leaks because
they are high-volume, low-resistance, portable suction devices capable of handling high airflow rates.14,15
FIGURE 24-2 A, Emerson pump. B, Emerson disposable chest drain system. (Courtesy J.H. Emerson, Cambridge, MA.)
• Tidaling, fluctuations that occur with inspiration and expiration, provides a continuous manometer of the pressure
changes in the pleural space and indicates overall respiratory effort. Absence of fluctuations suggests obstruction of
the drainage system from clots, contact with lung tissue, kinks, loss of subatmospheric pressure from fluid-filled
dependent loops, or complete reexpansion of the lung.1,10,19
• Except for the exit vent, an airtight system is required to assist in maintaining negative pressure in the pleura and to
prevent air entrapment in the pleural space.
• In general, clamping of chest tubes is contraindicated. Clamping a chest tube in a patient with a pleural air leak may
cause a tension pneumothorax. The few situations in which chest tubes may be clamped briefly (i.e., less than a
minute) include locating the source of an air leak, replacing the chest drainage system, determining whether a patient
is ready to have the chest tube removed, and during chest tube removal.1,14,15,21,26
EQUIPMENT
Disposable Setup (W et and Dry Systems)
• Disposable chest drainage unit
• Gloves
• Suction source and regulator
• Connecting tubing
• Tape (1-inch), one roll, or zip ties (Parham-Martin bands)
• 1-L bottle of sterile water or normal saline (NS) (for systems that use water)
• 50-mL Irrigation syringe (if not supplied with unit) for systems that use water
One-Bottle System
• Sterile 2-L bottle
• One short straw
• One long straw
• Sterile rubber stopper with two holes
Two-Bottle System
• Two sterile 2-L bottles
• Three short straws
• One long straw
• Two sterile rubber stoppers, one with two holes and the other with either two or three holes (depending on which
type of double-bottle system is used)
• Sterile connecting tubing (6 feet)
• One short sterile connecting tubing
• Suction source, if prescribed
Three-Bottle System
• Three sterile 2-L bottles
• Five short straws
• Two long straws
• Two sterile rubber stoppers with two holes
• One sterile rubber stopper with three holes
• Suction source
• Sterile connecting tubing (6 feet)
• Two short sterile connecting tubings
Four-Bottle System
• Four sterile 2-L bottles
• Seven short straws
• Three long straws
• Two sterile rubber stoppers with two holes
• Two sterile rubber stoppers with three holes
• Sterile connecting tubing (6 feet)
• Three short sterile connecting tubings
• Suction source
Patient Preparation
• Ensure the patient understands pre-procedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: This communication evaluates and reinforces understanding of previously presented
information.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Administer prescribed analgesics or sedatives as needed. Rationale: Analgesics and sedatives reduce the discomfort
and anxiety experienced, facilitating patient cooperation and improving outcomes.
FIGURE 24-3 One-bottle chest drainage system. (From Luce JM, Tyler ML, Pierson DJ: Intensive respiratory care, Philadelphia, 1984, Saunders.)
FIGURE 24-4 Tw o-bottle chest drainage system. A, Drainage collection bottle and a w ater-seal bottle. B, Water-seal/drainage collection bottle and suction
control bottle. (From Luce JM, Tyler ML, Pierson DJ: Intensive respiratory care, Philadelphia, 1984, Saunders.)
References
1. Allibone, L. Nursing management of chest drains. Nurs Stand. 2003; 17:45–56.
2. Alphonso, N, et al. A prospective randomized controlled trial of suction versus non-suction to the under-water
seal drains following lung resection. Eur J Cardiothorac Surg. 2005; 27:391–394.
3. Ayed, AK, Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax. prospective
randomized study. Ann Thorac Surg 2003; 75:1593–1596.
4. Baumann, MH. Management of spontaneous pneumothorax. Clin Chest Med. 2006; 27:369–381.
5. Baumann, MH, Management of spontaneous pneumothorax. an American College of Chest Physicians
Delphi -consensus statement. Chest 2001; 119:590–602.
6. Baumann, MH. What size chest tube? What drainage system is ideal? And other chest tube management
questions. Curr Opin Pulm Med. 2003; 9:276–281.
7. Baumann, MH, et al. Comparison of function of commercially available pleural drainage units and catheters.
Chest. 2003; 123:1878–1886.
8. Cerfolio, RJ. Recent advances in the treatment of air leaks. Curr Opin Pulm Med. 2005; 11:319–323.
9. Cerfolio, RJ, et al. The management of chest tubes in -patients with a pneumothorax and an air leak after -
pulmonary resection. Chest. 2005; 128:816–820.
10. Deshpande, KS, Tortolandi, AJ, Kvetan, V, Troubleshooting chest tube complications. how to prevent—or
quickly correct—the major problems. J Crit Ill. 2003; 18(6):275–280.
11. Duncan, C, Erickson, R. Pressures associated with chest tube stripping. Heart Lung. 1982; 11:71–166.
12. Duncan, C, Erickson, R, Wiegel, RM. Effect of chest tube management on drainage after cardiac surgery.
Heart Lung. 1987; 16:1–9.
13. Gordon, PA, et al, Positioning of chest tubes. effects on pressure and drainage. Am J Crit Care 1997; 6:33–38.
14. Gordon, PA, Norton, JM, Merrell, R, Redefining chest tube management. analysis of the state of practice.
Dimens Crit Care Nurs 1995; 14:6–13.
15. Gross, SB. Current challenges, concepts and controversies in chest tube management. AACN Clin Issues Crit
Care Nurs. 1993; 4:75–260.
16. Halm, MA. To strip or not to strip? Physiological effects of chest tube manipulation. Am J Crit Care. 2007;
16(6):609–612.
17. Henry, M, Arnold, T, Harvey, J. British Thoracic Society guidelines for the management of spontaneous
pneumothorax. Thorax. 2003; 58:39–52.
18. Isaacson, JJ, George, IT, Brewer, MJ. The effect of chest tube manipulation on mediastinal drainage. Heart
Lung. 1986; 15(6):601–605.
19. Kam, AC, O’Brien, M, Kam, PCA. Pleural drainage systems. Anaesthesia. 1993; 48:154–161.
20. Kelly, AM, Review of management of primary spontaneuos pneumothorax. is the best evidence clearer 15 years
on. Emerg Med Aust 2007; 19:303–308.
21. Lehwaldt, D, Timmins, F, Nurses’ knowledge of chest drain care. an exploratory descriptive survey. Nurs Crit
Care. 2005; 10(4):192–200.
22. Lim-Levy, F, et al. Is milking and stripping chest tubes really necessary. Ann Thorac Surg. 1986; 42:77–80.
23. Pierce, J, Piazza, D, Naftel, DC, Effects of two chest tube clearance protocols on drainage in patients after
myocardial revascularization surgery. Heart Lung . 1991; 20:125–130.
24. Schmelz, JO, et al. Effects of position of chest drainage tube on volume drained and pressure. Am J Crit Care.
1999; 8:319–323.
25. Stolz, AJ, et al. Predictors of prolonged air leak following pulmonary lobectomy. Eur J Cardiothorac Surg. 2005;
334–336.
26. Tang, AT, Velissaris, TJ, Weeden, DF, An evidence-based approach to drainage of the pleural cavity. evaluation
of best practice. J Eval Clin Pract 2002; 8:333–340.
27. Wallen, M, et al, Mediastinal chest drain clearance for cardiac surgery. Cochrane Database of Systematic Review
2004;, doi: 10/1002/14651858. CD003042. pub2. [2:Art. No. : CD003042].
Additional Readings
AtriumManaging c hest drainage. Hudson, NH: Atrium Medic al Corporation, 2007.
AtriumManaging dry suc tion c hest drainage. Hudson, NH: Atrium Medic al Corporation, 2007.
Carroll, PF, Ask the experts. Atrium dry suc tion c hest drainage system. Crit Care Nurse 2003; 23:4–73.
P R OC E D UR E 2 5
PURPOSE:
Needle thoracostomy is performed to reduce a tension pneumothorax to a simple pneumothorax in a patient with
a rapidly deteriorating condition. This temporary measure is followed quickly by the insertion of a chest tube for
more definitive management.
EQUIPMENT
• Personal protective equipment
• 14- to 16-gauge hollow needle or catheter with one-way valve attached or commercially available (Heimlich) flutter
valve
• Antiseptic solution
• 4 × 4 gauze dressing
• Tape
Additional equipment to have available as needed includes the following:
• Oxygen
• Self-inflating manual resuscitation bag-valve-mask device
• Oxygen source and tubing
The listed equipment can be used to create an emergency one-way valve:
Scissors
Sterile glove (powder-free)
Small rubber band
Cut a finger off the glove and attach it to the needle with the rubber band.1
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand the emergency nature of the procedure and preprocedural teachings, if
appropriate. Answer questions as they arise, and reinforce information as needed. Rationale: This communication
evaluates and reinforces understanding of previously taught information.
• Position patient in supine position with the head of the bed flat. Rationale: This positioning allows for identification
of landmarks for proper placement of needle and flutter valve.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
Procedure for Performing Needle Thoracostomy
References
1. American College of Surgeons Committee on Trauma. Advanced trauma life support manual, ed 7. Chicago:
American College of Surgeons; 2004.
2. Emergency Nurses Association, Trauma nursing core course. provider manual. ed 6. Emergency Nurses
Association, Des Plaines, IL, 2007.
3. Holleran, RS, Air and surface patient transport. principles and practice. ed 3. Mosby, St Louis, 2003.
4. National Association of Emergency Technicians, PHTLS. basic and advanced prehospital trauma life support.
ed 5. Mosby, St Louis, 2003.
5. Roberts, JR, Hedges, JR, Clinical procedures in emergency medicine. ed 4. Saunders, Philadelphia, 2004.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 2 6
Thoracentesis (Perform)
S usan Yeager
PURPOSE:
Thoracentesis is performed to assist in the diagnosis and therapeutic management of patients with pleural
effusions.
EQUIPMENT
Diagnostic Thoracentesis
• Baseline diagnostic study results (i.e., lateral decubitus chest radiograph, ultrasound imaging, CT scan, or MRI)
• Completed patient informed consent form
• Functional intravenous access
• Indelible marker
• Sterile gloves
• Sterile drapes
• Sterile towels
• Adhesive bandage or adhesive strip
• Antiseptic solution
• Sterile 4 × 4 gauze pads
• Intervention medications (opioid, sedative, or hypnotic agents, local anesthetic 1% or 2% lidocaine)
• One small needle (25-gauge, ⅝-inch long)
• 5-mL syringe for local anesthetic
• Three large needles (20- to 22-gauge, 1½ to 2 inches long)
• Three-way stopcock
• Sterile 20-mL syringe
• Sterile 50-mL syringe
• Two chemistry blood tubes
• Hemostat or Kelly clamp
• Pulse oximetry equipment
• Side table
• Pillow or blanket to be placed on side table
• Available: Atropine, oxygen, thoracostomy supplies, advanced cardiac life support (ACLS) equipment
• Ultrasound scan equipment as needed
Therapeutic Thoracentesis
The following equipment is needed in addition to equipment for diagnostic thoracentesis:
• 14-gauge needle
• 16-gauge catheter
• Sterile 50-mL syringe
• Vacutainers or evacuated bottles (1- to 2-L) with pressure tubing
Additional equipment (to have available depending on patient need) includes the following:
• Two complete blood count (CBC) tubes
• One anaerobic and one aerobic media bottle for culture and sensitivity
• Sterile tubes for fungal and tuberculosis cultures
Commercially prepackaged thoracentesis kits are available in some institutions
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise and reinforce
information. Rationale: This communication evaluates and reinforces understanding of previously taught
information.
• Obtain written informed consent for the procedure. Rationale: Invasive procedures, unless performed with implied
consent in a life-threatening situation, require written consent of the patient or significant other.
• Consider sedation or chemical paralysis. Rationale: Sedation or chemical paralysis may be necessary to maximize
positioning.
• Have atropine available. Rationale: Bradycardia, from a vasovagal reflex, is a common occurrence during
thoracentesis.
• Initiate pulse oximetry monitoring. Rationale: Pulse oximetry provides a noninvasive means for monitoring
oxygenation and heart rate at the bedside, which allows for prompt recognition and intervention should problems
develop.
Procedure for Diagnostic and Therapeutic Thoracentesis
FIGURE 26-1 Thoracentesis. A, Ideal patient position for thoracentesis. B, Ideal placement of needle insertion. C, Attach catheter to three w ay stopcock
syringe and vacutainer. Barton ED: Thoracentesis. In Rosen, P., Chan, T.C., Vilke, M., Sternbach, G., editors: Atlas of Emergency Procedures (pp. 36-37), St. Louis: Mosby.
References
1. Barton, E. Thoracentesis. In: Rosen P, Chan T, Vilke G, et al, eds. Atlas of emergency procedures. St Louis:
Mosby, 2001.
2. Colt, HG, Brewer, N, Barbur, EB. Evaluation of patient--related and procedure-related factors contributing to -
pneumothorax following thoracentesis. Chest. 1999; 116:134–138.
3. Doyle, JJ, et al. Necessity of routine chest roentgenography after thoracentesis. Ann Intern Med. 1996; 124:816–
820.
4. Gervais, DA, et al, US-guided thoracentesis. requirement for post procedure chest radiography in patients
who -receive mechanical ventilation versus patients who breathe spontaneously. Radiology 1997; 204:503–506.
5. Jones, PW, et al, Ultrasound-guided thoracentesis. is it a safer method. Chest 2003; 123:418–423.
6. Lichtenstein, D, et al. Feasibility and safety of ultrasound-aided thoracentesis in mechanically ventilated
patients. Intensive Care Med. 1999; 25:955–958.
7. Maskell, NA, Butland, RJA. BTS guidelines for the investigation of a unilateral pleural effusion in adults.
Thorax. 2003; 58:ii8.
8. Parsons, P, Tu, Y. Thoracentesis and percutaneous pleural biopsy. In: Parsons P, Heffner J, eds. Pulmonary
respiratory therapy secrets. Philadelphia: Mosby, 1997.
9. Qureshi, N, Momin, ZA, Brandstetter, RD. Thoracentesis in clinical practice. Heart Lung. 1994; 23:376–383.
10. Rahman, N, Chapman, S, Davies, R, Pleural effusion. a structured approach to care. Br Med Bull. 2005; 72(1):31–
47.
11. Wilson, M, Irwin, R, Thoracentesis. Procedures and techniques in intensive care medicine. Lippincot &
Williams & Wilkins, Philadelphia, 2003.
Additional Readings
Antunes, G, Neville, E, Duffy, J, et al. BTS guidelines for the management of malignant pleural effusions. Thora x. 2003; 58(S uppl 2):ii29–38.
Davies, CWH, Gleeson, FV, Davies, RJO. BTS guidelines for the management of pleural infec tion. Thora x. 2003; 58:ii18.
Heffner, JE, Brown, LK, Barbieri, CA. Diagnostic value of tests that disc riminate between exudative and transudative -pleural effusions. Chest. 1997; 111:970–980.
Light, RW, et al, Pleural effusion. the diagnostic separation of transudates and exudates. Ann Intern Med 1992; 77:507–513.
Loddenkemper, R. Pleural effusions. In: Albert R, S piro S , Jett J, eds. Clinica l respira tory medicine. Philadelphia: Mosby, 2004.
Mayo, PH, Goltz, HR, Tafreshi, M, et al. S afety of ultrasound-guided thorac entesis in patients rec eiving mec hanic al -ventilation. Chest. 2004; 125(3):1059–1062.
Peterson, WG, Zimmerman, R. Limited utility of c hest -radiograph after thorac entesis. Chest. 2000; 117:1038–1042.
Quigley, RL. Thorac entesis and c hest tube drainage. Crit Ca re Clin. 1995; 11:111–126.
Thomsen, TW, DelaPena, J, S tenik, GS . Thorac entesis, Videos in c linic al medic ine 355/e16(15). retrieved from http://-
c ontent.nejm.org/c gi/c ontent/video_preview/355/15/e16, 09/14/2008. [ac c essed].
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 2 7
Thoracentesis (Assist)
S usan Yeager
PURPOSE:
Thoracentesis is performed to assist in the diagnosis and therapeutic management of patients with pleural
effusions.
EQUIPMENT
Diagnostic Thoracentesis
• Baseline diagnostic study results (i.e., lateral decubitus chest radiograph, ultrasound scan imaging, CT scan, or MRI)
• Completed patient informed consent form
• Functional intravenous access
• Indelible marker
• Sterile gloves
• Sterile drapes
• Sterile towels
• Adhesive bandage or adhesive strip
• Antiseptic solution
• Sterile 4 × 4 gauze pads
• Intervention medications (opioid, sedative, or hypnotic agents, local anesthetic 1% or 2% lidocaine)
• One small needle (25-gauge, ⅝-inch long)
• 5-mL syringe for local anesthetic
• Three large needles (20-gauge to 22-gauge, 1½ to 2 inches long)
• Three-way stopcock
• Sterile 20-mL syringe
• Sterile 50-mL syringe
• Two chemistry blood tubes
• Hemostat or Kelly clamp
• Pulse oximetry equipment
• Side table
• Pillow or blanket to be placed on side table
• Available: Atropine, oxygen, thoracostomy supplies, advanced cardiac life support (ACLS) equipment
• Ultrasound scan equipment as needed
Therapeutic Thoracentesis
The following equipment is needed in addition to equipment for diagnostic thoracentesis:
• 14-gauge needle
• 16-gauge catheter
• Sterile 50-mL syringe
• Vacutainers or evacuated bottles (1- to 2-liter) with pressure tubing
Additional equipment (to have available depending on patient need) includes the following:
• Two complete blood count (CBC) tubes
• One anaerobic and one aerobic media bottle for culture and sensitivity
• Sterile tubes for fungal and tuberculosis cultures
Commercially prepackaged thoracentesis kits are available in some institutions.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands pre-procedural teachings. Answer questions as they arise and reinforce
information. Rationale: This communication evaluates and reinforces understanding of previously taught
information.
• Obtain written informed consent for the procedure. Rationale: Invasive procedures, unless performed with implied
consent in a life-threatening situation, require written consent of the patient or significant other.
• Position the patient. Several alternative positions may be used, as follows:
If the patient is alert and able, position the patient on the edge of the bed with legs supported and arms resting on a
pillow on the elevated bedside table (see Fig. 26-1).
The patient may sit on a chair backward and rest arms on a pillow on the back of the chair.
If the patient is unable to sit, position the patient on the unaffected side, with the back near the edge of the bed and
the arm on the affected side above the head. Elevate the head of the bed to 30 or 45 degrees, as tolerated.
Rationale: Positioning enhances ease of withdrawal of pleural fluid.
• Have an additional member of the healthcare team positioned in front of the patient. Rationale: This positioning
reassures or comforts the patient and provides additional assistance.
• Consider sedation or paralysis. Rationale: Sedation or paralysis may be necessary to maximize positioning.
• Have atropine available. Rationale: Bradycardia, from a vasovagal reflex, is a common occurrence during
thoracentesis.
• Initiate pulse oximetry monitoring. Rationale: Pulse oximetry provides a noninvasive means for monitoring
oxygenation and heart rate at the bedside, which allows for prompt recognition and intervention should problems
occur.
Procedure for Assisting with Diagnostic and Therapeutic Thoracentesis
References
1. Barton, E. Thoracentesis. In: Rosen P, Chan T, Vilke G, et al, eds. Atlas of emergency procedures. St Louis:
Mosby, 2001.
2. Colt, HG, Brewer, N, Barbur, EB. Evaluation of patient--related and procedure-related factors contributing to -
pneumothorax following thoracentesis. Chest. 1999; 116:134–138.
3. Gervais, DA, et al, US-guided thoracentesis. requirement for post procedure chest radiography in patients
who receive mechanical ventilation versus patients who breathe spontaneously. Radiology 1997; 204:503–506.
4. Maskell, NA, Butland, RJA. BTS guidelines for the investigation of a unilateral pleural effusion in adults.
Thorax. 2003; 58:ii8.
5. Peterson, WG, Zimmerman, R. Limited utility of chest radiograph after thoracentesis. Chest. 2000; 117:1038–
1042.
6. Rahman, N, Chapman, S, Davies, R, Pleural effusion. a structured approach to care. Br Med Bull. 2005; 72(1):31–
47.
Additional Readings
Antunes, G, Neville, E, Duffy, J, et al. BTS guidelines for the management of malignant pleural effusions. Thora x. 2003; 58(S uppl 2):ii29–38.
Davies, CWH, Gleeson, FV, Davies, RJO. BTS guidelines for the management of pleural infec tion. Thora x. 2003; 58:ii18.
Doyle, JJ, et al. Nec essity of routine c hest roentgenography after thorac entesis. Ann Intern Med. 1996; 124:816–820.
Heffner, JE, Brown, LK, Barbieri, CA. Diagnostic value of tests that disc riminate between exudative and transudative -pleural effusions. Chest. 1997; 111:970–980.
Light, RW, et al, Pleural effusion. the diagnostic separation of transudates and exudates. Ann Intern Med 1992; 77:507–513.
Loddenkemper R. Pleural effusions. In: Albert R, S piro S , Jett J, eds. Clinica l respira tory medicine. Philadelphia: Mosby, 2004.
Mayo, PH, Goltz, HR, Tafreshi, M, et al. S afety of ultrasound-guided thorac entesis in patients rec eiving mec hanic al -ventilation. Chest. 2004; 125(3):1059–1062.
Quigley, RL. Thorac entesis and c hest tube drainage. Crit Ca re Clin. 1995; 11:111–126.
Thomsen, TW, DeLaPena, J, S tenik, GS , Thorac entesis. Videos in Clinica l Medicine. 09; 355(15)-14-2008 e16 (15).
http://c ontent.nejm.org/c gi/c ontent/video_preview/355/15/e16 [retrieved from ac c essed].
Wilson, M, Irwin, R. Thora centesis. Procedures a nd techniques in intensive ca re medicine. Philadelphia: Lippinc ot Williams & Wilkins; 2003.
SECTION FOUR
Ventilatory Management
P R OC E D UR E 2 8
PURPOSE:
Noninvasive positive-pressure ventilation, delivered via nasal mask, pillows, or full face mask, is used to
prevent airway obstruction during sleep, to maintain or improve oxygenation, to maintain or improve ventilation,
and to provide respiratory muscle rest in different categories of patients in whom invasive mechanical
ventilation through an artificial airway is not desired.
NPPV Interfaces
• Noninvasive interfaces are selected on the basis of patients’ unique facial features, patient preferences, comfort, ease of
use, availability, and provider experience and preference and include full face masks, nasal masks, nasal pillows, and
helmets. Of these, full head helmets are the least commonly used (and not discussed further in this procedure) but
may be more prevalent in the future as experience with the interfaces increases.18 See Fig. 28-1 for NPPV interfaces.
FIGURE 28-1 Noninvasive patient interfaces. A, Nasal mask. B, Nasal pillow . C, Full face mask. (Images used with permission of Philips Respironics, Inc, Murrysville,
PA.)
Complications of NPPV
• Complications of NPPV are similar to invasive positive pressure ventilation (PPV) and include hemodynamic changes
and pulmonary barotrauma. These complications are described subsequently in this procedure.
EQUIPMENT
• Noninvasive interface (see Fig. 28-1)
• CPAP or BiPAP ventilator
• Electrocardiogram
• Pulse oximetry (oxygen saturation of hemoglobin measured with pulse oximetry: SpO2 )
• Self-inflating manual resuscitation bag-valve-mask device
• Oxygen source and tubing
• Suction equipment
• Intubation equipment and endotracheal tubes, should NPPV be unsuccessful (see Procedures 2, 3)
• Personal protective equipment (gloves, mask, goggles, gown, as appropriate)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands pre-procedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Premedicate as needed. Rationale: Cautious use of narcotics, sedatives, or anxiolytics may be necessary for comfort,
to help allay anxiety, and to improve the patient’s tolerance of NPPV. However, the use of the drugs should not
adversely affect spontaneous breathing or consciousness.
Procedure for Noninvasive Ventilation (CPAP and BiPAP Masks)
References
1. Annane, D, Orlikowaski, D, Chevret, S, et al, Nocturnal mechanical ventilation for chronic hypoventilation in
patients with neuromuscular and chest wall disorders. Cochrane Database Systematic Review 4, 2007.
[CD001941].
2. Antonelli, M, Conti, G, Esquinas, A, et al. A multiple-center survey on the use in clinical practice of noninvasive
ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med. 2007; 35:18–25.
3. Burns, KE, Adhikar, NK, Keenan, SP, et al, Use of non-invasive ventilation to wean critically ill adults off invasive
ventilation. meta analysis and systematic review. BMJ 2009; 338:b728.
4. Caples, SM, Gay, PC, Noninvasive positive pressure ventilation in the intensive care unit. a concise review. Crit
Care Med 2005; 33:2651–2658.
5. Crummy, F, Naughton, MT, Non-invasive positive pressure ventilation for acute respiratory failure. justified or
just hot air. Intern Med J 2007; 37:112–118.
6. Curtis, JR, Cook, DJ, Sinuff, T, et al, the Society of Critical Care Medicine’s Palliative Noninvasive Positive
Pressure Ventilation Task Force. Noninvasive positive pressure ventilation I critical and palliative care
settingsunderstanding the goals of therapy. Crit Care Med 2007; 35:932–939.
7. Esteban, A, Frutos-Vivar F, Ferguson, ND, et al. Noninvasive positive-pressure ventilation for respiratory
failure after extubation. N Engl J Med. 2004; 350:2452–2460.
8. Ferrer, M, Esquinas, A, Arancibia, F, et al, Noninvasive ventilation during persistent weaning failure. a
randomized controlled trial. Am J Respir Crit Care Med 2003; 168:70–76.
9. Ferrer, M, Valcencia, M, Nicolas, JM, et al. Early non-invasive ventilation averts extubation failure in patients at
risk; a randomized trial. Am J Respir Crit Care Med. 2006; 173:164–170.
10. Giacomini, M, Iapichino, G, Cigada, M, et al. Short-term noninvasive pressure support ventilation prevents
ICU admittance in patients with acute cardiogenic edema. Chest. 2003; 123:2057–2061.
11. Gray, A, Goodacre, S, Newby, DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J
Med. 2008; 359:142–151.
12. Hilbert, G, Gruson, D, Vargas, F, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary
infiltrates, fever and acute respiratory failure. N Engl J Med. 2001; 344:481–487.
13. Honrubia, T, Garcia-Lopez FJ, Franco, N, et al, Noninvasive vs conventional mechanical ventilation in acute
respiratory failure. a multicenter, randomized controlled trial. Chest 2005; 128:3790–3791.
14. Kaneko, Y, Floras, JS, Usui, K, et al. Cardiovascular effects of continuous positive airway pressure in patients
with heart failure and obstructive sleep apnea. N Engl J Med. 2003; 348:1233–1241.
15. Keenan, SP, Sinuff, T, Cook, DJ, et al. Does noninvasive positive pressure ventilation improve outcome in
acute hypoxemic respiratory failure? A systematic review. Crit Care Med. 2004; 32:2516–2523.
16. Mansfield, DR, Golloghy, NC, Kaye, DM, et al. Controlled trial of continuous positive airway pressure in
obstructive sleep apnea and heart failure. Am J Respir Crit Care Med. 2004; 169:361–366.
17. Nava, S, Carbone, G, DiBattista, N, et al, Noninvasive ventilation in cardiogenic pulmonary edema. a
multicenter randomized trial. Am J Respir Crit Care Med 2003; 168:1432–1437.
18. Navalesi, P, Costa, R, Ceriana, P, et al, Non-invasive ventilation in chronic obstructive pulmonary disease patients.
helmet versus facial mask. Intensive Care Med 2007; 33:74–81.
19. Park, M, Sangean, MC, Volpe M de S, et al. Randomized, prospective trial of oxygen, continuous positive
airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema. Crit
Care Med. 2004; 32:2407–2415.
20. Peter, JV, Moran, JL, Phillips-Hughes, J, et al, Noninvasive ventilation in acute respiratory failure. a meta-
analysis update. Crit Care Med 2002; 30:555–562.
21. Peter, JV, Moran, JL, Phillips-Hughes J, et al, Effect of non-invasive positive pressure ventilation (NIPPV) on
mortality in patients with acute cardiogenic pulmonary oedema. a meta-analysis. Lancet 2006; 367:1155–1163.
22. Rabitsch, W, Staudinger, T, Locker, GJ, et al, Respiratory failure after stem cell transplantation. improved
outcome with non-invasive ventilation. Leuk Lymphoma 2005; 46:1151–1157.
23. Schettino, G, Altobelli, N, Kacmarek, RM, Noninvasive positive–pressure ventilation in acute respiratory failure
outside clinical trials. experience at the Massachusetts General Hospital. Crit Care Med 2008; 36:441–447.
24. Vital, FM, Saconato, H, Ladeira, MT, et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for
cardiogenic pulmonary edema. Cochrane Database Systematic Review. 16, 2008. [CD005351].
25. Winck, JC, Azevedo, LF, Costa-Pereira A, et al, Efficacy and safety of non-invasive ventilation in the treatment of
acute cardiogenic pulmonary edema. a systematic review and meta-analysis. Crit Care 2006; 10:R69.
Additional Readings
Additional Readings
Pierc e, LNB, Invasive and noninvasive modes and methods of mec hanic al ventilationBurns S M, ed.. AACN protoc ols for prac tic e. c are of mec hanic ally ventilated
patients. ed 2. Jones and Bartlett Publishers, Boston, 2007.
Pierc e, LNB, Ma na gement of the mecha nica lly ventila ted pa tient. ed 2. Elsevier, S t Louis, 2007.
Tobin, MJ. Princ iples and prac tic e of mec hanic al ventilation, ed 2. New York: Mc Graw-Hill, 2006.
P R OC E D UR E 2 9
PURPOSE:
The arterial-venous oxygen content difference is calculated for a patient on mechanical ventilation to provide a
general indication of oxygen extraction from the blood. Arterial and venous oxygen content is also used to
calculate oxygen transport (delivery) and consumption (use).
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
Procedure for Arterial-Venous Oxygen Difference Calculation
References
1. Chulay, M, Gawlinski, A, AACN protocols for practice. -hemodynamic monitoring series. American
Association of Critical-Care Nurses, Aliso Viejo, CA, 1998.
2. Miller, LR. Hemodynamic monitoring. In: Chulay M, Burns SM, eds. AACN essentials of critical care -nursing.
New York: McGraw-Hill, 2006.
3. West, JB, Pulmonary pathophysiology. the essentials. Lippincott Williams & Wilkins, Baltimore, 2008.
4. West, JB, Respiratory physiology. the essentials. ed 8. Lippincott Williams & Wilkins, Baltimore, 2008.
Additional Readings
Johnson, KL. Diagnostic measures to evaluate oxygenation in c ritic ally ill adults. AACN Clin Issues. 2005; 15(4):506–524.
P R OC E D UR E 3 0
PURPOSE:
An end-expiratory hold maneuver is performed to calculate auto–positive end-expiratory pressure for the patient
on mechanical ventilation. The calculation of auto–positive end-expiratory pressure is necessary to assess
patient risk for a variety of conditions and the need for changes in ventilator parameters.
FIGURE 30-1 Auto-PEEP is PEEP over and above the set-PEEP. It can be measured by performing an end-expiratory hold maneuver and observing the
airw ay pressure manometer or digital display. Auto-PEEP is caused by insufficient expiratory time (e.g., high rates, short expiratory times, w ater in the
ventilator circuit, inverse respiratory ratios, bronchospasm, and high minute ventilations). Auto-PEEP can result in increased pulmonary pressures, decreased
venous return, and hypotension and barotrauma. (From Kinney M, et al: AACN clinical reference for critical care nursing, ed 4, St Louis, 1998, Mosby.)
• Auto-PEEP is associated with high minute ventilation requirements, small-diameter endotracheal tubes,
bronchospasm, long inspiratory times, high respiratory rates, and mechanical factors, such as water accumulation in
the ventilator tubing.2-11
• Auto-PEEP may result in an increased work of breathing. The set sensitivity of the ventilator is referenced to the
amount of set-PEEP selected by the clinician. Because auto-PEEP is not sensed by the ventilator, the patient has to
generate a pressure equal to the set sensitivity plus auto-PEEP to “trigger” inspiratory flow or a breath from the
ventilator.2,9
• Auto-PEEP may elevate static pressure (i.e., plateau pressure). High plateau pressures can result in barotrauma and
hemodynamic compromise.9
• Auto-PEEP may be a desirable outcome of select ventilator settings (e.g., pressure-controlled inverse ratio ventilation).
In these cases, the goal of auto-PEEP is to restore functional residual capacity and reduce shunt.
• Interventions to offset auto-PEEP include the use of large-diameter endotracheal tubes, bronchodilators, short
inspiratory times, long expiratory times, lower respiratory rates, frequent emptying of ventilator circuit water
accumulation (heated circuits may eliminate this complication), and the use of sedatives and narcotics (if the patient’s
breathing pattern is such that it increases the minute ventilation). Occasionally the addition of set-PEEP is used to
offset auto-PEEP. The addition of set-PEEP serves as a splint by keeping the airway open throughout exhalation,
decreasing auto-PEEP.2-7,11 An example of this technique is the patient with chronic obstructive pulmonary disease in
whom early airway closure during exhalation results in gas trapping.
EQUIPMENT
Generally, no additional equipment is necessary because most ventilators have an end-expiratory hold bu on to use for
determining auto-PEEP.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
Procedure for Auto-PEEP Calculation
References
1. Bidani, A, Tzouanakis, AE, Carenas, VJ, et al. Permissive hypercapnia in acute respiratory failure. JAMA. 1994;
272:957–962.
2. Burns, SM, Ventilating patients with acute severe asthma. what do we really know. AACN Advanced Crit Care
2006; 17:188–193.
3. Coussa, ML, Guerin, C, Eissa, NT, et al. Partitioning of work of breathing in mechanically ventilated COPD -
patients. J Appl Physiol. 1993; 75(4):1711–1719.
4. Georgopoulos, D, Giannouli, E, Patakas, D. Effects of -extrinsic positive end-expiratory pressure on
mechanically ventilated patients with chronic obstructive pulmonary disease and dynamic hyperinflation.
Intensive Care Med. 1993; 19:197–203.
5. Leatherman, JW, McArthur, C, Shapiro, RS. Effect of -prolongation of expiratory time on dynamic
hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med. 2004; 32:1542–1545.
6. Leatherman, JW, Ravenscraft, SA, Low-measured auto-positive end-expiratory pressure during mechanical
ventilation of patients with severe asthma. hidden auto-positive end expiratory pressure. Crit Care Med 1996;
24:541–546.
7. MacIntyre, NR, Cheng, KC, McConnell, R. Applied PEEP during pressure support reduces inspiratory
threshold of intrinsic PEEP. Chest. 1997; 111:188–193.
8. Pepe, PE, Marini, JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow
obstruction. Am Rev Respir Dis. 1994; 126:166–173.
9. Rossi, A, Gottfried, SB, Zocchi, L, et al, Measurement of static compliance of the total respiratory system in
patients with acute respiratory failure during mechanical ventilation. the effect of intrinsic positive end-expiratory
pressure. Am Rev Respir Dis. 1985; 131(5):672–677.
10. Smith, TC, Marini, JJ. Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction.
J Appl Physiol. 1988; 65:1488–1499.
11. Tobin, MJ, Alex, CA, Fahey, PJ. Fighting the ventilator. In: Tobin MJ, ed. Principles and practice of mechanical
ventilation. New York: McGraw-Hill, 2006.
Additional Readings
Burns, S . Mec hanic al ventilation and weaning. In: Carlson KK, ed. AACN a dva nced critica l ca re nursing. S t Louis: Elsevier, 2009.
Pierc e, LNB, Invasive and noninvasive modes and methods of mec hanic al ventilationBurns S M, ed.. AACN protoc ols for prac tic e. c are of mec hanic ally ventilated
patients. ed 2. Jones and Bartlett, Boston, 2007.
Pierc e, LNB, Mec hanic al ventilation. indic ations, ventilator performanc e of the respiratory c yc le, and inititationPierc e LNB, ed. Management of the mec hanic ally -
ventilated patient, ed 2, S t Louis: Elsevier, 2007.
P R OC E D UR E 3 1
PURPOSE:
Clinical measurements of compliance and resistance are performed to assess trends in respiratory status,
determine the effectiveness of therapy, and titrate therapy.
EQUIPMENT
• Calculator
• Ventilator measurements: Vt, PIP, static pressure, PEEP, (see Procedure 35) and auto-PEEP, if present (see Procedure
30)
Patient Preparation
• Ensure that the patient understands pre-procedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Premedicate as needed. Rationale: This measurement may be extremely difficult in a patient who is breathing
rapidly or is agitated. Sedation and paralytics are sometimes necessary.
Procedure for Compliance and Resistance Measurement
References
1. Dreyfuss, D, et al, High inflation pressure pulmonary edema. respective effects of high airway pressure, high
tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 1988; 137:1159–1164.
2. Marini, JJ, Lung mechanics determinations at the bedside. instrumentation and clinical applications. Respir
Care 1990; 35:669.
3. Pepe, PE, Marini, JJ. Occult positive end-expiratory -pressure in mechanically ventilated patients with airflow
obstruction. Am Rev Respir Dis. 1982; 126:166–170.
4. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with
traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;
342:1301–1307.
5. West, JB, Respiratory physiology. the essentials. ed 8. Lippincott Williams & Wilkins, Baltimore, 2008.
Additional Readings
Burns, S . Mec hanic al ventilation and weaning. In: Carlson KK, ed. AACN a dva nced critica l ca re nursing. S t Louis: Elsevier, 2009.
Pierc e, LNB. Prac tic al physiology of the pulmonary system. In Pierc e LNB, ed. : Ma na gement of the mecha nica lly ventila ted pa tient, ed 2, S t Louis: Elsevier, 2007.
West, JB Pulmonary pathophysiology. the essentials. Lippinc ott Williams & Wilkins, Baltimore, 2008.
P R OC E D UR E 3 2
PURPOSE:
The manual self-inflating resuscitation bag-valve device is used to provide ventilation and oxygenation with or
without an artificial airway in place and is referred to as “bagging.”
FIGURE 32-1 Proper technique of ventilation w ith manual self-inflating resuscitation bag-valve device and face mask. (From Wilkins RL, Stoller JK, Kacmarek RM:
Egan’ s fundamentals of respiratory care, ed 8, St Louis, 2008, Mosby.)
When signs and symptoms of respiratory distress are noted in a patient on mechanical ventilation, the patient
should be bagged on 100% oxygen if troubleshooting the ventilator does not immediately solve the problem.
Large bagged breaths or rapid rates during bagging may result in dynamic hyperinflation and resultant
hypotension.2,3 Hyperinflation occurs when exhalation time is inadequate, which results in auto–positive end-
expiratory pressure (auto-PEEP) and decreased venous return (see Procedure 30), with the resultant hypotension.
Dynamic hyperinflation is most commonly associated with bronchospasm and chronic obstructive pulmonary
disease.2 A high index of suspicion for the presence of dynamic hyperinflation is necessary if hypotension occurs
with bagging. A brief disconnection from the bag or the provision of longer exhalation times or both results in a
rapid increase in blood pressure. Bagging is resumed at a slower rate and with longer expiratory times.
EQUIPMENT
• Manual self-inflating resuscitation bag-valve device (of appropriate size) (Fig. 32-2) and appropriately sized mask
FIGURE 32-2 Manual self-inflating bags: bag-valve assembly w ith and w ithout reservoir.
Patient Preparation
• Ensure that the patient understands pre-procedural teachings, or if the patient’s condition precludes teaching, assure
the patient that bagging will help with less shortness of breath. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
Procedure for Manual Self-Inflating Resuscitation Bag
References
1. Grap, MJ, et al, Endotracheal suctioning. ventilator vs manual delivery of hyperoxygenation breaths. Am J
Crit Care 1996; 5:192–197.
2. Pepe, PE, Marini, JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow
obstruction. Am Rev Respir Dis. 1982; 126:166–170.
3. Pierce, LNB, Administration of oxygen humidification, and aerosol therapy. Management of the mechanically
ventilated patient. ed 2. Elsevier, St Louis, 2007.
Additional Readings
Guidelines Committee of the Americ an College of Critic al Care Medic ine. S oc iety of Critic al Care Medic ine and Americ an Assoc iation of Critic al-Care Nurses
Transfer Guidelines Task Forc e. Guidelines for the transfer of c ritic ally ill patients. Crit Ca re Med. 1994 Jul; 22(7):4–1203.
P R OC E D UR E 3 3
Indices of Oxygenation
S uzanne M. Burns
PURPOSE:
Alveolar-arterial oxygen difference, arterial partial pressure of oxygen–to–fraction of inspired oxygen ratio,
arterial partial pressure of oxygen–to–alveolar partial pressure of oxygen ratio, and blood flow shunted–to–blood
flow total ratio are calculated for identification of shunt as the primary mechanism of hypoxemia, assessment of
trends in oxygenation, and determination of effectiveness and titration of therapies.
EQUIPMENT
• Arterial blood gas (ABG) results (after 15 minutes of 100% FiO2 ) for calculation of A-aDO2 ; if other indices are used
(e.g., a:A ratio, P:F ratio), record the FiO2 level when the ABG is drawn
• Calculator
Table 33-2
Equation for Calculation of Arterial:Alveolar Ratio
PaO2 (obtained from arterial blood gas) = PAO2
S ee Table 33-1 for c alc ulation of Pao2.
Table 33-3
Equation for Calculation of PaO2:FiO2 (P:F) Ratio
PaO2 (obtained from arterial blood gas) ÷ FiO2 (expressed as a decimal)
References
1. West, JB, Respiratory physiology. the essentials. ed 8. Lippincott Williams & Wilkins, Baltimore, 2008.
2. West, JB, Pulmonary pathophysiology. the essentials. Lippincott Williams & Wilkins, Baltimore, 2008.
3. Covelli, HD, Nessan, VJ, Tuttle, WK. Oxygen derived -variables in acute respiratory failure. Crit Care Med.
1983; 11:646–649.
4. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with
traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;
342:1301–1307.
5. Theodore, AC, Jefferson, LS. Oxygenation and mechanisms of hypoxemia. UpToDate Online. 16(2), 2008.
Additional Reading
Johnson, KL. Diagnostic measures to evaluate oxygenation in c ritic ally ill adults. AACN Clini Issues. 2005; 15(4):506–524.
P R OC E D UR E 3 4
Shunt Calculation
S uzanne M. Burns
PURPOSE:
Shunt calculation is performed to differentiate shunting from other mechanisms of hypoxemia, to quantify the
shunt, to assess trends in progression or improvement of shunt, and to determine the effectiveness and
duration of therapy.
EQUIPMENT
• Calculator
• Qs/Qt equation
• Mixed venous and arterial blood gas and saturation measurements
• Pulmonary artery catheter, for drawing mixed venous blood samples, or venous oxygen saturation (S VO2 ) catheter. If
an S VO2 catheter is used, the mixed venous saturation recorded on the monitor can be used for the calculation (as long
as in vitro and in vivo calibrations have been done according to manufacturer’s recommendations)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Determine arterial oxygen tension or saturation. Rationale: Hypoxemia is confirmed by a decreasing arterial partial
pressure of oxygen (PaO2 ), decreasing arterial oxygen saturation (SaO2 ), an absolute Pao2 of less than 60 mm Hg, or an
absolute SaO2 of less than 90%. A low PaO2 and a low Sao2 with increasing supplemental oxygen confirm hypoxemia
caused by right-to-left intrapulmonary shunting.
• Determine Qs/Qt trends with therapies and interventions. Rationale: Calculation of Qs/Qt is indicated to help
differentiate mechanisms of hypoxemia and to provide appropriate interventions. The effect of therapies such as
positive end-expiratory pressure (PEEP), selected ventilator modes (e.g., pressure release ventilation, inverse ratio),
and prone positioning on shunting and oxygenation can be quantified.
Procedure for Shunt Calculation
Table 34-1
Qs/Qt Calculation
Qs/Qt = (Cco2 – Cao2 )/(Cco2 – Cvo2 )
Cco2 = (Hgb × 1.39* × Sat† [1.0] + (Pao2 ‡ × 0.003)
Cao2 = (Hgb × 1.39* × Sao2 ) + (Pao2 × 0.003)
Cvo2 = (Hgb × 1.39* × Svo2 ) + (Pvo2 × 0.003)
Cco2, This is the oxygen c ontent in mL/l00 ml (Volumes %) of blood that is reflec tive of a “model” alveolar/c apillary unit (blood flow and alveolar
ventilation are matc hed); Ca o2, arterial oxygen c ontent in mL/100 mL of blood; Cv-o2, mixed venous oxygen c ontent in mL/100 mL of blood;
Hgb, hemoglobin; Sa t, saturation of hemoglobin; Pv-o2, partial pressure of mixed venous oxygen.
For ease of c alc ulation, the portion of the equation that determines the O 2 dissolved in plasma may be eliminated bec ause the c ontribution of the
dissolved portion of O 2 to O 2 c ontent is extremely small. For c ontinuity purposes, this should be determined by unit polic y.
*Depending on institutional polic y, standards between 1.39 and 1.34 are used.
†In the equation for c alc ulation of Cc -o , saturation is assumed to be 100% as in an “ideal” c apillary with no shunt.
2
References
1. West, JB, Pulmonary pathophysiology. the essentials. Lippincott Williams & Wilkins, Baltimore, 2008.
2. West, JB, Respiratory physiology. the essentials. ed 8. Lippincott Williams & Wilkins, Baltimore, 2008.
*The use of heparin is not universal. Refer to c ritic al c are unit polic y. It is avoided in those with potential for or ac quired heparin-induc ed thromboc ytopenia.
P R OC E D UR E 3 5
PURPOSE:
Initiation and maintenance of positive-pressure ventilation through an artificial airway are accomplished to
maintain or improve oxygenation and ventilation and to provide respiratory muscle rest. Selection of volume or
pressure modes is dependent on the available evidence, clinical goals, availability of modes, and practitioner
preference.
Table 35-1
Traditional Modes of Mechanical Ventilation (on All Ventilators)
Volume Modes
Control Ventilation (CV) or Controlled Mandatory Ventilation (CMV)
Description: With this mode, the ventilator provides all of the patient’s minute ventilation. The clinician sets
the rate, Vt, inspiratory time, and PEEP. Generally, this term is used to describe situations in which the
patient is chemically relaxed or is paralyzed from a spinal cord or neuromuscular disease and is unable to
initiate spontaneous breaths. The ventilator mode se ing may be set on CM V, assist/control (A/C), or
synchronized intermittent mandatory ventilation (SIMV) because all these options provide volume breaths at
the clinician-selected rate.
Assist/Control (A/C) or Assisted Mandatory Ventilation (AMV)
Description: This option requires that a rate, Vt, inspiratory time, and PEEP be set for the patient. The
ventilator sensitivity also is set, and when the patient initiates a spontaneous breath, a full-volume breath is
delivered.
Synchronized Intermittent Mandatory Ventilation (SIMV)
Description: This mode requires that rate, Vt, inspiratory time, sensitivity, and PEEP are set by the clinician.
In between mandatory breaths, patients can spontaneously breathe at their own rates and Vt. With S IM V,
the ventilator synchronizes the mandatory breaths with the patient’s own inspirations.
Pressure Modes
Pressure Support Ventilation (PSV)
Description: This mode provides an augmented inspiration to a patient who is spontaneously breathing.
With PS , the clinician selects an inspiratory pressure level, PEEP, and sensitivity. When the patient initiates a
breath, a high flow of gas is delivered to the preselected pressure level, and pressure is maintained
throughout inspiration. The patient determines the parameters of Vt, rate, and inspiratory time.
Pressure-Controlled/Inverse Ratio Ventilation (PC/IRV)
Description: This mode combines pressure-limited ventilation with an inverse ratio of inspiration to
expiration. The clinician selects the pressure level, rate, inspiratory time (1:1, 2:1, 3:1, 4:1), and PEEP level.
With prolonged inspiratory times, auto-PEEP may result. The auto-PEEP may be a desirable outcome of the
inverse ratios. S ome clinicians use PC without IRV. Conventional inspiratory times are used, and rate,
pressure level, and PEEP are selected.
Positive End-Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP)
Description: This ventilatory option creates positive pressure at end exhalation. PEEP restores FRC. The term
PEEP is used when end-expiratory pressure is provided during ventilator positive pressure breaths.
Table 35-2
Volume and Pressure Modes and Corresponding Ventilator Parameters
Adapted with permission from Burns S: Pressure modes of mechanical ventilation: the good, bad and the ugly, AACN Adv Crit Care 19:399-411, 2008.
Table 35-3
Ventilator Alarms
Disconnect Alarms (Low -Pressure or Low -Volume Alarms)
When disconnection occurs, the clinician must be immediately notified. Generally, this alarm is a continuous
one and is triggered when a preselected inspiratory pressure level or minute ventilation is not sensed. With
circuit leaks, this same alarm may be activated even though the patient may still be receiving a portion of the
preset breath. Physical assessment, digital displays, and manometers are helpful in troubleshooting the cause
of the alarms.
Pressure Alarms
High-pressure alarms are set with volume modes of ventilation to ensure notification of pressures that exceed
the selected threshold. These alarms are usually set 10 to 15 cm H2 O above the usual peak inspiratory
pressure (PIP). S ome causes for alarm activation (generally an intermi ent alarm) include secretions,
condensate in the tubing, biting on the endotracheal tubing, increased resistance (i.e., bronchospasm),
decreased compliance (e.g., pulmonary edema, pneumothorax), and tubing compression.
Low-pressure alarms are used to sense disconnection, circuit leaks, and changing compliance and resistance.
They are generally set 5 to 10 cm H2 O below the usual PIP or 1 to 2 cm H2 O below the PEEP level or both.
M inute ventilation alarms may be used to sense disconnection or changes in breathing pa ern (rate and
volume). Generally, low–minute ventilation and high–minute ventilation alarms are set (usually 5 to 10
L/min above and below usual minute ventilation). When stand-alone pressure support ventilation (PS V) is in
use, this alarm may be the only audible alarm available on some ventilators.
FiO2 alarms are provided on most new ventilators and are set 5 to 10 mm Hg above and below the selected
FiO2 level.
Alarm silence or pause options are built in by ventilator manufacturers so that clinicians can temporarily
silence alarms for short periods (i.e., 20 seconds) because alarms must stay activated at all times. The
ventilators reset the alarms automatically.
Alarms provide important protection for patients on ventilation. However, inappropriate threshold se ings
decrease usefulness. When threshold gradients are set too narrowly, alarms occur needlessly and frequently.
Conversely, alarms that are set too loosely (wide gradients) do not allow for accurate and timely assessments.
From Burns SM: Mecha nica l ventila tion a nd wea ning. In Kinney MR, et a l, editors: AACN clinica l reference for critica l ca re nursing, ed 4, St Louis, 1998,
Mosby.
• Complications of PPV include volume-pressure trauma, hemodynamic changes, and pulmonary barotrauma.
Volume-pressure trauma, in contrast to barotrauma (or air leak disease), was first described in animals with stiff
noncompliant lungs who were ventilated with traditional lung volumes (range, 10 to 12 mL/kg). The investigators
noted that the large volumes translated into high plateau pressures (also known as static, distending, or alveolar
pressure) and subsequent acute lung injury. The lung injury was described as a loss of alveolar integrity (i.e.,
alveolar fractures) and movement of fluids and proteins into the alveolar space (sometimes called non-ARDS-
ARDS).28,29,37,70,93 Plateau pressures of 30 cm H2 O or more for greater than 48 to 72 hours were associated with the
injury.28
Studies in humans followed the recognition that large Vts may be associated with lung injury.42,86 The ARDS
Network conducted randomized controlled trial (RCTs) of adult patients with ARDS that compared low lung
volume ventilation (6 mL/kg) with more traditional volumes (i.e., 12 mL/kg). The results showed that the lower
volume ventilation resulted in a lower mortality rate.86 As a result, current recommendations are to limit volumes
(and lower pressures) in patients with stiff lungs. With pressure ventilation, pressure is limited by definition;
however, until additional evidence emerges on the efficacy of controlling pressures versus volumes in ARDS, a goal
should be to ensure a Vt in the 6 mL/kg range. Another lung protective strategy is that of is that of “recruitment”
and the prevention of “derecruitment.” Investigators showed that stiff noncompliant lungs were at risk of trauma
from the repetitive opening associated with tidal breaths. The application of higher levels of positive end-expiratory
pressure (PEEP) was associated with better recruitment and resulted in improved mortality rates.3,4,73
The extent of hemodynamic changes associated with PPV depends on the level of applied positive pressure, the
duration of positive pressure during different phases of the breathing cycle, the amount of pressure transmitted to
the vascular structures, the patient’s intravascular volume, and the adequacy of hemodynamic compensatory
mechanisms. PPV can reduce venous return, shift the intraventricular septum to the left, and increase right
ventricular afterload as a result of increased pulmonary vascular resistance.1,50 The hemodynamic effects of PPV
may be prevented or corrected by optimizing filling pressures to accommodate the PPV-induced changes in
intrathoracic pressures; by minimizing the peak pressure, plateau pressure, and PEEP; and by optimizing the
inspiratory-to-expiratory (I:E) ratio.
Pulmonary barotrauma (i.e., air leak disease) is damage to the lung from extrapulmonary air that may result from
changes in intrathoracic pressures during PPV. Barotrauma is manifested by pneumothorax, pneumomediastinum,
pneumopericardium, pneumoperitoneum, and subcutaneous emphysema. The risk of barotrauma in a patient
receiving PPV is increased with preexisting lung lesions (e.g., localized infections, blebs), high inflation pressures
(i.e., large Vt, PEEP, main-stem bronchus intubation, patient-ventilator asynchrony), and invasive thoracic
procedures (e.g., subclavian catheter insertion, bronchoscopy, thoracentesis). Barotrauma from PPV may be
prevented by controlling peak and plateau pressures, optimizing PEEP, preventing auto-PEEP, ensuring patient-
ventilator synchrony, and ensuring proper artificial airway position.
Auto-PEEP is a common complication of mechanical ventilation and can result in hemodynamic compromise and
even death. Because increased intrathoracic pressures are transmitted to the adjacent capillaries, venous return is
decreased and the effect can be profound. Auto-PEEP and dynamic hyperinflation should be assumed in the
patient on ventilation with acute severe asthma whose condition is hemodynamically compromised, and a brief
cessation of mechanical ventilation or decrease in rate and shortening of inspiratory time should be
accomplished.54,71 Auto-PEEP is caused by inadequate expiratory time relative to the patient’s lung condition. Auto-
PEEP is associated with prolonged inspiratory times, short expiratory times, high minute ventilation requirements,
bronchospasm, low elastic recoil, mucus hypersecretion, increased wall thickness, airway closure or collapse, and
mechanical factors (e.g., water in the ventilator circuit, pinched ventilator tubing).54,71 Correcting these factors
reduces auto-PEEP. In some cases, adding set PEEP results in reduction of the inspiratory trigger threshold and thus
improvement of patient triggering.15,58
• Associated complications of PPV include ventilator-associated pneumonia (VAP)6 , deep vein thrombosis (and
subsequent pulmonary embolus), and gastrointestinal bleeding. Although all the associated complications are
important and require that appropriate evidence-based prophylaxis regimens are initiated, only VAP is discussed.
Please refer to other system-specific chapters in this manual for information on the others.
VAP occurs after 3 to 5 days of mechanical ventilation and accounts for one third of all healthcare-associated
infections and between 50% and 83% of infections in the patient with MV.6,26,52,78,91
Modifiable risk factors to the aspiration of colonized organisms in the patient on ventilation include interventions
such as proper endotracheal tube cuff inflation (secretions that collect above the cuff of the endotracheal or
tracheostomy tube and leak past the cuff into the lungs), use of continuous aspiration subglottic suctioning (CASS)
tubes, decreased ventilator tubing changes, use of heat and moisture exchangers (HMEs), stringent hand washing,
backrest elevation (BRE) of greater than 30 degrees, and when possible, the use of noninvasive ventila- tion
(especially in patients with immunocompromise).5,6,10,16,22,26,32,43,45,51,64,72,83
Other interventions with a lower level of evidence supporting their use include oral care techniques such as mouth
care and oral decontamination with agents such as chlorhexidine or oral antibiotics.45 Of interest, gastric residual
volumes have not been found to be consistently associated with VAP.46,65 Table 35-4 lists the top recommendations
of authoritative professional organizations for the prevention of VAP.
Table 35-4
Top Modifiable VAP Prevention Interventions: Guidelines by Authoritative Professional Organizations.
Top Guideline Recommendations by Professional Associations*
BRE (>30 to 45 degrees)
CASS tubes
Cuff inflation
Hand washing and aseptic technique
HMEs
No routine ventilator circuit change
Noninvasive ventilation when possible
*ProfessionalAssoc iations: Americ an Thorac ic S oc iety (ATS ), Americ an Assoc iation of Critic al-Care Nurses (AACN), Centers for Disease
Control and Prevention (CDC), and Canadian Critic al Care Trials Group and the Canadian Critic al Care S oc iety (CCCT/CCCS ).
EQUIPMENT
• Endotracheal or tracheostomy tube (see Procedures 2 and 14)
• Electrocardiogram and pulse oximetry
• Manual self-inflating resuscitation bag-valve device (with PEEP adjusted to patient baseline level or with a PEEP valve)
• Appropriately sized resuscitation face mask
• Ventilator
• Suction equipment
• End-tidal carbon dioxide detector, with a colorimetric CO2 detector or continuous monitor: The colorimetric detectors
are used to ensure proper endotracheal tube placement and are a standard of care for intubation in many institutions.
The continuous monitors are used in assessment of patients on ventilation on an ongoing basis.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Premedicate as needed. Rationale: Administration of sedatives, narcotics, or muscle relaxants may be necessary to
provide adequate oxygenation and ventilation in some patients.
• Ensure patient is positioned properly for optimum ventilation. Rationale: Placement of the patient in a head of bed
elevation of at least 30 degrees enhances diaphragmatic excursion, decreases intrathoracic pressure and helps prevent
aspiration and VAP.
Procedure for Invasive Mechanical Ventilation (Through an Artificial Airway): Volume and Pressure Modes
References
1. Abraham, E, Yoshira, G. Cardiorespiratory effects of pressure controlled ventilation in severe respiratory
failure. Chest. 1990; 98:1445–1449.
2. Amato, MBP, et al, Volume-assured, pressure support ventilation (VAPSV). a new approach for reducing
muscle workload during acute respiratory failure. Chest 1992; 102:1225–1234.
3. Amato, MBP, et al. Beneficial effects of the “open lung approach” with low distending pressures in acute
respiratory distress syndrome. Am J Respir Crit Care Med. 1995; 152:1835–1846.
4. Amato, MBP, Barbas, CSV, Medeiros, DM, et al, Effect of a protective-ventilation strategy on mortality in the
acute respiratory distress syndrome. N Engl J Med 1998; 338 :347–354.
5. American Association of Critical-Care Nurses, AACN practice alert. ventilator-associated pneumonia.
www.aacn.org/WD/Practice/Docs/Ventilator_Associated_Pneumonia_1-2008.pdf, 2004 [retrieved from accessed
9/15/09].
6. American Thoracic Society and the Infectious Diseases Society of America. Guidelines for the management of
adults with hospital acquired, ventilator-associated and healthcare associated pneumonia. Am Rev Respir Crit Care
Med. 2005; 171:388–416.
7. Banner, MJ, Blanch, PB, Kirby, RR. Imposed work of breathing and methods of triggering a demand-flow
continuous positive airway system. Crit Care Med. 1993; 21:183–190.
8. Bellemare, F, Grassino, A. Evaluation of human diaphragm fatigue. J Appl Physiol. 1982; 53:1196–1206.
9. Bidani, A, et al. Permissive hypercapnia in acute respiratory failure. JAMA. 1994; 272:957–962.
10. Bonten, MJ, Kollef, MH, Hall, JB, Risk factors for ventilator-associated pneumonia. from epidemiology to
patient management. Clin Infect Dis 2004; 38:1141–1149.
11. Boots, RJ, et al. Clinical utility of hygroscopic heat and moisture exchanges in intensive care patients. Crit Care
Med. 1997; 25:1707–1712.
12. Bosma, K, Ferreyra, G, Ambrogio, C, et al, Patient-ventilator interaction and sleep in mechanicalliy ventilated
patients. pressure support versus proportional assist ventilation. Crit Care Med 2007; 35:1048–1054.
13. Brochard, L, et al. Inspiratory pressure support prevents diaphragmatic fatigue during weaning from
mechanical ventilation. Am Rev Respir Dis. 1989; 139:513–521.
14. Brochard, L, Pluskwa, F, Lemaire, R. Improved efficacy of spontaneous breathing with inspiratory pressure
support. Am Rev Respir Dis. 1987; 136:411–415.
15. Burns, SM, Ventilating patients with acute severe asthma. what do we really know. AACN Adv Crit Care 2006;
17:188–193.
16. Burns, SM, Prevention of aspiration pneumonia in the enterally fed critically ill ventilated patient. keeping the
head up takes a village. Pract Gastroenterol 2007; 31:63–72.
17. Burns, SM, Pressure modes of mechanical ventilation . the good, the bad and the ugly. AACN Adv Crit Care
2008; 19:399–411.
18. Calzia, E, Lindner, KH, Witt, S, et al. Pressure time product and work of breathing during biphasic continuous
positive airway pressure and assisted spontaneous breathing. Am J Respir Crit Care Med. 1994; 150:904–910.
19. Cane, RD, Peruzzi, WT, Shapiro, BA. Airway pressure release ventilation in severe acute respiratory failure.
Chest. 1991; 100:460–463.
20. Cohen, CA, et al. Clinical manifestations of inspiratory muscle fatigue. Am J Med. 1982; 73:308–316.
21. Cole, AGH, Weller, SF, Sykes, MK. Inverse ratio ventilation compared with PEEP in adult respiratory failure.
Intensive Care Med. 1984; 10:227–232.
22. Craven, DE, Kunches, LM, Kilinsky, V, et al. Risk factors for pneumonia and fatality in patients receiving
continuous mechanical ventilation. Am Rev Respir Dis. 1986; 133:792–796.
23. Davis, WB, et al, Pulmonary oxygen toxicity. early reversible changes in human alveolar structures induced by
hyperoxia. N Engl J Med 1983; 309:878–883.
24. Derak, S, et al, and the Multicenter Oscillatory Ventilation for Acute Respiratory Distress Syndrome Trial
(MOAT) Study Investigators. High-frequency oscillatory ventilation for acute respiratory distress syndrome in
adultsa randomized controlled trial. Am J Respir Crit Care Med 2002; 166:801–808.
25. Djedaini, K, et al. Changing heat and moisture exchanges every 48 hours rather than 24 hours does not alter
their efficacy and the incidence of nosocomial pneumonia. Am J Respir Crit Care Med. 1995; 152:1562–1569.
26. Dodek, P, Keenan, S, Cook, D, et al, for the Canadian Critical Care Trials Group and the Canadian Critical
Care Society. Evidence-Based Clinical Practice Guidelines for the Prevention of Ventilator-Associated Pneumonia.
Ann Intern Med 2004; 141:305–313.
27. Downs, JB, Stock, MC, Airway pressure release ventilation. a new concept of ventilatory support. Crit Care
Med 1987; 15:459–461.
28. Dreyfuss, D, et al, High inflation pressure pulmonary edema. respective effects of high airway pressure, high
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29. Dreyfuss, D, Saumon, G. The role of Vt, FRC, and end-inspiratory volume in the development of pulmonary
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Additional Readings
Burns, S . Mec hanic al ventilation and weaning. In: Carlson KK, ed. AACN a dva nced critica l ca re nursing. S t Louis: Elsevier, 2009.
Pierc e, LNB. Invasive and noninvasive modes and methods of mec hanic al ventilation. In Burns S , ed. : AACN protocols for pra ctice: ca re of mecha nica lly ventila ted
pa tients, ed 2, Boston: Jones and Bartlett, 2007.
Pierc e, LNB, Ma na gement of the mecha nica lly ventila ted pa tient. ed 2. Elsevier, S t Louis, 2007.
Tobin, MJ. Princ iples and prac tic e of mec hanic al ventilation, ed 2. New York: Mc Graw-Hill, 2006.
West, JB Respiratory physiology. the essentials. ed 8. Lippinc ott Williams & Wilkins, Baltimore, 2008.
West, JB Pulmonary pathophysiology. the essentials. Lippinc ott Williams & Wilkins, Baltimore, 2008.
PURPOSE:
Weaning criteria are measured to evaluate respiratory muscle strength (negative inspiratory force or pressure
and positive expiratory pressure) and endurance (spontaneous tidal volume and vital capacity). Another index,
the rapid shallow breathing index, has been developed to identify a breathing pattern associated with
unsuccessful weaning. The results of these criteria may help determine the need for intubation, the ability of the
patient to tolerate weaning trials, the presence of respiratory muscle fatigue, and extubation potential.
EQUIPMENT*
• An aneroid pressure manometer (also called a force meter)
• A respirometer, to measure volumes or monitor spontaneous volumes on the ventilator
• Appropriate adapters and one-way valves
• Self-inflating manual resuscitation bag-valve device, connected to an oxygen source
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands pre-procedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Consider positioning the patient in a high semi-Fowler’s position, if the patient’s condition allows. Rationale:
Placing the patient in a high semi-Fowler’s position, if possible, enables the patient to use the force of gravity during
measurements.
Procedure for Weaning Criteria
FIGURE 36-1 Measurement of negative inspiratory pressure (NIP) and positive expiratory pressure (PEP).
References
1. Burns, SM, Burns, JE, Truwit, JD. Comparison of five -clinical weaning indices. Am J Crit Care. 1994; 3:342–
352.
2. Burns, SM, The science of weaning. when and how. Crit Care Clin North Am 2004; 16:379–386.
3. Chevrolet, J, Deleamont, P. Repeated vital capacity -measurements as predictive parameters of mechanical
ventilation need and weaning success in the Guillain-Barre syndrome. Am Rev Respir Dis. 1991; 144:814–818.
4. Cook, D, et al. Evidence report on criteria for weaning from mechanical ventilation. Rockville, MD: Agency for
Health Care Policy and Research; 1999. [contract no. 290-97-0017].
5. Ely, EW, et al. Effect on the duration of mechanical -ventilation of identifying patients capable of breathing
spontaneously. N Engl J Med. 1996; 335:1964–1969.
6. Kollef, MH, et al. A randomized controlled trial of protocol directed versus physician directed weaning from
mechanical ventilation. Crit Care Med. 1997; 25:567–574.
7. Krieger, BP, et al. Serial measurements of the rapid shallow breathing index as a predictor of weaning
outcome in elderly medical patients. Chest. 1997; 112:1029–1034.
8. MacIntyre, NR, et al, Evidence-based guidelines for -weaning and discontinuing ventilatory support. a
collective task force facilitated by the American College of Chest Physicians; the American Association for
Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001; 120(6 Suppl):375S–395S.
9. Mador, MJ, Weaning parameters. are they clinically useful. Chest 1992; 102:1642.
10. Marelich, GP, et al, Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory
care practitioners and nurses. effect on weaning time and incidence of ventilator associated pneumonia. Chest
2000; 118:459–467.
11. Meade, M, Guyett, G, Cook, D, et al. Predicting success in weaning from mechanical ventilation. Chest. 2001;
120(6S):400–424.
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13. Yang, KL, Tobin, MJ. A prospective study of indexes predicting the outcome of trials of weaning from
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Additional Readings
Burns, S M. Mec hanic al ventilation and weaning. In: Carlson KK, ed. AACN a dva nced critica l ca re nursing. S t Louis: Elsevier, 2009.
Burns, S M. Weaning from mec hanic al ventilation. In Burns S M, ed. : AACN protocols for pra ctice: ca re of -mecha nica lly ventila ted pa tients, ed 2, Boston: Jones and
Bartlett, 2007.
Mahanes, D, Lewis, R, Ventilatory management. AACN-AANN protoc ols for prac tic e: monitoring tec hnologies in -c ritic ally ill neurosc ienc e patients, Publishers.
Jones and Bartlett, Boston, 2009.
*S ome ventilators allow for measurement of these parameters while the patient is on the ventilator. Refer to spec ific ventilator guidelines for measurement.
P R OC E D UR E 3 7
Weaning Process
S uzanne M. Burns
PURPOSE:
The purpose of the weaning process is to liberate patients from mechanical ventilation. Removal of the artificial
airway is a desirable outcome of the weaning process but is not essential for liberation from ventilatory support.
Weaning Assessment
• In the past, the assessment of weaning readiness was accomplished by determining whether or not the patient’s
condition was stable, the reason for mechanical ventilation was resolved or improving, and the results of selected
weaning criteria (or weaning indices) met threshold levels (Tables 37-1 and 37-2; see Procedure 36).10,41,50 Experts also
noted that before weaning trials were initiated, attention to other clinical factors was essential.12,32 Clinical tools and
checklists that ensure systematic attention to these factors help ensure good outcomes, an example of which is found
in Table 37-3. In addition, prophylaxis regimes are necessary to prevent complications in patients on ventilation.
These complications include ventilator-associated pneumonia (VAP), deep vein thrombosis, gastrointestinal bleeding,
and sinusitis. Refer to Procedure 35 for a discussion of VAP prophylaxis and system-specific chapters for the others.
Table 37-1
Standard Weaning Criteria
Negative inspiratory pressure, ≤−20 cm H2 O
Positive expiratory pressure, ≥+30 cm H2 O
Spontaneous tidal volume, ≥5 mL/kg
Vital capacity, ≥10 to 15 mL/kg
Fraction of inspired oxygen, ≤50%
Minute ventilation, ≤10 L/min
Modified from Burns SM: Mecha nica l ventila tion a nd wea ning. In Kinney MR, et a l, editors: AACN clinica l reference for critica l ca re nursing, ed 4, St Louis,
1998, Mosby.
Table 37-2
Rapid Shallow Breathing
fx/Vt
Spontaneous respiratory frequency in 1 minute divided by Vt in liters
fx/Vt > 105 = weaning success
fx/Vt < 105 = weaning failure
fx, Frequenc y; Vt, tidal volume.
Da ta from Ya ng KL, Tobin JM: A prospective study of indexes predicting the outcome of tria ls of wea ning from mecha nica l ventila tion, N Engl J Med 324:1445-
50, 1991.
Table 37-3
Burns Weaning Assessment Program (BWAP)*
Ca++, Calcium; Mg+, magnesium; ID, inside diameter; PO4, phosphate.
Copyright Burns SM, 1990.
*To score the BWAP: Divide the number of “Yes” responses by 26.
• Unfortunately, weaning indices have proven to be disappointing predictors of a patient’s ability to wean.12,32,35,45 Most
predictors focus on pulmonary-specific factors. Some investigators have combined indices and pulmonary factors to
enhance the comprehensive nature of the indices and their predictive potential. In general, the indices are poor
positive predictors (they do not tell us the patient will wean), but they are good negative predictors (they tell us the
patient will not wean).13,32,35,45 Thus, use of the indices is not widespread. In fact, the various weaning indices are best
used to evaluate the components from which they are designed (breathing pattern, respiratory muscle strength, etc.).
Table 37-4
Example CPAP Protocol
Table 37-5
Effect of Protocols for Weaning and Sedation on Selected Outcomes by Author
*Statistically significant.
Adherence to Protocols
• Although the RCTs described show the importance of wean screens, SBTs, sedation management, and tight glucose
control to weaning outcomes, studies on the adherence with the same are not encouraging. Adherence studies show
that acceptance is low and that the protocols may not be realistic for use in everyday practice33,36,38,49, Given the
increasing complexity of the clinical setting and the increasing shortage of ICU nurses and other healthcare
professionals, rigorous protocols designed and implemented by study investigators are unlikely to be easily
duplicated. We have much to learn in this area.
Multidisciplinary Approaches
• Weaning is the process of gradual reduction of ventilatory support. To that end, a plan for weaning is determined by
the multidisciplinary team and is applied and monitored carefully.8,9,14,15,23,24,34,44 The plan, whether it uses a protocol or
consists of a more individualized written plan, should be available to all healthcare workers involved in the weaning
process. Assessment of weaning potential may include checklists of factors important to weaning, such as the Burns
Weaning Assessment Program (BWAP8-10 ; Table 37-3). In addition, prophylaxis for VAP and other potential
complications associated with mechanical ventilation must be ensured.
• Outcomes of system initiatives designed to ensure the comprehensive implementation of evidence-based interventions
are promising. Advanced practice nurses were used to manage and monitor the conditions of patients in their
care.8,9,24,44 The results suggest that use of such models of care are to be encouraged, but few have been developed,
tested, and published (Table 37-6). Further, they tend to compare retrospective with prospective data elements, thus
limiting the strength of the evidence. Unfortunately, RCTs of such system initiatives are unlikely to be accomplished
in the future.
Table 37-6
Effect of System Initiatives, by Author, on Outcome Variables*
MICU, Medical ICU; SICU, surgical ICU; CCU, coronary care unit; STICU, surgical-trauma ICU; NICU, neuroscience ICU TCV: thoracic-cardiovascular ICU
*Statistically significant).
EQUIPMENT
• Weaning through the ventilator (e.g. CPAP, flow-by, automatic tube compensation ATC) requires that the digital
readout of tidal volume and respiratory rate be assessable to the clinician for monitoring purposes
• If T-piece or tracheotomy collar setup is needed, a flow meter with a functional heated aerosol humidifier for the trials
is necessary; the setup should have an in-line thermometer and a water trap
• Tracheotomy collar or T-piece adapters
• Personal protective equipment, as appropriate
Nonsterile gloves
Mask
Goggles
Gown
• Pressure manometers
• Weaning protocol or wean plan
• Extubation equipment (see Procedures 5 and 6)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Address factors that are impeding wean potential. These factors may include pH level, hemodynamic stability,
electrolytes, strength, endurance, mobility, nutrition, and fluid status, to name a few. A systematic approach with use
of a checklist helps avoid variation in practice. Rationale: Weaning has been associated with the correction of a
myriad of physiologic factors. Weaning is not solely dependent on respiratory muscle strength and endurance.
• Establish weaning screen criteria. Rationale: Weaning screen criteria are essential for the rapid and safe assessment
of weaning trial readiness.
• Wean trial duration should be set before beginning the trial. Rationale: Prolonged SBTs may fatigue the patient and
result in poor outcomes. All key bedside caregivers must be aware of the limits of the trial and when to stop should
signs of intolerance emerge.
Procedure for Weaning Trial
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collective task force facilitated by the American College of Chest Physicians; the American Association for
Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001; 120(6 Suppl):375S–395S.
33. Malesker, MA, Foral, PA, McPhillips, AC, et al. An efficiency evaluation of protocols for tight glycemic control in
intensive care units. Am J Crit Care. 2007; 16:589–598.
34. Marelich, GP, Murin, S, Battistela, F, et al, Protocol weaning of mechanical ventilation in medical and surgical
patients by respiratory care practitioners and nurses. effect on weaning time and ventilator associated
pneumonia. Chest 2000; 118:459–467.
35. Meade, M, Guyatt, G, Cook, D, et al. Predicting success in weaning from mechanical ventilation. Chest. 2001;
120(6 Suppl):400S–424S.
36. Metha, S, Burry, L, Fischer, S, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular
blocking agents in critically ill patients. Crit Care Med. 2006; 34:374–380.
37. Nieszkowska, A, Combes, A, Luyt, C, et al. Impact of tracheotomy on sedative administration, sedation level, and
comfort of mechanically ventilated intensive care unit patients. Crit Care Med. 2005; 33:2527–2533.
38. Oeyen, SG, Hoste, EA, Roosens, CD, et al, Adherence to and efficacy and safety of an insulin protocol in the
critically ill. a prospective observational study. AJCC 2007; 16:599–608.
39. Pandharipande, P, Shintani, A, Peterson, J, et al. Lorazapam is an independent risk factor for transitioning to
delirium in intensive care unit patients. Anesthesiology. 2006; 104:21–26.
40. Rumbak, MJ, Newton, M, Truncale, T, et al. A prospective, randomized study comparing early percutaneous
dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical
patients. Crit Care Med. 2004; 32:1689–1694.
41. Sahn, SA, Lakshminarayan, S. Bedside criteria for discontinuation of mechanical ventilation. Chest. 1973;
63:1002–1005.
42. Sassoon, CSH, et al. Inspiratory muscle work of breathing during flow-by, demand-flow, and continuous-flow
systems in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis. 1992; 145:1219–1222.
43. Schweickert, WD, Gehlbach, BK, Pohlman, AS, et al. Daily interruptions of sedative infusions and
complications of critical illness in mechanically ventilated patients. Crit Care Med. 2004; 32:1272–1276.
44. Smyrnios, NA, et al. Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program
on weaning from mechanical ventilation. Crit Care Med. 2002; 30:1224–1230.
45. Tanios, MA, Nevins, ML, Hendra, KP, et al. A randomized controlled trial of the role of weaning predictors in
clinical decision making. Crit Care Med. 2006; 34:2530–2535.
46. Tobin, MJ, et al. Konno-Mead analysis of ribcage-abdominal motion during successful and unsuccessful trials
of weaning from mechanical ventilation. Am Rev Respir Dis. 1987; 135:1320–1328.
47. Van den Berghe G, Wouters, P, Weekers, F, et al. Intensive insulin therapy in critically ill patients. N Engl J
Med. 2001; 354:1359–1367.
48. Vitacca, M, Vianello, A, Colombo, D, et al. Comparison of two methods for weaning COPD patients requiring
mechanical ventilation for more than 15 days. Am J Respir Crit Care Med. 2001; 164:225–230.
49. Weinert, CR, Calvin, AD. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in
a medical and surgical intensive care unit. Crit Care Med. 2007; 35:393–401.
50. Yang, KL, Tobin, JM. A prospective study of indexes predicting the outcome of trials of weaning from
mechanical ventilation. N Engl J Med. 1994; 324:1445–1450.
Additional Readings
Burns, S M. Mec hanic al ventilation and weaning. In: Carlson K, ed. AACN’s a dva nced critica l ca re nursing. S t Louis: Elsevier, 2009.
Burns, S M, Prac tic e protoc ol. weaning from mec hanic al ventilationBurns S , ed.. AACN protoc ols for prac tic e -series. c are of the mec hanic ally ventilated patient.
ed 2. Jones and Bartlett, S udbury, 2007.
Burns, S M. Weaning from mec hanic al ventilation. In Pierc e LNB, ed. : Ma na gement of the mecha nica lly ventila ted pa tient, ed 2, S t Louis: Elsevier, 2007.
Pierc e, LNB, Ma na gement of the mecha nica lly ventila ted pa tient. ed 2. Elsevier, S t Louis, 2007.
Tobin, MJ. Princ iples and prac tic e of mec hanic al ventilation, ed 2. New York: Mc Graw-Hill, 2006.
P R OC E D UR E 3 8
PURPOSE:
Peripheral nerve stimulators are used in association with the administration of neuromuscular blocking drugs to
assess nerve impulse transmission at the neuromuscular junction of select skeletal muscles.
Table 38-1
Train-of-Four Stimulation as a Correlation of Blocked Nerve Receptors
0/4 100
1/4 90
2/4 85
3/4 80
4/4 75 or less
• The stimulating current is measured in milliamperes (mA). The usual range of mA required to stimulate a peripheral
nerve and elicit a muscle twitch is 20 to 50 mA, although increasing the current to 70 or 80 mA may be necessary,
especially in the obese patient.9
• Some stimulators do not indicate the mA. Instead, digital or dialed numbers ranging from 1 to 10 represent the range
of mA from 20 to 80 mA. With use of these instruments, the usual setting is 2 to 5, although a setting of 10 is
sometimes necessary. Other stimulators (with and without digital displays) automatically adjust the voltage output
relative to resistance and deliver the current accordingly.10
• The ulnar nerve in the wrist is recommended for testing, although the facial and the posterior tibial nerves may also be
used.
• Peripheral nerve monitoring is used in conjunction with the assessment of clinical goals, and clinical decisions should
never be made solely on the basis of the twitch response.
• Titration of the drugs according to clinical assessment and muscle twitch response may help provide a sufficient level
of blockade without overshooting the goal. Overshooting the level of blockade with use of excessive doses of NMBDs
is of special concern in the critically ill patient because it may predispose the patient to prolonged paralysis and
muscle weakness, reported extensively in the literature.6 Monitoring with a PNS during the administration of NMBDs
results in the use of less medication, hastens recovery of spontaneous ventilation, and accelerates restoration of
neuromuscular transmission (NMT),2 which is necessary for resumption of muscle activity. Although some patients
have severe muscle weakness after neuromuscular blockade, peripheral nerve monitoring during NMBD therapy
facilitates prompt recovery of NMT when therapy is terminated.2
EQUIPMENT
• Peripheral nerve stimulator
• Two pre-gelled electrode pads (the same as is used for electrocardiography monitoring)
• Two lead wires packaged with the peripheral nerve stimulator
• Alcohol pads for skin degreasing and cleansing
Additional equipment, as needed, includes the following:
• A bipolar touch stimulator probe may be substituted for the pre-gelled electrodes and lead wires
• Scissors or clippers if hair removal is necessary
Patient Preparation
• Ensure that the patient and family understand pre-procedural teachings. Answer questions as they arise and reinforce
information as needed. Rationale: Evaluates and reinforces understanding of previously taught information.
• Clip hair at the electrode placement sites if necessary. Rationale: This action improves electrode contact, which
facilitates current flow to the nerve.
• Cleanse skin and degrease with alcohol. Rationale: Cleansing improves electrode contact, which facilitates current
flow to the nerve
• Apply the electrodes and test the TOF response to determine the adequacy of the location before initiating
administration of an NMBD. In an emergent situation, testing the TOF response before the administration of an
NMBD may not be possible. Rationale: Testing improves the reliability of the interpretation of the TOF response.
• Whenever possible, determine the supramaximal stimulation (SMS) level before initiating NMBDs. The SMS is the
level at which additional stimulating current elicits no further increase in the intensity of the four twitches. In an
emergent situation, determination of the SMS level before the administration of an NMBD may not be possible.
Rationale: This determination helps establish adequate stimulating current and improves reliability of testing.
Procedures for Peripheral Nerve Stimulators
FIGURE 38-1 Placement of electrodes along the ulnar nerve.
FIGURE 38-2 Placement of electrodes along the facial nerve.
References
1. De Laet I, Hoste, E, Verholen, E, et al, The effect of neuromuscular blockers in patients with intra-abdominal
hypertension. Intensive Care Med. 2007; 33(10):1811–1814 [Epub June 27, 2007].
2. Foster, J, Clark, AP. Functional recovery after neuromuscular blockade in mechanically ventilated critically ill -
patients. Heart Lung. 2006; 35(3):178–189.
3. Jacobi, J, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill
adult. Crit Care Med. 2002; 30:119–140.
4. Kim, KS, et al. The duration of immobilization causes the changing pharmacodynamics of mivacurium and
rocuronium in rabbits. Anesth Analg. 2003; 96:438–442.
5. Murray, M, et al. Clinical guidelines for sustained neuromuscular blockade in the adult critically ill patient.
Crit Care Med. 2002; 30:142–156.
6. Murray, MJ, Brull, SJ, Bolton, CF, Brief review. nondepolarizing neuromuscular blocking drugs and critical -
illness myopathy. Can J Anaesth. 2006; 53(11):1148–1156.
7. Nagelhout, JJ, Naglaniczny, KL. Nurse anesthesia, ed 3. Philadelphia: Saunders; 2004.
8. Saitoh, Y, et al. Monitoring of neuromuscular block after administration of vecuronium in patients with
diabetes mellitus. Br J Anaesth. 2003; 90:480–486.
9. Thompson, C, Monitoring the neuromuscular junction.
www.usyd.edu.au/su/anaes/lectures/nmj_monitoring_clt/nmjonitoring.html, August 5, 2008 [retrieved, from].
10. Viamed, Operator’s Manual Microstim. www.viamed.co.uk/products/microstim/microstim.htm, August 4, 2008
[retrieved, from].
Additional Reading
Arbor, R. Continuous nervous system monitoring, EEG, the bispec tral index, and neuromusc ular transmission. AACN Clin Issues. 2003; 14:185–207.
UNIT II
Cardiovascular System
SECTION FIVE
Cardiac Emergencies
P R OC E D UR E 3 9
PURPOSE:
An automated external defibrillator is a defibrillator that, with use of a computerized detection system, analyzes
cardiac rhythms, distinguishes between rhythms that require defibrillation and rhythms that do not, and delivers
a series of preprogrammed electrical shocks. The automated external defibrillator is designed to allow early
defibrillation by providers who have minimal or no training in rhythm recognition or manual defibrillation.
FIGURE 39-1 Automated external defibrillator device. (Courtesy Philips Medical Systems.)
• Time is the major determining factor in the success rates of defibrillation. For every minute defibrillation is delayed,
the chance of success decreases by 7% to 10%.1,2,5 When used in conjunction with effective CPR, the decrease in the
likelihood of success is more gradual and averages 3% to 4% per minute.1,2,5
• Although defibrillation is the definitive treatment for VF and pulseless VT, the use of the AED is not a stand-alone
skill; it is used in conjunction with CPR. CPR should be started as soon as the patient is found to be pulseless and not
stopped until the AED has been turned on, the pads have been attached, and the machine is prompting the provider
to “stand clear” or “don’t touch the patient.”1,2,5 Immediate postshock CPR starting with compressions has been
documented to lead to increased return of spontaneous circulation and increased cerebral survival,4,5 which is why
time is not taken to check for a rhythm or pulse after defibrillation.
• Ventricular fibrillation depletes the cardiac energy stores of adenosine triphosphate (ATP) more rapidly than a normal
rhythm. The longer a heart goes without circulation, the more depleted its energy stores. In a heart with depleted
energy stores, defibrillation is more likely to result in asystole because no fuel remains to support spontaneous
depolarization or myocardial contraction. Effective CPR can supply the needed oxygen and energy substrates to the
heart cells and allow them to return to a perfusing rhythm.4,5
• Three stages of VF are seen in cardiac arrest. The first phase is the electrical phase. During this phase, which is
considered the first 4 to 5 minutes of VF, defibrillation is most likely to be effective, and the sooner the shock can be
delivered the more likely it is to work. During the next 5 to 10 minutes after VF occurs, the hemodynamic or
circulatory phase, a brief period of CPR may “prime the pump” and provide oxygen and energy substrate to the
myocardial cells, improving the effectiveness of the defibrillation. If the patient is found during this phase, or if CPR is
not ongoing when the defibrillator arrives, effective CPR needs to be administered for approximately 2 minutes, or
five cycles of 30 compressions to two ventilations, before the shock. The metabolic phase starts 10 minutes after VF.
During this phase, the cardiac cells have experienced global ischemia and energy depletion if no CPR has been
initiated. CPR before defibrillation is more likely to be successful and needs to be used in conjunction with advanced
cardiac life support (ACLS) therapies.4,5
• The AED is attached to the patient with adhesive electrode pads. Through these pads, the rhythm is analyzed and a
shock delivered, if indicated. If the AED recognizes VF or VT, visual and verbal prompts guide the operator to deliver
a shock to the patient. The AED, not the operator, makes the decision about whether the rhythm is appropriate for
defibrillation.
• The chance of the AED shocking inappropriately is minimal.1,5,7 The AED should be applied only to unresponsive,
nonbreathing, pulseless patients. To keep artifact interference to a minimum, the patient should not be touched or
moved during the analysis time.
• The mnemonic “PAAD” makes it easy for the rescuer to remember the steps of operation of the AED: “P” for Power
on, “A” for Attach the pads, “A” for clear to Analyze, and “D” for clear to Defibrillate.
• Although AEDs are simple to use, healthcare personnel should be familiar with and technically competent in use of
their AED.
• The AED is recommended for use in children ages 1 through 8 years if the child shows no signs of circulation.
Approximately 5% to 15% of children in arrest have initial VF.1,5,6 Primary VF in children rapidly changes to asystole;
rhythm detection and rapid defibrillation in children is most effective. It is best if the defibrillator has a pediatric
switch or pediatric pads, which have an attenuator in the cord that decreases the amount of energy delivered. If
pediatric pads are not available, adult pads should be used.1-3,5,7 With use of adult pads, ensure that they do not touch
each other because this may cause electrical arcing and skin burns and divert defibrillation energy. The pads should
be at least 1 inch apart. If the pads cannot be fit on the child’s chest in a lead two position, an anterior-posterior pad
placement should be used.1-3,5,7,9 Never use pediatric pads on an adult or large child because the reduced energy levels
delivered by these electrodes may not be effective for treatment of VF.
• The use of AEDs in prehospital settings has increased the success of defibrillation. The goal in the hospital should be to
have the ability to defibrillate any person in cardiac arrest within 3 minutes or less of discovery. Placement of AED
units in nonmonitored patient units and in public use areas of a hospital increases patient chances of survival.2,5,6,8,10,11
AEDs are also recommended to be placed in freestanding or ambulatory care settings.
• Many manual defibrillators that can be purchased have analysis capability that allows a tiered response (i.e.,
individuals with different skill levels can use the same defibrillator).
• Most AEDs in use in emergency response systems (EMS) or in the hospital have a method of recording the event, in
the form of rhythm strip printouts, audio and event recording devices, data cards, or computer chips that can print
an event summary.
• AEDs can be purchased with and without monitor screens. AEDs with screens may allow the provider with rhythm
recognition skills to override the AED’s analysis and recommendations.
• An important safety issue an AED operator must address is the possibility of inadvertently shocking a bystander or
other provider at the scene. The operator must clear the patient verbally and visibly, by looking at the patient from
head to toe, before and during the discharge of the energy to the patient.
• All defibrillation programs need to include training for the potential operators. Training should include psychomotor
skills, troubleshooting, equipment maintenance, and how to interface with ACLS providers. Providers have the
responsibility to be familiar with the machine they will use.
• When a resuscitation team (e.g., 911 responders, code team, ACLS providers) arrives, the team assumes responsibility
for monitoring and treating the patient.
EQUIPMENT
• AED
• Nonsterile gloves
• Barrier device or airway management equipment (bag-valve device with mask and oxygen)
• Hand towel
• At least two sets of adult defibrillation pads and potentially one set of child defibrillation pads
Additional equipment to have available as needed includes the following:
• Trauma shears (with ability to cut through underwires)
• Clippers or scissors
• Extra electrocardiographic (ECG) paper
• Spare data card
• Backboard
Patient Preparation
• Remove clothing from the patient’s chest and ensure that the skin is dry where the AED electrodes will be placed.
Rationale: This action prepares the patient for placement of the AED electrodes and minimizes the risk of electrical
burns.
Procedure for Automated External Defibrillation
References
1. American Heart Association, Guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care, part 4. adult basic life support. Circulation. 2005; 112(Suppl IV):35–46. [IV].
2. American Heart Association. Health care provider basic life support provider manual. Dallas: American Heart
Association; 2006.
3. Atkinson, E, et al. Specificity and sensitivity of automated external defibrillator rhythm analysis in infant and
children. Ann Emerg Med. 2003; 42:185–196.
4. Berg, RA. Immediate post-shock chest compressions improve outcome from prolonged ventricular fibrillation. 0.
Resuscitation. 2008; 78:71–76.
5. Field JM, ed.. ACLS resource text. for instructors and experienced providers. American Heart -Association:
Dallas, 2008.
6. Gombotz, H, Weh, B, Mitterndorfer, W, et al, In-hospital cardiac resuscitation outside the ICU by nursing staff
equipped with automated external defibrillators. the first 500 cases. Resuscitation 2006; 70:416–422.
7. Markenson, D, Pyles, L, Neish, S, and the Committee on Pediatric Emergency Medicine and Section on
Cardiology and Cardiac Surgery. Ventricular fibrillation and the use of automated external defibrillators on
children. Pediatrics 2007; 120:1368–1379.
8. Martinez-Rubio A, et al, Advances for treating in-hospital cardiac arrest. safety and effectiveness of a new
automatic external cardioverter-defibrillator. J Am Coll Cardiol. 2003; 41(4):627–632.
9. Samson, R, Berg, R, Bingham, R, and PALS Task Force. Use of automated external defibrillators for children:
an update; an advisory statement from the Pediatric Advanced Life Support Task Force, International Liaison
Committee on Resuscitation. Resuscitation 2003; 57:237–243.
10. Sandroni, C, Nolan, J, Cavallaro, F, et al, In-hospital cardiac arrest. incidence, prognosis and possible measures to
improve survival. Intensive Care Med 2007; 33:237–245.
11. Zafari, M, et al. A program encouraging early defibrillation results in improved in-hospital resuscitation
efficacy. J Am Coll Cardiol. 2004; 44(4):846–852.
P R OC E D UR E 4 0
Cardioversion
Cynthia Hambac h
PURPOSE:
Cardioversion is the therapy of choice for termination of hemodynamically unstable tachydysrhythmias. It also
may be used to convert hemodynamically stable atrial fibrillation or atrial flutter into normal sinus rhythm.
EQUIPMENT
• Defibrillator/monitor with ECG oscilloscope/recorder capable of delivering a synchronized shock
• ECG cable
• Conductive gel or paste, prepackaged gelled conduction pads or self-adhesive defibrillation pads connected directly to
the defibrillator
• Intravenous sedative or analgesic pharmacologic agents as prescribed
• Bag-valve device with mask and oxygen delivery
• Flow meter for oxygen administration, oxygen source
• Emergency suction and intubation equipment
• Blood pressure monitoring equipment
• Pulse oximeter
• Intravenous infusion pumps
Additional equipment to have available as needed includes the following:
• Cardiac board
• Emergency medications
• Emergency pacing equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Ensure that informed consent is obtained. Rationale: Informed consent protects the rights of the patient and makes
competent decision-making possible for the patient, however, in emergency circumstances, time may not allow for
the consent form to be signed.
• Perform a pre-procedure verification and time out if non-emergent. Rationale: Ensures patient safety.
• Obtain 12 lead ECG. Rationale: Provides baseline data.
• Give the patient nothing by mouth per institution policy. Rationale: Decreases the risk of aspiration.
• Establish a patent intravenous access. Rationale: Medication administration may be necessary.3,5
• Assist the patient to a supine position. Rationale: Supine positioning provides the best access for procedure
initiation, intervention, and management of possible adverse effects.
• Remove all metallic objects from the patient. Rationale: Metallic objects are excellent conductors of electrical
current and could result in burns.
• Remove transdermal medication patches from the patient’s chest or ensure the defibrillator pads or paddles do not
touch patches. Rationale: Transdermal medication patches may block the transfer of energy from the pads or
paddles to the patient and may produce a chest burn when the pads or paddles are placed over it.3,5,10
• Ensure that the patient is in a dry environment, and dry the patient’s chest, if it is wet. Rationale: Water is a
conductor of electricity. If the patient and rescuer are in contact with water, the rescuer may receive a shock or the
patient may receive a skin burn. Also, if the patient’s chest is wet, the current may travel from one paddle across the
water to the other, resulting in a decreased amount of energy to the myocardium.3,5
• If the patient has a hairy chest, clipping or removing the hair from the chest (if time is available) may be necessary.
Rationale: This action allows the electrodes to adhere to the chest.3,5 Chest hair has been known to increase
transthoracic impedance in patients.13,15
• Remove loose-fitting dentures, partial plates, or other mouth prostheses. Rationale: Removal decreases the risk of
airway obstruction during the procedure. Evaluate each individual situation (e.g., dentures may facilitate a tighter seal
for airway management).
• Preoxygenate the patient as prescribed and appropriate to the condition. Rationale: Adequate oxygenation of
cardiac tissue diminishes the risk of cerebral and cardiac complications.5
• Maintain a patent airway with oxygenation throughout the procedure. Rationale: Respiratory depression and
hypoventilation can occur after administration of sedatives and analgesics.
• If time allows, consider administration of sedation and analgesia as prescribed. Rationale: These medications
provide amnesia and decrease anxiety and pain during the procedure.2,3,5-7
Procedure for Cardioversion
Table 40-1
American Heart Association Energy Level Recommendations for Treatment of Tachydysrhythmias
Note: These recommendations are for monophasic energy dose. Use of clinically equivalent biphasic energy dose is acceptable. Polymorphic ventricular tachycardia
should be treated as ventricular fibrillation. With elective cardioversion of atrial fibrillation, an initial biphasic dose of 100 J to 120 J may be follow ed w ith escalation as
needed. Also, consult the device manufacturer for specific recommendations.
(From Field JM: Advanced cardiac life support provider manual, Dallas, 2006, American Heart Association.)
FIGURE 40-1 R w ave synchronization. Note the vertical synchronization marker above each R w ave.
FIGURE 40-2 Paddle placement and current flow in A, monophasic defibrillation and B, biphasic defibrillation. (From Lewis SL, et al: Medical-surgical nursing:
assessment and management of clinical problems, ed 7, St Louis, 2007, Mosby.)
FIGURE 40-3 Anterior-posterior placement of self-adhesive defibrillation pads. A, Anterior pad placed over the left precordium. B, Posterior pad placed
under the right scapula.
References
1. American College of Cardiology, American Heart -Association/American College of Physicians Task Force on
Clinical Competence and Training. American College of Cardiology/American Heart Association 2006 update of
the clinical competence statement on invasive electrophysiology studies, catheter ablation and cardioversion.
Circulation 2006; 114:1654–1668.
2. American College of Cardiology, American Heart Association Task Force on Practice Guidelines and the
European Society of Cardiology Committee for Practice Guidelines. American College of Cardiology/American
Heart -Association/European Society of Cardiology 2006 guidelines for the management of atrial fibrillation.
Circulation 2006; 114:e257–354.
3. American Heart Association, 2005 Guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care, circulation, part 5. electrical therapiesautomated -external defibrillators, defibrillation,
cardioversion, and pacing. Circulation. 2005; 112(Suppl IV):35–46. [IV].
4. Botto, GI, et al, External cardioversion of atrial fibrillation. role of paddle position on technical efficacy and
energy requirements. Heart 1999; 82:726–730.
5. Field JM, ed. Advanced cardiac life support provider manual. Dallas: American Heart Association, 2006.
6. Gowda, SA, et al. Cardioversion of atrial fibrillation. Prog Cardiovasc Dis. 2005; 48(2):88–107.
7. Kim, SS, Knight, BP. Electrical and pharmacologic cardioversion for atrial fibrillation. Med Clin North Am.
2008; 92:101–120.
8. Kirchhof, P, et al, Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of
atrial fibrillation. a randomized trial. Lancet 2002; 360:1275–1279.
9. Klein, AL, et al, Efficacy of transesophageal echocardiography-guided cardioversion of patients with atrial
fibrillation at 6 months. a randomized controlled trial. Am Heart J 2006; 151:380–389.
10. Mair, M, Monophasic and biphasic defibrillators. the evolving technology of cardiac defibrillation. Am J Nurs
2003; 103:58–60.
11. Marinsek, M, et al. Efficacy and impact of monophasic versus biphasic countershocks for transthoracic
cardioversion of persistent atrial fibrillation. Am J Cardiol. 2003; 92:988–991.
12. Page, RL, et al. Biphasic versus monophasic shock -waveform for conversion of atrial fibrillation. J Am Coll -
Cardiol. 2002; 39:1956–1963.
13. Sado, DM, et al. Comparison of the effects of removal of chest hair with not doing so before external
defibrillation on transthoracic impedance. Am J Cardiol. 2004; 93:98–100.
14. Scholten, M, et al. Comparison of monophasic and -biphasic shocks for transthoracic cardioversion of atrial -
fibrillation. Heart. 2003; 89:1032–1034.
15. White, RD, et al. Transthoracic impedance does not affect defibrillation, resuscitation or survival in patients
with -out-of-hospital cardiac arrest treated with non-escalating biphasic waveform defibrillator. Resuscitation.
2005; 64:63–69.
P R OC E D UR E 4 1
Defibrillation (External)
Cynthia Hambac h
PURPOSE:
External defibrillation is performed to eradicate life-threatening ventricular fibrillation or pulseless ventricular
tachycardia. The goal for defibrillation is to restore coordinated cardiac electrical and mechanical pumping
action, resulting in restored cardiac output, tissue perfusion, and oxygenation.
EQUIPMENT
• Defibrillator with electrocardiogram (ECG) oscilloscope/recorder
• ECG cable
• Conductive gel, paste, or prepackaged gelled conduction pads or self-adhesive defibrillation pads connected directly to
the defibrillator
• Bag-valve device with mask and oxygen delivery
• Flow meter for oxygen administration, oxygen source
• Emergency suction and intubation equipment
• Blood pressure monitoring equipment
• Pulse oximeter
• Intravenous infusion pumps
Additional equipment to have available as needed includes the following:
• Cardiac board
• Emergency medications
• Emergency pacing equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teachings (if time is available). Answer questions as they
arise, and reinforce information as needed. Rationale: This communication evaluates and reinforces understanding
of previously taught information.
• If possible, ask a member of pastoral care or another designated healthcare provider to provide support for family
members during the procedure. Rationale: Pastoral care team members or the clergy may provide support to ease
family members’ anxiety during the procedure.
• Remove all metallic objects from the patient. Rationale: Metallic objects are excellent conductors of electrical
current and could result in burns.
• Remove transdermal medication patches from the patient’s chest or ensure the defibrillator pad or paddle does not
touch the patch. Rationale: Transdermal medication patches may block the transfer of energy from the pad or
paddle to the patient and produce a chest burn when the pad or paddle is placed over it.2,8
• Ensure that the patient is in a dry environment, and dry the patient’s chest, if it is wet. Rationale: Water is a
conductor of electricity. If the patient and rescuer are in contact with water, the rescuer may receive a shock or the
patient may receive a skin burn. Also, if the patient’s chest is wet, the current may travel from one paddle across the
water to the other, resulting in a decreased amount of energy to the myocardium.2,8
• If the patient has a hairy chest, clipping or removing the hair from the chest (if time is available) may be necessary.
Rationale: This action allows the electrodes to adhere to the chest.2,8 Chest hair has been known to increase
transthoracic impedance in patients.12,14
• Initiate basic life support (BLS) if immediate defibrillation is not available. Rationale: Basic life support maintains
cardiac output to diminish irreversible organ and tissue damage.2
• Oxygenate the patient with a bag-valve device with mask and 100% oxygen. Rationale: Adequate oxygenation
diminishes the risk of cerebral and cardiac complications.3,8
• Place the defibrillator in the defibrillation mode. Rationale: The defibrillation mode must be set to disperse the
electrical charge randomly because the synchronization mode does not fire in the absence of a QRS complex.
Procedure for Defibrillation (External)
References
1. AHA, Low-energy biphasic waveform defibrillation. -evidence-based review applied to emergency
cardiovascular care guidelines; a statement for healthcare professionals from the American Heart Association
Committee on Emergency Cardiovascular Care and the Subcommittees on Basic Life Support, Advanced Cardiac
Life Support and Pediatric Resuscitation. Circulation 1998; 97:1654–1667.
2. American Heart Association, 2005 Guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care, part 5. electrical therapiesautomated external -defibrillators, defibrillation, cardioversion, and
pacing. Circulation. 2005; 112(Suppl IV):IV-35–46.
3. American Heart Association, 2005 Guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care, part 7. 1. adjuncts for airway control and ventilation. Circulation. 2005; 112(Suppl IV):IV-51–
57.
4. American Heart Association, 2005 Guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care, part 7. 2. management of cardiac arrest. Circulation. 2005; 112(Suppl IV):IV-58–66.
5. American Heart Association, 2005 Guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care, part 7. 4. monitoring and medications. Circulation. 2005; 112(Suppl IV):IV-78–83.
6. American Heart Association, 2005 Guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care, part 7. 5. postresuscitation support. Circulation. 2005; 112(Suppl IV):IV-84–88.
7. Faddy, SC, et al, Biphasic and monophasic shocks for transthoracic defibrillation. a meta analysis of
randomized controlled trials. Resuscitation 2003; 58:9–16.
8. Field, JM. Advanced cardiac life support provider manual. Dallas: American Heart Association; 2006.
9. Graham-Garcia, J, et al, Defibrillation and biphasic shocks. implications for perianesthesia nursing. J
Perianesth Nurs. 2005; 20(1):23–34.
10. Mair, M, Monophasic and biphasic defibrillators. the evolving technology of cardiac defibrillation. Am J Nurs.
2003; 103(8):58–60.
11. Reek, S, et al. Clinical efficacy of a wearable defibrillator in acutely terminating episodes of ventricular
fibrillation using biphasic shocks. PACE. 2003; 26:2016–2022.
12. Sado, DM, et al. Comparison of the effects of removal of chest hair with not doing so before external
defibrillation on transthoracic impedance. Am J Cardiol. 2004; 93:98–100.
13. White, RD. New concepts in transthoracic defibrillation. Emerg Med Clin North Am. 2002; 20:785–807.
14. White, RD, et al. Transthoracic impedance does not affect defibrillation, resuscitation or survival in patients
with out-of-hospital cardiac arrest treated with non-escalating biphasic waveform defibrillator. Resuscitation. 2005;
64:63–69.
Additional Readings
Tough, J. Elec tive and emergenc y defibrillation. Nurs Sta nd. 2008; 22(38):49–57.
P R OC E D UR E 4 2
Defibrillation (Internal)
Linda S c hakenbac h
PURPOSE:
Internal defibrillation is the delivery of an electrical current directly to the myocardial surface via special paddles
placed through an open sternotomy or thoracotomy.
EQUIPMENT
• Surgical head cover, mask, eye protection, sterile gown, sterile gloves
• Open sternotomy or thoracotomy tray
• Sterile internal paddles (ensure compatibility with the defibrillator)
• Defibrillator with electrocardiogram (ECG) oscilloscope and recorder
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Large sterile suction catheter, tubing, suction canisters, suction regulator, and suction source
• Flow meter for oxygen administration
• Bag-valve device with mask capable of delivering 100% oxygen and at least 500-mL volumes
• Intubation equipment
• Intravenous access and IV fluids (e.g., 500 mL of normal saline)
Additional equipment as needed includes the following:
• Emergency medications
• Emergency pacemaker equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Place the patient in a flat supine position. Rationale: This position provides the best access during the procedure
and during intervention for management of adverse effects.
• Remove all metallic objects from the patient. Rationale: Metallic objects are conductors of electrical current and
may cause burns.
• Prepare the patient’s skin with antibacterial solution and drape the patient. Rationale: This preparation decreases
the potential for infection.
• Administer sedation and analgesia as prescribed. Rationale: Promotes patient comfort during the procedure.
• Assist with maintaining an airway and ventilation before the initiation of the procedure. Rationale: The patient’s
airway is protected and maintained, and a means for adequate ventilation and oxygenation is provided.
Procedure for Defibrillation Internal
FIGURE 42-1 Paddle placement for internal defibrillation. (From Kinkade S, Lohrman JE: Critical care nursing procedures: a team approach, Philadelphia, 1990, BC Decker.)
References
1. AORN, Association of periOperative Registered NursesPerioperative standards and recommended practices.
Denver: AORN, 2008.
2. Phillips, N. Berry & Kohn’s operating room technique,, ed 11. St Louis: Mosby; 2007.
3. Soar, J, et al, European Resuscitation Council guidelines -for resuscitation 2005 section 7. cardiac arrest in
special circumstances. Resuscitation. 2005; 67(Suppl 1):S135–S170.
4. Winterhalter, M, et al. Effectiveness and safety of internal rectilinear biphasic versus monophasic defibrillation
in -patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2005; 19(6):739–745.
Additional Readings
Americ an Heart Assoc iation. 2005 AHA guidelines for c ardiopulmonary resusc itation and emergenc y c ardiovasc ular c are. Circula tion. 112(24 S uppl), 2005.
Boyc e, JM, Pittet, D. Guidelines for hand hygiene in health-c are settings. MMWR. 2002; 51(RR16):1–44.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 4 3
PURPOSE:
Emergent open sternotomy for a patient after cardiac surgery is performed to identify and eliminate areas of
persistent hemorrhage, relieve pericardial tamponade, and provide access for open cardiac massage and
internal defibrillation.
EQUIPMENT
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Head cover, masks, eye protection, sterile gown, sterile gloves, sterile drapes
• Sterile open-chest set and sternotomy tray
Wire cutter
Rib spreader
Kelly clamps and skin snaps
Knife handle
Scissors
• Electrocautery equipment: Generator, cautery, electrical dispersing pad (e.g., grounding pad)
• Large sterile suction catheter (e.g., Yankauer)
• Suction containers, tubing, regulator, and suction source
• Radiopaque gauze or other surgical sponge materials
• Polypropylene (Prolene) suture (cutting needle) and other suture material according to preference
• Clip applicator and clips
• Syringes: 3 ml, 5 ml, 10 ml, and 20 ml
• Knife blades: Nos. 10, 11, 15
• Sternal wires or bands
• Sterile stapler or sutures
• Sterile dressing supplies
• Emergency medication and resuscitation equipment, including internal defibrillation paddles and external
defibrillation pads or paddles
Additional equipment as needed includes the following:
• Prescribed analgesia or sedation
• Prescribed blood products and intravenous solutions
• Sterile staple remover
• Defibrillator and compatible internal defibrillation paddles
• Warm saline solution with or without an antibiotic, as prescribed
• Chest tubes and chest tube drainage system
• Epicardial wires
• Intra-aortic balloon pump or other mechanical assist device
• Peripheral nerve stimulator (used if paralytic agents are administered)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand procedural teaching (if time is available). Answer questions as they arise
and reinforce information as needed. Rationale: Understanding of the information provided is evaluated and
reinforced.
• Obtain informed consent (may not be possible if the procedure is an emergency). Rationale: Informed consent
protects the rights of the patient and ensures a competent decision for the patient and the family.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• If time allows, obtain a transthoracic echocardiogram in an attempt to identify mediastinal fluid or clot and ventricular
filling and wall motion. Rationale: An echocardiogram aids in the diagnosis of effusion or tamponade and confirms
the necessity for an open sternotomy.
• Ensure the patient’s airway is protected and that supplemental oxygen is delivered. Rationale: The probability that
the patient’s ventilatory needs will be met is enhanced.
• Position the patient in the supine position with the head of the bed flat. Rationale: This position ensures
visualization of the chest and enhances hemodynamic stability.
• Prescribe and ensure that an analgesic or sedative is administered. Rationale: Promotes patient comfort.
Procedure for Performing Emergent Open Sternotomy
References
1. AORN, Association of periOperative Registered NursesPerioperative standards and recommended practices. -
Denver: AORN, 2008.
2. Chikwe, J, Beddow, E, Glenville, B. Cardiothoracic -surgery. New York: Oxford University Press Inc; 2006.
3. Mason, RJ, Broaddus, VC, Murray, JF, et al. Murray & Nadel’s textbook of respiratory medicine, ed 4. St Louis:
Saunders; 2005.
4. Phillips, N. Berry & Kohn’s operating room technique, ed 11. St Louis: Mosby; 2007.
5. Rothrock, JC. Alexander’s care of the patient in surgery, ed 13. St Louis: Mosby; 2007.
6. Sethares, K, Seifert, PC, Smith, H, Care of patients undergoing cardiac surgery. In Moser DK, Riegel B,
editorsCardiac nursing: a companion to Braunwald’s heart -disease. St Louis: Saunders, 2008.
7. Soar, J, et al, European Resuscitation Council guidelines for resuscitation 2005 section 7. cardiac arrest in
special circumstances. Resuscitation. 2005; 67(Suppl 1):S135–S170.
Additional Readings
Boyc e, JM, Pittet, D. Guidelines for hand hygiene in health-c are settings. MMWR. 2002; 51(RR16):1–44.
Christie, S L, S awatzky, JV, Ac ute c ardiac tamponade. antic ipate the c omplic ation. CACCN 2008; 19:13–17.
Currey, J, Botti, M. The haemodynamic status of c ardiac surgic al patients in the initial 2-h rec overy period. Eur J -Ca rdiova sc Nurs. 2005; 4:207–214.
Finkelmeier, BA. Ca rdiothora cic surgica l nursing, ed 2. Philadelphia: Lippinc ott; 2000.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 4 4
PURPOSE:
Emergent open sternotomy for a patient after cardiac surgery is performed to identify and eliminate areas of
persistent hemorrhage, relieve pericardial tamponade, and provide access for open cardiac massage and
internal defibrillation.
EQUIPMENT
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Head cover, masks, eye protection, sterile gown, sterile gloves, sterile drapes
• Sterile open-chest set and sternotomy tray
Wire cutter
Rib spreader
Kelly clamps and skin snaps
Knife handle
Scissors
• Electrocautery equipment: Generator, cautery, electrical dispersing pad (e.g., grounding pad)
• Large sterile suction catheter (e.g., Yankauer)
• Suction containers, tubing, regulator, and suction source
• Radiopaque gauze or other surgical sponge materials
• Polypropylene (Prolene) suture (cutting needle), other suture material according to preference
• Clip applicator and clips
• Syringes: 3 ml, 5 ml, 10 ml, and 20 ml
• Knife blades: Nos. 10, 11, 15
• Sternal wires or bands
• Sterile stapler or sutures
• Sterile dressing supplies
• Emergency medication and resuscitation equipment
Additional equipment as needed includes the following:
• Prescribed analgesia and sedation
• Blood products and intravenous solutions as prescribed
• Sterile staple remover
• Defibrillator and compatible internal defibrillation paddles
• Warm saline solution with or without an antibiotic, as prescribed
• Chest tubes and chest tube drainage system
• Epicardial wires
• Intra-aortic balloon pump or other mechanical assist device
• Peripheral nerve stimulator (used if paralytic agents are administered)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand procedural teachings (if time available). Answer questions as they arise,
and reinforce information as needed. Rationale: Understanding of the information provided is evaluated and
reinforced.
• Ensure that informed consent was obtained (may not be possible if the procedure is an emergency). Rationale:
Informed consent protects the rights of the patient and ensures a competent decision for the patient and the family.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure the patient’s airway is protected and that supplemental oxygen is delivered. Rationale: Ensures adequate
ventilation and oxygenation.
• Position the patient in the supine position with the head of the bed flat. Rationale: This position ensures
visualization of the chest and enhances hemodynamic stability.
• Provide analgesics and/or sedatives as prescribed. Rationale: Promotes patient comfort.
Procedure for Assisting with Emergent Open Sternotomy
References
1. AORN, Association of periOperative Registered Nurses. Perioperative standards and recommended practices.
AORN, Denver, 2008.
2. Chikwe, J, Beddow, E, Glenville, B. Cardiothoracic surgery. New York: Oxford University Press Inc; 2006.
3. Mason, RJ, Broaddus, VC, Murray, JF, et al. Murray & Nadel’s textbook of respiratory medicine, ed 4. St Louis:
Saunders; 2005.
4. Phillips, N. Berry & Kohn’s operating room technique, ed 11. St Louis: Mosby; 2007.
5. Sethares, K, Seifert, PC, Smith, H. Care of patients undergoing cardiac surgery. In: Moser DK, Riegel B, eds.
Cardiac nursing: a companion to Braunwald’s heart -disease. St Louis: Saunders, 2008.
6. Soar, J, et al, European Resuscitation Council guidelines for resuscitation 2005 section 7. cardiac arrest in
special -circumstances. Resuscitation. 2005; 67(Suppl 1):S135–S170.
Additional Readings
Boyc e, JM, Pittet, D. Guidelines for hand hygiene in health-c are settings. MMWR. 2002; 51(RR16):1–44.
Christie, S L, S awatzky, JV, Ac ute c ardiac tamponade. antic ipate the c omplic ation. CACCN 2008; 19:13–17.
Currey, J, Botti, M. The haemodynamic status of c ardiac surgic al patients in the initial 2-h rec overy period. Eur J Ca rdiova sc Nurs. 2005; 4:207–214.
Finkelmeier, BA. Ca rdiothora cic surgica l nursing, ed 2. Philadelphia: Lippinc ott; 2000.
Rothroc k, JC. Alexa nder’s ca re of the pa tient in surgery, 13. S t Louis: Mosby; 2007.
P R OC E D UR E 4 5
Pericardiocentesis (Perform)
Deborah E. Bec ker
PURPOSE:
Pericardiocentesis is performed for removal of fluid from the pericardial sac, analysis of this fluid for
identification of the etiology of pericardial effusion, and prevention or treatment of cardiac tamponade. Cardiac
output usually is improved after pericardiocentesis.
EQUIPMENT
• Pericardiocentesis tray (or thoracentesis tray)
• 16-gauge or 18-gauge, 3-inch cardiac needle or catheter over the needle
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Two packs of 4 × 4 gauze sponges
• No. 11 knife blade with handle (scalpel)
• Sterile 50-mL to 60-mL, 10-mL, 5-mL, and 3-mL syringes
• Sterile drapes and towels
• Masks, goggles or face shields, surgical head covers, sterile gowns, and gloves
• Two three-way stopcocks
• 1% Lidocaine (injectable)
• 12-lead ECG machine
• Culture bottles and specimen tubes for fluid analysis
• 2-inch and 3-inch tape
Additional equipment as needed includes the following:
• Emergency cart (defibrillator, emergency respiratory equipment, emergency cardiac medications, and temporary
pacemaker)
• Two-dimensional echocardiography equipment
• Sterile marker
• Echocardiogram contrast medium
• Suture supplies
• If continuous drainage is necessary:
J guidewire, 0.035 diameter
Vessel dilator, 7 Fr
Pigtail catheter, 7 Fr
Tubing and drainage bag or bottle
Three-way stopcock and nonvented caps
Patient Preparation
• Ensure that the patient and family understand pre-procedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Obtain informed consent (may not be possible if the procedure is an emergency). Rationale: Informed consent
protects the rights of the patient and ensures a competent decision for the patient and the family.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Coordinate the procedure with the echocardiogram technician to assist with the two-dimensional echocardiogram if
this approach is being taken. Rationale: Echocardiogram-directed pericardiocentesis allows for more precise
localization of the effusion and may help to prevent complications.1,2,7
• If tolerated, position the patient comfortably in the supine position with the head of the bed elevated 30 to 60 degrees.
Rationale: This position facilitates the aspiration of pericardial fluids and the ease of breathing.
• Prescribe and ensure that an analgesic or sedative is administered. Rationale: Analgesia and sedation reduce anxiety
and promote comfort.
• Apply the limb leads and connect the leads to the cardiac bedside monitoring system or to the 12-lead ECG machine.
Rationale: The ECG is analyzed during and after the procedure to monitor the patient for changes that may
indicate cardiac injury.
Procedure for Performing Pericardiocentesis
FIGURE 45-1 Subxiphoid approach to catheter placement into pericordial space. A, A short needle (16-gauge or 18-gauge) is inserted into the left
xiphocostal angle perpendicular to the skin and 3 to 4 mm below the left costal margin. B, After the needle is advanced to the inner aspect of the rib cage, the
needle’s hub is depressed so that the needle points tow ard the patient’s left shoulder. The needle is then cautiously advanced about 5 to 10 mm until fluid is
reached. The fingers may sense a distinct “give” w hen the needle penetrates the parietal pericardium. Successful removal of fluid confirms the needle’s
position. C, The syringe is then disconnected from the needle, and the flexible tip of the guidew ire is advanced into the pericardial space. The needle is
w ithdraw n and replaced w ith a soft multihole pigtail catheter (no. 6F to 8F) w ith use of the Seldinger technique. D, After dilation of the needle tract, the
catheter is advanced over the guidew ire into the pericardial space. E, Once the catheter is properly positioned, aspiration of fluid should result in rapid
improvement in blood pressure and cardiac output, a decrease in atrial and pericardial pressures, and a decrease in the degree of any paradoxical pulse.
Electrical alternans, if present, also decreases or disappears. (From Spodick DH: The technique of pericardiocentesis, J Crit Ill 2:91, 1987.)
References
1. Becker, RC. Pericardiocentesis. In Irwin RS, et al, eds. : Procedures and techniques in intensive care medicine,, ed 6,
Philadelphia: Lippincott Williams & Wilkins, 2008.
2. Belenkie, I. Pericardial disease. In Hall JB, et al, eds. : Principles of critical care, ed 3, Quebec, 2005.
3. Harper, RJ. Pericardiocentesis. In Roberts JR, et al, eds. : Clinical procedures in emergency medicine,, ed 4,
Philadelphia: Elsevier, 2004.
4. Hoit, BD. Circulation. Management of effusive and constrictive pericardial heart disease. 2002; 105:2939–2942.
5. LeWinter, MM, Pericardial diseasesLibby P, et al, eds.. Braunwald’s heart disease. a textbook of cardiovascular
medicine. ed 8. Saunders, Philadelphia, 2008.
6. O’Grady, NP, et al. Guidelines for the prevention of -intravascular catheter-related infections. Am J Infect -
Control. 2002; 30(8):476–489.
7. Rifkin, RD, Mernoff, DB. Noninvasive evaluation of -pericardial effusion composition by computed -
tomography. Am Heart J. 2005; 149:1120–1127.
8. Tsang, TS, et al, Echocardiographically guided pericardiocentesis. evolution and state-of-the-art technique.
Mayo Clin Proc 1998; 73:647–652.
Additional Readings
Kuhn, B, Peters, J, Marx, GR, et al. Etiology, management and outc ome of pediatric peric ardial effusions. Pedia tr Ca rdiol. 2008; 29:90–94.
Mavroukakis, S , S tine, A. Nursing management of adults with disorders of the c oronary arteries, myoc ardium,or peric ardium. In: Beare PG, Myers JL, eds.
Adult hea lth nursing. S t Louis: Mosby, 1998.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 4 6
Pericardiocentesis (Assist)
Deborah E. Bec ker
PURPOSE:
Pericardiocentesis is performed for removal of fluid from the pericardial sac, analysis of this fluid for
identification of the etiology of pericardial effusion, and prevention or treatment of cardiac tamponade. Cardiac
output usually is improved after pericardiocentesis.
EQUIPMENT
• Pericardiocentesis tray (or thoracentesis tray)
• 16-gauge or 18-gauge, 3-inch cardiac needle or catheter over the needle
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Two packs of 4 × 4 gauze sponges
• No. 11 knife blade with handle (scalpel)
• Sterile 50-mL to 60-mL, 10-mL, 5-mL, and 3-mL syringes
• Sterile drapes and towels
• Masks, goggles or face shields, surgical head covers, sterile gowns, and gloves for all personnel
• Two three-way stopcocks
• 1% lidocaine (injectable)
• 12-lead ECG machine
• Culture bottles and specimen tubes for fluid analysis
• 2-inch and 3-inch tape
Additional equipment as needed includes the following:
• Emergency cart (defibrillator, emergency respiratory equipment, emergency cardiac medications, and temporary
pacemaker)
• Two-dimensional echocardiography equipment
• Sterile marker
• Echocardiogram contrast medium
• Suture supplies
• If continuous drainage is necessary:
J guidewire, 0.035 diameter
Vessel dilator, 7 Fr
Pigtail catheter, 7 Fr
Tubing and drainage bag or bottle
Three-way stopcock and nonvented caps
Patient Preparation
• Ensure that the patient and family understand pre-procedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that informed consent is obtained. Rationale: Informed consent protects the rights of the patient and makes
competent decision making possible for the patient; however, in emergency circumstances, time may not allow for
the consent form to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Assist if needed with coordinating the procedure with the echocardiogram technician if the two-dimensional
echocardiogram approach will be used. Rationale: The echocardiogram technician locates the fluid accumulation,
which makes performing the pericardiocentesis easier for the provider.1,2,6
• If tolerated, position the patient comfortably in the supine position with the head of bed elevated 30 to 60 degrees.
Rationale: The supine position facilitates aspiration of pericardial fluids and ease of breathing.
• Administer analgesics or sedatives as prescribed. Rationale: Analgesia and sedation reduce anxiety and promote
comfort.
• Apply the limb leads and connect the patient to the cardiac bedside monitoring system or to the 12-lead ECG
machine. Rationale: The ECG is analyzed during and after the procedure to monitor the patient for changes that
may indicate cardiac injury.
Procedure for Assisting with Pericardiocentesis
References
1. Becker, RC. Pericardiocentesis. In Irwin RS, et al, eds. : Procedures and techniques in intensive care medicine,, ed 6,
Philadelphia: Lippincott Williams & Wilkins, 2008.
2. Belenkie, I. Pericardial disease. In Hall JB, et al, eds. : Principles of critical care,, ed 3, Quebec: McGraw-Hill,
2005.
3. Harper, RJ. Pericardiocentesis. In Roberts JR, et al, eds. : Clinical procedures in emergency medicine,, ed 4,
Philadelphia: Elsevier, 2004.
4. Hoit, BD. Management of effusive and constrictive pericardial heart disease. Circulation. 2002; 105:2939–2942.
5. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30(8):476–489.
6. Rifkin, RD, Mernoff, DB. Noninvasive evaluation of pericardial effusion composition by computed
tomography. Am Heart J. 2005; 149:1120–1127.
7. Tsang, TS, et al, Echocardiographically guided pericardiocentesis. evolution and state-of-the-art technique.
Mayo Clin Proc 1998; 73:647–652.
Additional Readings
Kuhn, B, Peters, J, Marx, GR, et al. Etiology, management and outc ome of pediatric peric ardial effusions. Pedia tr Ca rdiol. 2008; 29:90–94.
Mavroukakis, S , S tine, A. Nursing management of adults with disorders of the c oronary arteries, myoc ardium, or peric ardium. In: Beare PG, Myers JL, eds.
Adult hea lth nursing. S t Louis: Mosby, 1998.
SECTION SIX
Cardiac Pacemakers
P R OC E D UR E 4 7
Atrial Electrogram
Teresa Preuss and Debra Lynn-Mc Hale Wiegand
PURPOSE:
An atrial electrogram is obtained to determine the presence of atrial activity in a dysrhythmia or to identify the
relationship between atrial and ventricular depolarizations.
EQUIPMENT
• Nonsterile gloves
• Temporary atrial epicardial pacing wires placed during cardiac surgery
• Multichannel ECG monitor and recorder or 12-lead ECG machine (ensure that biomedical safety standards are met
and machine is safe for use with epicardial wires)
• Sterile dressings and materials needed for site care
Additional equipment as needed:
• ECG electrodes
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands pre-procedure teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Expose the patient’s chest and identify the epicardial pacing wires. Rationale: This action provides access to the
atrial pacing wires.
Procedure for Atrial Electrogram
FIGURE 47-1 Atrial w ires exit the chest to the right of the patient’s sternum. Ventricular w ires exit the chest to the left of the patient’s sternum. (Drawing by
Todd Sargood.)
FIGURE 47-2 Tip of atrial epicardial w ire in direct contact w ith the metal on the end of the V lead w ire. (Drawing by Paul W. Schiffmacher, Thomas Jefferson
University, Philadelphia.)
FIGURE 47-3 The tip of the atrial epicardial w ire in direct contact w ith the conductive gel on the adhesive side of the electrode. (Kern LS , McRae ME, Funk M:
ECG monitoring after cardiac surgery: post-opeative atrial fibrillation and the atrial electrogram, AACN Adv Crit Care 18[3]:298, 2007.)
FIGURE 47-4 An electrode w rapped around the tip of the atrial epicardial w ire. (Kern LS, McRae ME, Funk M: ECG monitoring after cardiac surgery: postoperative atrial
fibrillation and the atrial electrogram, AACN Adv Crit Care 18[3]:299, 2007.)
FIGURE 47-5 Unipolar AEG strip from lead V. The surface ECG w as obtained in lead II. On the basis of the surface ECG, the rhythm appears to be junctional
w ith no evidence of P w aves or atrial activity. The unipolar AEG show s retrograde P w aves that follow the QRS complex, confirming the junctional rhythm
interpretation.
FIGURE 47-6 Unipolar AEG strip from lead I. The surface ECG w as obtained in lead V. The unipolar AEG w as obtained in lead I. The atrial activity is
magnified in lead I.
FIGURE 47-7 Attach 12-lead ECG per procedure except that the RA lead w ire connects to one of the atrial-epicardial pacing w ires. (Drawing by Todd
Sargood.)
FIGURE 47-8 Bipolar AEG strip from lead I. The surface ECG w as obtained in lead V. The bipolar AEG w as obtained in lead I. The atrial activity is magnified
in lead I. Also note how small the ventricular activity is in lead I.
FIGURE 47-9 A 12-lead ECG obtained w ith tw o atrial pacing w ires connected to the RA and LA lead w ires. Lead I show s a bipolar AEG. The P w ave is
greater in size than the QRS complex. Leads II and III show unipolar AEGs. In leads II and III, atrial activity is enhanced. Throughout, the 12-lead ECG atrial
activity is enhanced.
References
1. Batra, AS, Balaji, S, Postoperative temporary epicardial pacing. when, how and why. Ann Ped Cardiol. 2008;
1(2):120–125.
2. Drew, BJ, et al, Practice standards for electrocardiographic monitoring in hospital settings. an American Heart
Association Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and
Cardiovascular -Disease in the Young. Circulation 2004; 110:2721–2746.
3. Kern, LS, McRae, ME, Funk, M, ECG monitoring after cardiac surgery. postopeative atrial fibrillation and the
atrial electrogram. AACN Adv Crit Care 2007; 18:294–304.
4. Miller, JN, Drew, BJ, Atrial electrogrms after cardiac -surgery. survey of clinical practice. Am J Crit Care 2007;
16:350–359.
5. Overbay, D, Criddle, L. Mastering temporary invasive cardiac pacing. Crit Care Nurs. 2004; 24(3):25–32.
6. O’Grady, NP, et al. Guidelines for prevention of intravascular catheter-related infections. Am J Infect Control.
2002; 30:476–489.
Additional Readings
Waldo, AL, Henthorn, RW, Plumb, VJ, Temporary epic ardial wire elec trodes in the diagnosis and treatment of arrhythmias after open heart surgery. Am J Surg .
1984; 148:275–283.
Waldo, AL, et al, Use of temporarily plac ed epic ardial atrial wire elec trodes for the diagnosis and treatment of c ardiac arrhythmias following open-heart
surgery. J Thora c Ca rdiova sc Surg . 1978; 76:500–506.
P R OC E D UR E 4 8
PURPOSE:
Atrial overdrive pacing is used to terminate reentrant atrial dysrhythmias, especially atrial flutter, and allow
restoration of sinus rhythm. Sinus rhythm enhances cardiac output by allowing atrial contraction to contribute to
ventricular filling.
FIGURE 48-1 A, Temporary dual-chamber pulse generator w ith overdrive atrial pacing capability. B, Enlargement of low er screen on the pacemaker
show ing rapid atrial pacing controls. (Courtesy Medtronic, Inc.)
• Advanced cardiac life support knowledge and skills are necessary.
• Supraventricular dysrhythmias (e.g., atrial flutter, reentrant atrial tachycardia, atrioventricular [AV] nodal reentry
tachycardia, reentrant tachycardias that use an accessory pathway, such as Wolff-Parkinson-White [WPW] syndrome)
sometimes can be terminated by overdrive atrial pacing.
• Atrial fibrillation occasionally terminates with overdrive atrial pacing, but this is not a reliable therapy for atrial
fibrillation.
• Overdrive atrial pacing is performed most commonly with epicardial atrial pacing wires placed during cardiac
surgery. A transvenous atrial pacing lead with an active fixation tip to help keep the lead in the atrium also can be
used.
• Overdrive atrial pacing involves the delivery of short bursts of rapid pacing stimuli through an epicardial atrial pacing
wire or a transvenous lead in the atrium. The physician or advanced practice nurse determines the duration and rate
of the burst.
One approach to overdrive pacing is to atrial pace the heart with 20 milliampere (mA) at a rate 20% to 30% faster
than the intrinsic atrial rate for 30 seconds, then stop pacing. An alternate approach is to initiate atrial pacing at a
rate 20 beats/min faster than the intrinsic atrial rate; if 1:1 capture does not occur after 30 seconds, the paced rate
can be increased by 20 beats/min; repeat every 30 seconds until 1:1 capture is achieved. Continue pacing until the
heart rate decreases from AV block (e.g., 2:1, 3:1) or 1 to 2 minutes of 1:1 pacing have occurred, then stop pacing.6
Successive bursts usually are performed at gradually increasing rates (maximal capability of the pulse generator for
overdrive atrial pacing is 800 pulses/min) and may be delivered for up to 2 minutes.7
• The atrial pacing wire or atrial pacing lead needs to be accurately identified with initiation of overdrive pacing because
pacing the ventricle at rapid rates may result in ventricular tachycardia or ventricular fibrillation.
• Rapid atrial pacing may result in degeneration of the atrial rhythm to atrial fibrillation with a rapid ventricular
response. This pacemaker-induced atrial fibrillation usually does not sustain itself for more than a few minutes before
it converts to normal sinus rhythm.6
• If an accessory pathway is present, rapid atrial pacing can result in conduction to the ventricles over the accessory
pathway, leading to ventricular fibrillation.
• Overdrive suppression of the sinus node may result in periods of bradycardia, asystole, junctional or ventricular
escape rhythms, or polymorphic ventricular tachycardia on termination of the atrial overdrive pacing and the atrial
tachydysrhythmia.
• Conversion of an atrial tachydysrhythmia can result in dislodgment of atrial thrombus and embolization of clots to the
pulmonary or systemic circulation.
EQUIPMENT
• Nonsterile gloves
• External pulse generator capable of rapid atrial pacing
• Connecting cable (between the pulse generator and the patient’s pacemaker leads)
• Cardiac monitor and recorder
• Electrocardiogram (ECG) electrodes
• Double alligator clip or wire with connector pins (if needed to create a ground wire)
• Materials for epicardial pacing wire site care:
Antiseptic pads or swab sticks (e.g., 2% chlorhexidine-based preparation)
Gauze pads
Tape
• Insulating material for epicardial pacing wires or transvenous pacing electrode connector pins (e.g., finger cots, glove,
needle caps)
• Blood pressure monitoring system
Additional equipment to have available as needed includes the following:
• Defibrillator
• Emergency medications
• Airway management equipment
• Standard pulse generator or transcutaneous pacemaker and equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Obtain informed consent (may not be possible in an emergency). Rationale: Informed consent protects the rights of
the patient and makes a competent decision possible for the patient.
• Ensure that the patient and family understand pre-procedural teaching. Answer questions as they arise and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Initiate continuous bedside cardiac monitoring (if not already in place). Rationale: The patient’s cardiac rate and
rhythm must be visible at the bedside during the procedure to determine atrial capture during pacing and to evaluate
the response of the patient’s cardiac rate and rhythm after pacing.
• Obtain a 12-lead ECG as needed. Rationale: The ECG may aid in determining the patient’s baseline cardiac rhythm.
• Assist the patient to a supine position. Rationale: This position facilitates access to the epicardial pacemaker wires or
the transvenous atrial pacing lead wire.
• Place a blood pressure cuff on the patient’s arm and obtain the patient’s blood pressure or obtain the patient’s blood
pressure from the arterial catheter. Rationale: This aids in assessment of the patient’s hemodynamic response to
rapid atrial pacing.
Procedure for Performing Atrial Overdrive Pacing
FIGURE 48-2 The top trace show s ECG lead II recorded during an episode of paroxysmal atrial tachycardia at a rate of 150 beats/min. Beginning w ith the
eighth beat in this trace (black dot), rapid atrial pacing at a rate of 165 beats/min w as initiated. In the middle trace, w hich begins 12 seconds after the top
trace, atrial capture is show n clearly. In the bottom trace, w hich is continuous w ith the middle trace, sinus rhythm appears w hen atrial pacing is terminated
abruptly (open circle). Paper recording speed w as 25 mm/s. S, Stimulus artifact. (From Cooper TB, MacLean WAH, Waldo AL: Overdrive pacing for supraventricular
tachycardia: a review of theoretical implications and therapeutic techniques, Pacing Clin Electrophysiol 1:200, 1978.)
FIGURE 48-3 Rhythm strip show s rapid atrial pacing in an attempt to terminate atrial flutter.
References
1. Batra, AS, Balaji, S, Post operative temporary epicardial pacing. when, how and why. Ann Pediatr Cardiol. 2008;
1(2):120–125.
2. Blomström-Lundqvist C, et, al, ACC/AHA/ESC guidelines for the management of patients with supraventricular
-arrhythmias. executive summarya report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines
(Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias).
J Am Coll Cardiol 2008; 42:1493–1531.
3. O’Grady, NP, et al. Guidelines for the prevention of -intravascular catheter-related infections. Am J Infect -
Control. 2002; 30:476–489.
4. Oligin, JE, Zipes, DP, et al, Specific arrhythmias. diagnosis and treatmentLibby P, ed. Braunwald’s heart disease:
a textbook of cardiovascular medicine, ed 8, Philadelphia: Saunders/Elsevier, 2008.
5. Overbay, D, Criddle, L. Mastering temporary invasive -cardiac pacing. Crit Care Nurs. 2004; 24(3):25–32.
6. Palazzo, MO. Atrial fibrillation and postoperative -cardiac surgery patient. Crit Care Nurs Clin North Am. 2007;
19:395–402.
7. Smith, W, Hood, M. Arrhythmias. In: Sidebotham D, et al, eds. Cardiothoracic critical care. Philadelphia:
Butterworth-Heinemann, 2007.
Additional Reading
Americ an Heart Assoc iation. AHA guidelines for c ardiopulmonary resusc itation and emergenc y c ardiovasc ular c are. Circula tion. 112(24 S uppl), 2005.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 4 9
PURPOSE:
Temporary epicardial pacing wires are inserted into the epicardium during cardiac surgery and are removed
when pacing therapy is no longer needed.
EQUIPMENT
• Gown, goggles or face shield with mask, nonsterile gloves
• Antiseptic solution (e.g., 2% chlorhexidine-based solution)
• Suture removal kit
• Sterile gauze
Additional equipment that may be needed includes the following:
• Emergency equipment
• Temporary transcutaneous or transvenous pacing equipment
Patient Preparation
• Verify correct patient with two patient identifiers. Rationale: Prior to performing a procedure, the nurse should
ensure the correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Evaluates and reinforces understanding of previously taught information.
• Remove epicardial pacing wires at least the day before discharge (approximately 24 hours or longer).3,6,9 Rationale:
Removal at this time provides time for observation for potential complications.
• Administer prescribed analgesic medication before removing the epicardial pacing wires.8 Rationale: Analgesics
may minimize discomfort during epicardial pacing wire removal.
• Determine the patency of an intravenous (IV) catheter. Rationale: A patent IV is necessary should emergency fluids
or medications be needed.
• Ensure that patient has electrocardiographic (ECG) monitoring. Rationale: ECG monitoring provides assessment for
the presence of potential dysrhythmias during epicardial wire removal.
Procedure for Epicardial Pacing Wire Removal
References
1. AORN, Association of periOperative Registered NursesPerioperative standards and recommended practices,.
Denver: AORN, 2008.
2. Carroll, KC, Reeves, LM, Andersen, G, et al. Risks associated with removal of ventricular epicardial pacing
wires after cardiac surgery. Am J Crit Care. 1998; 7(6):444–449.
3. Clark, L, Bedside nurses removing epicardial pacer wires. from concept to practice. Can J Cardiovascr Nurs.
2007; 17(1):27–30.
4. Conte, JV, et al. The Johns Hopkins manual of cardiac -surgical care, ed 2. Philadelphia: Mosby; 2008.
5. Mullin, MH, Roschkov, S, Jensen, L, et al. Sensations -during removal of epidural pacing wires after coronary -
artery bypass graft surgery. Heart Lung. 2009; 38(5):337–381.
6. Pennsylvania Patient Safety Authority. Minimizing complications from temporary epicardial pacing wires after
cardiac surgery. PA-PSRS Patient Safe Advis. 2006; 3(1):1–6.
7. Phillips, N. Berry & Kohn’s operating room technique,, ed 11. St Louis: Mosby; 2007.
8. Roschkov, S, Jensen, L. Coronary artery bypass graft -patients’ pain perception during epicardial pacing wire -
removal. Can J Cardiovasc Nurs. 14, 2004.
9. Wollan, DL, Removal of epicardial pacing wires. an -expanded role for nurses. Prog Cardiovasc Nurs. 1995;
10(4):21–26.
Additional Readings
Gentry, WH, Hassan, AA, Complic ations of retained epic ardial pac ing wires. an unusual bronc hial foreign body. Ann Thorac S urg. 1993; 56(6):1391–1393.
Hornig, GS , Ashley, E, Balsam, L, et al, Progressive dyspnea after CABG. c omplic ation of retained epic ardial pac ing wires. Ann Thorac S urg 2008; 86:1352–1354.
Matwiyoff, GN, Mc Kinlay, JR. Transepidermal migration of external c ardiac pac ing wire presenting as a c utaneous nodule. J Am Aca d Derma tol. 42(5), 2000.
Meier, DJ, Tamirisa, KP, Eitzman, DT. Ventric ular tac hyc ardia assoc iated with transmyoc ardial migration of an epic ardial pac ing wire. Ann Thora c Surg. 2004;
77:1077–1079.
Rothroc k, JC. Alexa nder’s ca re of the pa tient in surgery,, ed 13. S t Louis: Mosby; 2007.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 5 0
Implantable Cardioverter-Defibrillator
Carol A. Offutt and S haron R. Josephson-Keeven
PURPOSE:
The implantable cardioverter-defibrillator is a device that is used to prevent sudden cardiac death from
malignant ventricular dysrhythmias. The implantable cardioverter-defibrillator continuously monitors a patient’s
rhythm and attempts to convert ventricular tachycardia or ventricular fibrillation via antitachycardia pacing,
cardioversion, defibrillation, or some combination of these. The implantable cardioverter-defibrillator has the
capability for backup bradycardia pacing.
FIGURE 50-1 ICD and lead system (including superior vena cava lead, right ventricular lead, and coronary sinus lead). (Courtesy Boston Scientific Corporatio,
Natick, MA.)
• Battery longevity may be greater than 6 years, depending on the number of times therapies are delivered and the
frequency of pacing.5 The pulse generator is typically located in a pectoral subcutaneous pocket.
• The leads are insulated wires that sense the patient’s intrinsic rhythm and can pace or deliver therapies (Fig. 50-2).
Leads are classified as atrial or ventricular, endocardial (transvenous) or epicardial (myocardial), unipolar or bipolar,
and active or passive fixation.8 The lead systems may be single, double, or multiple.
FIGURE 50-2 Top, ICD patch that is placed on the right ventricle. Bottom, Superior vena cava lead. (Courtesy Boston Scientific Corporation, Natick, MA.)
• Leads may be attached to the heart via active or passive fixation. Active fixation leads use a screw, barb, or hook at the
tip that is embedded into the myocardium to ensure stability of the lead. Passive fixation leads use tines or fins at the
tip that allow the lead to attach to trabeculae of the myocardium.
• Most leads are endocardial (transvenous) leads and are inserted transvenously through the subclavian, cephalic, or
axillary veins.
• Epicardial leads are less common but are used in special circumstances. Epicardial pacing leads may be placed on the
outside of the left ventricular to provide biventricular pacing when coronary sinus placement of the LV lead has been
unsuccessful. Epicardial patches may be placed on the outside of the heart, both anteriorly and posterior. Epicardial
patches provide a greater surface area for defibrillation (See Fig. 50-2).
• All leads have a cathode (negative pole) and an anode (positive pole). A unipolar lead uses one conductor wire, with a
distal electrode as cathode and the metal can as the anode. This configuration produces a large electrical circuit and a
large pacing artifact on electrocardiography (ECG). Because of the large area covered, this configuration is susceptible
to stimulation of chest muscles and also to electromagnetic interference. A bipolar lead uses two electrodes on the
distal end of the lead to form the circuit. The cathode is located at the distal tip, and the anode several millimeters
proximal to the tip. Because of the closer circuitry, a smaller pacing artifact is seen on ECG.
• All ICDs function as pacemakers. Some ICDs are also biventricular pacemakers. Cardiac resynchronization therapy
(CRT) paces the right and left ventricles together to establish synchrony in an effort to improve LV function. CRT is
considered for patients with symptomatic heart failure, optimized medical therapy, LVEF less than 35%, and
prolonged QRS duration of greater than 120 milliseconds.1 Biventricular pacing must be as close to 100% as possible
for the greatest benefit. Biventricular pacing leads are placed in the right atrium, the right ventricle, and an epicardial
vein on the surface of the left ventricle accessed through the coronary sinus.
• The ICD detects tachydysrhythmias, delivers antitachycardia pacing (ATP) or electrical therapy (shock), and provides
bradycardia pacing. ATP attempts to convert monomorphic VT by pacing at a rate faster than the VT rate, thereby
terminating the dysrhythmia. ATP is a painless way of treating VT, sometimes avoiding shock therapy altogether. The
PainFree II trial demonstrated that compared with shocks, empirical ATP for fast VT was highly effective, equally safe,
and, improved quality of life.17 Cardioversion is generally referred to as synchronized electrical therapy. Defibrillation
is not synchronized and is generally used to convert ventricular dysrhythmias.
• The ICD therapies may be programmed from one to three zones. Typically, the zones are labeled as 1, VT, usually at
slower VT rates of 140 to180 beats per minute (varies according to physician preference and patient situation); 2, fast
VT, usually at rates in the range of 180 to 220 beats per minute or higher; and 3, VF for rates usually greater than 220
beats per minute. VT zones may be programmed for sequential therapies of ATP followed by electrical defibrillation if
ATP is unsuccessful.
• A defibrillator code was developed in 1993 by the North American Society of Pacing and Electrophysiology and the
British Pacing and Electrophysiology Group to describe the capabilities and operation of ICDs. The defibrillator code
is patterned after the pacemaker code; however, it has some important differences (Table 50-1).2 The defibrillator code
offers less information about the ICD’s antibradycardia pacing function but more specific information about the
shock functions.
Table 50-1
NASPE/BPEG Defibrillator Code
NASPE/BPEG, North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group.
From Bernstein AD, et al., 1993. The NASPE/BPEG defibrillator code (NBD code). Pacing Clin Electrophysiol, 16, 1776, 1993.
• A magnet applied over an ICD disables the device therapies of ATP and electrical cardioversion/defibrillation but does
not affect pacemaker function. The magnet is used during procedures that may cause electromagnetic interference
(EMI). EMI from cautery devices, for example, may be improperly sensed as a tachydysrhythmia, causing
inappropriate device shock. In most models, removal of the magnet restores normal ICD function. Some models,
however, do not resume previous settings once the magnet is removed.9 Checking with the manufacturer before
magnet use is best to determine the specific recommendations for each ICD. If a device programmer and trained
personnel are available, device tachydysrhythmia detection and therapies can be disabled through the programmer
for the duration of the procedure.
• Emotional adjustments vary with each patient and family. Patients may experience depression, anxiety, fear, and
anger. Some patients view the device as an activity restriction, and others see it as a life-saving device that allows
normal life to resume. Preimplantation psychologic variables, such as degree of optimism or pessimism, and an
anxious personality style may place patients at a higher level of risk for difficulty adjusting to the ICD.13 Support
groups may serve a vital role for ICD recipients who are anxious and for patients who may need additional support.10
Interventions to reduce psychologic distress and improve quality of life may reduce morbidity and mortality in these
patients.3,11,12,15
• The option of ICD deactivation should be discussed before the device is implanted.18 Early discussions of device
deactivation facilitate later discussions and are an important part of the informed consent process.
EQUIPMENT
• ECG monitor and recorder
• ECG electrodes
Additional equipment to have available as needed includes the following:
• ICD programmer (commonly obtained from the electrophysiology department or specific manufacturer)
• Magnet (doughnut or bar type)
• 12-lead ECG machine
• Analgesia and sedation as prescribed
• Emergency medications and resuscitation equipment
• Antidysrhythmia medications as prescribed
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand pre-procedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent has been obtained (before ICD insertion). Rationale: Informed consent protects the
rights of the patient and makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out (before ICD insertion). Rationale: Ensures patient safety.
• Provide analgesia or sedatives as prescribed and needed. Rationale: Analgesia and sedatives promote comfort and
may decrease anxiety.
Procedure for Implantable Cardioverter-Defibrillator
References
1. Abraham, WT, Yancy, CW, Cardiac resynchronization therapy. a practical guide for device optimization, part I.
CHF 2006; 12:169–173.
2. Bernstein, AD, et al. The NASPE/BPEG defibrillator code (NBD code). Pacing Clin Electrophysiol. 1993;
16:1776.
3. Bostwick, JM, Sola, CL. An updated review of implantable cardioverter/defibrillators, induced anxiety, and
quality of life. Psychiatr Clin North Am. 2007; 30(4):677–688.
4. Bubien, RS, et al. Defibrillation and resynchronization, AACN Clin Issues. 2004; 15(3):340–361.
5. Ellenbogen, KA, Wood, MA. Cardiac pacing & ICDs, ed 5. Oxford: Blackwell Publishing, 2008.
6. Epstein, AE, et al, ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. a
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac
Pacemakers and Antitachydysrhythmia Devices) developed in collaboration with the American Association for
Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008; 51(21):e1–e61.
7. Esptein, AE, et al. Circulation. 2007; 115:1170–1176.
8. Hayes, DL, Asirvatham, SJ. Dictionary of cardiac pacing, defibrillation, resynchronization, and arrythmias, ed 2.
Minneapolis, MN: Cardiotext Publishing, 2007.
9. McMullan, J, et al. Care of the pacemaker/implantable cardioverter-defibrillator patient in the ED. Am J Emerg
Med. 2007; 25(7):1–13.
10. Myers, GM, James, GD. Social support, anxiety, and support group participation in patients with an implantable
cardioverter defibrillator. Prog Cardiovasc Nurs. 2008; 23(4):160–167.
11. Sears, SF, et al, Effective management of ICD patients psychosocial issues and patient critical eventsJ Cardiovasc
Electrophysiol. epublication at printing/ahead of print, 2009.
12. Sears, SF, et al, State-of-the-art. anxiety management of patient with implantable cardioverter-defibrillators. Stress
Health. 2008; 24(3):239–248.
13. Shea, J, et al, Quality of life issues in patients with implantable cardioverter defibrillators. driving, occupation,
and recreation. AACN Clini Issues. 2004; 15(3):89–478.
14. Stevenson, WG, et al. Clinical assessment and management of patients with implanted cardioverter-
defibrillators presenting to nonelectrophysiologists. Circulation. 2004; 110:3866–3869.
15. Thomas, SA, et al. Quality of life and psychological status of patients with implantable cardioverter defibrillators.
Am J Crit Care. 2006; 15(4):389–398.
16. Trupp, RJ, Bubien, RS. Care of patients with implanted cardiac rhythm management devices. In: Moser DK,
Riegel B, eds. Cardiac nursing: a companion to Braunwald’s heart disease. St Louis: Elsevier, 2008.
17. Wathen, MS, et al, Prospective randomized multicenter trial of empirical antitachycardia pacing versus shocks
for spontaneous rapid ventricular tachycardia in patients with implantable cardioverter-defibrillators. Pacing Fast
Ventricular Tachycardia Reduces Shock Therapies (PainFREE Rx II) trial results. Circulation. 2004; 110(17):2591–
2596.
18. Wiegand, DL, Kalowes, P. Withdrawal of cardiac medications and devices. AACN Adv Criti Care. 2007; 18(4):415–
425.
19. Wilkoff, BL, et al, HRS/EHRA expert consensus on the monitoring of cardiovascular implantable electronic
devices (CIEDs). description of techniques, indications, personnel, frequency and ethical considerations. Heart
Rhythm. 2008; 5(6)
Additional Readings
Additional Readings
Abraham, WT, et al, for the MIRACLE S tudy Group. Cardiac resync hronization in c hronic heart failure. N Engl J Med 2002; 346:1845–1853.
Bardy, GH, Lee, KL, Mark, DB, et al, for the S udden Death -in Heart Failure Trial (S CD-HeFT) investigators. -Amiodarone or an implantable c ardioverter-
defibrillator for c ongestive heart failure. N Engl J Med 2005; 352:225–237.
Bristow, MR, S axon, LA, Boehmer, J, et al, Comparison of Medic al Therapy, Pac ing, and Defibrillation in Heart -Failure (COMPANION) investigators. c ardiac -
resync hronization therapy with or without an implantable defibrillator in advanc ed c hronic heart failure. N Engl J Med. 2004; 350(21):2140–2150.
Buxton, AE, et al, for the Multic enter Unsustained Tac hyc ardia Trial investigators. a randomized study of the prevention of sudden death in patients with c oronary
artery disease. N Engl J Med 1999; 341:1882–1890.
Gura, MT, et al. North Americ an S oc iety of Pac ing and -Elec trophysiology standards of professional prac tic e for the allied professional in pac ing and
elec trophysiology. PACE. 2003; 26:127–131.
Kadish, A, Dyer, A, et al. Prophylac tic defibrillator implantation in patients with nonisc hemic dilated c ardiomyopathy. N Engl J Med. 2004; 350:2151–2158.
Moss, AJ, Zareba, W, et al. Prophylac tic implantation of a defibrillator in patients with myoc ardial infarc tion and reduc ed ejec tion frac tion. N Engl J Med. 2002;
346:877–883.
Moss, AJ, et al, Improved survival with an implanted defibrillator in patients with c oronary disease at high risk for -ventric ular tac hydysrhthmia. Multic enter
Automatic -Defibrillator Implantation Trial investigators. N Engl J Med 1996; 335:1933–1940.
Mushlin, A, Jac kson Hall WJ, Zwanziger, J, et al, the -MADIT investigators. The c ost-effec tiveness of automatic implantable c ardiac defibrillatorsresults from
MADIT. Circ ulation 1998; 97:2129–2135.
S ears, S F, et al. Quality of death and ICDs. PACE. 2006; 29:637–642.
S t John S utton MG, et al. Effec t of c ardiac resync hronization therapy on left ventric ular size and func tion in c hronic heart failure. Circula tion. 2003; 107(15):1985–
1990.
Young, JB, Abraham, WT, S mith, AL, et al, Combined c ardiac resync hronization and implantable c ardioversion defibrillation in advanc ed c hronic heart failure. the
MIRACLE ICD trial. JAMA 2003; 289:2685–2694.
Wingate, S , Wiegand, D. End of life c are in the c ritic al c are unit for patients with heart failure. Crit Ca re Nurse. 2008; 28(2):84–96.
P R OC E D UR E 5 1
PURPOSE:
The purpose of permanent pacing is to electrically stimulate myocardial contraction, and to restore and maintain
an appropriate heart rate or ventricular synchrony when a chronic conduction or impulse formation disturbance
exists in the cardiac conduction system. Assessment of the permanent pacemaker is important in maintaining
proper function.
• Unipolar pacing involves a relatively large electrical circuit. The distal tip of the pacing lead is the negative electrode
and is in contact with the myocardium. The positive electrode encompasses the metallic pacemaker case, located in
the soft tissue. Energy is delivered from the negative electrode to the positive electrode, causing myocardial
depolarization. The electrocardiogram (ECG) tracing shows a large, easily visible spike.
• Bipolar pacing uses a smaller electrical circuit in which the distal tip of the pacing lead is the negative electrode in
contact with the myocardium. The pacing lead has a second positive electrode that is located within 1 cm of the
negative electrode. Energy is delivered from the negative electrode to the positive electrode, causing myocardial
depolarization. The ECG tracing may show small spikes, or the spikes may not be visible on a surface ECG.
• Basic principles of cardiac pacing include sensing, pulse generation, capture, and impedance (Table 51-1 lists
definitions).
Table 51-1
Pertinent Definitions Related to Pacemakers
• Depending on the type of pacemaker, the pacemaker lead may be placed in the atrium, the right ventricle, or the left
ventricle. A standard code exists to describe pacemakers (Table 51-2).2 The nurse must know the programmed mode
with the pacemaker code to determine whether the device is functioning appropriately. Refer to Table 51-3 to review
different programmed modes for pacemakers.
Table 51-2
Revised NASPE/BPEG Generic Code for Antibradycardia Pacing*
†Manufacturer’s designation only. NASPE, North American Society of Pacing and Electrophysiology; BPEG, British Pacing and Electrophysiology Group.
(From Bernstein AD, et al: The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing, Pacing Clin Electrophysiol 25:261,
2002.)
Table 51-3
Programmed Pacing Modes
Pacemaker
Pacemaker Response
Code
AOO Atrial pacing; no sensing; asynchronous mode→paces atria at fixed, preprogrammed rate.
AAI Atrial pacing, atrial sensing and inhibition; intrinsic P waves inhibit atrial pacing; if no sensed atrial events0paces in atria at preprogrammed rate.
AAIR Atrial pacing; atrial sensing; intrinsic P waves inhibit atrial pacing; if no sensed atrial events→paces in atria; rate response to patient’s activity.
VOO Ventricular pacing; no sensing; asynchronous mode→paces ventricle at fixed, preprogrammed rate.
VVI Ventricular pacing: ventricular sensing; intrinsic QRS inhibits ventricular pacing; if no sensed events→paces in ventricle at preprogrammed rate.
VVIR Ventricular pacing: ventricular sensing; intrinsic QRS inhibits ventricular pacing; if no sensed events→paces in ventricle; rate response to patient’s activity.
DOO Atrial and ventricular pacing: no sensing; asynchronous mode→paces atria and ventricles at fixed, preprogrammed rate.
DDI Atrial and ventricular pacing; atria and ventricular sensing; no tracking of atria: sensed atrial events inhibit atrial pacing/do not trigger a ventricular pacing
pulse; sensed atrial events with absent ventricular event inhibit atrial pacing but do pace ventricle at preprogrammed rate; if both atrial and ventricular
events absent→AV sequential pacing results at preprogrammed rate.
DDIR Atrial and ventricular pacing; atrial and ventricular sensing; no tracking of atria (as described previously in DDI); AV sequential rate modulation.
DDD Atrial and ventricular pacing; atrial and ventricular sensing; intrinsic P wave and intrinsic QRS can inhibit pacing; intrinsic P wave can trigger a paced QRS
(tracks the atrium).
May see four possible combinations in DDD mode: 1, atrial sensed/ventricular sensed; 2, atrial sensed/ventricular paced; 3, atrial paced/ventricular
sensed; 4, atrial paced/ventricular paced.
DDDR Atrial and ventricular pacing; atrial and ventricular sensing; tracks the atrium: intrinsic P wave and intrinsic QRS can inhibit pacing, intrinsic P wave can
trigger a paced QRS; AV sequential rate modulation.
• Dual-chamber or DDD pacemakers contain pacing leads that are located in the atrium and the ventricle. Pacing and
sensing occur in both chambers. Pacing is inhibited by sensed atrial or ventricular activity. Sensed or paced atrial
activity triggers a ventricular paced response in the absence of intrinsic ventricular activity within a programmed AV
interval.4
• Biventricular pacemakers (CRT) contain leads in the right atrium and the right ventricle and on the surface of the left
ventricles and simultaneously pace the right and left ventricle (Fig. 51-2).
FIGURE 51-2 Biventricular pacemaker (cardiac resynchronization therapy). (Courtesy Medtronic, Inc, Minneapolis, MN.)
• Some pacemaker systems also include an implantable cardioverter-defibrillator (ICD; see Procedure 50).
• Some pacemakers can be programmed to switch modes (e.g., DDD mode to VVI mode) to avoid pacing at the upper
rate in patients who experience intermittent atrial dysrhythmias in which rapid atrial rates are generated.
• Certain pacemakers can be programmed with pacing therapies for atrial dysrhythmias. This programming is called
antitachycardia pacing, in which the device paces faster than a patient’s heart rate in an attempt to convert the
rhythm.
• Rate-responsive pacemakers include a sensor and are designed to mimic normal changes in heart rate based on
physiologic needs. Most commonly, the sensor reacts to motion and vibration or respirations and initiates an
appropriate change in the pacing rate, depending on metabolic activity. These patients have a set pacemaker rate
range.
• Inappropriate pacemaker function includes failure of pulse generation, failure to sense, and failure to capture (see
Table 51-1 for definitions).
• Electromagnetic interference (EMI) may interfere with pacemaker function and includes electrocautery, cardioversion
and defibrillation, magnetic resonance imaging (which is contraindicated for patients on pacemakers), diathermy, and
transcutaneous nerve stimulators. Other outside causes of EMI include welding equipment less than 24 inches from
the device, electrical motors, chain saws, battery-powered cordless power tools and drills less than 12 inches from
device, magnetic mattresses and chairs, and airport wands for security checks. Household appliances such as
microwave ovens rarely cause EMI. Cell phones may cause EMI and should be used on the ear opposite the device.
The cell phone should be carried on the opposite side of the body, with at least 6 inches maintained between the cell
phone and the device.10 Patients who are pacemaker-dependent may experience dizziness, lightheadedness, near
syncope, or syncope if EMI inhibits proper sensing and therefore inhibits pacing.
• A pacemaker programmer appropriate for the pacemaker make and model is required for a device check or
“interrogation.” Note that some situations may require notification of the device manufacturer to obtain the proper
interrogation equipment (the device programmer). Manufacturer information can be found on the patient’s
pacemaker identification card.
EQUIPMENT
• ECG monitor and recorder with paper
• ECG cable and electrodes
Additional equipment to have available as needed includes the following:
• Pacemaker magnet
• Pacemaker programmer appropriate for the pacemaker manufacturer and model
Patient Preparation
• Verify the correct patient with two patient identifiers. Rationale: Prior to performing a procedure, the nurse should
ensure the correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand teaching. Answer questions as they arise, and reinforce information as
needed. Rationale: This communication evaluates and reinforces understanding of previously taught information.
• Pacemaker interrogation may be performed with the patient either sitting or in supine position. Rationale: This
position prepares the patient for pacemaker interrogation.
Procedure for Assessing Function of Permanent Pacemaker
FIGURE 51-3 DDD pacing, normal operation: atrial activity sensed, ventricle paced.
FIGURE 51-4 Dual-chamber DDD pacing, normal operation: atrial paced, ventricle paced.
FIGURE 51-7 Ventricular undersensing. Pacemaker appears to be firing asynchronously. The third and sixth ventricular complexes represent concurrent
intrinsic ventricular depolarization overlaid by inappropriate pacemaker fire.
FIGURE 51-8 DDD system w ith failure to capture or sense ventricular activity. All ventricular spikes show absence of corresponding ventricular
depolarization. No timing circuit reset by intrinsic ventricular complexes.
FIGURE 51-9 Biventricular pacing. A, Intrinsic ventricular activation (left bundle branch block). B, Right ventricular pacing. C, Left ventricular pacing. D,
Biventricular pacing. (Used with permission. Ellenbogen KA, Wood MA: Cardiac pacing & ICDs, ed 5, Oxford, 2008, Blackwell Publishing, 1095.)
References
1. Abraham, WT, et al, for the MIRACLE Study Group. Cardiac resynchronization in chronic heart failure. N
Engl J Med 2002; 346:1845–1853.
2. Bernstein, AD, et al. The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite
pacing. Pacing Clin Electrophysiol. 2002; 25:261.
3. Bristow, MR, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in
advanced chronic heart failure. N Engl J Med. 2004; 350:2140–2150.
4. Ellenbogen, KA, Wood, MA. Cardiac pacing & ICDs, ed 5. Oxford: Blackwell Publishing; 2008.
5. Epstein, AE, et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities.
JACC. 2008; 51(21):e1–e61.
6. Hayes, DL, Asirvatham, SJ. Dictionary of cardiac pacing, defibrillation, resynchronization, and arrhythmias.
Minneapolis: Cardiotext; 2007.
7. Scheibly, K, Tsiperfal, A. ECG evidence of biventricular capture. Progress Cardiovasc Nurs Summer. 2007; 177–
179.
8. St John Sutton MG, et al. Effect of cardiac resynchronization therapy on left ventricular size and function in
chronic heart failure. Circulation. 2003; 107(15):1985–1990.
9. Sweeney, MO. Programming and follow-up of cardiac resynchronization devices. In: Ellenbogan KA, et al, eds.
Clinical cardiac pacing, defibrillation, and resynchronization therapy. Philadelphia: Elsevier, 2007.
10. Trupp, RJ, Bubien, RS. Care of patients with implanted cardiac rhythm management devices. In: Moser DK,
Riegel B, eds. Cardiac nursing: a companion to Braunwald’s heart disease. St Louis: Elsevier, 2008.
11. Wilkoff, BL, Pacemaker remote follow-up evaluation and review. results of the PREFER triallate-breaking clinical
trial session. Heart Rhythm Society Sessions, San Francisco, May 14, 2008.
12. Wilkoff, BL, et al, HRS/EHRA expert consensus on the monitoring of cardiovascular implantable electronic
devices (CIEDs). description of techniques, indications, personnel, frequency and ethical considerations. Heart
Rhythm. 2008; 5(6)
Additional Readings
Albert, NM. Cardiac resync hronization therapy through biventric ular pac ing in patients with heart failure and ventric ular dyssync hrony. Crit Ca re Nurse. 2003;
23(3 S uppl):2–13.
Czarnec ki, R, Biventric ular pac ing. when one or two leads aren’t enough. Cardiac Insider S pring 2007; 7–10.
Epstein, LM. Prac tic al c onsiderations for remote monitoring. Congest Hea rt Fa il. 2008; 14(5 S uppl):25–28.
Germany, R. The use of devic e-based diagnostic s to manage patients with heart failure. Congest Hea rt Fa il. 2008; 14(5 S uppl):19–24.
Gura, MT, et al, North Americ an S oc iety of Pac ing Elec trophysiology. standards of professional prac tic e for the allied professional in pac ing and
elec trophysiology. Pac ing Clin Elec trophysiol 2003; 26:31–127.
Herbst, MC. Permanent pac emakers. In: Davis L, ed. Ca rdiova scula r nursing secrets. S t Louis: Elsevier, 2004.
Hesselson, AB. Simplified interpreta tion of pa cema ker ECGs. Baltimore: Futura/Blac kwell Public ations; 2003.
Kenny, T. The nuts a nd bolts of ca rdia c pa cing. Malden, MA: Blac kwell Publishing; 2005.
Kenny, T. The nuts a nd bolts of ca rdia c resynchroniza tion thera py. Malden, MA: Blac kwell Publishing; 2007.
Majorowic z, K, Persons requiring permanent pac emakers. Continuing educ ation for nurses 2003. CME Resourc e, S ac ramento, 2003.
S auer, WH, Bristow, MR. The c omparison of medic al therapy, pac ing, and defibrillation in heart failure (COMPANION) trial in perspec tive. J Interv Ca rd
Electrophysiol. 2008; 21(1):3–11.
P R OC E D UR E 5 2
PURPOSE:
Transcutaneous or external pacing stimulates myocardial depolarization through the chest wall. External pacing
is used as a temporary measure when normal cardiac conduction fails to produce myocardial contraction and the
patient experiences hemodynamic instability.
• Sensitivity refers to the ability of the pacemaker to detect intrinsic myocardial activity.
• In the nondemand or asynchronous mode, pacing occurs at the set rate regardless of the patient’s intrinsic rate. In the
demand or synchronous mode, the pacemaker senses intrinsic myocardial activity and paces when the intrinsic
cardiac rate is lower than the set rate on the external pulse generator.
• Pacing occurs when the external pulse generator delivers enough energy through the pacing electrodes to the
myocardium, which is known as pacemaker firing and is represented as a spike on the electrocardiographic (ECG)
tracing (Fig. 52-2).
FIGURE 52-2 ECG tracing of external pacing. (From Zoll Medical Corporation, Burlington, MA.)
• Electrical capture occurs when the pacemaker delivers enough energy to the myocardium so that depolarization
occurs. Capture is seen on the ECG with a pacemaker spike followed by a ventricular complex. The ventricular
complex occurs after the pacemaker spike, and the QRS is wide, with the initial and terminal deflections in opposite
directions. In Fig. 52-2, complexes 2 and 3 begin with a downward (negative) deflection and end with an upward
(positive) direction. Mechanical capture occurs when a paced QRS complex results in a palpable pulse.
• Standby pacing is when the pacing electrodes are applied in anticipation of possible use but pacing is not needed at the
time.
EQUIPMENT
• Blood pressure monitoring equipment
• External pulse generator
• Pacing cable
• Pacemaker electrodes (patches)
• ECG electrodes
• ECG monitor
• ECG cable
Additional equipment to have available as needed includes the following:
• Emergency cart with medications and other equipment
• Scissors
• Transvenous pacing equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand pre-procedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Maintain bedside ECG monitoring. Rationale: External pacing units do not provide central monitoring or
dysrhythmia detection.
• Administer sedative or analgesic medication as prescribed to a conscious patient before initiation of pacing.
Rationale: External cardiac pacing is uncomfortable.
• Assist the patient to the supine position and expose the patient’s torso while maintaining modesty. Rationale: This
positioning prepares for electrode (patch) placement.
Procedure for Temporary Transcutaneous (External) Pacing
FIGURE 52-3 Location of the posterior (back) pacing electrode. (Aehlert B: ACLS study guide, ed 3, St Louis, 2007, Mosby, 229.)
FIGURE 52-4 Location of the anterior (front) pacing electrode. (Aehlert B: ACLS study guide, ed 3, St Louis, 2007, Mosby, 229.)
FIGURE 52-5 Location of anterior-lateral pacing electrodes. (Aehlert B: ACLS study guide, ed 3, St Louis, 2007, Mosby, 229.)
References
1. Aehlert, B. ACLS study guide,, ed 3. St Louis: Mosby; 2007.
2. American Heart Association, Guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care: g. part5: electrical therapies: automated external defi brillators,defi brillation, cardioversion, and pacin.
Circulation. 2005; 112(Suppl IV):IV-35–IV-45.
3. American Heart Association, Guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care. part 7. 3management of symptomatic bradycardia and tachycardia. Circulation. 2005; 112(Suppl IV):IV-67–
IV-77.
4. Antman, EM, et al, ACC/AHA guidelines for management of patients with ST-elevation myocardial
infarction. a -report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. Circulation 2004; 100:e82–e293.
5. Drew, B, et al, Practice standards for electrocardiographic monitoring in hospital settings. an American Heart -
Association scientific statement from the Councils on -Cardiovascular Nursing, Clinical Cardiology, and -
Cardiovascular Disease in the Youngendorsed by the -International Society of Computerized Electrocardiology
and the American Association of Critical-Care Nurses. Circulation 2004; 110:2721–2746.
6. Field J, ed.. Part 4. ACLS core cases, bradycardia case in advanced cardiac life support provider manual.
American Heart Association: Dallas, 2006.
7. Gibson, T. A practical guide to external cardiac pacing. Nursing Standard. 2008; 22:20–48.
8. Medtronic Physio-Control Corp. LIFEPAK 20 defibrillator/monitor operating instructions. Inc. Redmond, WA:
Physio-Control; 2008.
9. Zoll, P. Noninvasive temporary cardiac pacing. J Electrophys. 1987; 1:2–161.
Additional Readings
Doukky, R, et al, Using transc utaneous c ardiac pac ing to best advantage. how to ensure suc c essful c apture and avoid c omplic ations. J Crit Illness 2003; 5:25–219.
Jac obson, C, Marzlin, K, Webner, C, Elec tric al management of arrhythmias in c ardiovasc ular nursing prac tic e Chapter 17. Cardiovasc ular Nursing Educ ation
Assoc iates, Burien, WA, 2007.
P R OC E D UR E 5 3
PURPOSE:
The purpose of temporary cardiac pacing is to ensure or restore an adequate heart rate and rhythm. A
transvenous pacemaker is inserted as a temporary measure when the normal conduction system of the heart
fails to produce or conduct an electrical impulse, resulting in hemodynamic compromise or other debilitating
symptoms.
• The pacing lead can be a hard-tipped or a balloon-tipped pacing catheter that is placed in direct contact with the
endocardium. Most temporary leads are bipolar with the distal tip electrode (seen as a metal ring) separated from the
proximal electrode by 1 to 2 cm of pacing catheter (also seen as a metal ring; see Fig. 53-1).
• Basic principles of cardiac pacing include sensing, pacing, and capture.
• Sensing refers to the ability of the pacemaker device to detect intrinsic myocardial electrical activity. Sensing occurs if
the pulse generator is in the synchronous or demand mode. The pacemaker either is inhibited from delivering a
stimulus or initiates an electrical impulse.
• Pacing occurs when the temporary pulse generator is activated and the programmed level of energy travels from the
pulse generator through the temporary pacing lead wire to the endocardium, which is known as pacemaker firing
and is represented as a vertical line or spike on the electrocardiogram (ECG) recording.
• Capture refers to the successful conduction of the pacemaker impulse through the myocardium, resulting in
depolarization. Capture is evidenced on the ECG by a pacemaker spike followed by either an atrial or a ventricular
complex, depending on the chamber being paced. The healthcare provider can assess whether the electrical
depolarization resulted in mechanical activity by observing the right atrial pressure, left atrial pressure, or pulmonary
artery or arterial pressure waveforms or whether the ventricle is paced by palpating a pulse.
• Temporary pulse generator features include the following:
The temporary pulse generator houses the controls and the energy source for pacing.
Pulse generators can be used for single-chamber pacing with one set of terminals at the top of the pulse generator,
into which the pacing wires are inserted (via connecting cable).
A dual-chamber pacemaker requires two sets of terminals, one each for the atrial and ventricular wires.
Different models of pacemakers use either dials or touch pads for changing the settings.
The pacing rate is determined by the rate set by the dial or rate pad.
The AV interval dial or pad on a dual-chamber pacemaker controls the amount of time between atrial and
ventricular stimulation (electronic PR interval).
The energy delivered to the endocardium is determined by setting the output (milliamperage [mA]) dial or pad on
the pulse generator.
Dual-chamber pacing requires that mA are set for the atria and the ventricle.
• The ability of the pacemaker to detect the patient’s intrinsic rhythm is determined by the pacing mode. In the
asynchronous mode, the pacemaker functions as a fixed-rate pacemaker and is not able to sense any of the patient’s
inherent cardiac electrical activity. In the synchronous mode, the pacemaker is able to sense the patient’s inherent
cardiac electrical activity.
• The ability of the pacemaker to depolarize the myocardium depends on many variables: position of the electrode and
degree of contact with viable endocardial tissue; level of energy delivered through the pacing wire; presence of
hypoxia, acidosis, or electrolyte imbalances; fibrosis around the tip of the catheter; and concomitant medication
therapy.2,4
• All electrical equipment in the patient’s room must be properly grounded to prevent interference from occurring.
EQUIPMENT
• Antiseptic skin preparation solution (e.g., 2% chlorhexidine-based solution)
• Sterile drapes, towels, masks, head cover, goggles or face shields, gowns, gloves, and dressings
• Balloon-tipped pacing catheter and insertion tray
• Pacing lead wire (if balloon-tipped catheter is unavailable)
• Pulse generator
• 9-V battery for pulse generator
• Connecting cables
• Alligator clips or wires with connecting pins
• ECG monitor and recorder
• Supplies for dressing at insertion site
Additional equipment as needed includes the following:
• Local anesthetic
• Percutaneous introducer needle or 14-gauge needle
• Introducer sheath with dilator
• Guidewire (per physician or advanced practice nurse choice)
• Suture with needle, syringes, needles, and scalpel
• Emergency equipment
• Portable ultrasound scan equipment
• Fluoroscopy
• Lead aprons or shields
• 12-lead ECG machine
Patient Preparation
• Verify correct patient using two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise and reinforce
information as needed. Rationale: Evaluates and reinforces understanding of previously taught information.
• Obtain informed consent. Rationale: Informed consent protects the rights of the patient and makes a competent
decision possible for the patient; however, in emergency circumstances, time may not allow a consent form to be
signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Connect the patient to a 5-lead monitoring system or to a 12-lead ECG machine. Rationale: This monitoring
facilitates the placement of the balloon-tipped catheter by indicating the position of the catheter during its placement.
Also, it allows for monitoring of the patient’s cardiac rhythm during the procedure.
• Prescribe and ensure that pain medication and/or sedation is administered. Rationale: Medication may be indicated
depending on the patient’s level of anxiety and pain. Sedation or pain medication may not be possible if the patient’s
condition is hemodynamically unstable.
Procedure for Performing Temporary Transvenous Pacemaker Insertion
FIGURE 53-2 Alligator clips. ECG, electrocardiogram.
FIGURE 53-3 ECG rhythm recorded in the right ventricle; elevated ST segments w hen the pacing electrode is w edged against the endocardial w all of the
right ventricle. (From Meltzer LE, Pinneo R, Kitchell JR: Intensive coronary care, ed 4, Bowie, MD, 1983, Robert J. Brady Co.)
References
1. Dahlberg, ST. Temporary cardiac pacing. In Irwin RS, et al, eds. : Procedures and techniques in intensive care
medicine,, ed 6, Philadelphia: Lippincott Williams & Wilkins, 2008.
2. Espiritu, JD, Keller, CA. Pneumomediastinum and subcutaneous emphysema from pacemaker placement.
Pacing Clin Electrophysiol. 2001; 24:1041–1042.
3. Harrigan, RA, Chan, TC, Moonblatt, S, et al. Temporary transvenous pacemaker placement in the emergency -
department. J Emerg Med. 2007; 32:105–111.
4. Huysmans, W, Budts, W. Late free atrial wall rupture after percutaneous atrial septal defect closure and
transvenous pacemaker implantation. Catheter Cardiovasc Interv. 2008; 72:286–288.
5. Macedo, W, Jr., et al, Ultrasonographic guidance of -transvenous pacemaker insertion in the emergency -
department. a report of three cases. J Emerg Med 1999; 17:491–496.
6. Norman, EM, Critical care extra. critical questions-avoiding electrical hazards, temporary pacing wires. Am J
Nurs 1998; 98:16GG-HH.
7. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 5 4
PURPOSE:
The purpose of temporary cardiac pacing is to ensure or restore an adequate heart rate and rhythm.
Transvenous and epicardial pacing are initiated as temporary measures when a failure of the normal conduction
system of the heart to produce an electrical impulse results in hemodynamic compromise.
The pacing lead can be a hard-tipped or balloon-tipped pacing catheter that is placed in direct contact with the
endocardium. Most temporary leads are bipolar, with the distal tip electrode separated from the proximal ring by 1
to 2 cm (see Fig. 53-1).
An external temporary pulse generator is connected to the transvenous pacing wire via a bridging or connecting
cable.
• Pacing via a PA catheter:
Temporary atrial or ventricular pacing via a thermodilution PA catheter can be done with combination catheters
that are specifically designed for temporary pacing.
PA pacing catheters feature atrial and ventricular ports for the introduction of the pacing lead wires (Fig. 54-2).
FIGURE 54-2 Pulmonary artery catheter w ith atrial and ventricular pacing lumens.
Use of a PA catheter combines the capabilities of PA pressure monitoring, thermodilution cardiac output
measurement, fluid infusion, mixed venous oxygen sampling, and temporary pacing.
One limitation of these multifunction catheters is that the simultaneous measurement of pulmonary artery occlusion
pressure (PAOP) and pacing is usually not possible. Balloon inflation can cause repositioning of the pacing electrode
with catheter movement; measurement of the PAOP may cause pacing to become intermittent.8
• Temporary epicardial pacing
Temporary epicardial pacing is a method of stimulating the myocardium through the use of polytetrafluoroethylene
(PTFE)-coated, unipolar or bipolar stainless steel wires that are sutured loosely to the epicardium after cardiac
surgery (Fig. 54-3).
The epicardial wires may be attached to the right atrium for atrial pacing, the right ventricle for ventricular pacing,
or both for AV pacing.
Each pacing wire is brought through the chest wall before the chest is closed.
Typically, the atrial wires are located on the right of the sternum, and the ventricular wires exit to the left of the
sternum (Fig. 54-4)
FIGURE 54-5 Single-chamber temporary pulse generator. (Courtesy Medtronic USA, Inc., Minneapolis, MN)
FIGURE 54-6 Dual-chamber temporary pulse generator. LED-light-emitting diode; LCD-liquid crystal display, (Courtesy Medtronic USA, Inc., Minneapolis, MN).
FIGURE 54-7 Connecting cables. (Courtesy Medtronic USA, Inc., Minneapolis, MN)
FIGURE 54-8 Pulse generator terminals to connect cables from atrial and ventricular leads.
• Different models of pacemakers use either dials or touch pads to change the settings.
The pacing rate is determined by the rate dial or touch pad.
The AV interval dial or pad on a dual-chamber pacemaker controls the amount of time between atrial and
ventricular stimulation (electronic PR interval).
The energy delivered to the myocardium is determined by setting the output (milliampere [mA]) dial or pad on the
pulse generator.
Dual-chamber pacing requires that mA be set for the atria and the ventricle.
• The ability of the pacemaker to detect the patient’s intrinsic rhythm is determined by the pacing mode and sensitivity
setting. In the asynchronous mode, the pacemaker functions as a fixed-rate pacemaker and is not able to sense any of
the patient’s inherent cardiac activity. In the synchronous mode, the pacemaker is able to sense the patient’s inherent
cardiac activity.
• The ability of the pacemaker to depolarize the myocardium depends on many variables: the position of the electrodes
and degree of contact with viable myocardial tissue; the level of energy delivered through the pacing wire; the
presence of hypoxia, acidosis, or electrolyte imbalances; fibrosis around the tip of the catheter; and concomitant
medication therapy.8,10
• Atrial and ventricular thresholds for epicardial wires increase by the fourth postoperative day.3
EQUIPMENT
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Nonsterile gloves
• Pacing lead wires
• Pulse generator
• 9-V battery for pulse generator
• Connecting cables
• ECG monitoring equipment
• Dressing supplies
Additional equipment to have available includes:
• Central venous catheter insertion supplies (see Procedure 81)
• Alligator clips or wire with connector pins
• Suture, needles, syringes
• Emergency equipment
• Fluoroscopy
• Lead aprons or shields
• Multiple-pressure transducer system, with use of PA catheter (see Procedure 76)
• 12-lead ECG machine
• Local anesthetic
• Sterile drapes, towels, masks, goggles or face shields, gowns, caps
FIGURE 54-10 Transvenous cable that connects to transvenous pacemaker leads w ith shrouded pins. (Courtesy Medtronic USA, Inc., Minneapolis, MN.)
FIGURE 54-11 Pacemaker ECG strip of atrioventricular pacing. Note the atrial pacing spike before each P w ave and the ventricular pacing spike before
each QRS complex.
References
1. Abate, E, Kusumoto, FM, Goldschlager, NF. Techniques for temporary pacing. In Kusumoto FM, Goldschlager
NF, eds. : Cardiac pacing for the clinician,, ed 2, New York: Springer-Verlag, 2007.
2. Drew, B, Practice standards for electrocardiographic monitoring in hospital settings. an American Heart
Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and
Cardiovascular Disease in the Youngendorsed by the International Society of Computerized Electrocardiology
and the American -Association of Critical-Care Nurses. Circulation 2004; 110:2721–2746.
3. Elmi, F, Tullo, NG, Khalighi, K. Natural history and predictors of temporary epicardial pacemaker wire
function in patients after open heart surgery. Cardiology. 2002; 98:175–180.
4. Finkelmeier, BA. Temporary pacing and defibrillation in cardiothoracic surgical nursing,. Philadelphia:
Lippincott; 2000.
5. Gammage, MD. Temporary cardiac pacing. Heart. 2000; 83:715–720.
6. Medtronic Corp. Model 5388 dual chamber temporary pacemaker technical manual. Minneapolis: Medtronic; 2007.
7. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
8. Overbay, D, Criddle, L. Mastering temporary invasive cardiac pacing. Crit Care Nurse. 2004; 24(3):25–32.
9. Reade, MC, Temporary epicardial pacing after cardiac surgery. a practical review: part 1: general
considerations in the management of epicardial pacing. Anaesthesia 2007; 62:264–271.
10. Timothy, PR, Rodeman, BJ, Temporary pacemakers in critically ill patients. assessment and management
strategies. AACN Clin Issues 2004; 15:305–325.
11. Woods SL, Froelicher ES, Adams S, et al, eds.. Pacemakers and implantable defibrillators. Cardiac nursing. ed
5. Lippincott Williams and Wilkins, Philadelphia, 2005.
Additional Readings
Batra, AS , Balaji, S , Post operative temporary epic ardial pac ing. when, how and why. Ann Pediatr Card. 2008; 1(2):120–125.
Conover, M. Electrica l stimula tion thera pies in understa nding electroca rdiogra phy, ed 8. S t Louis: Mosby; 2003. [Chapter 33].
Conover, M. Pa cema ker thera pies for bra dya rrhythmia s in understa nding electroca rdiogra phy, ed 8. S t Louis: Mosby; 2003. [Chapter 34].
Hongo, RH, Goldsc hlager, NF. Cardiac pac ing in the c ritic al c are setting. In Kusumoto FM, Goldsc hlager NF, eds. : Ca rdia c pa cing for the clinicia n, ed 2, New
York: S pringer-Verlag, 2007.
SECTION SEVEN
Circulatory Assist Devices
P R OC E D UR E 5 5
PURPOSE:
Intraaortic balloon pump therapy is designed to increase coronary artery perfusion, increase systemic perfusion,
decrease myocardial workload, and decrease afterload.
• The events of the cardiac cycle provide the stimulus for balloon function, and the movement of helium gas between
the balloon and the control console gas source produces inflation and deflation of the balloon.
• Recognition of the R wave or the QRS complex on the electrocardiogram (ECG) is the most commonly used trigger
source.
• Inflation occurs during ventricular diastole and causes an increase in aortic pressure. This increased pressure displaces
blood proximally to the coronary arteries and distally to the rest of the body. The result is an increase in myocardial
oxygen supply and subsequent improvement in cardiac output.
• Deflation occurs just before ventricular systole or ejection, which decreases the pressure within the aortic root,
reducing afterload and cardiac workload.
• Insertion and placement verification:
The IAB catheter is commonly placed in the femoral artery via percutaneous puncture or arteriotomy.
The IAB catheter can also be placed via a transthoracic approach.15
The IAB catheter lies approximately 2 cm inferior to the left subclavian artery and superior to the renal arteries. This
position allows for maximum balloon effect without occlusion of other arterial supplies (Fig. 55-2).
FIGURE 55-2 Intra-aortic balloon positioned in the descending thoracic aorta, just below the left subclavian artery but above the renal artery. (From Quaal SJ:
Comprehensive intraaortic balloon counterpulsation, ed 2, St Louis, 1993, Mosby.)
The IAB should not fully occlude the aorta during inflation. It should be 85% to 90% occlusive.
Fluoroscopy may be used to aid in IAB catheter positioning, especially for patients with a tortuous aorta.
Correct catheter position is verified via radiography if fluoroscopy is not used during catheter insertion. The
visibility of the IAB catheter tip may be enhanced when the IABP is temporarily placed on standby (follow
manufacturer’s guidelines).
The central lumen of many IAB catheters provides a means for monitoring aortic pressure.
Some IAB catheters use fiberoptic technology. These catheters have a fiberoptic sensor located at the tip of the IAB
catheter. The sensor transmits the pressure signal to the IAB console.
• Timing methods of IABP therapy vary slightly from manufacturer to manufacturer. With the traditional or
conventional method, the IAB deflates at the QRS complex, before isovolumetric contraction. The IAB also deflates at
the QRS complex with the real-time method. An important principle of real timing is the duration of the balloon
deflation during cardiac systole. During real timing, the IAB is timed to deflate at the onset of each QRS complex and
to remain deflated throughout systole. A constant diastolic interval is not necessary for real timing.5,6,19,22
• The mechanics of the IABP control console vary from manufacturer to manufacturer.
• Specific information concerning controls, alarms, troubleshooting, and safety features is available from each
manufacturer and should be read thoroughly by the nurse before use of the equipment.
EQUIPMENT
• IABP, gas supply
• ECG and arterial pressure monitoring supplies
• IAB catheter (size range, 7 Fr to 10 Fr for adults; balloon catheters vary in balloon volumes, 25 to 50 mL)
• IAB catheter insertion kit
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Caps, goggles or face shields, masks, sterile gowns, gloves, and drapes
• Sterile dressing supplies
• O-silk suture on a cutting needle or a sutureless securement device
• No. 11 scalpel, used for skin entry
• 1% Lidocaine without epinephrine, one 30-mL vial
• Stopcocks, one two-way and one three-way
• One Luer-Lok plug
• 500 mL of normal saline flush solution (refer to institution standards or physician prescription regarding use of a
heparin flush solution)
• Single-pressure transducer system (see Procedure 76)
Additional equipment to have available depending on patient status includes the following:
• Analgesics and sedatives as prescribed
• Lead apron (needed if procedure is performed with fluoroscopy)
• Prescribed intravenous (IV) solutions
• Emergency medications and resuscitation equipment
• Vasopressors as prescribed
• Antibiotics as prescribed
• Heparin infusion or dextran if prescribed
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Validate that the informed consent form has been signed. Rationale: Informed consent protects the rights of the
patient and makes a competent decision possible for the patient; however, in emergency circumstances, time may not
allow the form to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Validate the patency of central and peripheral intravenous access. Rationale: Central access is needed for
vasopressor administration; peripheral access is needed for fluid administration.
• Place the patient in a supine position and prepare the intended insertion site with an antiseptic solution. Rationale:
Prepares the intended access site and positions the patient for IAB insertion.
Procedure for Assisting with IAB Catheter Insertion
Procedure for Timing of the IABP
FIGURE 55-3 Intra-aortic balloon pump frequency of 1:2. (Courtesy Datascope Corp, Fairfield, NJ.)
FIGURE 55-11 A, Balloon pressure w aveform superimposed on the arterial pressure w aveform. B, Actual recording of an arterial pressure w aveform (top)
and balloon gas w aveform (bottom) from a patient w ith balloon pump. (Courtesy Arrow International.)
Additional Readings
Bates, ER, et al. The use of intra-aortic balloon c ounterpulsation as an adjunc t to reperfusion therapy in c ardiogenic shoc k. J Ca rdiol. 1998; 65(S uppl 1):S 37–
S 42.
Berger, PB, et al, Impac t of an aggressive invasive c atheterization and revasc ularization strategy on mortality in patients with c ardiogenic shoc k in the Global
Utilization of S treptokinase and Tissue Plasminogen Ac tivator for Oc c luded Coronary Arteries (GUS TO-I) trial. an observational study. Circ ulation 1997;
96:122–127.
Blusc h, T, et al, Vasc ular c omplic ations related to intra-aortic balloon c ounterpulsation. an analysis of ten years experienc e. Thorac Cardiovasc S urg 1997;
45:55–59.
Bream-Rouwenhorst HR, Hobbs, RA, Horwitz, PA. Thromboc ytopenia in patients treated with heparin, c ombination -antiplatelet therapy, and intra-aortic balloon
pump c ounterpulsation. J Interv Ca rdiol. 2008; 21(4):350–356.
Christenson, JT, et al. Evaluation of preoperative intra-aortic balloon pump support in high risk c oronary patients. Eur J Ca rdiothora cic Surg. 1997; 11:1097–
1103.
Christenson, JT, S c hmuziber, M, S imonet, F. Effec tive surgic al management of high-risk c oronary patients using preoperative intra-aortic balloon
c ounterpulsation therapy. Ca rdiova sc Surg. 2001; 9:383–390.
Field, ML, Rengarajan, A, Khan, O, et al, Preoperative intra aortic balloon pumps in patients undergoing c oronary artery bypass grafting . Coc hrane Database S yst
Rev 2007; 1
Garrett, K, Grady, KL, Intra-aortic balloon pumping through the c ommon iliac artery. management of the ambulatory intra-aortic balloon pump patient. Prog
Cardiovasc Nurs 2000; 15:14–20.
Kovak, PJ, et al. Thrombolysis plus aortic c ounterpulsation -improved survival of patients who present to the c ommunity hospital with c ardiogenic shoc k. J
Am Coll Ca rdiol. 1997; 29:454–458.
Low, R, Intra-aortic balloon c ounterpulsation in ac ute myoc ardial infarc tion. too few or too many. JACC 2003; 41:1946–1947.
Mertlic h, GB, et al, Effec t of inc reased intra-aortic balloon pressure on c atheter volume. relationship to c hanging -attitude. Crit Care Med 1992; 20:297–303.
Mishra, S , et al. Role of prophylac tic intra-aortic balloon pump in high-risk patients undergoing perc utaneous intervention. Am J Ca rdiol. 2006; 98(5):608–612.
Ohman, E, Hoc hman, J, Aortic c ounterpulsion in ac ute myoc ardial infarc tion. physiologic ally important, but does the -patient benefit. Am Heart J 2001;
141:889–892.
Osentowski, MK, Holt, DW. Evaluating the effic ac y of intra-aortic balloon pump timing using the auto-timing mode of operation with the Datasc ope CS 100. J
Extra corp Technol. 2007; 39(2):87–90.
Reid, MB, Cottrell, D. Nursing c are of patients rec eiving intra-aortic balloon c ounterpulsation. Crit Ca re Nurse. 2005; 25(5):40–49.
S anta-Cruz RA, Cohen, RA, Ohman, EM, Aortic c ounterpulsation. a review of the hemodynamic effec ts and indic ations for use. Catheter Cardiovasc Interv. 2006;
67(1):68–77.
S tone, GW, Ohman, E, Miller, M. Contemporary utilization and outc omes of intra-aortic balloon c ounterpulsation in ac ute myoc ardial infarc tion. JACC. 2003;
41:1940–1947.
Talley, JD, Ohman, EM, Mark, OB, Ec onomic implic ations of the prophylac tic use of intra-aortic balloon c ounterpulsation in the setting of ac ute myoc ardial
infarc tion. the Randomized IABP S tudy Group. Am J Cardiol 1997; 79:S 90–S 94.
P R OC E D UR E 5 6
PURPOSE:
Ventricular assist devices are used for cardiogenic shock and postcardiotomy support to allow for myocardial
recovery, for bridge to cardiac transplantation, and for destination therapy (permanent implantation) in patients
with New York Heart Association class IIIB or IV heart failure who are on optimal medical therapy and are not
eligible for cardiac transplant.3-6,9,14
The ABIOMED BVS 5000 is an extracorporeal, pneumatically driven pump capable of delivering short-term (less
than 3 weeks) left, right, or biventricular support.
The drive console controls systole by delivering air into the lower rigid plastic pumping chamber, displacing blood
from the blood sac. Blood drains passively from the patient’s atrium into the atrial chamber of the blood pump.
When the atrial chamber of the blood pump is full and the pressure inside the atrial chamber exceeds the pressure
inside the ventricular chamber, the trileaflet valve opens, allowing blood to flow into the ventricular chamber of the
blood pump. Blood pump diastole is completed as soon as the ventricular chamber is filled with 100 mL. The
diastolic filling time is adjusted automatically to changes in the patient’s preload to ensure the ventricular chamber
is filled to capacity (100 mL).
The vertically aligned pneumatic blood pumps are adjusted to optimize flow. The blood flow from the patient to the
blood pump depends on the console used. The BVS 5000t (transport) console and the AB 5000 console allow for
vacuum-assisted filling of the chamber. Filling of the pumps depends solely on gravity when the BVS 5000 or BVS
5000i (high-flow) consoles are used. The top of the blood pump should be between 0 and 10 inches below the level
of the patient’s atria when a 42 Fr atrial cannula is used and 4 to 14 inches when a 32 Fr or 36 Fr atrial cannula is
used (see Fig. 56-1). Moving the pump above or below this level can affect flow. Adjusting the height of the blood
pump alters filling of the blood chambers. It is important to allow 2 minutes for the system to adjust before making
additional changes.
Outflow from the BVS is used in place of cardiac output for calculations such as systemic vascular resistance,
pulmonary vascular resistance, and cardiac index.
External heat is not applied to the blood pump, tubing, or cannulas.
ABIOMED tubing insulators are used to retain heat in the tubing.
Anticoagulation therapy with heparin is necessary.
• ABIOMED AB 5000 ventricle1 (Fig. 56-2):
FIGURE 56-2 ABIOMED AB 5000 ventricle. (Courtesy Abiomed, Inc, Danvers, MA.)
The AB 5000 ventricle is a pulsatile, pneumatically driven blood pump approved for short-term (less than 3 weeks)
support to allow time for myocardial recovery. It can provide support for one or both ventricles and must be used
in conjunction with the AB 5000 circulatory support system console. The ventricle holds approximately 100 mL of
blood. Cannulas exit the skin, and the ventricle lies on the patient’s abdomen. Filling of the ventricle is facilitated
with a vacuum within the console and is not affected by height. The ventricle is made partially of aluminum and
plastic and has inflow and outflow valves to ensure unidirectional blood flow.
The following items must never come into contact with the ventricle because they could damage the plastic within
the ventricle: ketones, such as acetone; aromatic hydrocarbons, such as gasoline; halogenated hydrocarbon–based
anesthetic agents; other hydrocarbonated hydrocarbons, such as chloroform; and highly alkaline chemicals, such as
sodium hydroxide.
Anticoagulation therapy with heparin initially followed by warfarin (Coumadin) is necessary.
• HeartMate XVE (extended lead vented electric) left ventricular assist system (LVAS):17
Thoratec Corporation offers an implantable VAD for left ventricular assistance, the HeartMate XVE LVAD.
This VAD is used for long-term support.
The LVAD may be implanted intra-abdominally or preperitoneally in a rectus muscle pocket.
The HeartMate XVE LVAD is made of titanium, holds 83 mL of blood, and weighs approximately 3 lb. Blood flows
through a small tube placed in the left ventricular apex through a porcine inflow valve into the pump. When the
pump fills with blood, a sensor inside the device starts the electric motor. Blood is pumped through a second
porcine outflow valve through a graft into the aorta. The LVAD is placed in the left upper quadrant of the
abdomen.
A driveline is passed underneath the skin and exits the right upper quadrant of the abdomen. The driveline
connects the LVAD to a controller and a power source (batteries or a power base unit) and vents the electric motor
that is within the LVAD. The LVAD can run on the fixed rate mode (set rate) or on the automatic mode, which
responds to changes in preload. On the automatic mode, the pump rate varies between 50 and 120 beats/min to
meet the physiologic needs of the patients. Anticoagulation therapy with heparin or warfarin (Coumadin) is not
necessary with this LVAD. Most patients receive aspirin, 81 mg or 325 mg daily, however.
The device can be operated with the HeartMate IP console if the electric motor fails. Due to the increased risk of
thrombosis, this mode is only used for short duration until the device can be replaced. The patient will also be
anticoagulated with heparin or warfarin during this mode of operation.
• Thoratec Paracoporeal Ventricular Assist Device (PVAD):18
The Thoratec Paracorporeal VAD (PVAD) is made of polyurethane and is pneumatically driven. A flexible
polyurethane diaphragm divides the blood chamber. An influx of pressurized air (through the pneumatic tubing
and into the VAD) drives the flexible diaphragm against the blood chamber, pushing blood from the VAD to the
patient, and controls the duration of systole. Mechanical valves provide unidirectional blood flow. When the
pneumatic drive is used, the pump can only be run in a fixed mode (asynchronous) or auto mode (volume) for
right, left, or biventricular support
The Thoratec PVAD is approved for use as a bridge to transplant and post-cardiotomy recovery.
The Thoratec PVAD is connected via the driveline and a cable to the dual-drive console (DDC), which controls
pump function. The console is plugged into an electrical outlet when the patient is not ambulating. This VAD is
primarily for short-term and intermediate use. The VADs may also be connected to the smaller TLC-II driver giving
the patient 2 hours of battery life and a smaller 20 pound driver to push rather than the 500-pound dual-drive
hospital driver (DDC).
The Thoratec PVAD may be used in smaller patients.
The three major components of the system are the blood pump, cannulas, and drive console. The smooth, seamless
blood sac is enclosed within a rigid case. Small bubbles in a silicone oil lubricant may be seen during use. A small
magnetic switch (called the Hall effect switch) is mounted in the upper case. When the PVAD is full of blood, a
switch is tripped sending a signal to the console to eject blood.
• Thoratec IVAD18 :
The Thoratec IVAD (Thoratec Corporation) is an implantable pneumatic system approved for postcardiotomy use
and as a bridge to transplantation. It can provide univentricular or biventricular support. It is the only device
approved for long-term (greater than 3 weeks if necessary) biventricular support. It is also the device of choice in
patients who need ventricular support with a BSA less than 1.5 m 2 . The three major components of the system are
the blood pump, cannulas, and drive console. The smooth, seamless blood sac is enclosed within a rigid case. Two
mechanical valves provide unidirectional blood flow. A fill switch with the VAD signals the console to eject the
blood when the VAD is filled with blood. Either the dual-drive console or the TLC-II portable driver can operate the
VAD (Fig. 56-3).
FIGURE 56-3 Thoratec biventricular assist device. (Courtesy Thoratec Corporation, Pleasanton, CA.)
The Thoratec PVAD and IVADs18 are both driven by a dual-drive console, which contains two independent drive
modules for left and right ventricular support. Patients with biventricular assist devices (BiVADs) need both
modules, and patients with a right ventricular assist device (RVAD) or a LVAD need one module. When only one
module is being used, the other module can serve as a backup if pump failure occurs. The console supplies air
pressure to eject blood from the pump into the arterial system and vacuum to assist pump filling. A full 65-mL
stroke volume is possible from 20 to 110 beats/min, providing cardiac outputs of 1.2 to 7.2 L/min.
The recommended control modes for operation include asynchronous/fixed or volume/automatic. A fixed rate
allows the operator to choose a VAD rate that is asynchronous with the patient’s intrinsic heart rate. The automatic
mode also is asynchronous to the patient’s intrinsic heart rate but responds to changes in physiologic conditions.
Anticoagulation therapy with heparin initially followed by warfarin is needed.
• The HeartMate II LVAS 16 :
The HeartMate II left ventricular assist system (Thoratec Corp) HeartMate II LVAS (left ventricular assist system)16 is
a continuous flow pump and is approved as a bridge to transplant and destination therapy in patients with
advanced heart failure.
The LVAD may be implanted intra-abdominally or preperitoneally in a rectus muscle pocket.
The HeartMate II is made of titanium and weighs approximately 1.5 lb. Blood flows from the left ventricle through
the pump and back to the patient’s circulation via the outflow graft.
Continuous flow is generated by a small rotor inside the pump. The speed of the pump is set by the LVAD team
and does not change in response to preload.
The LVAD is placed in the left upper quadrant of the abdomen.
A driveline is passed underneath the skin and exits the right or left upper quadrant of the abdomen. The driveline
connects the LVAD to a controller and a power source (batteries or a power base unit or power module).
Anticoagulation therapy with heparin or warfarin is necessary with this LVAD with a goal INR range of 1.8 to 2.5.
Most patients receive aspirin, 81 mg or 325 mg daily in addition to warfarin.
• The Impella LP 2.5 and LP 5.0:
The Impella LP 2.5 and 5.0 systems (Abiomed Inc) are nonpulsatile microaxial flow devices that deliver 2.5 L
(Impella LP 2.5) or 5.0 L (Impella LP 5.0) of blood flow.10
The pumps are implanted percutaneously in the cardiac catheterization laboratory. A surgical cut down to expose
the femoral artery is necessary for the Impella LP 5.0.
The Impella 5.0 can also be implanted directly via sternotomy.
When positioned properly, the Impella sits across the aortic valve, with the inlet area in the left ventricle and the
outlet area in the ascending aorta.
Transesophageal echocardiography is needed to confirm proper placement.
The console continuously monitors pump placement and alerts the operator to catheter displacement and other
alarm states.
• The TandemHeart (CardiacAssist, Pittsburgh, PA):11 ,12
The TandemHeart is a continuous centrifugal flow device that delivers up to 4 L of blood flow.11 ,12 This is a left atrial
to femoral bypass system for short-term use.
The pumps are implanted via a percutaneous approach in the cardiac catheterization laboratory.
There is a 21 Fr cannula that is inserted to the left atrium via a transseptal cannulation from the right atrium and
blood is ejected to the centrifugal pump and returned via the femoral artery.
The TandemHeart operates via an electromagnetic rotor that operates at a range of 3000 to 7500 rpm.11,12
The pump is driven by a microprocessor controller
The TandemHeart has a dual-chamber pump. The upper housing allows for the movement of blood. The lower
housing communicates with the controller and contains a continuous flow of saline with heparin to decrease the
risk of thrombus formation and provide lubrication.11,12
EQUIPMENT
• VAD drive console/unit or monitor (Table 56-1)
Table 56-1
Equipment for Various Ventricular Assist Devices (VADs)
• Connection cables (specific to device; see Table 56-1)
• Backup drive console/unit/monitor, batteries, and controller (see Table 56-1)
• Emergency pump device (hand crank, foot pump, hand pump or bulb, depending on device; see Table 56-1)
• Vent filters (HeartMate XVE)
• Dressing supplies:
Sterile normal saline solution
4 × 4 sterile gauze pads
Tape, 1-inch and 2-inch
Sterile gloves
Head covers
Masks
Sterile gowns
Sterile drapes
Ace wrap (6-inch)
6 × 6 bordered gauze
• Suture removal kit
Additional equipment as needed includes the following:
• Emergency equipment and medications
• Flashlight
• Intravenous pole
• Four smooth chest clamps
• Blood pump set
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preoperative teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Ensure that informed consent has been signed (if it is known before surgery that the VAD will be placed).
Rationale: Informed consent protects the rights of the patient and makes a competent decision possible for the patient
and family.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Provide emotional support to the patient and family. Rationale: The patient and family are under an extreme
amount of stress.
Procedure for Ventricular Assist Devices
References
1. ABIOMED. IncAB 5000 ventricle training guide. Danvers, MA: Abiomed; 2003.
2. ABIOMED. Inc Clinical reference manual. Danvers, MA: Abiomed; 2003.
3. Chillocott, S, Atkins, P, Adamson, R. Left ventricular assist as a viable alternative for cardiac transplantation.
Crit Care Nurs Q. 1998; 20:64–69.
4. Drews, T, Jurmann, M, Michael, D, et al. Differences in pulsatile and non-pulsatile mechanical circulatory
support in long-term use. J Heart Lung Transplantation. 2008; 27:1096–1101.
5. Frazier, OH, Prologue. ventricular assist devices and total artificial heartsa historical perspective. Cardiol Clin
2003; 21:1–13.
6. Holmes, EA. Outpatient management of long-term assist devices. Cardiol Clin. 2003; 21:93–99.
7. Hravnak, M, George, E, Kormos, RL. Management of chronic left ventricular assist device percutaneous lead
insertion sites. J Heart Lung Transplant. 1993; 12(5):856–863.
8. Konstam, MA, Czerska, B, Bohm, M, et al, Continuous aortic flow augmentation. a pilot study of
hemodynamic and renal responses to a novel percutaneous intervention in decompensated heart failure.
Circulation 2002; 112:3107.
9. Kukuy, EL, et al. Devices as destination therapy. Cardiol Clin. 2003; 21:67–73.
10. LaRocca, GM, Shimbo, D, Rodriguez, CJ, et al, The Impella Recover LP 5. 0 left ventricular assist device. a bridge
to coronary artery bypass grafting and cardiac transplantation. J Am Soc Echocardiogr 2006; 19:468. [e5-7].
11. Lee, MS, Makkar, RR. Percutaneous left ventricular assist devices. Cardiol Clini. 2006; 24:265–275.
12. Lemos, PA, Cummins P, et alLee, CH. Usefulness of percutaneous left ventricular assistance to support high-
risk percutaneous coronary interventions. Am J Cardiol. 2003; 91:479–481.
13. Long. Improving outcomes with long-term destination therapy using left ventricular assist devices. J Thorac
Cardiovasc Surg. 2008; 135:1353–1361.
14. Rose, EA, et al. Long-term mechanical left ventricular assistance for end stage heart failure. N Engl J Med. 2001;
345:1435–1443.
15. Thiele, H, Lauer, B, Hambrecht, et al. Reversal of cardiogenic shock by percutaneous left atrial-to-femoral atrial
bypass assistance. Circulation. 2001; 104:2917–2922.
16. Thoratec Corporation. Thoratec HeartMate II LVAS clinical operation and patient management. Thoratec,
Pleasanton, CA, 2008.
17. Thoratec Corporation. HeartMate XVE LVAS operating manual. Thoratec, Pleasanton, CA, 2003.
18. Thoratec Corporation. Thoratec VAD and IVAD clinical operation and patient management. Thoratec,
Pleasanton, CA, 2004.
Additional Readings
Arabia, F, et al. Biventric ular c annulation for the Thoratec ventric ular assist devic e. Ann Thora c Surg. 1998; 66:2119–2120.
Bond, AE, et al. The left ventric ular assist devic e. Am J Nurs. 2003; 103:32–41.
DeRose, J, et al. Implantable left ventric ular assist devic es provide an exc ellent outpatient bridge to transplantation and rec overy. J Am Coll Ca rdiol. 1997;
30:1773–1777.
Dixon, JF, Farris, DD. The ABIOMED BVS 5000 system. AACN Clin Issues Crit Ca re Nurs. 1991; 2:552–561.
Goldstein, DJ, Oz, MC. Ca rdia c a ssist devices. New York: Futura Publishing; 2000.
John, R, et al. Low thromboembolic risk for patients with the Heartmate II left ventric ular assist devic e. J Thora c Ca rdiova sc Surg. 2008; 136:1318–1323.
Livinston, E, et al. Inc reased ac tivation of the c oagulation and fibrinolytic systems leads to hemorrhagic c omplic ations during left ventric ular assist
implantation. Circula tion. 1996; 94(S uppl II):II227–II234.
Mc Carthy, P, et al, One hundred patients with the HeartMate left ventric ular assist devic e. evolving c onc epts and tec hnology. J Thorac Cardiovasc S urg 1998;
115:904–912.
Mc Gee E Ci Jr, Mc Carthy P Mi, Moazami N i. Temporary Mec hanic al Circ ulatory S upport. In: Cohn Lh, ed. Ca rdia c Surgery in the Adult. New York: Mc Graw-Hill;
2008:507–534.
Miller, L, Pagani, F, Russell, S , et al. Use of a c ontinuous-flow devic e in patients awaiting heart transplantation. N Engl J Med. 2007; 357:885–896.
Mussivand, T, et al. Critic al anatomic dimensions for intrathorac ic c irc ulatory assist devic es. Artif Orga ns. 1992; 16:281–285.
Pitsis, AA, Visouli, AN. Update on ventric ular assist devic e management in the ICU. Curr Opin Crit Ca re. 2008; 14(5):569–578.
S c hakenbac h, LH, Care of the patient with a ventric ular assist devic e. InProtoc ols for prac tic e. Americ an Assoc iation of Critic al-Care Nurses, Aliso Viejo, CA,
2002.
Wiegand, DL, Kalowes, PG. Withdrawal of c ardiac medic ations and devic es. AACN Adv Crit Ca re. 2007; 18(4):415–425.
Windec ker, S . Perc utaneous left ventric ular assist devic es for treatment of patients with c ardiogenic shoc k. Curr Opin Crit Ca re. 2007; 13:521–527.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
SECTION EIGHT
Electrocardiographic Leads and Cardiac Monitoring
P R OC E D UR E 5 7
PURPOSE:
Continuous electrophysiologic monitoring is performed routinely for most patients with acute and critical
illnesses. A key component of electrophysiologic monitoring is the electrocardiogram. The electrocardiogram
provides a continuous graphic picture of cardiac electrical activity. The electrocardiogram can be used for
diagnostic, documentation, and treatment purposes.
• Telemetry systems have electrodes and lead wires that are attached from the patient to a battery pack and transmit
impulses to the monitor via radio wave transmission (Fig. 57-2).
FIGURE 57-2 Telemetry monitoring system. (Courtesy Philips Medical Systems, Andover, MA.)
• Telemetry is useful in progressive ambulation and evaluation of activity tolerance. A disadvantage to telemetry is that
ambulation and activity can increase distortion of the ECG pattern.
• Specific areas of the chest are used for electrode placement to obtain a view of the electrical activity in a particular area
of the heart (commonly called a lead).
• ECG monitors use a three-lead or five-lead wire system to provide different views (leads) of the heart’s electrical
activity. Most acute and critical care units use a five-lead system for continuous bedside monitoring or telemetry.
• Standardized placement of leads is important so that information obtained is assessed within a common frame of
reference and so that appropriate judgments can be made on the patient’s cardiac status. Alterations of electrode
position may distort the appearance of the waveform significantly and can lead to misdiagnosis or mistreatment.
• The two major factors that determine the views of the ECG deflection on the monitor are the location of the electrodes
on the body and the direction of the cardiac impulse in relation to the position of the electrode.
• A basic rule of electrocardiography is the rule of electrical flow. This rule notes that if electricity flows toward the
positive electrode, an upright pattern is produced on the monitor or graph paper. If the electricity flows away from
the positive electrode (or toward the negative electrode), a downward pattern or deflection is produced on the
monitor or graph paper. Lead wires attached to the patient are coded (+, P [positive]; or –, N [negative]; RA [right
arm]; RL [right leg]; LA [left arm]; LL [left leg]; V or C [V or precordial vector and C or chest lead] in some way for
ease in correct placement. Placement of the leads gives different views of the electrical conduction through the heart.
• Information from the bedside via hardwire or telemetry can be transferred to a central monitor, where it can be
printed, stored, and analyzed (Fig. 57-3).
FIGURE 57-3 Central station. (Courtesy Philips Medical Systems, Andover, MA.)
• Five-lead bedside monitoring systems provide a continuous readout of two or more leads simultaneously. This readout
provides more information and a comparison of the ECG patterns. Optimal lead selection is based on the goals of
monitoring for each patient’s clinical situation.
• Bedside electrophysiologic monitoring may also provide continuous derived 12-lead ECG acquisition via a torso-
positioned reduced lead system (e.g., the EASI lead system; Philips Monitoring, Andover, MA). In this application,
the reduced lead configuration varies according to the manufacturer and the device but provides the availability of a
continuous 12-lead ECG, which can be accessed for information over a predetermined time (commonly 24 to 48
hours). This application greatly expands the information available from bedside monitors and requires accurate and
consistent lead placement based on the manufacturer’s requirements. Derived ECGs are not equivalent to standard
12-lead ECGs and are not recommended as a substitute.1
EQUIPMENT
• ECG monitor (central and bedside monitor) or battery pack (telemetry monitoring only)
• Electrodes, pregelled and disposable
• Nonsterile gloves
• Dry gauze pads or terrycloth washcloth
• Cleansing pads or nonemollient soap and water
• Lead wires (no longer than 18 inches)
• Patient cable (should be compatible with the monitor and the lead wires)
• ECG calipers (may be available electronically via the central monitor)
• Alcohol pads
Additional equipment to have available as needed includes the following:
• Skin preparation solution, such as skin barrier wipe or tincture of benzoin, if needed
• Pouch or pocket gown to hold telemetry unit (telemetry monitoring only)
• Clippers or scissors to clip hair from the chest as needed
PATIENT AND FAMILY EDUCATION
• Assess the readiness of the patient and family to learn. Rationale: Anxiety and concerns of the patient and family
may inhibit the ability to learn.
• Provide explanations of the equipment and alarms to the patient and family. Rationale: These explanations assist in
making the patient and family feel more comfortable with monitoring and may reduce anxiety.
• Reassure the patient and family that monitoring is continuous and that the patient’s heart rate and rhythm will be
monitored and treated as indicated. Rationale: The patient and family are reassured that immediate care is
available.
• Emphasize that the patient should feel free to move about in bed. Rationale: This emphasis encourages movement
on the part of the patient and allays fears about disruption of the monitoring system.
• Explain the importance of reporting any symptoms, such as pain, dizziness, palpitations, or chest discomfort.
Rationale: Reporting of symptoms ensures appropriate and timely assessment and intervention.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces the understanding of previously
taught information.
• Assist the patient to the supine position. Rationale: This position enables easy access to the chest for electrode
placement.
• Assist the patient in removing clothing that covers the chest while providing for the patient’s privacy. Rationale:
Clothing removal provides a clear view of the chest and allows for identification of landmarks and proper placement
of leads while the patient’s privacy is maintained.
Procedure for Electrophysiologic Monitoring: Hardwire and Telemetry
FIGURE 57-4 Three-lead w ire system. (Courtesy Philips Medical Systems, Andover, MA.)
FIGURE 57-5 Five-lead w ire system. (Courtesy Philips Medical Systems, Andover, MA.)
FIGURE 57-6 Three-lead application. (From Drew B: Bedside electrocardiographic monitoring, AACN Clin Issues Crit Care 4:28, 1993.)
FIGURE 57-7 Three-lead system w ith Lew is lead.
FIGURE 57-8 Five-lead application. (From Drew B: Bedside electrocardiographic monitoring, AACN Clin Issues Crit Care 4:26, 1993.)
FIGURE 57-9 Monitor strip of clear ECG pattern.
References
1. AACN, AACN practice alert, dysrhythmia monitoring. 2008 . American Association of Critical Care: Aliso Viejo,
CA.
2. Drew, BJ, et al, Practice standards for electrocardiographic monitoring in hospital settings. an American Heart
Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and
Cardiovascular Disease in the Young. Circulation 2004; 110:2721–2746.
3. Kligfield, P, et al, Recommendations for the standardization and interpretation of the electrocardiogram: . part 1:
the electrocardiogram and its technology: a scientifi c statement from the American Heart Association
Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology: The American College of
Cardiology Foundation; and the Heart Rhythm -Society. Circulation 2007; 115:1306–1324.
Leeper, B. Continuous S T-segment monitoring. AACN Clin Issues. 2003; 14:145–154.
Additional Readings
Alspac h, J. Core curriculum for critica l ca re nursing. Philadelphia: S aunders; 2006.
Donnely, MP, et al, Lead selec tion. old and new methods -for loc ating the most elec troc ardiogram information. J Elec troc ardiol 2008; 41:257–263.
Drew, BJ, Kingfield, P, S tandardizing elec troc ardiograpic leads. introduc tion to a symposium. J Elec troc ardiol 2008; 41:187–189.
Drew, BJ, Putting it all together. c ase studies on ECG -monitoring. AACN Adv Crit Care 2007; 18:305–317.
Drew, BJ. Pitfalls and artifac ts in elec troc ardiography. Ca rdiol Clin. 2006; 24:309–315.
Drew, BJ, et al, Prac tic e standards for ECG monitoring in hosptial settings. exec utive summary and guide for implementation. Crit Care Nurs Clin North Am 2006;
18:157–168.
Jahrsdoerfer, M, et al. Clinic al usefulness of the EAS I -12-c ontinuous elec trographic monitoring system. Crit Ca re Nurse. 2005; 25:28–38.
S ole, M, Klein, D, Moseley, M. Introduction to critica l ca re nursing, ed 4. Philadelphia: S aunders; 2004.
P R OC E D UR E 5 8
PURPOSE:
Extra electrocardiographic leads are used in conjunction with the standard 12-lead electrocardiogram to provide
additional diagnostic information.
EQUIPMENT
• Dry gauze pads or terrycloth washcloth
• Nonsterile gloves
• Cleansing pads or nonemollient soap and water
• Alcohol pads
• Indelible marker
• 12-lead ECG machine with attached patient cable and lead wires
• ECG electrodes
Additional equipment to have available as needed includes the following:
• Hair clipper or scissors to clip hair from chest if needed
• Skin preparation solution, such as skin barrier wipe or tincture of benzoin
FIGURE 58-1 Baseline ST-segment deviation as a result of left bundle-branch block before percutaneous coronary intervention (left panel, before
angioplasty). During angioplasty balloon inflation of the proximal left circumflex (LCX) coronary artery (right panel, LCX occlusion), the patient developed
myocardial ischemia w ith chest pain radiating to the left arm. ST segments in the left posterior leads (V 7, V 8, and V 9) became elevated compared w ith the
baseline preangioplasty tracing to produce a normal-looking, isoelectric ST segment. This pseudonormalization of the ST segment during ischemia can be
misinterpreted as normal w ithout assessment of the baseline ECG.
• Interpret the patient’s standard 12-lead ECG for any signs of myocardial ischemia or MI and dysrhythmias.
Rationale: Nurses should be able to evaluate the standard 12-lead ECG for the location of ischemia or infarction and
assess the possibility of RV and posterior involvement (Fig. 58-2).
FIGURE 58-2 Initial ECG in a patient admitted to the emergency department w ith an acute inferior MI (elevated ST segments and Q w aves in leads II, III, and
aVF) w ith apical involvement (elevated ST segment in leads V 4, V 5, and V 6). ST-segment depression in leads V 1, V 2, and V 3 suggests posterior involvement.
Left posterior and right precordial leads should be recorded to assess posterior and RV involvement.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces the understanding of previously
taught information.
• Assist the patient to the supine position and expose the patient’s torso while maintaining the patient’s modesty.
Rationale: This position enables the recording of a standard 12-lead ECG and allows comparison of serial ECGs and
comparison with standard waveforms. Body positional changes, such as elevation and rotation, can change recorded
amplitudes and axes.
FIGURE 58-3 Electrode locations for recording a right precordial ECG. (From Drew BJ, Ide B: Right ventricular infarction, Prog Cardiovasc Nurs 10:46, 1995.)
FIGURE 58-5 Electrode locations for recording a left posterior ECG.
References
1. Adams, MG, Drew, BJ, Body position effects on the ECG. implication for ischemia monitoring. J
Electrocardiol 1997; 30:285–291.
2. Adams-Hamoda MG, Caldwell, MA, Stotts, NA, et al. Factors to consider when analyzing 12-lead
electrocardiograms for evidence of acute myocardial ischemia. Am J Crit Care. 2003; 12:9–18.
3. Baevsky, RH, Haber, MD, Blank, FS, et al, Supine vs semirecumbent and upright 12-lead electrocardiogram.
does change in body position alter the electrocardiographic -interpretation for ischemia. Am J Emerg Med . 2007;
25:753–756.
4. Braat, SH, Brugada, P, den Dulk K, et al. Value of lead V4R for recognition of the infarct coronary artery in -
acute inferior myocardial infarction. Am J Cardiol. 1984; 53:1538–1541.
5. Braat, SH, Gorgels, AP, Bar, FW, et al. Value of the ST-T segment in lead V4R in inferior wall acute myocardial
-infarction to predict the site of coronary arterial occlusion. Am J Cardiol. 1988; 62:140–142.
6. Casas, RE, Marriott, HJ, Glancy, DL. Value of leads -V7-V9 in diagnosing posterior wall acute myocardial -
infarction and other causes of tall R waves in V1-V2. Am J Cardiol. 1997; 80:508–509.
7. Cohn, JN, Guiha, NH, Broder, MI, et al, Right ventricular infarction. clinical and hemodynamic features. Am J
Cardiol 1974; 33:209–214.
8. Drew, BJ. Pitfalls and artifacts in electrocardiography. Cardiol Clin. 2006; 24:309–315. [vii].
9. Drew, BJ. Pseudo myocardial injury patterns because -of nonstandard electrocardiogram electrode placement. J
Electrocardiol. 2008; 41:202–204.
10. Drew, BJ, et al, Practice standards for electrocardiographic monitoring in hospital settings. an American Heart
Association Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and
Cardiovascular Disease in the Young. Circulation 2004; 110:2721–2746.
11. Haisty, WK, Jr., Pahlm, O, Wagner, NB, et al. Performance of the automated complete Selvester QRS scoring
system in normal subjects and patients with single and multiple myocardial infarctions. J Am Coll Cardiol. 1992;
19:341–346.
12. Kligfield, P, Gettes, LS, Bailey, JJ, et al, Recommendations for the standardization and interpretation of the
electrocardiogram: part I. the electrocardiogram and its technology: a scientifi c statement from the American
Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the
American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International
Society for Computerized Electrocardiology. Circulation 2007; 115:1306–1324.
13. Nelwan, SP, Meij, SH, van Dam TB, et al. Correction of ECG variations caused by body position changes and
electrode placement during ST-T monitoring. J Electrocardiol. 2001; 34:213–216. [(Suppl)].
14. Pharand, C, Nasmith, JB, Rajaonah, JC, et al, Distinction between myocardial ischemia and postural changes in
continuous ECG monitoring based on ST-segment amplitude and vector orientation. preliminary results. Can J
Cardiol 2003; 19:1023–1029.
15. Wung, SF. Discriminating between right coronary artery and circumflex artery occlusion by using a noninvasive
18-lead electrocardiogram. Am J Crit Care. 2007; 16:63–71.
P R OC E D UR E 5 9
PURPOSE:
Bedside ST-segment monitoring provides ongoing surveillance for detection of transient myocardial ischemia.
This technology should be applied to patients who are being evaluated or are diagnosed with acute coronary
syndrome, including acute myocardial infarction and unstable angina.2,3,8,13,16 For these patients, continuous ST-
segment monitoring is valuable in determining the success of thrombolytic therapy and percutaneous coronary
intervention and detecting recurrent or transient ischemia. The goal of continuous ST-segment monitoring is to
detect new or recurrent myocardial ischemia.
FIGURE 59-1 The importance of assessing the trend of the ST segments over time. The three-dimensional image illustrates ST-segment deviation in
millimeters (Y-axis) in all 12 ECG leads (X-axis) over a 15-hour period (Z-axis). Illustrated are three separate ischemic events, characterized by ST-segment
elevation, in leads V 3 to V 5. (Adapted from Pelter MM, Adams MG, Drew BJ: Transient myocardial ischemia is an independent predictor of adverse in-hospital outcomes in patients
with acute coronary syndromes treated in the telemetry unit, Heart Lung 32:71-78, 2003.)
• Other nonischemic causes for a change in the ST-segment trend are movement of the skin electrodes, dysrhythmias,
intermittent bundle-branch block pattern, body position changes, and ventricular paced rhythms.8,12
• The first type of ischemia seen in patients with acute coronary syndrome (ACS) is supply-related ischemia from
coronary occlusion. Coronary occlusion is brought on by disruption of an atherosclerotic plaque followed by cycles of
plaque rupture, platelet stimulation, coronary vasospasm, and thrombus formation.5,6,14,19 Because this type of
ischemia threatens the entire thickness of the myocardium, immediate treatment to reestablish blood flow to the
heart is essential. The typical ECG manifestation of total coronary occlusion is ST-segment elevation visible in the ECG
leads that lie directly over the ischemic myocardial zone. Occlusion of the right coronary artery (RCA) typically
produces ST-segment elevation in leads II, III, and augmented vector foot or aVF (Fig. 59-2). Occlusion of the left
anterior descending (LAD) coronary artery typically produces ST-segment elevation in leads V2 , V3 , and V4 (Fig. 59-3).
Diagnosis of total coronary occlusion of the left circumflex coronary artery (LCX) is more complex because placement
of the standard ECG electrodes is on the anterior chest, opposite the wall that this coronary artery supplies. Occlusion
of the LCX may produce ST-segment depression in leads V1 , V2 , or V3 , which reflects the reciprocal, or mirror image,
ST-segment elevation occurring in the posterior wall of the myocardium.
FIGURE 59-2 The typical ST-segment pattern of supply-related ischemia in the inferior w all. The RCA is likely occluded, resulting in ST-segment elevation in
leads II, III, and aVF.
FIGURE 59-3 The typical ST-segment pattern of supply-related ischemia in the anterior w all. The LAD artery is likely occluded, resulting in ST-segment
elevation in leads V 2 to V 4.
• A second type of ischemia for which patients with ACS or stable angina are at risk is demand-related ischemia. This
type of ischemia may occur when the demand for oxygen (i.e., exercise, tachycardia, or stress) exceeds the flow
capabilities of a coronary artery with a stable atherosclerotic plaque. The ST-segment pattern of demand-related
ischemia is depression, often appearing in several ECG leads (Fig. 59-4).
FIGURE 59-4 The typical ST-segment pattern of demand-related ischemia. Note the ST-segment depression appearing in nearly every ECG lead, w ith the
exception of V 1 and aVR. Note also that this patient is experiencing tachycardia, a common cause of demand-related ischemia.
• Diagnosis of myocardial ischemia necessitates continuous monitoring of all 12 ECG leads because the mechanism of
ischemia may vary (i.e., occlusion versus demand-related ischemia), resulting in distinctly different ST-segment
patterns (e.g., elevation or depression). If only two ECG leads are available, however, the best two are leads III and V3 .8
Patient-specific monitoring also may be done if a prior 12-lead ECG was obtained during acute ischemia (i.e., ST-
segment elevation MI, percutaneous coronary intervention [PCI], or treadmill test). In this scenario, the ECG lead or
leads showing maximal ST-segment deviation should be selected for continuous monitoring to detect recurrent
ischemia.
• According to current consensus statements,8,9 multilead ST-segment monitoring is indicated in most patients with the
following diagnoses:
Early phase of acute MI (ST elevation, non-ST elevation, “rule-out”)
Chest pain (or anginal equivalent) that prompts a visit to the emergency department
After nonurgent PCI procedures with suboptimal results
Variant angina resulting from coronary vasospasm
• According to these same guidelines,8,9 ST-segment monitoring may be of benefit for the following cases:
Postacute MI
After nonurgent uncomplicated PCI
With high risk for ischemia after cardiac or noncardiac surgery
• ST-segment monitoring may not be appropriate for certain patient groups because current software cannot reliably
interpret ST-segment changes resulting from myocardial ischemia.8,9 Specifically, it may not be suitable to monitor
patients with:
Left bundle-branch block
Ventricular paced rhythm
Confounding dysrhythmias that obscure the ST segment
Agitation causing excessive artifact
• A variety of bedside and telemetry cardiac monitors are currently available for use in clinical practice. Not all
monitoring systems are equipped with ST-segment monitoring software, however. Clinicians must determine
whether their cardiac monitoring system has ST-segment monitoring capabilities.
EQUIPMENT
• Electrodes, pregelled and disposable
• Cardiac monitor with ST-segment monitoring capability and patient cable
• Nonsterile gloves
• Gauze pads or terrycloth washcloth
• Cleansing pads or nonemollient soap and water
• Alcohol pads
• ECG calipers
Additional equipment to have available as needed includes the following:
• Clippers or scissors to clip hair from chest if needed
• Indelible marker
• 12-lead ECG machine
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This communication evaluates and reinforces understanding of previously
taught information.
• Place the patient in a resting supine position in bed, and expose the patient’s torso while maintaining modesty.
Rationale: This preparation provides access to the patient’s chest for electrode placement and ensures that an artifact-
free ECG is obtained.
Procedure for Continuous ST-Segment Monitoring
FIGURE 59-5 Correct lead placement for 12-lead ST-segment monitoring. Limb electrodes must be located as close as possible to the junction to the limb
and the torso. To ensure an inferior view of the myocardium, the left leg (LL) electrode must be placed w ell below the level of the umbilicus. For V 1, the
electrode is located at the fourth intercostal space to the right of the sternum. V 2 is in the same fourth intercostal space just to the left of the sternum, and V 4
is in the fifth intercostal space on the midclavicular line. Placement of lead V 3 is halfw ay on a straight line betw een leads V 2 and V 4. Leads V 5 and V 6 are
positioned on a straight line from V 4, w ith V 5 in the anterior axillary line and V 6 in the midaxillary line. RA, Right arm; LA, left arm; RL, right leg.
FIGURE 59-6 A, Normal ECG complex. Measurement points used in ST-segment analysis are indicated. The PR segment is used to identify the isoelectric
line. The ST segment begins at the J point, w hich is the end of the QRS complex. The ST-segment measurement point can be measured at 60 or 80 ms past
the J point. B, ST-segment elevation. The ST segment show n measures +4 mm. C, ST-segment depression. The ST segment show n measures –4 mm.
(Adapted from Tisdale LA, Drew BJ: ST segment monitoring for myocardial ischemia, AACN Clin Issues Crit Care Nurs 4:36, 1993.)
References
1. Adams, MG, Drew, BJ, Body position effects on the ECG. implication for ischemia monitoring. J
Electrocardiol. 1997; 30(4):285–291.
2. Adams, MG, Pelter, MM, Wung, SF, et al, Frequency of silent myocardial ischemia with 12-lead ST segment
monitoring in the coronary care unit. are there sex-related differences. Heart Lung. 1999; 28(2):81–86.
3. Akkerhuis, KM, Klootwijk, PA, Lindeboom, W, et al. Recurrent ischaemia during continuous multilead ST-
segment monitoring identifies patients with acute coronary syndromes at high risk of adverse cardiac events;
meta-analysis of three studies involving 995 patients. Eur Heart J. 2001; 22(21):1997–2006.
4. Clochesy, JM, Cifani, L, Howe, K, Electrode site preparation techniques. a follow-up study. Heart Lung. 1991;
20(1):27–30.
5. Cura, FA, Escudero, AG, Berrocal, D0, et al. Protection of distal embolization in high-risk patients with acute ST-
segment elevation myocardial infarction (PREMIAR). Am J Cardiol. 2007; 99(3):357–363.
6. DeWood, MA, Spores, J, Notske, R, et al. Prevalence of -total coronary occlusion during the early hours of
transmural myocardial infarction. N Engl J Med. 1980; 303(16):897–902.
7. Drew, BJ, Adams, MG, Clinical consequences of ST-segment changes caused by body position mimicking
transient myocardial ischemia. hazards of ST-segment monitoring. J Electrocardiol. 2001; 34(3):261–264.
8. Drew, BJ, Califf, RM, Funk, M, et al, AHA scientifi c statement: practice standards for electrocardiographic
monitoring in hospital settings. an American Heart Association Scientifi c Statement from the Councils on
Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the
International Society of Computerized electrocardiology and the American Association of Critical-Care Nurses. J
Cardiovasc Nurs. 2005; 20(2):76–106.
9. Drew, BJ, Krucoff, MW, Multilead ST-segment monitoring in patients with acute coronary syndromes. a
consensus statement for healthcare professionals ST-Segment Monitoring Practice Guideline International
Working Group,. Am J Crit Care. 1999; 8(6):372–388.
10. Drew, BJ, Pelter, MM, Adams, MG. Frequency, characteristics, and clinical significance of transient ST
segment elevation in patients with acute coronary syndromes. Eur Heart J. 2002; 23(12):941–947.
11. Drew, BJ, Pelter, MM, Lee, E, et al, Designing prehospital ECG systems for acute coronary syndromes. lessons
learned from clinical trials involving 12-lead ST-segment monitoring. J Electrocardiol. 2005; 38(4 Suppl):180–185.
12. Drew, BJ, Wung, SF, Adams, MG, et al, Bedside diagnosis of myocardial ischemia with ST-segment
monitoring technology. measurement issues for real-time clinical decision making and trial designs . J
Electrocardiol . 1998; 30:157–165. [(Suppl)].
13. Gottlieb, SO, Weisfeldt, ML, Ouyang, P, et al. Silent ischemia as a marker for early unfavorable outcomes in
patients with unstable angina. N Engl J Med. 1986; 314(19):1214–1219.
14. Krucoff, MW, Croll, MA, Pope, JE, et al. Continuously updated 12-lead ST-segment recovery analysis for
myocardial infarct artery patency assessment and its correlation with multiple simultaneous early angiographic
observations. Am J Cardiol. 1993; 71(2):145–151.
15. Medina, V, Clochesy, JM, Omery, A. Comparison of electrode site preparation techniques. Heart Lung. 1989;
18(5):456–460.
16. Pelter, MM, Adams, MG, Drew, BJ. Transient myocardial ischemia is an independent predictor of adverse in-
hospital outcomes in patients with acute coronary syndromes treated in the telemetry unit. Heart Lung. 2003;
32(2):71–78.
17. Shusterman, V, Goldberg, A, Schindler, DM, et al. Dynamic tracking of ischemia in the surface
electrocardiogram. J Electrocardiol. 2007; 40(6 Suppl):S179–S186.
18. Stephens, KE, Anderson, H, Carey, MG, et al, Interpreting 12-lead electrocardiograms for acute ST-elevation
myocardial infarction. what nurses know. J Cardiovasc Nurs. 2007; 22(3):186–193.
19. Stone, GW, Webb, J, Cox, DA, et al, Distal microcirculatory protection during percutaneous coronary
intervention in acute ST-segment elevation myocardial infarction. a randomized controlled trial. JAMA. 2005;
293(9):1063–1072.
Additional Readings
Adams, MG, Pelter, MM, hospital c ardiac monitoring Conover M, ed.. Understanding elec troc ardiography. ed 8. Mosby, S t Louis, 2003:431–443.
Adams-Hamoda MG, et al, Fac tors to c onsider when analyzing 12-lead elec troc ardiograms for evidenc e of ac ute myoc ardial isc hemia . Am J Crit Care 2003;
12:9–18.
Wagner, GS , Marriott’s prac tic al elec troc ardiology . ed 11 . 2008 . Lippinc ott Williams & Wilkins: Philadelphia.
P R OC E D UR E 6 0
Twelve-Lead Electrocardiogram
Mary G. Mc Kinley
PURPOSE:
A 12-lead electrocardiogram provides information about the electrical system of the heart from 12 different views
or leads. The electrocardiogram is the most commonly conducted cardiovascular diagnostic procedure.3
Common uses of a 12-lead electrocardiogram include diagnosis of acute coronary syndromes, identification of
dysrhythmias and conduction disturbances, and determination of the effects of medications or electrolytes on
the electrical system of the heart.
FIGURE 60-1 Vertical plane leads: I, II, III, aVR, aVL, aVF.
FIGURE 60-2 Horizontal plane leads: V 1 to V 6.
• The graphic display consists of the P, Q, R, S, and T waves, which represent electrical activity within the heart.
• Serial 12-lead ECGs (more than two ECGs recorded at different times) may be obtained. The accuracy of
interpretation relies on consistent electrode placement. Indelible markers can be used to identify the electrode
locations to ensure that the same lead placement is used when serial ECGs are recorded.
• Advances in technology have allowed for online or wireless transmission, networking capabilities, and computerized
interpretation of the 12-lead ECG (Fig. 60-3). The 12-lead ECG cable is attached to a processing device that digitizes
the 12-lead ECG recording and transfers the information to the wireless device, which transmits the information to
the medical record. This increases access to the 12-lead ECG for review and can assist with rapid interpretation and
treatment of the patient.
FIGURE 60-3 Example of a w ireless ECG device. The 12-lead cable is attached to a processing device that can then be transmitted to the medical record.
EQUIPMENT
• 12-lead ECG machine and recorder
• Electrodes
• Gauze pads or terrycloth washcloth
• Cleansing pads or nonemollient soap and water
• Patient cable and lead wires
• Alcohol pads
Additional equipment to have available as needed includes the following:
• Skin preparation solution (e.g., skin barrier wipe or tincture of benzoin)
• Indelible marker
• Clippers or scissors to clip hair from chest if needed
PATIENT AND FAMILY EDUCATION
• Assess the readiness of the patient and family to learn. Rationale: Anxiety and concerns of the patient and family
may inhibit the ability to learn.
• Provide explanations of the equipment and procedure to the patient and family. Rationale: Information may
decrease anxiety.
• Emphasize that the patient should not talk but should relax, lie still, and breathe normally. Rationale: Chest
movement can distort the ECG picture.
• Reassure the patient and family that the 12-lead ECG will be reviewed and that any alterations or problems will be
addressed. Rationale: Patients and families need to be reassured that immediate care is available if it is needed.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: This information evaluates and reinforces understanding of previously taught
information.
• Assist the patient to a supine position. Rationale: This position allows easy access to the chest for electrode
placement; changes in body position may affect the accuracy of the ECG recording.
• Assist the patient in removing clothing that covers the chest while providing for the patient’s privacy. Rationale:
Removal of clothing provides a clear view of the chest and allows for identification of landmarks and proper
placement of leads while maintaining the patient’s privacy.
Procedure for 12-Lead Electrocardiogram
FIGURE 60-4 Limb lead placement in 12-lead ECG.
FIGURE 60-5 Precordial or chest lead placement.
FIGURE 60-6 Multiple-channel ECG machine. (Courtesy Philips Medical Systems, Andover, MA.)
FIGURE 60-7 Clear 12-lead ECG recording.
FIGURE 60-8 Limb lead reversal on 12-lead ECG in lead I. A, Correct placement. B, Incorrect placement.
References
1. Drew, BJ. Pitfalls and artifacts in electrocardiography. Cardiol Clin. 2006; 24:309–315.
2. Drew, BJ, et al, Practice standards for electrocardiographic monitoring in hospital settings. an American Heart
Association Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and
Cardiovascular Disease in the Young. Circulation 2004; 110:2721–2746.
3. Kligfield, P, et al, Recommendations for the standardization and interpretation of the electrocardiogram . part 1:
the electrocardiogram and its technology: a scientific statement from the American Heart Association
Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology: The American College of
Cardiology Foundation; and the Heart Rhythm Society. Circulation 2007; 115:1306–1324.
Additional Readings
Adams-Hamoda MG, et al. Fac tors to c onsider when analyzing 12-lead elec troc ardiograms for evidenc e of ac ute myoc ardial isc hemia. Am J Crit Ca re. 2003; 12:9–
16.
Adams-Hamoda MG, Pelter, M. Interpreting a postoperative 12-lead ECG waveform. Am J Crit Ca re. 2003; 12:267–268.
Alspac h, J. Core curriculum for critica l ca re nursing. Philadelphia: S aunders; 2006.
Donnely, MP, et al, Lead selec tion. old and new methods for loc ating the most elec troc ardiogram information. J Elec troc ardiol 2008; 41:257–263.
Drew, BJ, Kligfield, P, S tandardizing elec troc ardiographic leads. introduc tion to a symposium. J Elec troc ardiol 2008; 41:187–189.
Drew, BJ, Putting it all together. c ase studies on ECG monitoring. AACN Adv Crit Care 2007; 18:305–317.
Drew, BJ, et al. An Americ an Heart Assoc iation sc ientific statement from the Counc ils on Cardiovasc ular Nursing, Clinic al Cardiology, and Cardiovasc ular Disease
in the Young. Circula tion. 2004; 110:2721–2746.
Gregg, RE, et al. What is inside the elec troc ardiograph. J Electroca rdiol. 2008; 41:8–14.
Jefferies, P, Woolf, S , Linde, B, Tec hnology-based vs. traditional instruc tion. a c omparison of two methods for teac hing the skill of performing a 12-lead ECG .
Nurs Educ Perspec t . 2003; 24:70–74.
SECTION NINE
Hemodynamic Monitoring
P R OC E D UR E 6 1
PURPOSE:
Arterial catheters are used for continuous monitoring of blood pressure and frequent arterial blood gas and
laboratory sampling.
EQUIPMENT
• 2-inch, 20-gauge, nontapered Teflon cannula-over-needle; or prepackaged kit that includes a 6-inch, 18-gauge, Teflon
catheter with appropriate introducer and guidewire
• Single-pressure transducer system (see Procedure 76)
• Monitoring equipment consisting of a connecting cable, monitor, oscilloscope display screen, and recorder
• Nonsterile gloves, head covering, goggles
• Sterile gloves and gown
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Sterile 4 × 4 gauze pads
• Suture material
• 1% lidocaine without epinephrine, 1 to 2 mL
• 3-mL syringe with 25-gauge needle
• Sheet protector
• Sterile drape
• 2-inch tape
• Chlorhexidine-impregnated sponge
Additional supplies to have available as needed include the following:
• Bath towel
• Small wrist board
• Sutureless securement device
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Obtain informed consent. Rationale: Informed consent protects the rights of the patient and makes a competent
decision possible for the patient; however, in emergency circumstances, time may not allow the form to be signed.
• Place the patient supine with the head of the bed at a comfortable position. The limb into which the arterial catheter
will be inserted should be resting comfortably on the bed. Rationale: This placement provides patient comfort and
facilitates insertion.
• Place a towel under the back of the wrist to hyperextend the wrist and tape it in place or have someone hold it (if the
radial artery is being used). Rationale: This placement positions the arm and brings the artery closer to the surface.
• Elevate and hyperextend the patient’s arm. Support the arm with a pillow (when using the brachial artery).
Rationale: This action increases accessibility of the artery.
• When the femoral artery is used, position the patient supine with the head of the bed at a comfortable angle. The
patient’s leg should be straight with the femoral area easily accessible. Rationale: This position is the best for
localizing the femoral artery pulse.
Procedure for Performing Arterial Catheter Insertion
References
1. Abu-Omar Y, et al. Duplex ultrasonography predicts safety of radial artery harvest in the presence of an
abnormal -Allen test. Ann Thorac Surg. 2004; 77:116–119.
2. Barone, JE, Madlinger, RV. Should an Allen test be performed before artery cannulation. J Trauma. 2006; 61:468–
470.
3. Buffington, S. Specimen collection and testing. In: Nattina, Sandra M, eds. Lippincott’s nursing procedures. ed
2. Springhouse, PA: Springhouse Corp; 1996:145–147.
4. Celenski, SA, Seneff, MG, et al. Arterial line placement and care. In: Irwin RS, ed. Procedures and techniques in
intensive care medicine. ed 6. Philadelphia: Lippincott Williams & Wilkins; 2008:38–46.
5. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related
infections. MMWR. 2002; 51(RR-10):1–31.
6. Chernecky CC, Berger BJ, eds. Laboratory tests and diagnostic procedures, ed 5, St Louis: Saunders Elsevier,
2008.
7. Clarke, S, Arterial lines. an analysis of good practice. J Child Healthcare 1999; 3:22–27.
8. Cummins RO, ed.. Advanced cardiac life support. 1997. American Heart Association: Dallas:13. 9–13. 10.
9. Giner, J, et al. Pain during arterial puncture. Chest. 1996; 110:1443–1445.
10. Gomella, LG, Haist, SA, Bedside proceduresGomella LG, Haist SA, eds.. Clinician’s pocket reference: the scut
monkey. ed 11. 2007. www.accessmedicine.com/content.aspx?aID=2694363 [available at].
11. Hudson, TL, Dukes, SF, Reilly, K. Use of local anesthesia for arterial punctures. Am J Crit Care. 2006; 15:595–599.
12. Hussey, VM, Poulin, MV, Fain, JA. Effectiveness of lidocaine hydrochloride on venipuncture sites. AORN J.
1997; 66:472–475.
13. Imperial-Perez, F, McRae, M, Protocols for practice . hemodynamic monitoring series. arterial pressure
monitoring. American Association of Critical-Care Nurses, Aliso Viejo, CA, 1998.
14. Intravenous Nurses Society. Infusion nursing standards of practice. J Infusion Nurs. 2006; 29(1 Suppl):S1–92. [Jan-
Feb].
15. Martin, C, et al. Long-term arterial cannulation in ICU patients using the radial artery or dorsalis pedis artery.
Chest. 2001; 119:901–906.
16. National Committee for Clinical Laboratory Standards, Procedures for the collection of arterial blood
specimens. approved standards H11-A4. ed 4. National Committee for Clinical Laboratory Standards, Wayne,
PA, 2004.
17. Oettle, AC, et al. Evaluation of Allen’s test in both arms and arteries of left and right-handed people. Surg Radiol
Anat. 2006; 28:3–6.
18. Okeson, GC, Wulbrecht, PH. The safety of brachial artery puncture for arterial blood sampling. Chest. 1998;
114:748–751.
19. Qvist, J, Peterfreund, R, Perlmutter, G. Transient compartment syndrome of the forearm after attempted
radial artery cannulation. Anesth Anal. 1996; 83:183–185.
20. Shiver, S, Blaivas, M, Lyon, M. A prospective comparison of ultrasound-guided and blindly placed radial arterial
catheters. Acad Emerg Med. 2006; 13:1275–1279.
21. Williams, DJ, Ahmed, ST, Latto, IP. A survey of venous and arterial cannulation techniques used for routine
adult coronary artery bypass grafting. Internet J Anesthesiol. 2003; 6:12.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institution standard.
P R OC E D UR E 6 2
PURPOSE:
Arterial catheters are used to continuously monitor blood pressure, to titrate vasoactive agents, and to obtain
serial blood gases or other laboratory specimens in patients with critical illnesses.
• The difference between the systolic and diastolic pressures is the pulse pressure, with a normal value of about 40 mm
Hg.
• Arterial pressure is determined by the relationship between blood flow through the vessels (cardiac output) and the
resistance of the vessel walls (systemic vascular resistance). The arterial pressure is therefore affected by any factors
that change either cardiac output or systemic vascular resistance.
• The average arterial pressure during a cardiac cycle is called the mean arterial pressure (MAP). MAP is not the average
of the systolic plus the diastolic pressures because during the cardiac cycle, the pressure remains closer to diastole
than to systole for a longer period (at normal heart rates). The MAP is calculated automatically by most patient
monitoring systems; however, it can be calculated with the following formula:
• MAP represents the driving force (perfusion pressure) for blood flow through the cardiovascular system. MAP is at its
highest point in the aorta. As blood travels through the circulatory system, systolic pressure increases and diastolic
pressure decreases, with an overall decline in the MAP (Fig. 62-2).
FIGURE 62-2 Arterial pressure from different sites in the arterial tree. The arterial pressure w aveform varies in configuration, depending on the location of
the catheter. With transmission of the pressure w ave into the distal aorta and large arteries, the systolic pressure increases and the diastolic pressure
decreases; w ith a resulting heightening of the pulse, pressure declines steadily. (From Smith JJ, Kampine JP: Circulating physiology, Baltimore, 1980, Williams & Wilkins,
57.)
• The location of arterial catheter placement depends on the condition of the arterial vessels and the presence of other
catheters (i.e., the presence of a dialysis shunt is a contraindication for placement of an arterial catheter in the same
extremity). Once inserted, the arterial catheter causes little or no discomfort to the patient and allows continuous
blood pressure assessment and intermittent blood sampling. If intraaortic balloon pump therapy is necessary, arterial
pressure may be directly monitored from the tip of the balloon in the aorta.
• The radial artery is the most common site for arterial pressure monitoring. When arterial pulse waveforms are
recorded from a peripheral site (instead of a central site), the waveform morphology changes. The anacrotic limb
becomes more peaked and narrowed, with increased amplitude; therefore, the systolic pressure in peripheral sites is
higher than the systolic pressure recorded from a more central site (see Fig. 62-2). In addition, the diastolic pressure
decreases, the diastolic downslope may show a secondary wave, and the dicrotic notch becomes less prominent from
distal sites.
• Vasodilators and vasoconstrictors may change the appearance of the waveforms from distal sites. Vasodilators may
cause the waveform to take on a more central appearance. Vasoconstrictors may cause the systolic pressure to become
more exaggerated because of enhanced resistance in the peripheral arteries.
• Several potential complications are associated with arterial pressure monitoring. Infection at the insertion site can
develop and cause sepsis. Clot formation in the catheter can lead to arterial embolization. The catheter can cause
vessel perforation with extravasation of blood and flush solution into the surrounding tissue. Finally, the distal
extremity can develop circulatory or neurovascular impairment.
EQUIPMENT
• 1- to 2-inch (2.5- to 5-cm) over-the-needle catheter (14-gauge to 20-gauge for adults) or prepackaged kit with catheter,
introducer, and guidewire
• Single-pressure transducer system (see Procedure 76)
• Monitoring equipment consisting of a connecting cable, monitor, oscilloscope display screen, and recorder
• Nonsterile gloves, head coverings, goggles
• Sterile gloves and gowns
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Sterile 4 × 4 gauze pads
• Suture materials
• 1% lidocaine without epinephrine, 1 to 2 mL
• 3-mL syringe with 25-gauge needle
• Sheet protector
• Sterile drape
• 2-inch tape
• Nonvented caps for stopcock
• Chlorhexidine-impregnated sponge
Additional equipment to have available as needed includes the following:
• Bath towel
• Small wrist board
• Sutureless securement device
• Blood-conserving closed system
• Arm board
• Transparent dressing
• Suture removal kit
• Transducer holder, intravenous pole, and carpenter or laser level (for pole mounts)
• 70% alcohol
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent is obtained. Rationale: Informed consent protects the rights of the patient and allows
a competent decision to be made by the patient; however, in emergency circumstances, time may not allow the form
to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Place the patient’s extremity in the appropriate position with adequate lighting of the insertion site. Rationale: This
placement prepares the site for cannulation and facilitates an accurate insertion.
Procedure for Assisting with Insertion of an Arterial Catheter
FIGURE 62-3 Dynamic response test (square w ave test) using the fast flush system. A, Optimally damped system. B, Overdamped system. C,
Underdamped system. (From Darovic GO, Zbilut JP: Fluid-filled monitoring systems. In Hemodynamic monitoring, ed 3, Philadelphia, 2002, Saunders, 122.)
Procedure for Troubleshooting an Overdamped Waveform
FIGURE 62-4 Overdamped arterial w aveform (1, systole; 2, diastole). (From Daily EK, Schroeder JS: Hemodynamic waveforms, St Louis, 1990, Mosby, 110.)
FIGURE 62-5 Patient developed supraventricular tachycardia (SVT) w ith a fall in arterial pressure. Note how the arterial w aveform appears overdamped
but is in fact reflecting a severe hypotensive episode associated w ith the tachycardia.
Additional Readings
Barbeito, A, Mark, JB. Arterial and c entral venous pressure monitoring. Anesthesiol Clin. 2006; 24:717–735.
Bridges, EJ, et al. Ask the experts. Crit Ca re Nurse. 1997; 17:96–102.
Chulay, M, Holland, S , Ask the experts. where should the transduc er be leveled for radial or femoral arterial pressure monitoring. Crit Care Nurse 1996; 16:103–
107.
Darovic , GO, Arterial pressure monitoring. In: Hemodyna mic monitoring: inva sive a nd noninva sive clinica l a pplica tion. ed 3. S aunders, Philadelphia, 2002.
Foster, B. Continuing disc ussion on transduc er plac ement. ask the experts c olumn of the Dec ember issue 1996. zero referenc ing arterial lines. Crit Ca re Nurse.
1997; 17:18.
Gorny, DA. Arterial blood pressure measurement tec hnique. AACN Clin Issues. 1993; 4:66–80.
Halm, MS , Flushing hemodynamic c atheters. what does the sc ienc e tell us. Am J Crit Care 2008; 17:73–76.
Imperial-Perez, F, Mc Rae, M, Protoc ols for prac tic e. applying researc h at the bedsidearterial pressure monitoring. Crit Care Nurse 2002; 22:70–72.
Imperial-Perez, F, Mc Rae, M, Protoc ols for prac tic e. hemodynamic monitoring seriesarterial pressure monitoring. Americ an Assoc iation of Critic al-Care Nurses,
Aliso Viejo, CA, 1998.
Lapum, JL, Patenc y of arterial c atheters with heparinized solutions versus non-heparinized solutions. a review of the literature. Can J Cardiovasc Nurs 2006; 16:64–
67.
Leeper, B, Ask the experts. what is the standard regarding isotonic sodium c hloride solution versus heparin in pressure monitoring systems. Crit Care Nurse 2006;
26:137–138.
O’Grady, NP, et al, Patient safety and the sc ienc e of prevention. the time for implementing the guidelines for the prevention of intravasc ular c atheter-related
infec tions is now. Crit Care Med 2003; 31:291–292.
S haffer, C. Diagnostic blood loss in mec hanic ally ventilated patients. Hea rt Lung. 2007; 36:217–222.
Tunc ali, BE, et al. A c omparison of the effic ac y of heparinized and nonheparinized solutions for maintenanc e of perioperative radial arterial c atheter patenc y and
subsequent oc c lusion. Anesth Ana lg. 2005; 100:1117–1121.
P R OC E D UR E 6 3
PURPOSE:
Arterial pressure-based cardiac output monitoring is a minimally invasive technology that can be used to obtain
hemodynamic data on a continuous basis.
EQUIPMENT
• Invasive arterial catheter and insertion kit
• Specialized sterile transducer and sensor kit (manufacturer-specific)
• Intravenous (IV) pole and cartridge holder (manufacturer-specific)
• Pressure transducer system, including flush solution recommended according to institution standard, a pressure bag
or device, pressure tubing with transducer, and flush device
• Pressure module and cable for interface with the monitor
• Monitoring system (central and bedside monitor)
• Special monitor to interface with the bedside monitor for trending and display of hemodynamic values
(manufacturer-specific)
• Dual-channel recorder
• Indelible marker
• Nonvented caps
• Leveling device (low-intensity laser or carpenter level)
• Sterile and nonsterile gloves
Additional equipment as needed includes the following:
• Heparin
• 3-mL syringe
• 4 × 4 gauze pads or hydrocolloid gel pad
• Tape
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Validate the patency of the peripheral IV line. Rationale: Access may be needed for administration of emergency
medications or fluids.
• Place the patient’s extremity in the appropriate position with adequate lighting of the insertion site. Rationale: This
placement prepares the site for cannulation and facilitates an accurate insertion.
Procedure for Arterial Pressure-Based Cardiac Output Monitoring
FIGURE 63-1 FloTrac sensor and Vigileo monitor. (Courtesy of Edwards Lifesciences, LLC, 2009.)
References
1. American Association of Critical-Care Nurses, Evaluation of the effects of heparinized and nonheparinized
flush -solutions on the patency of arterial pressure monitoring lines. the AACN Thunder Project. Am J Crit Care
1993; 2:3–15.
2. Barone, J, Madlinger, RV. Should an Allen test be performed before radial artery cannulation. J Trauma. 2006;
6:468–470.
3. Button, D, Weibel, L, Reuthebuch, O, et al. Clinical evaluation of the FloTrac/Vigileo system and two established
continuous cardiac output monitoring devices in patients undergoing cardiac surgery. Br J Anaesth. 2007;
99(3):329–336.
4. Cecconi, M, Wilson, J, Rhodes, A. Pulse pressure analysis. In: Vincent JL, ed. Yearbook of intensive care and
emergency medicine. Brussels: Springer-Verlag; 2006:176–184.
5. Chakravarthy, M, Patil, TA, Jayaprakash, K, et al, Comparison of simultaneous estimation of cardiac output by
four techniques in patients undergoing off-pump coronary -artery bypass surgery. a prospective observational
study. Ann Cardiac Anaesth. 2007; 10(2):121–126.
6. Chong, BH. Heparin-induced thrombocytopenia. Br J Haematol. 1995; 89:431–439.
7. de Waal E, Kalkma, C, Rex, S, et al. Validation of a new -arterial pulse contour-based cardiac output device. Crit
Care Med. 2007; 35(8):1904–1909.
8. Greenwood, MJ, et al, Vascular communications of the hand in patients being considered for transradial
coronary angiography. is the Allen’s test accurate. J Am Coll Cardiol 2005; 46:2013–2017.
9. Headley, JM. Clinically relevant monitoring using arterial pressure-based technologies and stroke volume
variation to assess fluid responsiveness. NTI News Online. 2007; 20(21):1–6.
10. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections, Centers for
Disease Control and Prevention. MMWR. 2002; 51(RR-10):1–36.
11. Prasser, C, Bele, S, Keyl, C, et al. Evaluation of a new arterial pressure-based cardiac output device requiring no
external calibration. BMC Anesthesiol. 2007; 7(186):1471–2253. [7-9].
12. Randolph, AG, et al, Benefit of heparin in peripheral venous and arterial catheters. systematic review and
meta-analysis of randomised controlled trials. BMJ 1998; 316:969–975.
13. Slogoff, S, Keats, AS, Arlund, C. On the safety of radial artery cannulation. Anesthesiology. 1983; 59:42–47.
14. Zevola, DR, Dioso, J, Moggio, R. Comparison of heparinized solutions for maintaining patency of arterial and
pulmonary artery catheters. Am J Crit Care. 1997; 6:52–55.
Additional Reading
Mc Gee, WT, Malloux, P, Jodka, P, et al. The pulmonary artery c atheter in c ritic al c are. Semin Dia l. 2006; 19:480–491.
P R OC E D UR E 6 4
PURPOSE:
Blood sampling from an arterial catheter is performed to obtain blood specimens for arterial blood gas analysis
or other laboratory testing.
EQUIPMENT
• Nonsterile gloves
• Sterile 4 × 4 gauze pads
• Appropriate blood specimen tubes (or arterial blood gas [ABG] kit)
• Labels with the patient’s name and appropriate identifying data
• Laboratory form and specimen labels
• Goggles or fluid shield face mask
• Needleless blood sampling access device
• Extra blood specimen tube (for discard)
• Sterile nonvented cap or needleless cap
• Antiseptic solution
Additional equipment as needed includes the following:
• Bag of ice
• Syringes, 5- and 10-mL
• Needleless cannula (for closed arterial blood sampling system)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Expose the stopcock to be used for blood sampling, and position the patient’s extremity so that the site can easily be
accessed. Rationale: This prepares the site for blood withdrawal.
Procedure for Blood Sampling from an Arterial Catheter
FIGURE 64-1 Needleless blood sampling access device. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University Hospital, Philadelphia, PA.)
FIGURE 64-2 A, The needleless blood sampling access device attached to the port of the three-w ay stopcock. The stopcock is turned “off” to the port of
the stopcock. B, A syringe attached to the port of the three-w ay stopcock. The stopcock is turned “off” to the port of the stopcock). (Drawing by Paul W.
Schiffmacher, Thomas Jefferson University Hospital, Philadelphia, PA.)
FIGURE 64-3 The needleless blood sampling access device attached to the port of the three-w ay stopcock. The stopcock is turned “off” to the flush
solution. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University Hospital, Philadelphia, PA)
FIGURE 64-4 A, A syringe attached to the port of the three-w ay stopcock. The stopcock is turned “off” to the patient. B, A syringe attached to the top of
the three-w ay stopcock. The stopcock is turned “off” to the flush solution. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University Hospital, Philadelphia, PA.)
FIGURE 64-5 Closed blood sampling system. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University Hospital, Philadelphia, PA.)
FIGURE 64-6 The stopcock of the closed blood sampling system in the open and closed position. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University
Hospital, Philadelphia, PA.)
FIGURE 64-7 The needleless cannula for the closed blood sampling system. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University Hospital, Philadelphia,
PA.)
FIGURE 64-8 A, The needleless cannula attached to a needleless blood sampling access device. B, The needleless cannula attached to a syringe. (Drawing
by Paul W. Schiffmacher, Thomas Jefferson University Hospital, Philadelphia, PA.)
FIGURE 64-9 Attachment of the needleless cannula into the blood sampling port of the closed blood sampling system. (Drawing by Paul W. Schiffmacher, Thomas
Jefferson University Hospital, Philadelphia, PA.)
FIGURE 64-10 Removal of the needleless cannula from the blood sampling port of the closed blood sampling system. (Drawing by Paul W. Schiffmacher, Thomas
Jefferson University Hospital, Philadelphia, PA.)
References
1. Casey, AL, et al. A randomized, prospective clinical trial to assess the potential infection risk associated with
the PosiFlow needleless connector. J Hosp Infection. 2003; 54:288–293.
2. Darovic, GO, Arterial pressure monitoringInHemodynamic monitoring. invasive and noninvasive clinical -
application. ed 3. Saunders, Philadelphia, 2002.
3. Gleason, E, Grossman, S, Campbell, C. Minimizing diagnostic blood loss in critically ill patients. Am J Crit
Care. 1992; 1:85–90.
4. Gregersen, RA, et al. Accurate coagulation studies from heparinized radial artery catheters. Heart Lung. 1987;
16(6):686–692.
5. Harper, J. Use of intraarterial lines to obtain coagulation samples. Focus Crit Care. 1988; 15:51–55.
6. Laxson, CJ, Titler, MG, Drawing coagulation studies from arterial lines. an integrative literature review. Am J
Crit Care 1994; 3:16–24.
7. MacIsaac, CM, et al. The influence of a blood conserving device on anaemia in intensive care patients. Anaesth
Intensive Care. 2003; 31:653–657.
8. Molyneaux, RD, Papciak, B, Rorem, DA. Coagulation studies and the indwelling heparinized catheter. Heart
Lung. 1987; 16:20–23.
9. O’Grady, NP, et al, Guidelines for the prevention of intravascular catheter-related infections. Centers for
Disease Control and Prevention. MMWR Rec Rep. 2002; 51(RR-10):1–29.
10. Peruzzi, WT, et al. A clinical evaluation of a blood conservation device in medical intensive care unit patients.
Crit Care Med. 1993; 21:501–506.
11. Preusser, BA, et al. Quantifying the minimum discard sample required for accurate arterial blood gases. Nurs
Res. 1989; 38:276–279.
12. Rickard, CM, et al, A discard volume of twice the deadspace ensures clinically accurate arterial blood gases
and electrolytes and prevents unnecessary blood loss. Care Med. Crit . 2003; 31:1654–1658.
13. Rudisill, PT, Moore, LA. Relationship between arterial and venous activated partial thromboplastin time values
in patients after percutaneous transluminal coronary angioplasty. Heart Lung. 1989; 18:514–519.
14. Silver, MJ, et al. Evaluation of a new blood-conserving arterial line system for patients in intensive care units.
Crit Care Med. 1993; 21:507–511.
15. Silver, MJ, et al. Reduction of blood loss from diagnostic sampling in critically ill patients using a blood-
conserving arterial line system. Chest. 1993; 104:1711–1715.
Additional Readings
Alzetani, A, Vohra, HA, Patel, RL. Can we rely on arterial line sampling in performing ac tivated plasma thromboplastin time after c ardiac surgery. Eur J Ana esthesiol.
2004; 21:384–388.
Andrews, T, Waterman, H, Hillier, V, Blood gas analysis. a study of blood loss in intensive c are. J Adv Nurs 1999; 30:851–857.
Cannon, K, Mitc hell, KA, Fabian, TC. Prospec tive randomized evaluation of two methods of drawing c oagulation studies from heparinized arterial lines. Hea rt
Lung. 1985; 14:392–395.
Dirks, JL, Innovations in tec hnology. c ontinuous intra-arterial blood gas monitoring. Crit Care Nurs 1995; 15:19–29.
Heap, MJ, et al. Are c oagulation studies on blood sampled from arterial lines valid. Ana esthesia . 1997; 52:640–645.
Hoste, EAJ, et al. S ignific ant inc rease of ac tivated partial thromboplastin time by heparinization of the radial artery c atheter flush solution with a c losed arterial
system. Crit Ca re Med. 2002; 30:1030–1034.
Imperial-Perez F, Mc Rae, M, Protoc ols for prac tic e. hemodynamic monitoring seriesarterial pressure monitoring. Americ an Assoc iation of Critic al-Care Nurses,
Aliso Viejo, CA, 1998.
Kaplow, R, Comparison of two tec hniques for obtaining samples for c oagulation studies. venipunc ture and intraarterial. Heart Lung 1988; 17:651–653.
Kajs, M. Comparison of c oagulation values obtained by traditional venipunc ture and intra-arterial line methods. Hea rt Lung. 1986; 15:622–627.
Martinez, JA, et al. Clinic al utility of blood c ultures drawn from c entral venous or arterial c atheters in c ritic ally ill surgic al patients. Crit Ca re Med. 2002; 30:7–13.
Reinhardt, AC, et al. Minimum disc ard volume from arterial c atheters to obtain c oagulation studies free from heparin effec t. Hea rt Lung. 1987; 16:699–705.
Ric hiuso, N. Ac c urac y of aPTT values drawn from heparinized arterial lines in c hildren. DCCN. 1998; 17:14–19.
Templin, K, S hively, M, Riley, J. Ac c urac y of drawing c oagulation samples from heparinized arterial lines. Am J Crit Ca re. 1993; 2:88–95.
P R OC E D UR E 6 5
PURPOSE:
To obtain blood from the central venous catheter for laboratory analysis.
EQUIPMENT
• Nonsterile gloves
• Goggles or fluid shield face mask
• Antiseptic solution (e.g., 2% chlorexidine-based solution)
• Needleless blood sampling access device
• Blood specimen tubes
• 10-mL syringe
• Sterile normal saline solution for injection
• Extra blood specimen tube for discard
• Laboratory form and patient identification specimen labels
Additional equipment to have available as needed includes the following:
• 4 × 4 gauze pad
• Needleless caps
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Position the patient so that the blood sampling port is exposed. Rationale: This positioning improves the ease of
obtaining the blood sample and minimizes the contamination of the stopcock.
Procedure for Blood Sampling from Central Venous Catheters
FIGURE 65-1 Needleless blood sampling device attached to the needleless capped stopcock of the hemodynamic monitoring system. The stopcock is open
to the transducer system. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 65-2 Needleless blood sampling device attached to the needleless capped stopcock of the hemodynamic monitoring system. The stopcock is turned
“off” to the monitoring system and flush solution. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 65-3 A syringe attached to the port of the three-w ay stopcock. The stopcock is turned “off” to the patient. The system is open betw een the flush
solution and the syringe attached to the needleless cap. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 65-4 A syringe attached to the port of the three-w ay stopcock. The stopcock is turned “off” to the monitoring system and flush solution. The
system is open betw een the patient and the syringe attached to the needless cap. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 65-5 The needleless blood sampling device attached to the needleless cap of the CVC port. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University,
Philadelphia, PA.)
References
1. Bouza, E, et al, A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub
colonization. a prospective randomized study. J Hosp -Infection 2003; 54:279–287.
2. Carlson, KK, et al. Obtaining reliable plasma sodium and glucose determinations from pulmonary artery
catheters. Heart Lung. 1990; 19:613–619.
3. Casey, AL, et al. A randomized, prospective clinical trial to assess the potential infection risk associated with
the PosiFlow needleless connector. J Hosp Infection. 2003; 54:288–293.
4. Kluger, DM, Maki, DG. The relative risk of intravascular device related bloodstream infections in adults
[abstract]. In: In Abstracts of the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy. San
Francisco, CA: American Society for Microbiology; 1999:514.
5. Krueger, KE, et al. The reliability of laboratory data from blood samples collected through pulmonary artery
catheters. Arch Pathol Lab Med. 1981; 105:343–344.
6. Maki, DG. Pathogenesis, prevention and management of infections due to intravascular devices used for
infusion therapy. In: Bison AL, Waldvogel F, eds. Infections -associated with indwelling medical devices. Washington,
DC: American Society for Microbiology; 1989:161–177.
7. Mermel, LA, Prevention of central venous catheter--related infections. what works other than impregnated or
coated catheters. J Hosp Infection. 2007; 65(Supp 2):30–33.
8. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
9. Palermo, LM, Andrews, RW, Ellison, N. Avoidance of heparin contamination in coagulation studies drawn
from indwelling lines. Anesth Analg. 1980; 59:222–224.
10. Pittet, D, Tarara, D, Wenzel, RP, Noscomial bloodstream infection in critically ill patients. excess length of stay,
extra costs and attributable mortality. JAMA 1994; 271:1598–1601.
11. Safdar, N, Kluger, DM, Maki, DG. A review of risk factors for catheter-related bloodstream infection caused
by percutaneously inserted, noncuffed central venous catheters. Medicine. 2002; 81:466–479.
12. Smith, RL, Meixler, SM, Simberkoff, MS. Excess mortality in critically ill patients with nosocomial
bloodstream infections. Chest. 1991; 100:164–167.
Additional Readings
Beutz, M, et al. Clinic al utility of blood c ultures drawn from c entral vein c atheters and peripheral venipunc ture in c ritic ally ill medic al patients. Chest. 2003; 123:854–
861.
Maki, DG, et al, The risk of bloodstream infec tion in adults with different intravasc ular devic es. a systematic review of 200 published prospec tive studies. Mayo
Clin Proc 2006; 81:1159–1171.
S hapey, IM, et al, Central venous c atheter-related bloodstream infec tions. improving post-insertion c atheter c are. J Hosp Infec tion 2009; 71:117–122.
P R OC E D UR E 6 6
PURPOSE:
Blood is removed from the pulmonary artery catheter for determination of mixed venous oxygen saturation.
EQUIPMENT
• Nonsterile gloves
• Goggles or fluid shield face mask
• Antiseptic solution
• Needleless blood sampling access device
• Two 10-mL syringes
• Blood specimen tubes
• Blood gas sampling syringe
• Needleless cap or nonvented cap
• Laboratory form and specimen label
Additional equipment to have available as needed includes the following:
• Bag of ice
• Sterile 4 × 4 gauze pad
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teaching. Answer questions as they arise, and reinforce information
as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Position the patient so that the stopcock for blood sampling is exposed. Rationale: This positioning improves the
ease of obtaining the blood sample and minimizes the contamination of the stopcock.
Procedure for Blood Sampling from a Pulmonary Artery Catheter
FIGURE 66-1 A syringe attached to the port of the three-w ay stopcock. The stopcock is turned “off” to the port of the stopcock. (Drawing by Paul W.
Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 66-2 A syringe attached to the port of the three-w ay stopcock. The stopcock is turned “off” to flush solution. (Drawing by Paul W. Schiffmacher, Thomas
Jefferson University, Philadelphia, PA.)
References
1. Carlson, KK, et al. Obtaining reliable plasma sodium and glucose determinations from pulmonary artery
catheters. Heart Lung. 1990; 19:613–619.
2. Casey, AL, et al. A randomized, prospective clinical trial to assess the potential infection risk associated with
the PosiFlow needleless connector. J Hosp Infection. 2003; 54:288–293.
3. Krueger, KE, et al. The reliability of laboratory data from blood samples collected through pulmonary artery
catheters. Arch Pathol Lab Med. 1981; 105:343–344.
4. O’Grady, NP, et al, Guidelines for the prevention of intravascular catheter-related infections . Am J Infect
Control. 2002; 30(8):476–489.
5. Palermo, LM, Andrews, RW, Ellison, N. Avoidance of heparin contamination in coagulation studies drawn
from indwelling lines. Anesth Analg. 1980; 59:222–224.
Additional Readings
Darovic , GO, Hemodynamic monitoring. invasive and noninvasive c linic al applic ation. ed 3. S aunders, Philadelphia, 2002.
Goodric h, C. Continous c entral venous oximetry monitoring. Crit Ca re Nurs North Am. 2006; 18:203–209.
P R OC E D UR E 6 7
PURPOSE:
Cardiac output measurements are performed for assessment and monitoring of cardiovascular status. Cardiac
output measurements are used in evaluation of patient responses to clinical interventions, mechanical assist
devices, and vasoactive and inotropic medications. When a pulmonary artery catheter is in place, cardiac output
measurements provide useful initial and trend data that may improve care for critically ill patients with
hemodynamic instability.
• Normal CO is 4 to 8 L/min. The four physiologic factors that affect CO are preload, afterload, contractility, and heart
rate.
• Stroke volume is the amount of blood volume ejected from either ventricle during one beat. Left ventricular stroke
volume is the difference between left ventricular end-diastolic volume and left ventricular end-systolic volume. Left
ventricular stroke volume is normally 60 to 100 mL/beat. Major factors that influence stroke volume are preload,
afterload, and contractility.
• Right heart preload refers to the amount of blood in the right ventricle (RV) at the end of diastole and is measured by
the RAP or CVP. Elevations in left heart filling pressures may be accompanied by parallel changes in RAP, especially
in patients with left systolic ventricular dysfunction. Other factors that affect RAP are venous return, intravascular
volume, vascular capacity, and pulmonary pressure. Right heart preload is increased in right heart failure, right
ventricular infarction, pericardial tamponade, tension pneumothorax, tricuspid regurgitation, and fluid overload.
Right heart preload is decreased in hypovolemic states.
• Left heart preload refers to the amount of blood in the left ventricle (LV) at the end of diastole and is measured by the
PAOP or PAWP. When LV preload or end-diastolic volume increases, the muscle fibers are stretched. The increased
tension or force of contraction that accompanies an increase in diastolic filling is called the Frank-Starling law. The
Frank-Starling law allows the heart to adjust its pumping ability to accommodate various levels of venous return.
Note: In patients with advanced chronic LV dysfunction and remodeled hearts (spherical or globular-shaped LV
instead of the normal elliptical-shaped LV), the Frank-Starling law does not apply. In these patients, muscle fibers of
the heart are already maximally lengthened; as a result, the heart cannot respond significantly to increased filling or
stretch with increased force of contraction.
• Afterload refers to the force the ventricular myocardial fibers must overcome to shorten or contract. It is the force that
resists contraction. The amount of force the LV must overcome influences the amount of blood ejected into the
systemic circulation. Afterload is influenced by peripheral vascular resistance (the force opposing blood flow within
the vessels), systolic blood pressure, systolic stress, and systolic impedance. Peripheral resistance is affected by the
length and radius of the blood vessel, arterial blood pressure, and venous constriction or dilation. The systolic force of
the heart is increased in conditions that cause vasoconstriction (increased afterload), including aortic stenosis,
hypertension, or hyperviscosity of blood (e.g., polycythemia). The systolic force of the heart is decreased in conditions
that cause vasodilation or decrease the viscosity of blood (e.g., anemia). Right ventricular afterload is measured as
pulmonary vascular resistance. Left ventricular afterload is measured as systemic vascular resistance.
• Contractility is defined as the ability of the myocardium to contract and eject blood into the pulmonary or systemic
vasculature. Contractility is increased by sympathetic neural stimulation, the release of calcium, and norepinephrine
and decreased by parasympathetic neural stimulation, acidosis, and hyperkalemia. Contractility and HR can be
influenced by neural, humoral, and pharmacologic factors.
• In addition to stroke volume, CO is affected by heart rate. Normally, nerves of the parasympathetic and sympathetic
nervous system regulate heart rate through specialized cardiac electrical cells. Heart rate and rhythm are influenced
by neural, humoral, and pharmacologic factors. Decreased HR can be the result of increased parasympathetic neural
stimulation, decreased sympathetic neural stimulation, or decreased body temperature. Increased HR can be triggered
by exercise, catecholamine release, or hypotension. At HRs greater than 180 beats/min, there may be inadequate time
for diastolic filling, resulting in decreased CO. Because multiple factors regulate cardiac performance and impact CO,
these factors must be assessed (Fig. 67-1).
FIGURE 67-1 Systematic assessment of the determinants of cardiac output may assist the clinician in defining the etiologic factors of cardiac output
alteration more precisely. (From Whalen DA, Keller R: Cardiovascular patient assessment. In Kinney MR, et al, editors: AACN clinical reference for critical care nurse,ed 4, St
Louis, 1998, Mosby, 227-319.)
• Cardiac index adjusts the CO to an individual’s body size (square meter of body surface area). It is a more precise
measurement of cardiac performance than CO.
• Refer to Table 67-1 for normal hemodynamic values and calculations.
Table 67-1
Hemodynamic Parameters
Body surface area (BSA) Weight (kg) × height (cm) × 0.007184 Varies w ith size (range = 0.58 to 2.9 m2)
CO HR × SV 4-8 L/min
Stroke volume (SV) CO × 1000 ÷ HR 60-100 mL/beat
Stroke volume index (SVI) SV ÷ BSA 30-65 mL/beat/m 2
Pressures:
MAP DBP + ⅓ (SBP − DBP) 70-105 mm Hg
PAMP PADP + ⅓ (PASP − PADP) 9-16 mm Hg
DBP, Diastolic blood pressure; MAP, mean arterial pressure; LVEDP, left ventricular end-diastolic pressure; RVEDP, right ventricular end-diastolic pressure; PAMP,
pulmonary artery mean pressure; PAOP, pulmonary artery occlusion pressure; LVEDV, left ventricular end-diastolic volume; RVEDV, right ventricular end-diastolic
volume; PASP, pulmonary artery systolic pressure; PADP, pulmonary artery diastolic pressure; SBP, systolic blood pressure.
Adapted from Tuggle D: Optimizing hemodynamics: strategies for fluid and medication titration in shock. In Carlson K, editor: AACN advanced critical care nursing,
St Louis, 2009, Saunders, 1106; and Ahrens T: Hemodynamic monitoring, Crit Care Nurs Clin N Am 11:19-31, 1999.
• At the bedside, cardiac output measurements are obtained through a PA catheter via the intermittent bolus
thermodilution CO method (TDCO) or the continuous CO (CCO) method.
• The TDCO method proceeds as follows:
An injectate (5% dextrose in water) of a known volume (10 mL) and temperature (room or cold temperature) is
injected into the right atrium (RA) through the proximal port of the PA catheter. This injectate exits in the RA,
where it mixes with blood and flows through the right ventricle to the PA. A thermistor located at the tip of the PA
catheter senses the change in blood temperature as the blood passes the tip of the catheter in the PA. The CO is
calculated as the difference in temperatures on a time versus temperature curve.
• CO can be calculated from PA catheters with two types of thermistors:
A single thermistor has one inline temperature sensor near the tip of the catheter that lies in the PA when in proper
position.
A dual thermistor has two inline temperature sensors, one in the right atrium/superior caval vein (immediately
above the injectate port opening) and one near the tip of the catheter (same position as single thermistor). Because a
temperature sensor is located in the right atrium, there is no need to enter a “correction factor” or “computation
constant” into the computer to account for the loss in thermal indicator (heat) from the hub of the RA injectate port
to the RA. Investigators found that the second thermistor improved accuracy when compared with Fick CO
measurements and also improved precision or repeatability of CO measurements in both cold and room
temperature.4,24 In one study, cold injectate had excellent precision with the standard single-thermistor PA catheter.
Researchers concluded that the dual-thermistor PA catheter provided the greatest benefit in decreasing
measurement variability when room temperature injections were used to measure CO.4
• The change in temperature over time is plotted as a curve and displayed on the bedside monitor screen. CO is
mathematically calculated from the area under the curve and is displayed digitally and graphically on the monitor
screen (Fig. 67-2). The area under the curve is inversely proportional to the rate of blood flow. Thus, a high CO is
associated with a small area under the curve, whereas a low CO is associated with a large area under the curve (Fig.
67-3, A).
FIGURE 67-2 A, Examining cardiac output curves to establish reliability of values. B, Normal cardiac output curve w ith rapid upstroke and smooth
progressive decrease in temperature sensing. (B: From Ahrens T: Hemodynamic monitoring, Crit Care Nurs Clin North Am 11[1]:28, 1999.)
FIGURE 67-3 A, Variations in the normal cardiac output curve seen in certain clinical conditions. B, Abnormal cardiac output curves that produce an
erroneous cardiac output value. (From Urden LD, Stacy KM, Lough ME: Critical care nursing: diagnosis and management, ed 6, St Louis, 2010, Mosby.)
• The thermistor near the distal tip of the catheter detects the temperature change and sends a signal to the CO
computer and bedside monitor. The computer calculates the CO with the modified Stewart Hamilton equation, and
the CO number is displayed on the monitor screen. The average result of three to five measurements is used to
determine CO.
• Accuracy of TDCO is dependent on adequate mixing of blood and injectate, forward blood flow, steady baseline
temperature in the PA, and appropriate procedural technique.3,16,19 In addition, loss of thermal indicator (heat),
respiratory artifact, and hemodynamic instability can cause variability from one injection to another.19,29
• Commercially available closed system delivery sets (CO-Set, Edwards Lifesciences, LLC, Irvine, CA) can be used with
both cold and room temperature injectate (Figs. 67-4 and 67-5).
FIGURE 67-4 Closed injectate delivery system. Cold temperature injectate. (From Edwards Lifesciences, LLC, Irvine, CA.)
FIGURE 67-5 Closed injectate delivery system. Room temperature injectate. (From Edwards Lifesciences, LLC, Irvine, CA.)
EQUIPMENT
• Nonsterile gloves
• Cardiac monitor
• Hemodynamic monitoring system (see Procedure 76)
• PA catheter (in place)
• CO computer or module
• Connecting cables
• Injectate temperature probe
• Injectate solution
Additional equipment as needed includes the following:
• Bolus thermodilution
Four 10-mL D5 W syringes (prefilled or empty with cold or room temperature solution)*
D5 W injectate solution bag with intravenous (IV) tubing and three-way Luer-Lok stopcock*
Ice (for cold injectate only)
Nonvented caps for stopcocks
• Setup for CCO
• Syringe holder or automatic injector device
• Printer
• Dispensing port
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Assist the patient to the supine position. Rationale: CO measurements are most accurate in the supine position.
Procedure for Measurement of Cardiac Output with the Closed or Open Thermodilution Method
Procedure for Closed-Method of Syringe Preparation and Cardiac Output Determination
Procedure for Open Method of Syringe Preparation and Cardiac Output Determination
Procedure for Measurement of Cardiac Output with Continuous Cardiac Output Method
References
1. Albert, NM, Spear, B, Hammell, J. Agreement and clinical utility of two techniques for measuring cardiac
output in patients with low cardiac output. Am J Crit Care. 1999; 8:464–474.
2. Baillard, C, et al, Haemodynamic measurements (continuous cardiac output and systemic vascular resistance)
in critically ill patients. transesophageal Doppler versus continuous thermodilution. Anaesth Intensive Care 1999;
27:33–37.
3. Balik, M, Pachl, J, Hendl, J. Effect of the degree of tricuspid regurgitation on cardiac output measurements by
-thermodilution. Intensive Care Med. 2002; 28:1117–1121.
4. Berthelsen, PG, et al, Thermodilution cardiac output. cold vs. room temperature injectate and the importance
of measuring the injectate temperature in the right atrium. Acta Anaesthesiol Scand 2002; 46:1103–1110.
5. Bilfinger, TV, Lin, CY, Anagnostopoulos, CE. In vitro determination of accuracy of cardiac output
measurement by thermal dilution. J Surg Res. 1982; 33:409–414.
6. Boldt, J, et al. Is continuous cardiac output measurement using thermodilution reliable in the critically ill
patient. Crit Care Med. 1994; 22:1913–1918.
7. Bourdillon, PDV, Fineberg, N. Comparison of iced and room-temperature injectate for thermodilution cardiac
output. Cathet Cardiovasc Diagn. 1989; 17:116–120.
8. Bridges, EJ. Hemodynamic monitoring. In: Woods SL, et al, eds. Cardiac nursing. ed 5. Philadelphia: JB
Lippincott Williams & Wilkins; 2005:478–526.
9. Daily, EK, Mersch, J, Thermodilution cardiac outputs using room and ice temperature injectate. comparison
with the FICK method. Heart Lung 1987; 16:294–300.
10. Doering, L, Dracup, K. Comparisons of cardiac output in supine and lateral positions. Nurs Res. 1988; 37:114–
118.
11. Driscoll, A, et al. The effect of patient position on the reproducibility of cardiac output measurements. Heart
Lung. 1995; 24:38–44.
12. Elkayam, U, et al, Cardiac output by thermodilution technique. effect of injectate’s volume and temperature
on accuracy and reproducibility in the critically ill. Chest 1983; 84:418–422.
13. Enghof, E, Sjogren, S. Thermal dilution for measurement of cardiac output in the pulmonary artery catheter
in man in relation to choice of indicator volume and injection time. Ups J Med Sci. 1973; 78:33–37.
14. Frazier, SK, Hemodynamic monitoring Moser D, Reigel B, eds. Cardiac nursing: a companion to Braunwald’s
heart disease. Philadelphia: Saunders, 2008.
15. Gawlinski, A, Protocols for practice. hemodynamic monitoring seriescardiac output monitoring,. American
Association of Critical-Care Nurses, Aliso Viejo, CA, 1998.
16. Giuliano, KK, et al. Backrest angle and cardiac output measurement in critically ill patients. Nurs Research.
2003; 52:242–248.
17. Grap, MJ, et al, Use of backrest elevation in critical care. a pilot study. Am J Crit Care 1999; 8:495–496.
18. Griffin, K, et al, Thermodilution cardiac output measurements during simultaneous volume infusion through
the venous infusion port of the pulmonary artery catheter. J Cardiothorac Vasc Anesth 1997; 11:437–439.
19. Groeneveld, AB, et al. Effect of mechanical ventilatory cycle on thermodilution right ventricular volumes and
cardiac output. J Appl Physiol. 2000; 89:89–96.
20. Grose, BL, Wood, SL, Laurent, DJ. Effect of backrest position on cardiac output measured by the
thermodilution method in acutely ill patients. Heart Lung. 1981; 10:661–665.
21. Kalassian, KG, Raffin, TA, The technique of thermodilution cardiac output measurements. J Crit Illness 1996;
11 :249–256.
22. Kiely, M, Byers, LA, Greenwood, R, Thermodilution measurement of cardiac output in patients with low
output. room temperature versus iced injectate. Am J Crit Care 1998; 7:436–438.
23. Kleven, M. Effect of backrest position on thermodilution cardiac output in critically ill patients receiving
mechanical ventilation with positive end-expiratory pressure. Heart Lung. 1984; 13:303–304.
24. Lehmann, KG, Platt, MS. Improved accuracy and precision of thermodilution cardiac output measurement
using a dual thermistor catheter system. J Am Coll Cardiol. 1999; 33:883–891.
25. Levett, JM, Replogle, RL, Thermodilution cardiac output. a critical analysis and review of the literature. J Surg
Res 1979; 27:392–404.
26. Loveys, BJ, Woods, SL. Current recommendations for thermodilution cardiac output measurement. Progress
Cardiovasc Nurs. 1986; 1:24–32.
27. Marcum, J, et al. A comparison of varying injectate volumes in determining thermodilution cardiac output in
critically ill postsurgical patients. Am J Crit Care. 1995; 2:262.
28. McCloy, K, Leung, S, Beldon, J. Effects of injectate volume on thermodilution measurements of cardiac output
in patients with low ventricular ejection fraction. Am J Crit Care. 1999; 8:86–92.
29. Medin, DL, et al. Validation of continuous thermodilution cardiac output in critically ill patients with analysis
of systematic errors. J Crit Care. 1998; 13:184–189.
30. Mihaljevic, T, et al, Continuous versus bolus thermodilution cardiac output measurement. a comparative
study. Crit Care Med 1995; 23:944–949.
31. Nelson, LD, Martinez, OV, Anderson, HB. Incidence of microbial colonization in open versus closed delivery
systems for thermodilution injectate. Crit Care Med. 1986; 14:291–293.
32. Nishikawa, R, Dohi, S, Slowing of heart rate during cardiac output measurement by thermodilution .
Anesthesiology . 1982; 57:538–539.
33. Pearl, RG, et al. Effect of injectate volume and temperature on thermodilution cardiac output determination.
Anesth. 1986; 64:798–801.
34. Plachetka, JR, et al. Comparison of two closed systems for thermodilution cardiac output. Crit Care Med. 1981;
9:487–489.
35. Riedinger, MS, Shellock, FG, Swan, HJ. Reading pulmonary artery and pulmonary capillary wedge pressure
waveforms with respiratory variations. Heart Lung. 1981; 10:675–678.
36. Rocca, GD, et al, Continuous and intermittent cardiac output measurement. pulmonary artery catheter versus
aortic transpulmonary technique. Br J Anaesth 2002; 88:350–356.
37. Rodig, G, et al. Intraoperative evaluation of a continuous versus intermittent bolus thermodilution technique
of cardiac output measurement in cardiac surgical patients. Eur J Anesthesiol. 1998; 15:196–201.
38. Shellock, FG, Riedinger, MS. Reproducibility and accuracy of using room-temperature vs ice-temperature
injectate for thermodiltion cardiac output determination. Heart Lung. 1983; 12:175–176.
39. Shellock, FG, et al, Thermodilution cardiac output determination in hypothermic postcardiac surgery patients.
room vs. ice temperature injectate. Crit Care Med 1983; 11 :668–670.
40. Snyder, JV, Powner, DJ. Effects of mechanical ventilation on the measurement of cardiac output by
thermodilution. Crit Care Med. 1982; 10:677–682.
41. Stevens, JH, et al. Thermodilution cardiac output measurement:effects of the respiratory cycle on its
reproducibility. JAMA. 1985; 253:2440–2442.
42. Todd, MM, Atrial fibrillation induced by right atrial injection of cold fluid during thermodilution cardiac
output determination. a case report. Anesthesiology 1983; 59:253–255.
43. Wallace, DC, Winslow, EH. Effects of iced and room-temperature injectate on cardiac output measurements in
critically ill patients with low and high cardiac outputs. Heart Lung. 1993; 22:55–63.
44. Weil, MH. Measurement of cardiac output. Crit Care Med. 1977; 5:117–119.
45. Wetzel, RC, Latson, TW. Major errors in thermodilution cardiac output measurement during rapid volume
infusion. Anesthesiology. 1985; 62:684–687.
46. Whitman, GR, Howaniak, DL, Verga, TS. Comparison of cardiac output measurements in 20-degree right-
and left-lateral recumbent positions. Heart Lung. 1982; 11:256–257.
47. Wilson, AE, et al. Effect of backrest position on hemodynamic and right ventricular measurements in critically
ill adults. Am J Crit Care. 1996; 5:264–270.
48. Woods, S, Osguthorpe, S. Cardiac output determination. AACN Clin Issue Crit Care Nurs. 1993; 4(1):81–97.
Additional Readings
Ahrens, T. Hemodynamic monitoring. Crit Ca re Nurs Clin North Am. 1999; 11:19–31.
Brandsteller, RD, et al, S wan-Ganz c atheter. misc onc eptions, pitfalls, and inc omplete user knowledgean identified trilogy in need of c orrec tion. Heart Lung J Ac ute
Crit Care 1998; 27:218–222.
Burc hell, S A, et al. Evaluation of a c ontinuous c ardiac output and mixed venous oxygen saturation c atheter in c ritic ally ill surgic al patients. Crit Ca re Med. 1997;
25:388–391.
Ditmyer, CE, S hively, M, Burns, CB. Comparison of c ontinuous with intermittent bolus thermodilution c ardiac output measurement. Am J Crit Ca re. 1995; 4:460–
465.
Headley, JM. S trategies to optimize the c ardiorespiratory status of the c ritic ally ill. AACN Clin Issues Crit Ca re Nurs. 1995; 6:121–134.
Headley, J, Invasive hemodynamic monitoring. physiologic al princ iples and c linic al applic ation. Edwards Lifesc ienc es, Irvine, CA, 2002.
Hollenberg, S M, Hoyt, J. Pulmonary artery c atheters in c ardiovasc ular disease. N Horiz. 1997; 5:207–213.
Jansen, JR, et al. Mean c ardiac output by thermodilution with a single c ontrolled injec tion. Crit Ca re Med. 2001; 29:1868–1873.
S andham, JD, et al. A randomized, c ontrolled trial of the use of pulmonary-artery c atheters in high-risk surgic al patients. N Engl J Med. 2003; 348:5–14.
Taylor, RW. Controversies in pulmonary artery c atheterization. N Horiz. 1997; 5:1–296.
*CO-S et may be used in lieu of these items. The CO-S et is a c losed system that c ontains IV tubing with a snap c lamp, syringe, and stopc oc k.
P R OC E D UR E 6 8
PURPOSE:
Central venous catheters are removed when therapy is completed, when the presence of the catheter presents
a risk for complications (e.g., the catheter is occluded or malpositioned), or when the patient has a catheter-
related infection.
EQUIPMENT
• Goggles or face shield
• Face mask, sterile glows, nonsterile gloves
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Sterile scissors
• 4 × 4 gauze pads
• One roll of 2-inch tape
• Two moisture-proof absorbent pads
Additional equipment to have as needed includes the following:
• Additional dressing supplies (e.g., transparent dressing)
• Sterile specimen container (needed if culture of catheter tip will be obtained)
• Antibiotic ointment
• Suture removal kit
• Emergency equipment
Patient Preparation
• In collaboration with the physician, determine when the CVC should be removed. Rationale: The invasive catheter
is removed when it is no longer indicated.
• In collaboration with the physician, determine whether the tip of the catheter will be cultured. Rationale: This
discussion determines additional supplies that may be needed.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Place the patient in a supine position with the head of the bed in a slight Trendelenburg’s position (or flat if
Trendelenburg’s position is contraindicated or not tolerated by the patient). Rationale: A normal pressure gradient
exists between atmospheric air and the central venous compartment that promotes air entry if the compartment is
open. Placing the patient in a head-down position decreases the risk of air being drawn into the venous circulation.
• Start a new peripheral intravenous (IV) line or ensure that an existing peripheral IV line is patent. Rationale: IV
access is established for fluids or medications.
Procedure for Central Venous Catheter Removal
References
1. Ely, EW, et al, Venous air embolism from central venous catheterization. a need for increased physician
awareness. Crit Care Med 1999; 27:2113–2117.
2. Eyer, S, et al, Catheter-related sepsis. prospective, randomized study of three methods of long-term catheter
maintainence. Crit Care Med 1990; 18:1073–1079.
3. Hsiung, GR, Swanson, PD. Cerebral air embolism after central venous catheter removal. Neurolgy. 2000;
55:1063–1064.
4. Kim, DK, et al, The CVC removal distress syndrome. an unappreciated complication of central venous
catheter removal. Am Surgeon 1998; 64:344–347.
5. McCarthy, PM, et al. Air embolism in single-lung transplant patients after central venous catheter removal.
Chest. 1995; 107:1178–1179.
6. Mennim, P, Cormac, FC, Taylor, JD. Venous air embolism associated with removal of central venous catheter.
BMJ. 1992; 305:171–172.
7. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
8. Oztekin, DS, et al. Comparison of complications and procedural activities of pulmonary artery catheter removal
by critical care nurses versus medical doctors. Nurs Crit Care. 2008; 13:105–115.
9. Pronovost, PJ, Wu, AW, Sexton, JB, Acute decompensation after removing a central line. practical approaches
to increasing safety in the intensive care unit. Ann Intern Med 2004; 140:1025–1033.
10. Rountree, WD, Removal of pulmonary artery catheters by registered nurses. a study in safety and
complications. Focus Crit Care 1991; 18:313–318.
11. Safdar, N, Klugar, DM, Maki, DG, A review of risk factors for catheter-related bloodstream infection caused
by percutaneously inserted, noncuffed central venous catheters. implications for preventive strategies . Medicine
2002; 81:466–472.
12. Turnage, WS, Harper, JV. Venous air embolism occurring after removal of a central venous catheter. Anesth
Analg. 1991; 72:559–560.
13. Wadas, TM. Pulmonary artery catheter removal. Crit Care Nurse. 1994; 14:62–72.
Additional Reading
Dec euninc k, O, DeRoy, L, Moruzi, S , et al, Massive air embolism after c entral venous c atheter removal . Circ ulation . 2007; 116:e516–e518.
P R OC E D UR E 6 9
PURPOSE:
Site care of the central venous catheter allows for assessment and care of the catheter insertion site.
EQUIPMENT
• Nonsterile and sterile gloves
• Transparent dressing or sterile 4 × 4 gauze
• Roll of 2-inch tape
• Face mask
• Prepackaged sterile dressing kit (may include some of the above items)
• Antiseptic solution (e.g., 2% chlorhexidine based)
• Chlorhexidine-impregnated sponge
Additional equipment as needed includes the following:
• Stabilizing device (used with nonsutured central venous catheters)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• If the patient is on ventilatory support, assess the patient’s need for suctioning before beginning the procedure.
Femoral catheter sites need to be inspected for potential contamination with urine or stool. Rationale: The risk for
catheter site contamination by secretions or excretions is minimized.
Procedure for Central Venous Catheter Site Care
References
1. Balamongkhon, B, Thamlikitkul, V. Implementation of chlorhexidine gluconate for central venous catheter site
care at Siriraj Hospital, BangkokThailand. Am J Infect Control. 2007; 35:585–588.
2. Chaiyakunapruk, N, Veenstra, DL, Lipsky, BA, et al, Chlorhexidine compared with povidone-iodine solution
for vascular catheter-site care. a meta-analysis. Ann Intern Med 2002; 136:792–807.
3. Eggimann, P, Harbarth, S, Constantin, M. Impact of a prevention strategy targeted at vascular-access care on
incidence of infections acquired in intensive care. Lancet. 2000; 355:1864–1868.
4. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006; 29:S1–S92.
5. Maenthaisong, R, Chaiyakunapruk, N, Visanu, T. Cost--effective analysis of chlorhexidine gluconate compared
with povidone-iodine solution for catheter-site care in Siriraj -HospitalThailand. J Med Assoc Thai. 2006; 89:S94–
S101.
6. Maki, DG, Narans, LL, Knasinski, V, et al. Prospective, randomized, investigator-masked trial of novel
chlohexidine-impregnated disk (Biopatch) on central venous and arterial catheters [abstract]. Infect Control Hosp
Epidemiol. 2000; 21:96.
7. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:89–476.
8. Safdar, N, Klugar, DM, Maki, DG, A review of risk factors for catheter-related bloodstream infection caused
by percutaneously inserted, noncuffed central venous catheters. implications for preventive strategies. Medicine
2002; 81:466–472.
Additional Readings
Alexander, M, Corrigan, A, Gorski, L. Infusion Nurses -Society Infusion NursingAn Evidence-Ba sed Approa ch, ed 3. S aunders; 2010.
Gillies, D, et al. Ga uze a nd ta pe a nd tra nspa rent polyuretha ne dressings for centra l venous ca theters, Cochra ne Da ta ba se Sys Rev. Chic hester, UK: John Wiley & S ons, Ltd;
2003.
Maki, DG, Kluger, DM, Crnic h, CJ, The risk of bloodstream infec tion in adults with different intravasc ular devic es. a system review of 200 published prospec tive
studies. May Clin Proc 2006; 81:1159–1171.
P R OC E D UR E 7 0
PURPOSE:
Central venous/right atrial pressure monitoring provides information about the patient’s intravascular volume
status and right ventricular preload. The central venous pressure or the right atrial pressure allows for
evaluation of right-sided heart hemodynamics and evaluation of patient response to therapy. Central venous
pressure and right atrial pressure are used interchangeably.
Table 70-1
Central Venous Pressure
Conditions Causing Increased CVP
Elevated intravascular volume
Depressed right-sided cardiac function (RV infarct, RV failure)
Cardiac tamponade
Constrictive pericarditis
Pulmonary hypertension
Chronic left ventricular failure
Conditions Causing Decreased CVP
Reduced intravascular volume*
Decreased mean arterial pressure (MAP)
Venodilation
RV, Right ventric ular.
*Although the measured CVP is low, c ardiac func tion may be depressed, normal, or hyperdynamic when there is reduc ed vasc ular volume.
• Monitoring parameters from the femoral catheter is not recommended. The catheter is too distant from the right
atrium to produce reliable data.
EQUIPMENT
• Pressure transducer system, including flush solution recommended according to institution standard, a pressure bag
or device, pressure tubing with transducer, and flush device (see Procedure 76)
• Pressure module and cable for interface with the monitor
• Dual-channel recorder
• Leveling device (low-intensity laser or carpenter level)
• Nonsterile gloves
• Nonvented caps
Additional equipment to have available as needed includes the following:
• Indelible marker
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand teaching. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Place the patient in the supine position with the head of the bed flat or elevated up to 45 degrees. Rationale: This
positioning prepares the patient for hemodynamic monitoring.
Procedure for Central Venous/Right Atrial Pressure Monitoring
FIGURE 70-1 CVP w aveform w ith a, c, and v w aves present. The a w ave is usually seen just after the p w ave of the ECG. The c w ave appears at the
time of the RST junction on the ECG. The v w ave is seen in the TP interval.
FIGURE 70-2 Reading the RAP from paper printout at end expiration in a spontaneously breathing patient. While observing the patient, identify inspiration.
The point just before inspiration is end expiration. Arrow indicates the point of end expiration. Reading is taken as a mean value. The RAP value for this patient
is 16 mm Hg.
References
1. Blanch, L, et al. Short-term effect of prone position in critically ill patients with acute respiratory distress
syndrome. Intensive Care Med. 1997; 23:1003–1039.
2. Brussel, T, et al. Mechanical ventilation in the prone position for acute respiratory failure after cardiac surgery.
J Cardiothorac Vasc Anesth. 1993; 7:541–546.
3. Cason, CL, et al. Effects of backrest elevation and position on pulmonary artery pressures. Cardiovasc Nurs.
1990; 26:1–5.
4. Chulay, M, Miller, T. The effect of backrest elevation on pulmonary artery and pulmonary capillary wedge
pressures in patients after cardiac surgery. Heart Lung. 1984; 13:138–140.
5. Clochesy, J, Hinshaw, AD, Otto, CW. Effects of change of position on pulmonary artery and pulmonary
capillary wedge pressure in mechanically ventilated patients. NITA. 1984; 7:223–225.
6. Deitcher, SR, et al, Safety and efficacy of alteplase for restoring function in occluded central venous catheters .
results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol 2002; 20:317–324.
7. Dobbin, K, et al, Pulmonary artery pressure measurement in patients with elevated pressures. effect of
backrest elevation and method of measurement. Am J Crit Care 1992; 1:61–69.
8. Fridrich, P, et al. The effects of long-term prone positioning in patients with trauma-induced adult respiratory
distress syndrome. Anesth Analg. 1996; 83:1206–1211.
9. Groom, L, Frisch, SR, Elliot, M. Reproducibility and accuracy of pulmonary artery pressure measurement in
supine and lateral positions. Heart Lung. 1990; 19:147–151.
10. Jolliet, P, Bulpa, P, Chevrolet, JC. Effects of prone position on gas exchange and hemodynamics in severe acute
respiratory distress syndrome. Crit Care Med. 1998; 26:1977–1985.
11. Keating, D, et al. Effect of sidelying positions on pulmonary artery pressures. Heart Lung. 1986; 15:605–610.
12. Kennedy, GT, Bryant, A, Crawford, MH. The effects of lateral body positioning on measurements of
pulmonary artery and pulmonary wedge pressures. Heart Lung. 1984; 13:155–158.
13. Lambert, CW, Cason, CL, Backrest elevation and pulmonary artery pressures. research analysis. Dimens Crit
Care Nurs 1990; 9:327–335.
14. Langer, M, et al. The prone position in ARDS patients. Chest. 1982; 94:103–107.
15. Laulive, JL. Pulmonary artery pressures and position changes in the critically ill adult. Dimens Crit Care Nurs.
1982; 1:28–34.
16. Luskin, RL, et al, Extended use of disposable pressure transducers. a bacteriologic evaluation. JAMA 1986;
255:916–920.
17. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
18. O’Malley, MK, et al. Value of routine pressure monitoring system changes after 72 hours of use. Crit Care
Med. 1994; 22:1424–1430.
19. Osida, C, Measurement of pulmonary artery pressures . supine verses side-lying head elevated positions. Heart
Lung 1989; 18:298–299.
20. Pappert, D, et al. Influence of positioning on ventilation-perfusion relationships in severe adult respiratory
distress syndrome. Chest. 1994; 106:1511–1516.
21. Pelosi, P, et al. Effects of the prone position on respiratory mechanics and gas exchange during acute lung
injury. Am J Respir Crit Care Med. 1998; 157:387–393.
22. Ponec, D, et al, Recombinant tissue plasminogen activator (Alteplase) for restoration of flow in occluded
central venous access devices. a double-blind placebo-controlled trialthe cardiovascular thrombolytic to open
occluded lines (COOL) efficacy trial. J Vasc Interv Radiol 2001; 12:951–955.
23. Voggenreiter, G, et al. Intermittent prone positioning in the treatment of severe and moderate posttraumatic
lung injury. Crit Care Med. 1999; 27:2375–2382.
24. Vollman, KM, Bander, JJ. Improved oxygenation utilizing a prone positioner in patients with acute respiratory
distress syndrome. Intensive Care Med. 1996; 22:1105–1111.
25. Wild, L. Effect of lateral recumbent positions on measurement of pulmonary artery and pulmonary artery
wedge pressures in critically ill adults. Heart Lung. 1984; 13:305.
26. Wilson, AE, et al. Effect of backrest position on hemodynamic and right ventricular measurements in critically
ill adults. Am J Crit Care. 1996; 5:264–270.
27. Woods, SL, Mansfield, LW. Effect of body position upon pulmonary artery and pulmonary capillary wedge
pressures in noncritically ill patients. Heart Lung. 1976; 5:83–90.
Additional Readings
Bridges, EJ, Pulmonary artery pressure monitoring. when, how, and what else to use. AACN Adv Crit Care 2006; 17:286–305.
Darovic , GO, Hemodynamic monitoring. invasive and noninvasive c linic al applic ation. ed 3. S aunders, Philadelphia, 2002.
Kec keisen, M, Protoc ols for prac tic e. hemodynamic monitoring seriespulmonary artery pressure monitoring. Americ an Assoc iation of Critic al-Care Nurses, Aliso
Viejo, CA, 1997.
Magder, S , Invasive intravasc ular hemodynamic monitoring. tec hnic al issues. Crit Care Clin 2007; 23:401–414.
P R OC E D UR E 7 1
PURPOSE:
The left atrial catheter measures pressure from the left atrium for assessment of left ventricular function after
cardiac surgery in the setting of severe left ventricular dysfunction, pulmonary hypertension, presence of
circulatory assist devices, or cardiac transplantation.2 The left atrial catheter provides information about left-
sided intracardiac pressure. Hemodynamic information obtained with the left atrial catheter is used to guide
therapeutic interventions, including administration of fluids and medications and titration of vasoactive and
inotropic medications.
FIGURE 71-1 LAP (left atrial pressure) w aveform and its components: a w ave, the presystolic w ave resulting from atrial contraction; x descent, the
dow nslope of the a w ave caused by atrial relaxation; c w ave, a sharp inflection caused by mitral valve closure; v w ave, an atrial pressure w ave rising to a
peak during late ventricular systole caused by filling of the atrium w hile the mitral valve is closed; y descent, the dow nslope of the v w ave caused by early
diastolic runoff through the mitral valve. Changes in the w aveform configuration may indicate valve or myocardial disease. For example, an elevated a w ave
is seen in mitral stenosis and an elevated v w ave in mitral insufficiency. Both the a and the v w aves are elevated in cardiac tamponade.
• Understanding of a, c, and v waves is necessary. The a wave reflects left atrial contraction. The c wave reflects closure
of the mitral valve. The v wave reflects passive filling of the left atrium during left ventricular systole.
• The LAP is measured with a polyvinyl catheter placed in the left atrium during cardiac surgery. The left atrial catheter
can be inserted via a needle puncture of the right superior pulmonary vein, with subsequent threading into the left
atrium, or it can be inserted via direct cannulation of the left atrium through a needle puncture at the intraatrial
groove.20
• LAP monitoring may be used in the following situations:
For patients with prosthetic tricuspid or pulmonic valves, in whom pulmonary artery catheters are contraindicated
For patients with abnormal heart anatomy (e.g., those with a single ventricle or tricuspid atresia)
For patients with high pulmonary artery pressures, which may interfere with the correlation of pulmonary artery
diastolic pressure (PADP) with pulmonary artery occlusion pressure (PAOP)
For accurate information when vasoconstriction medications are infused in conjunction with pulmonary vasodilator
medications
For patient monitoring after cardiac transplantation
• The normal LAP is 4 to 12 mm Hg.
• One danger with use of this catheter is the potential for air or a blood clot embolus to enter the left atrium and be
carried to the brain or other body organs. Close attention to the hemodynamic monitoring system and assessment of
the waveform are imperative.
EQUIPMENT
• Left atrial catheter (inserted in the operating room)
• Hemodynamic monitoring system (see Procedure 76).
• Sterile dressing supplies
• Indelible marker
• Nonsterile gloves and mask
• Gown and goggles or face shield
Additional equipment to have available, if needed, includes the following:
• Air filter (institution-specific) between the left atrial (LA) catheter and the pressure transducer tubing
• Suture removal kit or supplies
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand teaching. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Consider administration of sedation as prescribed. Rationale: An agitated or restless patient could accidentally pull
out the LA catheter.
Procedure for Care of the Left Atrial Catheter
FIGURE 71-2 LAP catheter that has slipped into the left ventricle (LV). Note anacrotic notch on upstroke of LV w aveform (circled). Note also that paper
w as not calibrated in this example. LAP, left atrial pressure, ECG, electrocardiogram, RAP, right atrial pressure.
Additional Readings
Ahrens, TS , Taylor, LA. Hemodyna mic wa veform a na lysis. Philadelphia: S aunders; 1992.
Gawlinski, A. Fac ts and fallac ies of patient positioning and hemodynamic management. J Ca rdiova sc Nurs. 1997; 12:1–15.
Leitman, BS , et al, The left atrial c atheter. its uses and c omplic ations. Radiology 1992; 185:611–612.
Rao, PS , S athyanarayana, PV, Transseptal insertion of left atrial line. a simple and safe tec hnique. Ann Thorac S urg 1993; 55:785–786.
S antini, F, et al, Routine left atrial c atheterization for the post-operative management of c ardiac surgic al patients. is the risk justified. Eur J Cardiothorac ic S urg
1999; 16:218–221.
Yeo, TC, et al, Retained left atrial c atheter. an unusual c ardiac sourc e of embolism identified by transesophageal ec hoc ardiography. J Am S oc Ec hoc ardiogr
1998; 11:66–70.
P R OC E D UR E 7 2
PURPOSE:
Pulmonary artery catheters are used for determination of hemodynamic status in critically ill patients. Pulmonary
artery catheters provide information about right-sided and left-sided intracardiac pressures and cardiac output.
Additional functions available are fiberoptic monitoring of mixed venous oxygen saturation, intracardiac pacing,
and assessment of right ventricular volumes and ejection fraction.
FIGURE 72-1 West’s lung zones. Schema of the heart and lungs demonstrating the relationship betw een the cardiac chambers and the blood vessels and
the physiologic zones of the lungs. Zone 1 (PA>Pa>Pv): Absence of blood flow . Zone 2 (Pa>PA>Pv): Intermittent blood flow . Zone 3 (Pa>Pv>PA): Continuous
blood flow , resulting in an open channel betw een the pulmonary artery catheter and the left atrium. PA, Pulmonary artery; Pa, pressure arterial; Pv, pressure
venous. (From Copstead LC, Banasik JL: Pathophysiology: biological and behavioral perspectives, ed 2, Philadelphia, 2000, Saunders.)
The PA catheter should lie in lung zone 3, below the level of the left atrium in the dependent portion of the lung.19 In
lung zone 3, both arterial and venous pressures exceed alveolar pressure and PAOP reflects vascular pressures rather than
alveolar pressures.19
• Common indications for insertion of a PA catheter include the following1,2,7,8,12,14,16 :
Acute coronary syndrome or myocardial infarction (MI) complicated by hemodynamic instability, heart failure,
cardiogenic shock, mitral regurgitation, ventral septal rupture, subacute cardiac rupture with tamponade,
postinfarction ischemia, papillary muscle rupture, or severe heart failure (e.g., cardiomyopathy, constrictive
pericarditis)
Hypotension unresponsive to fluid replacement or with heart failure
Cardiac tamponade, significant dysrhythmias, right ventricular infarct, acute pulmonary embolism, and tricuspid
insufficiency
Anesthesia in cardiac surgery with any of the following:
Evidence of previous MI
Resection of ventricular aneurysm
Coronary artery bypass graft (reoperation)
Coronary artery bypass graft (left main or complex coronary disease)
Complex cardiac surgery (multivalvular surgery)
High-risk surgery (e.g., pulmonary hypertension)
General surgery:
Vascular procedures (abdominal aneurysm repair, aortobifemoral bypass)
Patients at high risk 1,15,17
Hypotensive anesthesia1
Cardiac disorders:
Unstable angina that necessitates vasodilator therapy
Heart failure unresponsive to conventional therapy (cardiomyopathy)1,2,18
Pulmonary hypertension during acute medication therapy
Distinguishing cardiogenic from noncardiogenic pulmonary edema
Constrictive pericarditis or cardiac tamponade
Evaluation of pulmonary hypertension for a precardiac transplant workup
Pulmonary disorders:
Acute respiratory failure with chronic obstructive pulmonary diseases
Cor pulmonale with pneumonia
Optimization of positive end-expiratory pressure (PEEP) and volume therapy in patients with acute respiratory
distress syndrome1
Patients who need intraaortic balloon pump therapy
Critically ill pregnant patients (e.g., severe preeclampsia with unresponsive hypertension, pulmonary edema,
persistent oliguria)
Extensive multisystem infection
Severe shock states
Drug overdose
Major trauma or burn
Azotemia
• Relative contraindications to PA catheter insertion include the following:
Preexisting left bundle-branch block
Presence of fever (>101°F [38°C])
Mechanical tricuspid valve
Coagulopathic state
Presence of an endocardial pacemaker
History of heparin-induced thrombocytopenia
EQUIPMENT
• Percutaneous sheath introducer kit and sterile catheter sleeve
• PA catheter (non–heparin-coated catheters and latex-free PA catheters are available)
• Bedside hemodynamic monitoring system with pressure and cardiac output monitoring capability
• Pressure modules and cables for interface with the monitor
• Cardiac output cable with a thermistor/injectate sensor
• Pressure transducer system, including flush solution recommended according to institution standard, a pressure bag
or device, pressure tubing with transducers, and flush device (see Procedure 76)
• Dual-channel recorder
• Sterile normal saline intravenous fluid for flushing the introducer and catheter infusion ports
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Head covering, fluid-shield masks, sterile gowns, sterile gloves, nonsterile gloves, and sterile drapes
• 1% lidocaine without epinephrine
• Sterile basin or cup
• Sterile water or normal saline solution
• Sterile dressing supplies
• Chlorhexidine-impregnated sponge
• Stopcocks (may be included with the pressure tubing systems)
• Nonvented caps or needleless caps
• Leveling device (low-intensity laser or carpenter level)
Additional equipment to have available as needed includes the following:
• Fluoroscope
• Emergency equipment
• Temporary pacing equipment
• Indelible marker
• Transducer holder and intravenous (IV) pole
• Heparin
• 3-mL syringe
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teaching. Answer questions as they arise, and reinforce information
as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Obtain informed consent. Rationale: Informed consent protects the rights of a patient and makes a competent
decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Place the patient in the supine position and prepare the area with the antiseptic solution (e.g., 2% chlorhexidine–based
preparation).13,15 Rationale: The site access is prepared for PA catheter insertion.
• Prescribe sedation or analgesics as needed. Rationale: Sedation and analgesics minimize anxiety and discomfort.
Movement of the patient may inhibit insertion of the PA catheter.
• If the patient is obese or muscular and the preferred site is the internal jugular vein or subclavian vein, place a towel
posteriorly between the shoulder blades. Rationale: This action helps extend the neck and provide better access to
the subclavian and internal jugular veins.
• If the brachial vein is used, stabilize the arm on a padded arm board. Rationale: Visualization of the brachial vein is
aided.
• Drape sterile drapes over the prepared area. Rationale: Sterile drapes provide an aseptic work area.
Procedure for Performing Pulmonary Artery Catheter Insertion
FIGURE 72-2 Pulmonary artery catheter advancing through the heart w ith appropriate w aveforms. (Adapted from Bucher L, Melander S: Critical care nursing,
Philadelphia, 1999, Saunders.)
References
1. American Society of Anesthesiology. Practice guidelines for pulmonary artery catheters. Anesthesiology. 2003;
99:988–1014.
2. Amin, DK, Shah, PK, Swan, HJC. Deciding when hemodynamic monitoring is appropriate. J Crit Illn. 1993;
8:1053–1061.
3. Bridges, EJ, Woods, SL, Pulmonary artery measurement. state of the art. Heart Lung 1993; 22:99–111.
4. Burns, D, Burns, D, Shively, M. Critical care nurses’ knowledge of pulmonary artery catheters. Am J Crit
Care. 1996; 5:49–54.
5. Cohen, Y, et al, The “hands-off” catheter and the prevention of systemic infections associated with pulmonary
artery catheter. a prospective study. Am J Respir Crit Care Med 1998; 157:284–287.
6. Corcoran, TB, Grape, S, Duff, O, et al, The pulmonary artery catheter sleeve. protective or infective. Anaesth
Intensive Care. 2009; 37(2):290–295.
7. Darovic, GO, Pulmonary artery pressure monitoring. Hemodynamic monitoring: invasive and noninvasive
clinical application. Saunders, Philadelphia, 2002.
8. Davis, D, et al, Impact of formal continuing medical education. do conferences, workshops, rounds and other
traditional continuing education activities change physician behavior or health care outcomes. JAMA 1999;
282:867–874.
9. Eggimann, P, et al. Impact of a prevention strategy targeted at vascular-access care on incidence of infections
acquired in intensive care. Lancet. 2000; 355:1864–1868.
10. Herbert, KA, Glancy, DL. Indications for Swan-Ganz catheterization. Heart Dis Stroke. 1994; 3:196–200.
11. Iberti, TJ, et al. A multicenter study of physicians’ knowledge of the pulmonary artery catheter. JAMA. 1990;
22:2928–2933.
12. Iberti, TJ, et al. Assessment of critical care nurses’ knowledge of the pulmonary artery catheter. Crit Care Med.
1994; 22:1674–1678.
13. Lorente, L, Henry, C, Martin, M, et al. Central venous catheter-related infection in a prospective and
observational study of 2,595 catheters. Crit Care. 2005; 9:R631–R635.
14. Morris, AH, Chapman, RH. Wedge pressure confirmation by aspiration of pulmonary capillary blood. Crit
Care Med. 1985; 13:756–759.
15. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
16. Pulmonary Artery Consensus Conference Participants, Pulmonary Artery Catheter Consensus Conference .
consensus statement. Crit Care Med 1997; 25:910–925.
17. Silver, D, Kapsch, DN, Tsoi, EK. Heparin-induced thrombocytopenia, thrombosis, and hemorrhage. Ann Surg.
1983; 198:301–306.
18. Sandham, JD, Hull, LD, Brant, LF, et al. A randomized, controlled trial of the use of pulmonary-artery
catheters in high-risk surgical patients. N Engl J Med. 2003; 348:5–14.
19. West, JB, Dollery, CT, Naimark, A, Distribution of blood flow in isolated lung. relation to vascular and alveolar
pressure. J Appl Physiol 1964; 19:713–724.
Additional Readings
Ahrens, TS , Taylor, LK. Hemodyna mic wa veform a na lysis. Philadelphia: S aunders; 1992.
Americ an Assoc iation of Critic al Care Nurses, Evaluation of the effec ts of heparinized and nonheparinized flush solutions on the patenc y of arterial pressure
monitoring lines. the AACN Thunder Projec t. Am J Crit Care 1993; 2:3–15.
Amin, DK, S hah, PK, S wan, HJC, The S wan-Ganz c atheter. tec hniques for avoiding c ommon errors. J Crit Illn 1993; 8:1263–1271.
Amin, DK, S hah, PK, S wan, HJC. The tec hnique of inserting a S wan-Ganz c atheter. J Crit Illn. 1993; 8:1147–1156.
Baxter, JK, et al, Effec tiveness of right heart c atheterization. time for a randomized trial. JAMA 1997; 277:108.
Blot, F, Chac haty, E, Raynard, B, et al. Mec hanisms and risk fac tors for infec tion of pulmonary artery c atheters and -introduc er sheaths in c anc er patients admitted to
an -intensive c are unit. J Hosp Infect. 2001; 48(4):289–297.
Chernow, B, Pulmonary artery flotation c atheters. a statement by the Americ an College of Chest Physic ians and the Americ an Thorac ic S oc iety. Chest 1997;
111:261.
Connors, AF, et al. The effec tiveness of right heart c atheterization in the initial c are of c ritic ally ill patients. JAMA. 1996; 276:889–897.
Daily, EK, S c hroeder, JS . Techniques in bedside hemodyna mic monitoring, ed 5. S t Louis: Mosby; 1994.
Darovic , GO, Hemodynamic monitoring. invasive and noninvasive c linic al applic ation. S aunders, Philadelphia, 2002.
Friesinger, GC, Williams, S V, ACP/ACC/AHA Task Forc e on Clinic al Privileges in Cardiology. Clinic al c ompetenc e in hemodynamic monitoring. J Am Coll
Cardiol 1990; 15:1460.
Gardner, PE, Bridges, EJ. Hemodynamic monitoring. In: Woods S L, et al, eds. Ca rdia c nursing. ed 3. Philadelphia: Lippinc ott; 1995:424–458.
Ginosar, Y, Pizov, R, S prung, CL, Arterial and pulmonary artery c atheters. In Critic al c are medic ine. Mosby, S t Louis, 1995.
Hadian, M, Pinsky, MR, Evidenc e-based review of the use of the pulmonary artery c atheter. impac t, data and c omplic ations. Crit Care. 2006; 10(S uppl 3):S 11–S 18.
Harvey, S , et al, Assessment of the c linic al effec tiveness of pulmonary artery c atheters in management of patients in intensive c are (PAC-Man). a randomized
c ontrolled trial. Lanc et. 2005; 366(9484):472–477.
Harvey, S , et al. Pulmonary artery c atheters for adult patients in intensive c are. Cochra ne Da ta ba se Syst Rev. 2006; 19:3. [July].
Kec keisen, M, Protoc ols for prac tic e. hemodynamic monitoring series: pulmonary artery pressure monitoring. Americ an Assoc iation of Critic al-Care Nurses,
Aliso Viejo, CA, 1997.
Leeper, B, Monitoring right ventric ular volumes. a paradigm shift. AACN Clin Issues Adv Prac t Ac ute Crit Care 2003; 14:208–219.
Pinsky, MR. Hemodynamic monitoring over the past 10 years. Crit Ca re. 2006; 10:117–119.
Pulmonary Artery Catheter Consensus Conferenc e Partic ipants, Pulmonary Artery Catheter Consensus Conferenc e. c onsensus statement. Crit Care Med 1997;
25:910–925.
Rapoprot, LJ, Teres, D, S teingrub, J. Patient c harac teristic s and ICU organizational fac tors that influenc ing of frequenc y of PA c atheter. JAMA. 2000; 283:2555.
S wan, JHC. What role today for hemodynamic monitoring. J Crit Illn. 1993; 8:1043–1050.
S wan, JHC, Ganz, W, Forrester, JS . Catheterization of the heart in a man with the use of a flow-direc ted balloon-tipped c atheter. N Engl J Med. 1970; 280:447.
The Americ an S oc iety of Anesthesiologists’ Task Forc e on Pulmonary Artery Catheterization. Prac tic e guidelines for pulmonary c atheterization. Anesthesiology.
1993; 78:380–394.
The National Heart, Lung, and Blood Institute Ac ute Respiratory Distress S yndrome Clinic al Trial Network, Wheeler AP, et al. Pulmonary artery vs c entral venous
c atheter to guide treatment of ac ute lung injury. N Engl J Med. 2006; 354(21):2213–2224.
Tuggle, D, Optimizing hemodynamic s. strategies for fluid -and medic ation titration in shoc k, AACN advanc ed -c ritic al c are nursing. Elsevier, Philadelphia,
2009:1099–1133.
Wiener, R, Welc h, H. Trends in the use of the pulmonary artery c atheter in the United S tates 1993-2004. JAMA. 2007; 298(4):423–429.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institution standard.
P R OC E D UR E 7 3
PURPOSE:
Pulmonary artery catheters are used to determine hemodynamic status in critically ill patients. Pulmonary artery
catheters provide information about right-sided and left-sided intracardiac pressures and cardiac output.
Additional functions available are fiberoptic monitoring of mixed venous oxygen saturation, intracardiac pacing,
and assessment of right ventricular volumes and ejection fraction. Hemodynamic information obtained with a
pulmonary artery catheter is used to guide therapeutic intervention, including administration of fluids and
diuretics and titration of vasoactive and inotropic medications.
FIGURE 73-2 Pulmonary artery (PA) catheter location w ithin the heart. Pulmonary artery occlusion pressure (PAOP) is an indirect measure of left atrial (LA)
and left ventricular (LV) end-diastolic pressure. Pulmonary artery occlusion pressure (PAOP) is also referred to as pulmonary artery w edge pressure
(PAWP). (From Kersten LD: Comprehensive respiratory nursing, Philadelphia, 1989, Saunders.)
• Knowledge of the setup of the hemodynamic monitoring system (see Procedure 76) is essential.
• Understanding of normal hemodynamic values (see Table 67-1) is needed.
• The pulmonary artery catheter contains a proximal injectate lumen port, a PA distal lumen port, a thermistor
connector, and a balloon-inflation valve. Some catheters also have two infusion ports, right atrial (RA) and right
ventricular (RV) lumens, that can be used for infusion of medications and intravenous fluids.
• The PA distal lumen is used to monitor systolic, diastolic, and mean pressures in the pulmonary artery. This lumen
also allows for sampling of mixed venous blood. The proximal injectate lumen is used to monitor the right atrial
pressure and inject the solution used to obtain cardiac output (CO). The balloon-inflation valve is used to obtain the
pulmonary artery occlusion pressure (PAOP).
• PAOP may be referred to as pulmonary artery wedge pressure.
• The PA diastolic pressure and the PAOP are indirect measures of left ventricular end-diastolic pressure (LVEDP).
Usually, the PAOP is approximately 1 to 4 mm Hg less than the pulmonary artery diastolic pressure (PADP). Because
these two pressures are similar, the PADP is commonly followed, which minimizes the frequency of balloon inflation,
thus decreasing the potential of balloon rupture and pulmonary artery trauma.
• Differences between the PADP and the PAOP may exist for patients with pulmonary hypertension, chronic
obstructive lung disease, acute respiratory distress syndrome (ARDS), pulmonary embolus, and tachycardia.
• Indications for PA catheter therapy (see Procedure 72 for additional indications) are as follows:
Aid in the diagnosis of complications after acute myocardial infarction (MI), which may include heart failure,
cardiogenic shock, papillary muscle rupture, mitral regurgitation, ventricular septal rupture, or cardiac rupture
with tamponade.
Assessment of ventricular function in heart failure.
Management of high-risk cardiac patients undergoing surgical procedures during preoperative, intraoperative, or
postoperative periods.
Differentiation of hypotensive states, such as hypovolemia, sepsis, heart failure, and cardiac tamponade.
Hemodynamic monitoring and evaluation of patients with major organ dysfunction who need fluid management
and infusion of vasoactive medications, such as patients with burns, trauma, ARDS, or gastrointestinal bleeding.
• Hemodynamic monitoring with a PA catheter has no absolute contraindications, but an assessment of risk versus
benefit to the patient should be considered. Relative contraindications to pulmonary artery catheter insertion include
presence of fever, presence of a mechanical tricuspid valve, and a coagulopathic state. A patient with left bundle-
branch block may have a right bundle-branch block develop during PA catheter insertion, resulting in complete heart
block. In these patients, a temporary pacemaker should be readily available.
• Pulmonary artery pressures may be elevated as a result of pulmonary artery hypertension, pulmonary disease, mitral
valve disease, left ventricular failure, atrial or ventricular left-to-right shunt, pulmonary emboli, or hypervolemia.
• Pulmonary artery pressures may be decreased due to hypovolemia or vasodilation.
• Waveforms that occur during insertion include RA, RV, PA, and pulmonary artery occlusion (PAO; Fig. 73-3).
FIGURE 73-3 Schematic of w aveform progression as a pulmonary artery catheter is inserted through the various cardiac chambers. (From Abbott Critical Care
Systems, Mountain View, CA.)
The a wave reflects atrial contraction, the c wave reflects closure of the atrioventricular valve, and the v wave reflects
passive filling of the atria during ventricular systole (Figs. 73-4 and 73-5).
FIGURE 73-4 Identification of a, c, and v w aves in the w aveform for right atrial and central venous pressure (RA/CVP). Atrial w aveforms are characterized
by three components: a, c, and v w aves. The a w ave reflects atrial contraction, the c w ave reflects closure of the tricuspid valve, and the v w ave reflects
passive filling of the atria. (From Ahrens TS, Taylor LK: Hemodynamic waveform analysis, Philadelphia, 1992, Saunders.)
FIGURE 73-5 Normal pulmonary artery occlusion pressure (PAOP) w aveform. Note the delay in the a, c, and v w aves because of the time needed for the
mechanical events to show a pressure change. This w aveform is from a spontaneously breathing patient. The arrow indicates end expiration, w here the
mean of a w ave pressure is measured. Pulmonary artery occlusion pressure (PAOP) is also referred to as pulmonary artery w edge pressure (PAWP).
The a wave reflects right ventricular filling at end diastole. The mean of the a wave is determined by averaging the
top and bottom values of the a wave.
Elevated a and v waves may be evident in right atrial pressure (RAP/central venous pressure [CVP]) and in PAOP
waveforms. These elevations may occur in patients with cardiac tamponade, constrictive pericardial disease, and
hypervolemia.
Elevated a waves in the RAP/CVP waveform may occur in patients with pulmonic or tricuspid stenosis, right
ventricular ischemia or infarction, RV failure, pulmonary artery hypertension, and atrioventricular (AV)
dissociation.
Elevated a waves in the PAOP waveform may occur in patients with mitral stenosis, acute left ventricular ischemia
or infarction, left ventricular failure, and AV dissociation.
Elevated v waves in the RAP/CVP waveform may occur in patients with tricuspid insufficiency.
Elevated v waves in the PAOP waveform may occur in patients with mitral insufficiency or a ruptured papillary
muscle.
• Insertion and placement verification should occur as follows:
The PA catheter may be inserted through the subclavian, internal jugular, femoral, external jugular, or antecubital
veins.
The standard 7.5 Fr PA catheter is 110 cm long and has black markings at 10-cm increments and wide black
markings at 50-cm increments for facilitation of insertion and positioning (see Fig. 73-1). The catheter should reach
the PA after being advanced 40 to 55 cm from the internal jugular vein, 35 to 50 cm from the subclavian vein, 60
cm from the femoral vein, 70 cm from the right antecubital fossa, and 80 cm from the left antecubital fossa.
Verification of PA catheter placement is validated with waveform analysis. Correct catheter placement shows a PAO
tracing when the balloon is inflated and a PA tracing when the balloon is deflated.
Catheter placement is also verified with chest radiography.
The PA catheter balloon contains latex, which may cause allergic reactions. Latex-free catheters are available.
EQUIPMENT
• PA catheter (non–heparin-coated PA catheters and latex-free PA catheters are available)
• Percutaneous sheath introducer kit and sterile catheter sleeve
• Pressure modules and cables for interface with the monitor
• Cardiac output cable with a thermistor/injectate sensor
• Pressure transducer system, including flush solution recommended according to institution standard, a pressure bag
or device, pressure tubing with transducers, and flush device
• Dual-channel recorder
• Sterile normal saline intravenous (IV) solution for flushing of the introducer and catheter infusion ports
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Head covers, fluid-shield masks, sterile gowns, sterile gloves, nonsterile gloves, and sterile drapes
• 1% lidocaine without epinephrine
• Sterile basin or cup
• Sterile water or normal saline solution
• Sterile dressing supplies
• Chlorhexidine-impregnated sponge
• Stopcocks (may be included in some pressure tubing systems)
• Nonvented caps or needleless caps
• Leveling device (low-intensity laser or carpenter level)
Additional equipment as needed includes the following:
• Fluoroscope
• Emergency equipment
• Temporary pacing equipment
• Indelible marker
• Transducer holder and intravenous (IV) pole
• Heparin
• 3-mL syringe
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Validate the patency of the peripheral IV line. Rationale: Access may be needed for administration of emergency
medications or fluids.
• Assist the patient to the supine position. Rationale: This position prepares the patient for skin preparation, catheter
insertion, and setup of the sterile field.
• Sedate the patient or provide prescribed analgesics as needed. Rationale: Movement of the patient may inhibit
insertion of the PA catheter.
Procedure for Assisting with Pulmonary Artery Catheter Insertion and Pressure Monitoring
FIGURE 73-6 Pulmonary artery catheter gate valve. Top left: Gate valve in the open position. Bottom left: Gate valve in the closed position. (From Baxter
Edwards Corporation.)
FIGURE 73-7 Note vertical lines draw n from the beginning of the P w ave of tw o of the electrocardiogram (ECG) complexes dow n to the right atrial (RA)
w aveform. The first positive deflection of the RA w aveform is the a w ave; the second positive deflection is the v w ave. The c w ave, w hich w ould lie
betw een the a w ave and the v w ave, is not evident in this strip.
FIGURE 73-8 Obtaining measurements of right atrial and central venous pressures (RA/CVP). Aligning the a w ave on the RA/CVP w aveform w ith the PR
interval on the electrocardiogram facilitates accurate measurement of RA/CVP at end diastole. (From Ahrens TS, Taylor LK: Hemodynamic waveform analysis,
Philadelphia, 1992, Saunders.)
FIGURE 73-9 Obtaining measurements of pressure in the pulmonary artery (PA). For systolic pressure, align the peak of the systolic w aveform w ith the QT
interval on the electrocardiogram (ECG). For PA diastolic pressure, use the end of the QRS as a marker to detect the PA diastolic phase. Obtain the reading
just before the upstroke of the systolic w aveform. (From Ahrens TS, Taylor LK: Hemodynamic waveform analysis, Philadelphia, 1992, Saunders.)
FIGURE 73-10 Change in pulmonary artery pressure (PAP) w aveform to pulmonary artery occlusion pressure w aveform w ith balloon inflation. The balloon
is inflated w hile the bedside monitor is observed for change in the w aveform. Balloon inflation (arrow) in patient w ith normal pulmonary artery occlusion
pressure. Pulmonary artery occlusion pressure (PAOP) is also referred to as pulmonary artery w edge pressure (PAWP).
FIGURE 73-11 Obtaining measurement of the pulmonary artery occlusion pressure (PAOP). For accurate readings, align the a w ave from the PAO
w aveform w ith the end of the QRS on the electrocardiogram (ECG) at end diastole. Pulmonary artery occlusion pressure (PAOP) is also referred to as
pulmonary artery w edge pressure (PAWP). (From Ahrens TS, Taylor LK: Hemodynamic waveform analysis, Philadelphia, 1992, Saunders.)
FIGURE 73-12 Respiratory fluctuations of pulmonary artery pressure (PAP) w aveform in a spontaneously breathing patient. The location of inspiration (I) is
marked on the w aveform. The points just before inspiration are end expiration, w here readings are taken.
FIGURE 73-13 Patient on mechanical ventilation (on pressure support-type ventilator) w ho had no spontaneous respiration because of neuromuscular-
blocking agent (vecuronium). The point of end expiration is located just before the ventilator artifact. Pulmonary artery occlusion pressure (PAOP) is also
referred to as pulmonary artery w edge pressure (PAWP).
FIGURE 73-14 Intermittent mandatory ventilation (IMV) mode of ventilation and the effect on the pulmonary artery (PA) w aveform. (From Ahrens TS, Taylor LK:
Hemodynamic waveform analysis, Philadelphia, 1992, Saunders.)
References
1. Blanch, L, et al. Short term effects of prone position in critically ill patients with acute respiratory distress
syndrome. Intensive Care Med. 1997; 23:1033–1039.
2. Brussel, T, et al. Mechanical ventilation in the prone position for acute respiratory failure after cardiac surgery.
J Cardiothorac Vasc Anesth. 1993; 7:541–546.
3. Cason, CL, et al. Effects of backrest elevation and position on pulmonary artery pressures. Cardiovasc Nurs.
1990; 26:1–5.
4. Chen, Y, et al. Comparison between replacement at 4 days and 7 days on the infection rate for pulmonary
artery catheters in an intensive care unit. Crit Care Med. 2003; 31:1353–1358.
5. Chong, BH. Heparin-induced thrombocytopenia. Br J Haematol. 1995; 89:431–439.
6. Chulay, M, Miller, T. The effect of backrest elevation on pulmonary artery and pulmonary capillary wedge
pressures in patients after cardiac surgery. Heart Lung. 1984; 13:138–140.
7. Clochesy, J, Hinshaw, AD, Otto, CW. Effects of change of position on pulmonary artery and pulmonary
capillary wedge pressure in mechanically ventilated patients. NITA. 1984; 7:223–225.
8. Cohen, Y, et al, The “hands-off” catheter in the prevention of systemic infections associated with pulmonary
artery catheter. a prospective study. Am J Respir Crit Care Med 1998; 157:284–287.
9. Daily, EK, Schroeder, JS. Techniques in bedside hemodynamic monitoring,, ed 5. St Louis: Mosby; 1994.
10. Dobbin, K, et al, Pulmonary artery pressure measurement in patients with elevated pressures. effect of
backrest elevation and method of measurement. Am J Crit Care 1992; 1:61–69.
11. Eyer, S, et al, Catheter-related sepsis. prospective, randomized study of three methods of long-term catheter
maintenance. Crit Care Med 1990; 18:1073–1079.
12. Fridrich, P, et al. The effects of long-term prone positioning in patients with trauma-induced adult respiratory
distress syndrome. Anesth Analg. 1996; 83:1206–1211.
13. Groom, L, Frisch, SR, Elliot, M. Reproducibility and accuracy of pulmonary artery pressure measurement in
supine and lateral positions. Heart Lung. 1990; 19:147–151.
14. Hannan, AT, Brown, M, Bigman, O. Pulmonary artery catheter induced hemorrhage. Chest. 1984; 85:128–131.
15. Infusion Nurses Society. Infusion nursing standards of practice. J Infusion Nurs. 2006; 29:S1–S92.
16. Jolliet, P, Bulpa, P, Chevrolet, JC. Effects of prone position on gas exchange and hemodynamics in severe acute
respiratory distress syndrome. Crit Care Med. 1998; 26:1977–1985.
17. Keating, D, et al. Effect of sidelying positions on pulmonary artery pressures. Heart Lung. 1986; 15:605–610.
18. Kennedy, GT, Bryant, A, Crawford, MH. The effects of lateral body positioning on measurements of
pulmonary artery and pulmonary wedge pressures. Heart Lung. 1984; 13:155–158.
19. Lambert, CW, Cason, CL, Backrest elevation and pulmonary artery pressures. research analysis. Dimens Crit
Care Nurs 1990; 9:327–335.
20. Langer, M, et al. The prone position in ARDS patients. Chest. 1988; 94:103–107.
21. Laulive, JL. Pulmonary artery pressures and position changes in the critically ill adult. Dimens Crit Care Nurs.
1982; 1:28–34.
22. Luskin, RL, et al, Extended use of disposable pressure transducers. a bacteriologic evaluation. JAMA 1986;
255:916–920.
23. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
24. O’Malley, MK, et al. Value of routine pressure monitoring system changes after 72 hours of use. Crit Care
Med. 1994; 22:1424–1430.
25. Osika, C, Measurement of pulmonary artery pressures. supine verses side-lying head-elevated positions. Heart
Lung 1989; 18:298–299.
26. Pappert, D, et al. Influence of positioning on ventilation-perfusion relationships in severe adult respiratory
distress syndrome. Chest. 1994; 106:1511–1516.
27. Pelosi, P, et al. Effects of the prone position on respiratory mechanics and gas exchange during acute lung
injury. Am J Respir Crit Care Med. 1998; 157:387–393.
28. Randolph, AG, et al. Benefit of heparin in central venous and pulmonary artery catheters. Chest. 1998;
113:165–171.
29. Voggenreiter, G, et al. Intermittent prone positioning in the treatment of severe and moderate posttraumatic
lung injury. Crit Care Med. 1999; 27:2375–2382.
30. Vollman, KM, Bander, JJ. Improved oxygenation utilizing a prone positioner in patients with acute respiratory
distress syndrome. Intensive Care Med. 1996; 22:1105–1111.
31. Wild, L. Effect of lateral recumbent positions on measurement of pulmonary artery and pulmonary artery
wedge pressures in critically ill adults. Heart Lung. 1984; 13:305.
32. Wilson, AE, et al. Effect of backrest position on hemodynamic and right ventricular measurements in critically
ill adults. Am J Crit Care. 1996; 5:264–270.
33. Woods, SL, Mansfield, LW. Effect of body position upon pulmonary artery and pulmonary capillary wedge
pressures in noncritically ill patients. Heart Lung. 1976; 5:83–90.
Additional Readings
Abreu, AR, Campos, MA, Krieger, BP, Pulmonary artery rupture induc ed by a pulmonary artery c atheter. a c ase report and review of the literature. J Intensive
Care Med 2004; 19:291–296.
Ahrens, TS , Taylor, LA. Hemodyna mic wa veform a na lysis. Philadelphia: S aunders; 1992.
Americ an Assoc iation of Critic al-Care Nurses, AACN prac tic e alert. pulmonary artery pressure measurement. www.aac n.org, 2004 [available at].
Anonymous, Pulmonary artery c atheter c onsensus c onferenc e. c onsensus statement. Crit Care Med 1997; 25:910–925.
Bridges, EJ, Pulmonary artery pressure monitoring. when, how, and what else to use. AACN Adv Crit Care 2006; 17:286–305.
Daily, EK. Hemodynamic waveform analysis. J Ca rdiova sc Nurs. 2001; 15:6–22,87-88.
Darovic , GO, Hemodynamic monitoring. invasive and noninvasive c linic al applic ation,. ed 3. S aunders, Philadelphia, 2002.
Houghton, D, et al. Routine daily c hest radiography in patients with pulmonary artery c atheters. Am J Crit Ca re. 2002; 11:261–265.
Kec keisen, M, Protoc ols for prac tic e. hemodynamic monitoring seriespulmonary artery pressure monitoring,. Americ an Assoc iation of Critic al-Care Nurses,
Aliso Viejo, CA, 1997.
Liu, C, Webb C, From the Food and Drug Administration pulmonary artery rupture. serious c omplic ation assoc iated with pulmonary artery c atheters. Int J
Trauma Nurs 2000; 6:19–26.
Ott, K, Johnson, K, Ahrens, T. New tec hnologies in the assessment of hemodynamic parameters. J Ca rdiova sc Nurs. 2001; 15:41–55.
Quaal, S J. Improving the ac c urac y of pulmonary artery c atheter measurement. J Ca rdiova sc Nurs. 2001; 15:71–82.
Quaal, S J. Is it nec essary to perform a square wave test routinely to test for ac c urac y in hemodynamic monitoring? Or is it rec ommended only if there is a
problem. Crit Ca re Nurse. 1995; 15:92–93.
Rauen, CA, Flynn, MB, Bridges, E, Evidenc e-based prac tic e habits. transforming researc h into bedside prac tic e. Crit Care Nurse 2009; 29:46–59.
Rizvi, K, et al. Effec t of airway pressure display on interobserver agreement in the assessment of vasc ular pressures in patients with ac ute lung injury and ac ute
respiratory distress syndrome. Crit Ca re Med. 2005; 33:98–103.
P R OC E D UR E 7 4
PURPOSE:
The pulmonary artery catheter is removed when the patient’s condition is improved sufficiently that
hemodynamic monitoring is no longer necessary, when there is risk for complications from the presence of the
catheter (e.g., dysrhythmias, pseudoaneurysm), or when there is risk for infection associated with the prolonged
use of intravascular catheters.
EQUIPMENT
• 1.5-mL syringe
• Sterile and nonsterile gloves
• Gown
• Fluid-shield face mask or goggles
• 4 × 4 sterile gauze pads
• Central line dressing kit
• Two moisture-proof absorbent pads
• One roll of 2-inch tape
Additional equipment to have available as needed includes the following:
• Obturator/cap for hemostasis valve
• Additional dressing supplies (e.g., transparent dressing)
• Suture removal kit
• Emergency equipment
Patient Preparation
• In collaboration with the physician, determine when the PA catheter should be removed. Rationale: The invasive
catheter is removed when it is no longer indicated.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Place the patient in a supine position with the head of the bed in a slight Trendelenburg’s position (or flat if
Trendelenburg’s position is contraindicated or not tolerated by the patient). Rationale: A normal pressure gradient
exists between atmospheric air and the central venous compartment that promotes air entry if the compartment is
open. The lower the site of entry below the heart, the lower the pressure gradient, thus minimizing the risk of venous
air embolism.
Procedure for Pulmonary Artery Catheter Removal
FIGURE 74-1 While stabilizing the introducer, gently w ithdraw the PA catheter using a constant, steady motion. (From Wadas TM: Pulmonary artery catheter
removal, Crit Care Nurse 14:63, 1994.)
References
1. Baldwin, IC, Heland, M. Incidence of cardiac dysrhythmias in patients during pulmonary artery catheter -
removal after cardiac surgery. Heart Lung. 2000; 29:155–160.
2. Chen, Y, et al. Comparison between replacement at 4 days and 7 days on the infection rate for pulmonary
artery -catheters in an intensive care unit. Crit Care Med. 2003; 31:1353–1358.
3. Ely, EW, et al, Venous air embolism from central venous catheterization. a need for increased physician
awareness. Crit Care Med 1999; 27:2113–2117.
4. Eyer, S, et al, Catheter-related sepsis. prospective, -randomized study of three methods of long-term -catheter
maintainence. Crit Care Med 1990; 18:1073–1079.
5. Kim, DK, et al, The CVC removal distress syndrome. an unappreciated complication of central venous
catheter removal. Am Surgeon 1998; 64:344–347.
6. McCarthy, PM, et al. Air embolism in single-lung transplant patients after central venous catheter removal.
Chest. 1995; 107:1178–1179.
7. Mennim, P, Cormac, FC, Taylor, JD. Venous air embolism associated with removal of central venous catheter.
BMJ. 1992; 305:171–172.
8. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
9. Oztekin, DS, et al. Comparison of complications and procedural activities of pulmonary artery catheter removal
by critical care nurses versus medical doctors. Nurs Crit Care. 2008; 13:105–115.
10. Peter, DA, Saxman, C, Preventing air embolism when removing CVCs. an evidence-based approach to
changing practice. Medsurg Nurs 2003; 12:223–229.
11. Rountree, WD, Removal of pulmonary artery catheters by registered nurses. a study in safety and
complications. Focus Crit Care 1991; 18:313–318.
12. Turnage, WS, Harper, JV. Venous air embolism occurring after removal of a central venous catheter. Anesth
Analg. 1991; 72:559–560.
13. Wadas, TM. Pulmonary artery catheter removal. Crit Care Nurse. 1994; 14:62–72.
Additional Readings
Arnaout, S , et al. Rupture of the c hordae of the tric uspid valve after knotting of the pulmonary artery c atheter. Chest. 2001; 120:1742–1744.
Darovic , GO, Hemodynamic monitoring. invasive and noninvasive c linic al applic ation. ed 3. S aunders, Philadelphia, 2002.
Mirski, MA, Lele, AV, Fitzsimmons, L, et al. Diagnosis and treatment of vasc ular air embolism. Anesthesiology. 2007; 106:164–177.
Woodrow, P. Central venous c atheters and c entral venous pressure. Nursing Sta nda rd. 2002; 16:45–54.
P R OC E D UR E 7 5
PURPOSE:
Troubleshooting of the pulmonary artery catheter is important to maintain catheter patency, to ensure that data
from the pulmonary artery catheter are accurate, and to prevent the development of catheter-related and patient-
related complications.
EQUIPMENT
• Nonsterile gloves
• Syringes (5- or 10-mL)
• Sterile nonvented caps
• Sterile 4 × 4 gauze
• Stopcocks
• Needleless blood sampling access device
• Pressure monitoring cables
• Pressure transducer system, including flush solution recommended according to institution standard, a pressure bag
or device, pressure tubing with transducers, and flush device
• Dual-channel recorder
• Leveling device (low-intensity laser or carpenter level)
Additional equipment to have available as needed includes the following:
• Emergency equipment
• Blood specimen tubes
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teaching. Answer questions as they arise, and reinforce information
as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Determine the patency of the patient’s intravenous catheters. Rationale: Access may be needed for administration
of emergency medication or fluids.
Procedure for Pulmonary Artery Catheter and Pressure Lines, Troubleshooting
FIGURE 75-1 Balloon inflation (arrow). Overw edging of balloon (balloon has been overinflated). The danger of overinflating the balloon is that the pulmonary
artery (PA) vessel may rupture from the pressure of the balloon. ECG, electrocardiogram; PAP, Pulmonary artery pressure.
FIGURE 75-2 The stopcock is open to the transducer. (From Ahrens TS, Taylor LK: Hemodynamic waveform recognition, Philadelphia, 1993, Saunders.)
FIGURE 75-3 Effects of overdamping on PAP and RAP w aveforms. A, Normal w aveform w ith elevated pulmonary artery (PA) pressures (1, systole; 2,
dicrotic notch; 3, diastole). B, Overdamped PAP w aveform. C, Overdamping of RAP w aveform. Overdamping of the w aveform may result from clots at the
catheter tip, catheter against vessel or heart w all, air in lines, stopcock partially closed, or deflated pressure bag. ECG, electrocardiogram; PAP, Pulmonary
artery pressure; RAP, right atrial pressure.
FIGURE 75-4 Air betw een the patient and stopcock. (Courtesy Edwards Lifesciences, Irvine, CA.)
FIGURE 75-5 RVP w aveform. This w aveform w as seen coming from the PA (distal) lumen of a PA catheter. The catheter w as coiled in the RV. ECG,
electrocardiogram; RV, right ventricle.
References
1. Blanch, L, et al. Short term effects of prone position in critically ill patients with acute respiratory distress
syndrome. Intensive Care Med. 1997; 23:1033–1039.
2. Brussel, T, et al. Mechanical ventilation in the prone position for acute respiratory failure after cardiac surgery.
J Cardiothorac Vasc Anesth. 1993; 7:541–546.
3. Cason, CL, et al. Effects of backrest elevation and position on pulmonary artery pressures. Cardiovasc Nurs.
1990; 26:1–5.
4. Chulay, M, Miller, T. The effect of backrest elevation on pulmonary artery and pulmonary capillary wedge
pressures in patients after cardiac surgery. Heart Lung. 1984; 13:138–140.
5. Clochesy, J, Hinshaw, AD, Otto, CW. Effects of change of position on pulmonary artery and pulmonary
capillary wedge pressure in mechanically ventilated patients. NITA. 1984; 7:223–225.
6. Dobbin, K, et al, Pulmonary artery pressure measurement in patients with elevated pressures. effect of
backrest -elevation and method of measurement. Am J Crit Care 1992; 1:61–69.
7. Fridrich, P, et al. The effects of long-term prone positioning in patients with trauma-induced adult respiratory
-distress syndrome. Anesth Analg. 1996; 83:1206–1211.
8. Groom, L, Frisch, SR, Elliot, M. Reproducibility and accuracy of pulmonary artery pressure measurement in
supine and lateral positions. Heart Lung. 1990; 19:147–151.
9. Jolliet, P, Bulpa, P, Chevrolet, JC. Effects of prone position on gas exchange and hemodynamics in severe
acute -respiratory distress syndrome. Crit Care Med. 1998; 26:1977.
10. Keating, D, et al. Effect of sidelying positions on pulmonary artery pressures. Heart Lung. 1986; 15:605–610.
11. Kennedy, GT, Bryant, A, Crawford, MH. The effects of lateral body positioning on measurements of
pulmonary artery and pulmonary wedge pressures. Heart Lung. 1984; 13:155–158.
12. Lambert, CW, Cason, CL, Backrest elevation and pulmonary artery pressures. research analysis. Dimens Crit
Care Nurs 1990; 9:327–335.
13. Langer, M, et al. The prone position in ARDS patients. Chest. 1988; 94:103–107.
14. Laulive, JL. Pulmonary artery pressures and position changes in the critically ill adult. Dimens Crit Care Nurs.
1982; 1:28–34.
15. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
16. Osika, C, Measurement of pulmonary artery pressures. supine verses side-lying head-elevated positions. Heart
Lung 1989; 18:298–299.
17. Pappert, D, et al. Influence of positioning on ventilation-perfusion relationships in severe adult respiratory
distress syndrome. Chest. 1994; 106:1511–1516.
18. Pelosi, P, et al. Effects of the prone position on respiratory mechanics and gas exchange during acute lung
injury. Am J Respir Crit Care Med. 1998; 157:387–393.
19. Voggenreiter, G, et al. Intermittent prone positioning in the treatment of severe and moderate posttraumatic
lung injury. Crit Care Med. 1999; 27:2375–2382.
20. Vollman, KM, Bander, JJ. Improved oxygenation utilizing a prone positioner in patients with acute respiratory
distress syndrome. Intensive Care Med. 1996; 22:1105–1111.
21. Wild, L. Effect of lateral recumbent positions on measurement of pulmonary artery and pulmonary artery
wedge pressures in critically ill adults. Heart Lung. 1984; 13:305.
22. Wilson, AE, et al. Effect of backrest position on hemodynamic and right ventricular measurements in critically
ill adults. Am J Crit Care. 1996; 5:264–270.
23. Woods, SL, Mansfield, LW. Effect of body position upon pulmonary artery and pulmonary capillary wedge
pressures in noncritically ill patients. Heart Lung. 1976; 5:83–90.
Additional Readings
Bridges, EJ, Pulmonary artery pressure monitoring. when, how, and what else to use. AACN Adv Crit Care 2006; 17:286–305.
Darovic , GO, Hemodynamic monitoring. invasive and noninvasive c linic al applic ation. ed 3. S aunders, Philadelphia, 2002.
Kec keisen, M, Protoc ols for prac tic e. hemodynamic monitoring seriespulmonary artery pressure monitoring. Americ an Assoc iation of Critic al-Care Nurses,
Aliso Viejo, CA, 1997.
Rauen, CA, Flynn, MB, Bridges, E, Evidenc e-based prac tic e habits. transforming researc h into bedside prac tic e. Crit Care Nurse 2009; 29:46–59.
P R OC E D UR E 7 6
PURPOSE:
Single-pressure and multiple-pressure transducer systems provide a catheter-to-monitor interface so that
intravascular and intracardiac pressures can be measured. The transducer detects a biophysical event and
converts it to an electronic signal.
• A double-pressure transducer system is used to measure pressure from two catheters (e.g., arterial and central venous)
or two ports (e.g., pulmonary artery and right atrial) from a single catheter (e.g., pulmonary artery catheter; Fig. 76-2).
FIGURE 76-2 Double-pressure transducer system. ECG, Electrocardiogram; ART, arterial; CO, cardiac output. (Drawing by Paul W. Schiffmacher, Thomas
Jefferson University, Philadelphia, PA.)
• A triple-pressure transducer system is commonly used to measure pressures from the arterial and pulmonary artery
catheters. With this system, arterial pressures, pulmonary artery pressures, and right atrial pressures can be obtained
(Fig. 76-3).
FIGURE 76-3 Triple-pressure transducer system. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
• For accuracy of the hemodynamic values obtained from any transducer system, leveling and zeroing are essential.
• All hemodynamic values (pulmonary artery, right atrial, and arterial) are referenced to the level of the atria. The
external reference point of the atria is the phlebostatic axis.
EQUIPMENT
• Invasive catheter (e.g., arterial, pulmonary artery)
• Pressure modules and cables for interface with the monitor
• Cardiac output cable with a thermistor/injectate sensor for use with the pulmonary artery catheter
• Pressure transducer system, including flush solution recommended according to institution standard, a pressure bag
or device, pressure tubing with transducers, and flush device
• Monitoring system (central and bedside monitor)
• Dual-channel recorder
• Indelible marker
• Nonvented caps
• Leveling device (low-intensity laser or carpenter level)
Additional equipment as needed includes the following:
• Heparin
• 3-mL syringe
• Stopcocks
• 4 × 4 gauze pads or hydrocolloid gel pad
• Tape
• Nonsterile gloves
• Transducer holder and intravenous (IV) pole
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and the family understand preprocedural teaching. Answer questions as they arise, and
reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and
reinforced.
• Position the patient in the supine position with the head of bed flat or elevated up to 45 degrees. Rationale: This
positioning prepares the patient for hemodynamic monitoring.
Procedure for Single-Pressure and Multiple-Pressure Transducer Systems
FIGURE 76-4 Stopcock off to the patient. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 76-5 Stopcock open to the transducer. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 76-6 Transducers in pole mount. (Courtesy Edwards Lifesciences, Irvine, CA.)
FIGURE 76-9 Air-fluid interface (zeroing stopcock) is level w ith the phlebostatic axis using a carpenter level. (Drawing by Paul W. Schiffmacher, Thomas Jefferson
University, Philadelphia, PA.)
References
Americ an Assoc iation of Critic al-Care Nurses, Evaluation of the effec ts of heparinized and nonheparinized flush solutions on the patenc y of arterial pressure
monitoring lines. the AACN Thunder Projec t. Am J Crit Care 1993; 2:3–15.
Bisnaire, D, Robinson, L. Ac c urac y of leveling hemodynamic transduc er systems. CACCN. 1999; 10:16–19.
Blanc h, L, et al. S hort term effec ts of prone position -in c ritic ally ill patients with ac ute respiratory distress syndrome. Intensive Ca re Med. 1997; 23:1033–1039.
Bridges, EJ, et al. Effec t of 30 degree lateral rec umbent position on pulmonary artery and pulmonary artery wedge pressures in c ritic ally ill adult c ardiac surgery
patients. Am J Crit Ca re. 2000; 9:262–275.
Bridges, EJ, et al, Direc t arterial vs. osc illometric monitoring of blood pressure. stop c omparing and pic k one . Crit Care Nurse 1997; 17:96–102. [[c omment]].
Brussel, T, et al. Mec hanic al ventilation in the prone -position for ac ute respiratory failure after c ardiac surgery. J Ca rdiothora c Va sc Anesth. 1993; 7:541–546.
Buxton, AE, et al. Failure of disposable domes to prevent septic emia ac quired from c ontaminated pressure transduc ers. Chest. 1978; 74:508–513.
Cason, CL, et al. Effec ts of bac krest elevation and -position on pulmonary artery pressures. Ca rdiova sc Nurs. 1990; 26:1–5.
Chulay, M, Miller, T. The effec t of bac krest elevation on pulmonary artery and pulmonary c apillary wedge pressures in patients after c ardiac surgery. Hea rt Lung.
1984; 13:138–140.
Cloc hesy, J, Hinshaw, AD, Otto, CW. Effec ts of c hange of position on pulmonary artery and pulmonary c apillary wedge pressure in mec hanic ally ventilated
patients. NITA. 1984; 7:223–225.
Dobbin, K, et al, Pulmonary artery pressure measurement in patients with elevated pressures. effec t of bac krest elevation and method of measurement. Am J Crit
Care 1992; 1:61–69.
Fridric h, P, et al. The effec ts of long-term prone positioning in patients with trauma-induc ed adult respiratory distress syndrome. Anesth Ana lg. 1996; 83:1206–1211.
Groom, L, Frisc h, S R, Elliot, M. Reproduc ibility and ac c urac y of pulmonary artery pressure measurement in supine and lateral positions. Hea rt Lung. 1990; 19:147–
151.
Jolliet, P, Bulpa, P, Chevrolet, JC, Effec ts of prone position on gas exc hange and hemodynamic s in severe ac ute respiratory distress syndrome. Crit Ca re Med 1998;
26 :1977–1985.
Keating, D, et al. Effec t of sidelying positions on pulmonary artery pressures. Hea rt Lung. 1986; 15:605–610.
Kec keisen, M, Protoc ols for prac tic e. hemodynamic monitoring seriespulmonary artery pressure monitoring. 1997. Americ an Assoc iation of Critic al-Care Nurses:
Aliso Viejo, CA.
Kennedy, GT, Bryant, A, Crawford, MH. The effec ts of lateral body positioning on measurements of pulmonary artery and pulmonary wedge pressures. Hea rt
Lung. 1984; 13:155–158.
Kirkhoff, KT, Rebenson-Piano M, Mean arterial pressure readings. variations with positions and transduc er level. Nurs Res 1984; 33:343–345.
Kulkarni, M, et al. Heparinized saline versus normal saline in maintaining patenc y of the radial artery c atheter. Ca n J Surg. 1994; 37:37–42.
Lambert, CW, Cason, CL, Bac krest elevation and pulmonary artery pressures. researc h analysis. Dimens Crit Care Nurs 1990; 9:327–335.
Langer, M, et al. The prone position in ARDS patients. Chest. 1988; 94:103–107.
Laulive, JL. Pulmonary artery pressures and position c hanges in the c ritic ally ill adult. Dimens Crit Ca re Nurs. 1982; 1:28–34.
Luskin, RL, et al, Extended use of disposable pressure transduc ers. a bac teriologic evaluation. JAMA 1986; 255 :916–920.
Maki, DG, Martin, WT, Nationwide epidemic of septic emia c aused by c ontaminated infusion produc ts. IV: growth of mic robial pathogens in fluids for intravenous
infusion. J Infec t Dis 1975; 131:267–272.
Mc Ghee, BH, Bridges, MEJ, Monitoring arterial blood pressure. what you may not know. Crit Care Nurse 2002; 22:60–79.
O’Grady, NP, et al. Guidelines for the prevention of intravasc ular c atheter-related infec tions. Am J Infect Control. 2002; 30:476–489.
O’Malley, MK, et al. Value of routine pressure monitoring system c hanges after 72 hours of use. Crit Ca re Med. 1994; 22:1424–1430.
Osika, C, Measurement of pulmonary artery pressures. supine verses side-lying head-elevated positions. Heart Lung 1989; 18:298–299.
Paolella, LP, et al, Topographic loc ation of the left atrium by c omputed tomography. reduc ing pulmonary artery c atheter c alibration error. Crit Care Med 1988;
16:1154–1156.
Pappert, D, et al. Influenc e of positioning on ventilation-perfusion relationships in severe adult respiratory distress syndrome. Chest. 1994; 106:1511–1516.
Pauc a, AL, et al. Does radial artery pressure ac c urately reflec t aortic pressure. Chest. 1992; 102:1193–1198.
Pelosi, P, et al. Effec ts of the prone position on respiratory mec hanic s and gas exc hange during ac ute lung injury. Am J Respir Crit Ca re Med. 1998; 157:387–393.
Randolph, AG, et al. Benefit of heparin in c entral venous and pulmonary artery c atheters. Chest. 1998; 113:165–171.
Ric e, WP, et al. A c omparison of hydrostatic leveling methods in invasive pressure monitoring. Crit Ca re Nurse. 2000; 20:20–30.
Ross, CJ, Jones, R. Comparisons of pulmonary artery pressure measurements in supine and 30 degree lateral positions. Ca n J Ca rdiova sc Nurs. 1995; 6:4–8.
S olomon, S L, et al. Nosoc omial fungemia in neonates assoc iated with intravasc ular pressure-monitoring devic es. Pedia tr Infect Dis. 1986; 5:680–685.
Voggenreiter, G, et al. Intermittent prone positioning in the treatment of severe and moderate posttraumatic lung injury. Crit Ca re Med. 1999; 27:2375–2382.
Vollman, KM, Bander, JJ. Improved oxygenation utilizing a prone positioner in patients with ac ute respiratory distress syndrome. Intensive Ca re Med. 1996;
22:1105–1111.
Wild, L. Effec t of lateral rec umbent positions on measurement of pulmonary artery and pulmonary artery wedge pressures in c ritic ally ill adults. Hea rt Lung. 1984;
13:305.
Wilson, AE, et al. Effec t of bac krest position on hemodynamic and right ventric ular measurements in c ritic ally ill adults. Am J Crit Ca re. 1996; 5:264–270.
Woods, S L, Mansfield, LW. Effec t of body position upon pulmonary artery and pulmonary c apillary wedge pressures in nonc ritic ally ill patients. Hea rt Lung. 1976;
5:83–90.
Additional Readings
Darovic , GO, Hemodynamic monitoring. invasive and noninvasive c linic al applic ation. ed 3. S aunders, Philadelphia, 2002.
Imperial-Perez F, Mc Rae, M, Protoc ols for prac tic e. hemodynamic monitoring series: arterial pressure monitoring. Americ an Assoc iation of Critic al-Care Nurses,
Aliso Viejo, CA, 1998.
Kee, LL, et al. Ec hoc ardiographic determination of valid zero referenc e levels in supine and lateral positions. Am J Crit Ca re. 1993; 2:72–80.
Mermel, LA, Maki, DG, Epidemic bloodstream infec tions from hemodynamic pressure monitoring. signs of the times. Infec t Control Hosp Epidemiol 1989; 10:47–
53.
Pearson, ML, Hospital infec tion c ontrol prac tic es advisory c ommittee. guideline for prevention of intravasc ular devic e-related infec tions. Infec t Control Hosp
Epidemiol 1996; 17:438–473.
Quaal, S J, Weir, C, Effec t of head of bed position on pulmonary artery pressure measurements. a review of the literature. Online J Knowledge S ynthesis Nurs 1995;
2:1–10.
S hih, F. Patient positioning and the ac c urac y of pulmonary artery pressure measurements. Int J Nurs Studies. 1999; 36:497–505.
Vollman, KM. What are the prac tic e guidelines for prone positioning of ac utely ill patients? S pec ific ally, what are the rec ommendations related to hemodynamic
monitoring and tube feeding. Crit Ca re Nurse. 2001; 21:84–86.
SECTION TEN
Special Cardiac Procedures
P R OC E D UR E 7 7
PURPOSE:
Arterial and venous sheaths are placed for cardiac catheterizations and interventional procedures. Achieving
and maintaining hemostasis after their removal is essential to prevent access site complications.
FIGURE 77-1 FemoStop in the correct position. (From Barbiere C: A new device for control of bleeding after transfemoral catheterization, Crit Care Nurse 15[1]:52, 1995.)
Collagen plug devices (e.g., VasoSeal, Datascope Corp, Montvale, NJ; Angioseal, St Jude Medical, St Paul, MN).
Percutaneous suture-mediated closure devices (e.g., Perclose, Abbott Vascular Devices, Redwood City, CA; X-Site,
Datascope Corp)
Percutaneous staple-mediated closure devices (e.g., Angiolink, Medtronic, Santa Rosa, CA; Starclose, Abbott
Vascular Devices).
• Collagen plug devices, percutaneous suture-mediated closure devices, and percutaneous staple-mediated closure
devices can be deployed into the artery by the physician at the end of the catheterization or interventional procedure.
• Sheath removal can be associated with many complications, including the following:
External bleeding at the site
Internal bleeding (e.g., localized hematoma or retroperitoneal bleed)
Vascular complications (e.g., pseudoaneurysm, arteriovenous [AV] fistula, dissection, thrombus, or embolus)
Neurovascular complications (sensory or motor changes in the affected extremity)
Vasovagal complications
EQUIPMENT
• Cardiac monitoring system
• Blood pressure monitoring system
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Nonsterile gloves
• Sterile gloves
• Protective eyewear
• Dressing supplies
• 10-mL syringe
Additional equipment as needed includes the following:
• Selected hemostasis option (mechanical compression device or noninvasive hemostasis pad)
• Alcohol pads
• Indelible marker
• Selected analgesic and/or sedative as prescribed
• Portable Doppler ultrasound machine
• Suture removal kit
• ACT machine
• Readily available emergency medications (e.g., atropine), additional intravenous fluids, and resuscitation equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and the family understand preprocedural teaching. Answer questions as they arise, and
reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and
reinforced.
• Administer analgesia or sedation as prescribed before removal of the sheaths. Rationale: Pain and anxiety are
managed.
• Place the patient with the head of the bed flat. Rationale: This positioning improves the ability to achieve
hemostasis.
• Mark the distal pulses with an indelible marker. Rationale: Marking facilitates the ability to locate pulses after the
procedure.
• If a mechanical device is used to maintain pressure, position the device under the patient. Rationale: The device is
positioned before sheath removal because patient movement must be minimized after sheath removal.
Procedure for Arterial and Venous Sheath Removal
References
1. Baim, DS, Simon, DI, Percutaneous approach including trans-septal and apical puncture Baim DS, ed..
Grossman’s cardiac catheterization, angiography, and intervention. ed 7. Lippincott Williams & Wilkins,
Philadelphia, 2006:79–106.
2. Barbiere, CC, A new device for control of bleeding after transfemoral catheterization. the FemoStop system.
Crit Care Nurse 1995; 15:51–53.
3. Benson, LM, et al, Determining best practice. comparison of three methods of femoral sheath removal after
cardiac interventional procedures. Heart Lung J Acute Crit Care 2004; 34:115–121.
4. Bogart, MA, Time to hemostasis. a comparison of manual versus mechanical compression of the femoral
artery. Am J Crit Care 1995; 4:149–156.
5. Bowden, SM, Worrey, JA, Assessing patient comfort . Local infiltration of lidocaine during femoral sheath
removal. Am J Crit Care 1995; 4:368–369.
6. Coyne, C, et al. Controlled trial of backrest elevation after coronary angiography. Am J Crit Care. 1994; 3:282–
288.
7. Fowlow, B, Price, P, Fung, T, Ambulation after sheath removal. a comparison of 6 and 8 hours of bedrest after
sheath removal in patients following a PTCA procedure. Heart Lung J Acute Crit Care 1995; 24:28–37.
8. Jones, T, McCutcheon, H. Effectiveness of mechanical compression devices in attaining hemostasis after
femoral sheath removal. Am J Crit Care. 2002; 11:155–162.
9. Keeling, AW. Reducing time in bed after percutaneous transluminal coronary angioplasty (TIBS III). Am J Crit
Care. 2000; 9:185–187.
10. Kiat Ang C, et al. Effect of local anesthesia and intravenous sedation on pain perception and vasovagal
reactions during femoral arterial sheath removal after percutaneous coronary intervention. Int J Cardiol. 2005;
116:321–326.
11. Koreny, M, et al, Arterial puncture closing devices compared with manual compression after cardiac
catheterization: . systematic review and meta-analysis. JAMA 2004; 291:350–357.
12. Logemann, T, et al. Two versus six hours of bed rest following left-sided cardiac catheterization and a meta-
analysis of early ambulation trials. Am J Cardiol. 1999; 84:486–488.
13. Nikolsky, E, et al. Vascular complications associated with arteriotomy closure devices in patients undergoing
percutaneous coronary procedures. J Am Coll Cardiol. 2004; 44:1200–1209.
14. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter- related infections, Centers for
Disease Control and Prevention. MMWR Recommend Rep. 2002; 51(RR-10):1–29.
15. Rudisill, PT, et al. Study of mechanical versus manual-mechanical compression following various
interventional cardiology procedures. J Cardiovasc Nurs. 1997; 11:15–21.
16. Simon, A, et al. Manual versus mechanical compression for femoral artery hemostasis after cardiac
catheterization. Am J Crit Care. 1998; 7:308–313.
17. Sulzbach, LM, Munro, BH, Hirshfeld, JW. A randomized clinical trial of the effect of bed position after PTCA.
Am J Crit Care. 1995; 4:221–226.
18. Tagney, J, Lackie, D, Bed-rest post-femoral arterial sheath removal. what is safe practice? A clinical audit. Nurs
Crit Care 2005; 10:167–173.
19. Vlasic, W, Almond, D, Massel, D, Reducing bedrest following arterial puncture for coronary interventional
procedures-impact on vascular complications. the BAC Trial. J Invasive Cardiol 2001; 13:788–792.
20. Wadas, TM, Hill, J. Is lidocaine infiltration during femoral sheath removal really necessary. Heart Lung J Acute
Crit Care. 1998; 27:31–36.
21. Walker, S, et al. Comparison of complications in percutaneous coronary intervention patients mobilized at 3, 4
and 6 hours after femoral arterial sheath removal. J Cardiovasc Nurs. 2008; 23:407–413.
22. Walker, SB, Cleary, SR, Higgins, M. Comparison of the FemoStop device and manual pressure in reducing
groin puncture site complications following coronary angioplasty and coronary stent placement. Int J Nurs Pract.
2001; 7:366–375.
23. Wensley, CJ, et al, Pain relief for the removal of femoral sheath in interventional cardiology patients Art. No.
:CD006043. Cochrane Database Syst Rev 2008; 4, doi: 10. 1002/14651858. CD006043. pub2.
Additional Readings
Chlan, LL, S abo, J, S avik, K. Effec ts of three groin c ompression methods on patient disc omfort, distress, and vasc ular c omplic ations following a prec utaneous
c oronary intervention proc edure. Nurs Res. 2005; 54:391–398.
Christensen, BV, et al. Vasc ular c omplic ations after angiography with and without the use of sandbags. Nurs Res. 1998; 47:51–53.
Cura, FA, et al. S afety of femoral c losure devic es after perc utaneous c oronary interventions in the era of glyc oprotein IIb/IIIa platelet bloc kade. Am J Ca rdiol.
2000; 86:780–782.
Dressler, DK, Dressler, KK, Caring for patients with femoral sheaths. after perc utaneous c oronary intervention, sheath removal and site monitoring are the nurse’s
responsibility. AJN 2006; 106:64.
Dueling, JHH, et al, Closure of the femoral artery after c ardiac c atheterization. a c omparison of Angio-S eal, S tarClose, and manual c ompression. Cathet Cardiovasc
Interv 2008; 71:518–523.
Dumont, CJP, et al. Predic tors of vasc ular c omplic ations post diagnostic c ardiac c atheterization and perc utaneous c oronary intervention. Dimens Crit Ca re Nurs.
2006; 25:137–142.
Galli, A, Palatnik, A, Ask the experts. what is the proper ac tivated c lotting time (ACT) at whic h to remove a femoral sheath after PCI? What are the best
“protoc ols” for sheath removal. Crit Care Nurse 2005; 25:88–95.
Juergens, CP, et al. Vaso-vagal reac tions during femoral arterial sheath removal after perc utaneous c oronary intervention and impac t on c ardiac events. Int J
Ca rdiol. 2007; 127:252–254.
Kim, M. Vasc ular c losure devic es. Ca rdiol Clin. 2006; 24:277–286.
Nic kolaus, MJ, Gilc hrist, IC, Ettinger, S M, The way to the heart is all in the wrist. transradial c atheterization and interventions. AACN Clin Issues 2001; 12:62–
71.
S abo, J, Chlan, LL, S avik, K. Relationships among patient c harac teristic s, c omorbidities, and vasc ular c omplic ations post-perc utaneous c oronary intervention. Hea rt
Lung J Acute Crit Ca re. 2008; 37:190–195.
S c hic kel, S , et al, Removal of femoral sheaths by registered nurses. issues and outc omes. Crit Care Nurse 1996; 16:32–36.
S mith, TT, Labriola, R. Developing best prac tic e in arterial sheath removal for registered nurses. J Nurs Ca re Qua l. 2001; 16:61–67.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 7 8
PURPOSE:
An indwelling pericardial catheter allows for the slow and complete evacuation of a pericardial effusion. The
catheter also allows for the infusion of medications, such as antibiotics or chemotherapeutic agents, into the
pericardial space.
• The pericardial catheter may also be left in place to allow the instillation of certain medications (i.e., nonabsorbable
corticosteroid or antineoplastic agents) depending on the patient’s underlying disease state.8,12
• The indwelling pericardial catheter is usually removed within 48 to 72 hours after placement to avoid the risk of
infection or iatrogenic pericarditis.13,14 The indwelling pericardial catheter may be left in place for longer periods of
time to promote the resolution of a pericardial effusion or cardiac tamponade.1 Pericardial catheters are immediately
removed if there is an abrupt rise in the white blood cell (WBC) level.12
• Pericardial catheters are usually removed when the total amount of drainage has decreased to less than 25 to 30 mL
over the preceding 24 hours.1,13,14
• Extended catheter drainage is associated with a reduction of the re-occurrence of cardiac tamponade compared with a
single pericardiocentesis in patients with pericardial effusion related to malignancy.2,3
EQUIPMENT
• Pericardial catheter
• Sterile drapes: small drapes and a full-body drape
• Sterile and nonsterile gloves, gowns, masks, protective eyewear
• Sterile 0.9% normal saline solution for irrigation and sterile basin
• Anticoagulant flush available for dwell as prescribed (i.e., heparin)
• Sterile syringes: 3-, 5-, 30-, or 60-mL Luer-Lok
• Sterile 1000-mL vacuum bottle available for the initial procedure
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Sterile 4 × 4 gauze
• Sterile transparent occlusive dressing
• Adhesive tape
• Sterile three-way Luer-Lok stopcock with nonvented caps and replacement caps
Additional equipment as needed includes the following:
• Drainage tubing
• Pericardial drainage bag
• Cytotoxic disposal receptacle (when chemotherapeutic or cytotoxic agents are prescribed and used to avoid
aerosolization of the medication once disconnected from the patient)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that in nonemergent situations, informed consent has been obtained. Rationale: Informed consent protects
the rights of the patient and makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Administer analgesia or anxiolytic as prescribed before pericardial catheter insertion. Rationale: Comfort is
promoted and anxiety is reduced.
Procedure for Pericardial Catheter Management
References
1. Cornily, JC, et al, Cardiac tamponade in medical patients. a 10 year follow-up survey. Cardiology. 2008;
111(3):197–201.
2. Gandhi, S, et al. Has the clinical presentation and clinician’s index of suspicion of cardiac tamponade changed
over the past decade. Echocardiography. 2008; 25(3):237–241.
3. Hammel, WJ. Care of patients with an indwelling pericardial catheter. Crit Care Nurse. 1998; 18:40–45.
4. Infusion Nurses Society. Policies and procedures for -infusion nursing, 3rd ed. Norwood, MA: Author; 2006.
5. Intravenous Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006; 29(1S):S1–S90. [(2006)].
6. Johnson, KK, Soundarraj, D, Patel, P. Tenecteplase for -malignant pericardial effusion. Pharmacotherapy. 2007;
27(2):303–305.
7. Kolski, BC, et al. Echocardiographic assessment of the -accuracy of computed tomography in the diagnosis of -
hemodynamically significant pericardial effusions. J Am Soc Echocardiogr. 2007; 21(4):377–379.
8. Maruyama, R, et al, Catheter drainage followed by the -instillation of bleomycin to manage malignant pericardial
effusion in non-small cell lung cancer. a multi-institutional phase II trial. J Thorac Oncol. 2007; 2(1):65–68.
9. O’Grady, NP, et al, Guidelines for the prevention of intravascular catheter-related infections. Centers for
Disease Control and Prevention. MMWR Recommend Rep. 2002; 51(RR-10):1–29.
10. Seferovic, PM, et al. Management strategies in pericardial emergencies. Herz. 2006; 31(9):891–900.
11. Staltari, D, et al, Laparoscopic pericardio-peritoneal window. An alternative approach in the treatment of
recurrent pericardial effusion, in-hospital evolution and survival. Surg Laparosc Endosc Percutan Tech. 2007;
17(2):116–119.
12. Swanson, N, Mirza, I, Wijesinghe, N, et al. Primary percutaneous balloon pericardiotomy for malignant
pericardial effusion. Cath Cardiovasc Interv. 2008; 71(4):504–507.
13. Valley, VT, et al. Pericarditis and cardiac tamponade,. available at www.eMedicine.com, updated May 12, 2008.
14. Yarlagadda, C. Cardiac tamponade,. available at www.eMedicine.com, updated May 24, 2008.
Additional Reading
Field JN, ed.. ACLS provider manual. Americ an Heart Assoc iation: Dallas, 2006:51–58.
P R OC E D UR E 7 9
PURPOSE:
Transesophageal echocardiography offers an alternative approach for obtaining high-quality images of the heart
structure that are not well visualized with a conventional transthoracic approach. A transesophageal
echocardiography obtains images of the heart from a transducer inside the esophagus. The esophagus lies
immediately behind the heart, and with this technology, clear images of the heart can be obtained.
• Various modes of echocardiography are used to examine the heart, blood vessels, valve function, and blood flow. The
three techniques are as follows17 :
Motion-mode (M-mode) echocardiography: This is a one-dimensional echocardiogram that visualizes time, depth,
and intensity. It looks like a tracing instead of a picture of the heart and is used to measure the exact size of the
heart chambers.
Two-dimensional (2-D) echocardiography: This shows the actual shape and motion of the different heart structures.
These images represent “slices” of the heart in motion.
Doppler echocardiography: This assesses the flow of blood through the heart. The signals that represent blood flow
are displayed as a series of black-and-white tracings or color images on the screen.
• Transesophageal echocardiography (TEE) imaging is more risky than transthoracic imaging because of the insertion of
the probe in the esophagus and the need for IV conscious sedation.4,16
• Indications for TEE are as follows:
Evaluation of (pre) clot formation in the heart, especially in the atria and appendages, in patients with an atrial
dysrhythmia.3,6,15,18,20
Evaluation of spontaneous echocardiographic contrast or “smoke” presenting as dynamic echoes within the left
atrium and appendage, which resembles swirling smoke in 2-D images. It is manifested by erythrocyte and platelet
aggregates in regions of low blood flow; it has a significant correlation with previous embolic events and may serve
as a marker for increased risk for embolism.3,6,15,18,20
TEE before cardioversion is advocated in patients in whom early cardioversion would be clinically beneficial.
Patients with atrial fibrillation undergoing electrical cardioversion with short-term anticoagulation therapy have
lower hemorrhagic complications. Cardioversion may be performed more safely, after only a short period of
anticoagulant therapy, in patients without atrial cavity or appendage thrombus. with TEE. Cardioversion is delayed
in patients at high risk with thrombus detected by TEE. Conventional treatment has been to give patients
undergoing elective cardioversion therapeutic anticoagulation therapy for 3 weeks before and 4 weeks after
cardioversion, to decrease the risk for thromboembolism.11,12,16
Transient ischemic attack or stroke evaluation to rule out cardiac source of emboli and structure abnormalities (e.g.,
patent foramen ovale) or other abnormalities not identified before a neurologic event.3,15,16
Multiple factors may obstruct the penetration of the ultrasound beams from the transthoracic approach. Poor-
quality TTE images can be found in patients with obesity, chronic obstructive lung disease, chest wall deformities,
multiple chest trauma, and thick surgical chest dressings.3,15
Assessment of native cardiac valve defects, particularly of the mitral valve.1-3,15
Assessment of prosthetic cardiac valve function.3,15,16,18
Assessment of intracardiac foreign bodies, tumors, or masses.3,15,16,18
Assessment of vegetative endocarditis and abscess.3,8,15,16
Assessment of congenital heart defects.3,15,16,18
The superior sensitivity and specificity of TEE for aortic disease, including aneurysm, dissection, atherosclerosis,
mobile plaque, congenital aortic disease, pseudoaneurysm, and traumatic aortic disruption, make it the test of
choice in many clinical situations.3,15,16,18
Disease in the ascending and transverse aorta often necessitates a TEE for complete evaluation; however, a short
portion of the distal ascending aorta and proximal transverse arch is usually not visible. This portion is a blind area
because of the carina passing between the aorta and the esophagus.3,15,16,18
TEE used in combination with stress test for the evaluation of patients with coronary artery disease. Transesophageal
echocardiography–dobutamine stress echocardiography (TEE-DSE) has been reported to be highly accurate for
detection of ischemia in patients with suspected coronary artery disease.19
Transesophageal atrial pacing stress echocardiography (TAPSE) is an efficient alternative to DSE for the detection of
coronary artery disease. The heart rate can be rapidly increased, resulting in myocardial ischemia in regions
supplied by stenosed coronary arteries. In contrast to TEE-DSE, termination of pacing results in nearly
instantaneous restoration of the patient’s intrinsic heart rate.10
Intraoperative guide to left ventricular function and intracardiac blood flow and evaluation of cardiac surgical
repair.13
Assessment of a donor heart for transplant.18
Intracardiac shunt evaluation. Right-sided echocardiography saline contrast studies are performed to document an
atrial septal defect or a patent foramen ovale and to increase the signal strength of the tricuspid regurgitant jet to
allow a more accurate estimate of pulmonary artery pressures.18 Saline contrast for TEE is an IV injection of
microbubbles formed by agitating a saline solution. This saline contrast results in a marked increase in echogenicity
of the right-sided cardiac chambers.22
Cardiac assessment in the interventional laboratory during percutaneous interventions, such as transcatheter closure
for atrial septal defects and ventricular septal defects.16,18
Cardiac assessment during interventional procedures, such as balloon mitral valvuoplasty, nonsurgical reduction of
the ventricular septum in patients with hypertrophic cardiomyopathy, and transseptal catheterization for
placement of a catheter during radiofrequeny ablation of cardiac dysrythmias.16,18
Cardiac evaluation of left ventricular assist devices for optimal device performance, evaluation of hypoxemia, correct
positioning of the cannula to optimize left ventricular filling, and determination of the patient’s ability to be weaned
from the mechanical device.16,18
Assessment of the critically ill patient as an alternative for the technically limited TTE study.
Assessment of unexplained hypotension, volume status, suspected massive pulmonary embolism, unexplained
hypoxemia, and complications of cardiothoracic surgery.17,18
• Contraindications to TEE can be divided into absolute and relative.
• Absolute contraindications are3,12,18 :
Tumor of the upper gastrointestinal (GI) tract
Esophageal obstruction, stenosis, fistulae, or varices
A history of esophageal radiation or unresolved esophageal dilation
GI bleeding
Gastric volvulus or perforation
Perforated viscus
Patients who ate within 6 to 8 hours of the study
Unwilling patients
Inability to obtain intravenous access
• Relative contraindications are13 :
Upper GI surgery
Severe thrombocytopenia (platelets 20,000 to 50,000/mm 3 )
Oropharyngeal distortion
Prior esophageal surgery
Esophagitis
Loose teeth
• Antibiotics are no longer administered before the procedure in patients with a prosthetic valve. Echocardiography
does not pose a risk for infection.23
EQUIPMENT
• Omniplane transesophageal probe
• Echocardiography machine (compatible with the probe)
• Constant low wall suction with connecting tubing and rigid pharyngeal suction tip catheter
• Protective mask and goggles
• Nonsterile gloves
• Barrier gowns
• Water-soluble lubricant (institution-specific)
• Oxygen with both nasal prongs and mask available
• Topical anesthetic such as 2% or 4% lidocaine solution with an administration device (i.e., mucosal atomization
device), 2% viscous lidocaine, or benzocaine spray (institution-specific)
• Premedications for sedation and appropriate reversal agents (as prescribed)
• Alcohol prep pads
• IV insertion kit and IV setup with solution (usually 0.9% normal saline [NS] solution)
• Three-way stopcock and syringes for saline contrast injection (at least two 10-mL syringes with normal saline flush
solution)
• Syringes for sedation medications (at least one 5-mL and one 10-mL)
• Tongue depressor
• Emesis basin
• Tonsillar forceps and cotton balls with radiopaque string attached (institution-specific)
• Flashlight (to assess the oropharyngeal area, especially in the case of trauma)
• Disposable bite guard (may use the type with or without a strap to hold it in place)
• Thermometer
• Continuous electrocardiographic (ECG) monitoring
• Continuous oximetric monitoring
• Automatic blood pressure cuff (with manual blood pressure cuff available for backup use)
• Pillow (to support/position neck when the patient lies on the left side during the procedure)
Additional equipment as needed includes the following:
• Methylene blue, if benzocaine spray is used
• Emergency equipment
• Emergency intubation equipment
• Continuous capnography (institution-specific)7
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
Patient and family anxiety is decreased.
• Ensure that informed consent has been obtained. Rationale: Informed consent is necessary before invasive
procedures and the administration of conscious sedation. Informed consent protects the rights of the patient and
makes a competent decision possible for the patient; however, in emergency circumstances, time may not allow the
form to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure that the patient has not eaten for at least 6 to 8 hours before the procedure. Rationale: Undigested material
in the stomach increases the risk for aspiration.
• Instruct the patient to void before the procedure. Rationale: Voiding before the procedure minimizes disruption of
the examination.
• Initiate or continue ECG monitoring, apply an automatic blood pressure cuff, and initiate oxygen saturation
monitoring and if prescribed, capnography. Rationale: These measures allow for close cardiovascular and
respiratory monitoring during the procedure. Follow institution standard regarding capnography monitoring.
• Ensure the IV access is in place and functional. Rationale: IV access is needed to administer premedications and for
possible emergency medications.
• Maintain IV infusion during the procedure. Rationale: IV infusion maintenance ensures the IV is functioning and
available should an emergency situation arise.
• Have the patient remove any dentures or dental prostheses. Rationale: Dentures may interfere with the safe passage
of the transesophageal probe.
• Set up the suction system with the connecting tubing and a rigid pharyngeal suction tip attached and ready for use.
Rationale: This setup is necessary for suctioning the patient’s oral secretions during the procedure.
• Administer a small amount of supplemental oxygen if prescribed. Rationale: Administration of oxygen may
maintain adequate patient oxygenation during the procedure.
• Have a sedative (e.g., midazolam, diazepam) or analgesic (e.g., morphine sulfate, fentanyl) available (as prescribed)
and administer when requested. Naloxone and flumazenil must be available for narcotic or sedative reversal.
Rationale: Sedatives and analgesics reduce patient anxiety, promote comfort, facilitate cooperation during the
procedure, and decrease myocardial workload.
• Have atropine available at the bedside. Rationale: Atropine is necessary if a vagal reaction occurs with the insertion
and passage of the transesophageal probe.
• Have the saline contrast agent available if prescribed. Rationale: The contrast agent enhances the ability to evaluate
cardiac structures and function.
Procedure for Transesophageal Echocardiography (Assist)
References
1. de Waroux JB, Pouleur, AC, Goffinet, C, et al, Functional anatomy of aortic regurgitation. accuracy, prediction -of
surgical repairability, and outcome implications of transesophageal echocardiography. Circulation 2007; 116:-
264–269.
2. Duran, CM, TEE. the ‘roadmap’ for mitral valve repair. J Heart Valve Dis 2006; 15:521–523.
3. Feigenbaum, H, Armstrong, WF, Thomas, R. Feigenbaum’s echocardiography. Philadelphia: Lippincott
Williams & Wilkins; 2004.
4. Ferson, D, Thakar, D, Swafford, J, et al, Use of deep intravenous sedation with propofol and the laryngeal
mask airway during transesophageal echocardiography. J Cardiothoracic Vasc Anesth 2003; 17:443–446.
5. Fu, ES, Downs, JB, Schweiger, JW, et al. Supplemental oxygen impairs detection of hypoventilation by pulse
oximetry. Chest. 2004; 126:1552–1558.
6. Fuster, V, Ryden, LE, et al, ACC/AHA/ESC 2006 guidelines for the management of patients with atrial
fibrillation. a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to
Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation)developed in collaboration
with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114(7):e257–354.
7. Green, SM. Research advances in procedural sedation and analgesia. Ann Emerg Med. 2007; 49:31–36.
8. Harris, KM, Li, DY, L’Ecuyer, P, et al. The prospective role of transesophageal echocardiography in the
diagnosis and management of patients with suspected infective endocarditis. Echocardiography. 2003; 20:57–62.
9. Kane, GC, Hoehn, SM, Behrenbeck, TR, et al, Benzocaine-induced methemoglobinemia based on the Mayo
Clinic experience from 28,478 transesophageal echocardiograms. incidence, outcomes, and predisposing factors.
Arch Intern Med 2007; 167:1977–1982.
10. Kobal, SL, Pollick, C, Atar, S, et al, Stress echocardiography in octogenarians. transesophageal atrial pacing is
accurate, safe, and well tolerated. J Am Soc Echocardiogr 2006; 19:1012–1016.
11. Maltagliati, A, Galli, CA, Tamborini, G, et al. Usefulness of transoesophageal echocardiography before
cardioversion in patients with atrial fibrillation and different anticoagulant regimens. Heart. 2006; 92:933–938.
12. Marchiondo, K, Transesophageal imaging and interventions. nursing implications. Crit Care Nurse 2007; 27 :25–
32.
13. Marymont, J, Murphy, GS, Intraoperative monitoring with transesophageal echocardiography. indications, risks,
and training. Anesthesiol Clin 2006; 24:737–753.
Min, JK, S penc er, KT, Furlong, KT, et al, Clinic al features of c omplic ations from transesophageal ec hoc ardiography. a single-c enter c ase series of 10,000
c onsec utive examinations. J Am S oc Ec hoc ardiogr 2005; 18:925–929.
15. Oh, JK, Seward, JB, Tajik, AJ. The echo manual. Philadelphia: Lippincott Williams & Wilkins; 2006.
16. Peterson, GE, Brickner, ME, Reimold, SC, Transesophageal echocardiography. clinical indications and
applications. Circulation 2003; 107:2398–2402.
17. Rose, DD. Transesophageal echocardiography as an alternative for the assessment of the trauma and critical
care patient. AANA J. 2003; 71:223–228.
S engupta, PP, Khandheria, BK. Transoesophageal ec hoc ardiography. Hea rt. 2005; 91:541–547.
19. Siddiqui, TS, Stoddard, MF. Safety of dobutamine stress transesophageal echocardiography in obese patients
for evaluation of potential ischemic heart disease. Echocardiography. 2004; 21:603–608.
20. Singer, DE, Albers, GW, Dalen, JE, et al, Antithrombotic therapy in atrial fibrillation. the Seventh ACCP
Conference on Antithrombotic and Thrombolytic Therapy . Chest. 2004; 126(3):429S–456S.
21. Soto, RG, Fu, ES, Vila, H, Jr., et al, Capnography accurately detects apnea during monitored anesthesia care.
Anesth Analg . 2004; 99:379–382.
22. Trevelyan, J, Steeds, RP. Comparison of transthoracic echocardiography with harmonic imaging with
transoesophageal echocardiography for the diagnosis of patent foramen ovale. Postgrad Med J. 2006; 82:613–614.
23. Wilson, W, Taubert, K A, Gewitz M, et al, American Heart Association Rheumatic Fever, Endocarditis, and
Kawasaki Disease Committee, American Heart Association Council on Cardiovascular Disease in the Young,
American Heart Association Council on Clinical Cardiology, American Heart Association Council on
Cardiovascular Surgery and Anesthesia, and Quality of Care and Outcomes Research Interdisciplinary Working
Group . Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from
the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on
Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery
and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation.
2007; 116(15):1736–1754.
Additional Readings
Ball, M. S GNA position statement. statement on the use of sedation and analgesia in the gastrointestinal endosc opy setting. Ga stroenterol Nurs. 2003; 26(5):201–209.
Gilman, G, Nelson, JM, Murphy, AT, et al. The role of the nurse in c linic al ec hoc ardiography. J Am Soc Echoca rdiogr. 2005; 18(7):773–777.
Hashimoto, S , Nakatani, S , Tanimura, M, et al. Usefulness of c onsc ious sedation with midazoram during transesophageal ec hoc ardiographic examination. J Ca rdiol.
2004; 44(5):195–200.
Hoole, S P, Falter, F. Evaluation of hypoxemic patients with transesophageal ec hoc ardiography. Crit Ca re Med. 2007; 35(8 S uppl):S 408–S 413.
Jiminez, MA, Polena, S , Coplan, NL, et al. Methemoglobinemia and transesophageal ec ho. Proceed Western Pha rma col Soc. 2007; 50:134–135.
Mart CR, Parrish, M, Rosen, KL. S afety and effic ac y of sedation with propofol for transoesophageal ec hoc ardiography in c hildren in an outpatient setting. Ca rdiol
Young. 2006; 16(2):152–156.
Miyake, M, Izumi, C, Takahashi, S , et al. Effic ac y of transesophageal ec hoc ardiography in patients with c ardiac arrest or shoc k. J Ca rdiol. 2004; 44(5):189–194.
Pino, RM. The nature of anesthesia and proc edural sedation outside of the operating room. Curr Opin Ana esthesiol. 2007; 20(4):347–351.
Porembka, DT. Importanc e of transesophageal ec hoc ardiography in the c ritic ally ill and injured patient. Crit Ca re Med. 2007; 35(8 S uppl):S 414–S 430.
S ubramaniam, B, Talmor, D. Ec hoc ardiography for management of hypotension in the intensive c are unit. Crit Ca re Med. 2007; 35(8 S uppl):S 401–S 407.
SECTION ELEVEN
Vascular Access
P R OC E D UR E 8 0
Arterial Puncture
Linda Buc her and Joel M. Brown, II
PURPOSE:
Arterial puncture is performed to obtain a sample of blood for arterial blood gas analysis.
FIGURE 80-1 Anatomic landmarks for locating the radial and brachial arteries.
• The preferred artery for arterial puncture is the radial artery. Although this artery is smaller than the ulnar artery, it is
more superficial and can be more easily stabilized during the procedure.6 The use of the brachial artery is a safe and
reliable alternative site for arterial puncture.16
• At times, the femoral artery is used for arterial puncture. The use of this artery can be technically difficult because of
the proximity of the artery to the femoral vein (Fig. 80-2).
• Arterial cannulation is considered for patients who need frequent arterial blood samples, continuous arterial pressure
monitoring, or evaluation of vasoactive medication therapy (see Procedures 61 and 62).5
• The most common complications associated with arterial puncture include pain, vasospasm, hematoma formation,
infection, hemorrhage, and neurovascular compromise.5,9,16,19
• Site selection proceeds as follows:
Use the radial artery as first choice. The radial artery is small and easily stabilized as it passes over a bony groove
located at the wrist (see Fig. 80-1).
Use the brachial artery as second choice, except in the presence of poor pulsation from shock, obesity, or sclerotic
vessel (e.g., because of previous cardiac catheterization). The brachial artery is larger than the radial artery.
Hemostasis after arterial puncture is enhanced by its proximity to bone if the entry point is approximately 1.5
inches above the antecubital fossa (see Fig. 80-1).
Use the femoral artery in the case of cardiopulmonary arrest or altered perfusion to the upper extremities. The
femoral artery is a large superficial artery located in the groin (see Fig. 80-2). It is easily palpated and punctured.
Complications related to femoral artery puncture include hemorrhage and hematoma because bleeding can be
difficult to control; inadvertent puncture of the femoral vein because of the close proximity of the vein to the artery;
infection because aseptic technique in the groin area is difficult to maintain; and limb ischemia if the femoral artery
is damaged.
EQUIPMENT
• One prepackaged ABG kit that contains the following:
One 20-gauge to 25-gauge, 1-inch to 1.5-inch hypodermic needle (note: longer needles are needed for brachial and
femoral artery puncture)
One 1- to 5-mL preheparinized (if available) syringe with a rubber stopper or cap
One 1-mL ampule of sodium heparin, 1:1000 concentration (if preheparinized syringe is not available)
Two 2 × 2 gauze pads
2% chlorhexidine–based antiseptic solution
One plastic bag (for transport of sample to laboratory)
One adhesive bandage
• Appropriate laboratory form, specimen label
• One pair of nonsterile examination gloves and eye protection
• 1% lidocaine (without epinephrine), 1-mL, or eutectic mixture of local anesthetics (EMLA) cream
Additional supplies as needed include the following:
• Small rolled towel (to support the patient’s wrist)
• Sterile gloves
• 1-mL syringe with 25-gauge needle (if lidocaine is used)
• Ice
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Perform a preprocedure verification and time-out, if non-emergent. Rationale: Ensures patient safety.
• If the patient is receiving oxygen or mechanical ventilation, check that the current therapy has been underway for at
least 20 to 30 minutes before obtaining ABGs.5,8,11,14,18 Rationale: Accurate laboratory results are achieved, which is
most important in patients with an abnormal ventilation/perfusion ratio.14
• Position the patient appropriately. Rationale: Positioning enhances the accessibility to the insertion site and
promotes patient comfort.
• Radial artery puncture:
Assist the patient to a semirecumbent position. Rationale: A position of comfort decreases anxiety and may
facilitate respiratory effort.
Elevate and hyperextend the wrist. A small rolled towel may be placed under the wrist for support. Rationale:
This action moves the artery closer to the skin surface, making the artery easier to palpate.
Palpate for the presence of a strong radial pulse. Rationale: Identification and localization of the pulse increases
the chance of a successful arterial puncture.
• Brachial artery puncture:
Assist the patient to a semirecumbent position. Rationale: A position of comfort decreases anxiety and may
facilitate respiratory effort.
Elevate and hyperextend the patient’s arm. A small pillow may be placed under the arm for support. Rationale:
This action increases accessibility for puncture.
Rotate the patient’s arm and palpate for the presence of a strong brachial pulse. Rationale: Identification and
localization of the pulse increase the chance of a successful arterial puncture.
• Femoral artery puncture:
Assist the patient to a supine, straight-leg position. Rationale: This position provides the best position for
localizing the femoral artery pulse.
Palpate for the presence of a strong femoral pulse. Rationale: Identification and localization of the pulse increase
the chance of a successful arterial puncture.
Procedure for Arterial Puncture
FIGURE 80-3 Modified Allen’s test. Elevate the patient’s hand and instruct the patient to open and close the fist several times. A, With the patient’s fist
clenched, simultaneously occlude the radial and ulnar arteries. B, Instruct the patient to low er and open his or her fist. Observe for pallor in the patient’s hand.
C, Release the pressure over the ulnar artery and observe the hand for the return of color. (From Bucher L, Melander SD: Critical care nursing, Philadelphia, 1999,
Saunders.)
FIGURE 80-4 Radial artery puncture w ith the syringe at a 30-degree angle to the artery.
FIGURE 80-5 Brachial artery puncture w ith the syringe at a 45-degree angle to the artery.
FIGURE 80-6 Femoral artery puncture w ith the syringe at a 60-degree angle to the artery.
References
1. Abu-Omar, Y, et al. Duplex ultrasonography predicts safety of radial artery harvest in the presence of an
abnormal Allen test. Ann Thorac Surg. 2004; 77:116–119.
2. Barone, JE, Madlinger, RV. Should an Allen Test be performed before artery cannulation. J Trauma. 2006;
61:468–470.
3. Carlson KK, ed. Advanced critical care nursing. St Louis: Saunders, 2009.
4. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related
infections. MMWR. 2002; 51(RR-10):1–31.
5. Chernecky CC, Berger BJ, eds. Laboratory tests and diagnostic procedures, ed 5, St Louis: Saunders, 2008.
6. Flynn JC, ed. Procedures in phlebotomy, ed 3, St Louis: Saunders, 2004.
7. Giner, J, et al. Pain during arterial puncture. Chest. 1996; 110:1443–1445.
8. Hess, D, et al. The validity of assessing arterial blood gases 10 minutes after an Fio2 change in mechanically
ventilated patients without chronic pulmonary disease. Respir Care. 1985; 30:1037–1041.
9. Hudson, TL, Dukes, SF, Reilly, K. Use of local anesthesia for arterial punctures. Am J Crit Care. 2006; 15:595–599.
10. Hussey, VM, Poulin, MV, Fain, JA. Effectiveness of lidocaine hydrochloride on venipuncture sites. AORN J.
1997; 66:472–475.
11. Intravenous Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006; 29(1S):S1–S90.
12. Joly, LM, et al. Topical lidocaine-prilocaine cream (EMLA) versus local infiltration of anesthesia for radial
artery cannulation. Anesth Analg. 1998; 87:403–406.
13. Lander, J, et al, Evaluation of a new topical anesthetic agent. a pilot study. Nurs Res 1996; 45:50–52.
14. National Committee for Clinical Laboratory Standards, Procedures for the collection of arterial blood
specimens. approved standard H11-A4. ed 4. National Committee for Clinical Laboratory Standards, Wayne, PA,
2004.
15. Nott, M, Peacock, J, Relief of injection pain in adults. EMLA cream for 5 minutes before venipuncture.
Anaesthesia 1990; 45:772–774.
16. Okeson, GC, Wulbrecht, PH. The safety of brachial artery puncture for arterial blood sampling. Chest. 1998;
14:748–751.
17. Oettle, AC, et al. Evaluation of Allen’s test in both arms and arteries of left and right-handed people. Surg Radiol
Anat. 2006; 28:3–6.
18. Sherter, CB, et al. Prolonged rate of decay of arterial Po2 following oxygen breathing in chronic airway
obstruction. Chest. 1975; 67:259.
19. Siegel, JD, et al, and the Healthcare Infection Control Practices Advisory Committee. Guideline for isolation
precautions: preventing transmission of infectious agents in healthcare settings.
www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf, 2007 [retrieved October 10, 2008].
20. Thibodeau, GA, Patton, KT. Anatomy and physiology,, ed 6. St Louis: Mosby; 2007.
21. Tran, NQ, Pretto, JJ, Worsnop, CJ. A randomized controlled trial of the effectiveness of topical amethocaine in
reducing pain during arterial puncture. Chest. 2002; 122:1357–1360.
Additional Reading
Infusion Nurses S oc iety. Polic ies and proc edures for infusion nurses, ed 2. Norwood, MA: Infusion Nurses S oc iety, 2006.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institution standard.
P R OC E D UR E 8 1
PURPOSE:
Central venous catheters are inserted for measurement of right atrial pressure and central venous pressure
with jugular or subclavian catheter placement. Clinically useful information can be obtained about right
ventricular preload, cardiovascular status, and fluid balance in patients who do not need pulmonary artery
pressure monitoring. Central venous catheters also are placed for infusion of vasoactive medications, total
parenteral nutrition, and hemodialysis access. In addition, central venous catheters are used to administer
medication and intravenous products to patients with limited peripheral intravenous access and to provide
access for pulmonary artery catheters and transvenous pacemakers.
Table 81-1
Complications of Central Venous Catheter Insertion
PEEP, positive end-expiratory pressure.
EQUIPMENT
• CVC insertion kit
• CVC of choice (single, dual, or triple lumen) usually supplied with insertion needle, dilator, syringe, and guidewire.
• Large sterile drapes or towels
• 1% lidocaine without epinephrine
• One 25-gauge ⅝-inch needle
• Large package of 4 × 4 gauze sponges
• Suture kit (hemostat, scissors, needle holder)
• 3-0 or 4-0 nylon suture with curved needle
• Three-way stopcock
• Syringes: one 10- to 12-mL syringe; two 3- to 5-mL syringes; two 22-gauge, 1½-inch needles
• Masks, head coverings, goggles (shield and mask combination may be used), sterile gloves, and sterile gowns
• No. 11 scalpel
• Skin protectant pads or swab sticks
• Roll of 2-inch tape
• Dressing supplies
• Waterproof pad
• Chlorhexidine-impregnated sponge
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Nonsterile gloves
• Normal saline flush syringes or 0.9% sodium chloride vials, 10- to 30-mL
Additional equipment as needed includes the following:
• Hemodynamic monitoring system (see Procedure 76)
• Sutureless catheter securement device
• Intravenous (IV) solution with Luer-Lok administration set for IV infusion
• Luer-Lok extension tubing
• Bedside monitor and oscilloscope with pulse oximetry
• Supplemental oxygen supplies
• Emergency equipment
• Package of alcohol pads or swab sticks
• Package of povidone-iodine pads or swab sticks
• Heparin flushes
• Needleless caps
• Arm board
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Obtain informed consent. Rationale: Informed consent protects the rights of the patient and makes a competent
decision possible for the patient; however, in emergency circumstances, time may not allow for this form to be
signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Prescribe sedation or analgesics as needed. Rationale: The patient may need sedation or analgesics to promote
comfort and to ensure adequate cooperation and appropriate placement.
• If the patient is obese or muscular and the preferred site is the internal jugular vein or subclavian vein, place a towel
posteriorly between the shoulder blades. Rationale: This placement helps extend the neck and provide better
access to the subclavian and internal jugular veins.
FIGURE 81-1 Anatomy of the jugular vein. A, Anatomy of the internal jugular vein show ing its low er location w ithin the triangle formed by the
sternocleidomastoid muscle and the clavicle. B, Triangle draw n over the clavicle and sternal and clavicular portions of the sternocleidomastoid muscle is
centered over the internal jugular vein (inset). (FromDailey EK, Schroeder JS: Techniques in bedside hemodynamic monitoring, St Louis, 1994, Mosby; and Daily PO, Griepp RB,
Shumway NE: Percutaneous internal jugular vein cannulation, Arch Surg 101:534-536, 1970. Copyright 1970, American Medical Association.)
References
1. Eyer, S, et al, Catheter-related sepsis. prospective, -randomized study of three methods of long-term catheter
maintainence. Crit Care Med 1990; 18:1073–1079.
2. Infusion Nurses Society. Policies and procedures for infusion nursing, ed 3. Norwood, MA: AuthorINS; 2006.
3. Intravenous Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006; 29(1S):S1–S90.
4. Kumar, A, Darovic, GO. Establishment of cardiovascular access. In: Hemodynamic monitoring invasive and
noninvasive clinical application. Philadelphia: Saunders; 2000.
5. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
6. Safdar, N, Klugar, DM, Maki, DG, A review of risk factors for catheter-related bloodstream infection caused
by -percutaneously inserted, noncuffed central venous catheters. implications for preventive strategies. Medicine
2002; 81:466–472.
7. Venus, G, Mallory, DL, Vascular cannulationCritical CareCivetta J, Taylor W, Kirby R. ed 5. Lippincott, Williams,
Wilkins, Philadelphia, 2009.
Additional Readings
Dailey, EK, S c hroeder, JS . Techniques in bedside hemodyna mic monitoring, ed 5. S t Louis: Mosby; 1994.
Darovic , GO. Hemodyna mic monitoring inva sive a nd noninva sive clinica l a pplica tion. Philadelphia: S aunders; 2000.
Eggimann, P, et al. Impac t of a prevention strategy targeted at vasc ular-ac c ess c are on inc idenc e of infec tions ac quired in intensive c are. La ncet. 2000; 355:1864–
1868.
Friesinger, GC, Williams, S V, ACP/AHA Task Forc e on Clinic al Privileges in Cardiology. c linic al c ompetenc e in hemodynamic monitoring. J Am Coll Ca rdiol.
1990; 15:1460.
Lorente, L, Henry, C, Martin, M, et al. Central venous c atheter-related infec tion in a prospec tive and observational study of 2,595 c atheters. Crit Ca re. 2005;
9:R631–R635.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institution standard.
P R OC E D UR E 8 2
PURPOSE:
Central venous catheters are inserted to measure and obtain right atrial pressure and central venous pressure
with jugular or subclavian catheter placement. Clinically useful information can be obtained about right
ventricular preload, cardiovascular status, and fluid balance in patients who do not need pulmonary artery
pressure monitoring. Central venous catheters also are placed for infusion of vasoactive medications, total
parenteral nutrition, hemodialysis access, and the use of pulmonary artery catheters. In addition, central venous
catheters are used to administer medication and intravenous products to patients with limited peripheral
intravenous access and to provide access for pulmonary artery catheters and transvenous pacemakers.
EQUIPMENT
• CVC insertion kit
• CVC of choice (single, dual, or triple lumen) usually supplied with insertion needle, dilator, syringe, and guidewire
• Large sterile drapes or towels
• 1% lidocaine without epinephrine
• One 25-gauge, ⅝-inch needle
• Large package of 4 × 4 gauze sponges
• Suture kit (hemostat, scissors, needle holder)
• 3-0 or 4-0 nylon suture with curved needle
• Three-way stopcock
• Syringes: One 10-mL to 12-mL syringe; two 3- to 5-mL syringes; two 22-gauge, 1½-inch needles
• Face masks, head coverings, goggles (shield and mask combination may be used), sterile gloves, and sterile gowns
• No. 11 scalpel
• Skin protectant pads or swab sticks
• Roll of 2-inch tape
• Dressing supplies
• Chlorhexidine-impregnated sponge
• Moisture-proof underpad
• Antiseptic solution (e.g., 2% chlorhexidine–based preparation)
• Nonsterile gloves
• Saline flushes or 0.9% sodium chloride vials, 10 to 30 mL
Additional equipment as needed includes the following:
• Hemodynamic monitoring system (see Procedure 76)
• Intravenous (IV) solution with Luer-Lok administration set for IV infusion
• Sutureless catheter securement device
• Luer-Lok extension tubing
• Bedside monitor and oscilloscope with pulse oximetry
• Supplemental oxygen supplies
• Emergency equipment
• Package of alcohol pads or swab sticks
• Package of povidone-iodine pads or swab sticks
• Heparin flushes
• Needleless caps
• Arm board
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent was obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient; however, in emergency circumstances, time may not allow for
this form to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Administer prescribed sedation or analgesics as needed. Rationale: The patient may need sedation or analgesia to
ensure adequate cooperation and appropriate placement. During the procedure, restlessness and an altered level of
consciousness may represent a pneumothorax, hypoxia, or placement in the carotid artery.
• If the patient is obese or muscular and the preferred site is the internal jugular vein or subclavian vein, assist with
placing a towel posteriorly between the shoulder blades. Rationale: This placement helps extend the neck and
provides better access to the subclavian and internal jugular veins.
Procedure for Assisting with Central Venous Catheter Insertion
FIGURE 82-1 Area of skin preparation for central venous catheter insertions. A, Subclavian insertion: Scrub from shoulder to contralateral nipple line and
neck to nipple line. B, Jugular insertions: Scrub mid clavicle to opposite border of the sternum and from the ear to a few inches above the nipple. C,
Peripherally inserted central venous catheters (PICC): Scrub the entire arm. (Courtesy Suredesign.)
References
1. Eyer, S, et al, Catheter-related sepsis. prospective, randomized study of three methods of long-term catheter
maintenance. Crit Care Med 1990; 18:1073–1079.
2. Infusion Nurses Society. (2006). Policies and procedures for infusion nursing.,, ed 3. Norwood, MA: AuthorINS;
2006.
3. Intravenous Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006; 29(1S):S1–S90.
[(2006)].
4. Kumar, A, Darovic, GO. Establishment of cardiovascular access. In: Darovic, GO, eds. Hemodynamic monitoring
invasive and noninvasive clinical application. Philadelphia: Saunders, 2000.
5. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
6. Safdar, N, Klugar, DM, Maki, DG, A review of risk factors for catheter-related bloodstream infection caused
by percutaneously inserted, noncuffed central venous catheters. implications for preventive strategies. Medicine
2002; 81:466–472.
7. Venus, G, Mallory, DL. Vascular cannulation. In Civetta J, Taylor W. &, Kirby R, eds. : Critical Care, ed 5,
Philadelphia: Lippincott, Williams & Wilkins, 2009.
Additional Readings
Dailey, EK, S c hroeder, JS . Techniques in bedside hemodyna mic monitoring, ed 5. S t Louis: Mosby; 1994.
Darovic , GO. Hemodyna mic monitoring inva sive a nd noninva sive clinica l a pplica tion. Philadelphia: S aunders; 2000.
Eggimann, P, et al. Impac t of a prevention strategy targeted at vasc ular-ac c ess c are on inc idenc e of infec tions ac quired in intensive c are. La ncet. 2000; 355:1864–
1868.
Friesinger, GC, Williams, S V, ACP/AHA Task Forc e on Clinic al Privileges in Cardiology. Clinic al c ompetenc e in hemodynamic monitoring. J Am Coll Cardiol
1990; 15:1460.
Lorente, L, Henry, C, Martin, M, et al. Central venous c atheter-related infec tion in a prospec tive and observational study of 2,595 c atheters. Crit Ca re. 2005;
9:R631–R635.
P R OC E D UR E 8 3
PURPOSE:
Implantable venous access devices or ports are used for delivery of medications, parenteral solutions, blood
products, and cytotoxic agents and for blood sampling for patients who need long-term venous access.
• The implanted venous access device is percutaneously accessed with a noncoring needle.
• The use of a noncoring needle allows for repeated access of the venous device without damage to the silicone core.
• The noncoring needle chosen should be of optimal length, with the most common length for adults 1½ or 1¾ inches.
Patients with increased subcutaneous tissue may need a longer needle for access. Too short a needle may cause the
flanges to press against the skin surrounding the portal chamber, leading to patient discomfort and possibly resulting
in damage to the skin overlying the venous access device. Too long a needle may result in a rocking motion that can
cause discomfort, possible migration out of the portal septum, or damage to the integrity of the septum, impairing it
for further use.
EQUIPMENT
• Nonsterile gloves
• Sterile gloves
Noncoring needle, winged with 90-degree angle and extension tubing (available in lengths of ¾, 1, 1¼, 1½, and 1¾
inches)
• Dressing supplies
• Skin antiseptic solution (e.g., 2% chlorhexidine–based solution)
• Two 10-mL syringes
• Luer-Lok vial access device
• Prepierced needleless injection cap
• Single-use 30-mL vial NS
• ½-inch steri-strips
• Heparin flush, 100 units/mL concentration
• Central venous catheter dressing change kit
• Needleless blood sampling access device
Additional equipment as needed includes the following:
• 10% betadine solution and 70% alcohol solution site preparation swabs
• Supplies for obtaining blood samples for laboratory analysis
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Assist the patient to a supine position with the head of the bed elevated up to a 30-degree angle. Rationale:
Positioning prepares the patient and allows optimal access to the implanted venous access device.
Procedure for Implantable Venous Access Device: Access, Deaccess, and Care
FIGURE 83-3 Triangulating the Pow erPort® Implanted Port w ith the non-dominant hand. (Courtesy of Bard Corporation.)
FIGURE 83-4 Needle access of the Pow erPort® Implanted Port w ith a non-coring Pow erLoc® Needle. (Courtesy of Bard Corporation.)
FIGURE 83-5 The non-coring Pow erLoc® Needle is inserted until the base of the port reservoir is felt. (Courtesy of Bard Corporation.)
References
1. Barton, JC, Poon, MC. Coagulation testing of Hickman catheter blood in patients with acute leukemia. Arch
Intern Med. 1986; 146(11):2165–2169.
2. Beck, SL, et al. Standards of care for the patient with a venous access device. Salt Lake City, UT: American Cancer
Society, Utah Division; 1990.
3. Camp, Sorrell, D, Accessing and Deaccessing Ports. Where is the evidence. Clin Jour of Oncol Nurs 2009;
13:587–590.
4. CDC. Guidelines for the prevention of intravascular catheter related bloodstream infection. MMWR. 2002;
5:1–26.
5. Deltec, Incorporated, Clinician information Port-A-Cath®, Port-A-Cath II and P. A. S. Port systems,. Deltec
Incorporated, St Paul, MN, 2002:1–24. [Deltec, Inc].
6. Frey, AM, Drawing blood from vascular access devices. J Infusion Nurs 2003; 26:285–293.
7. Hartkopf, L. Implanted Ports, computed tomography, power injectors, and catheter rupture. Clin J of Oncol Nurs.
2008; 12:809812.
8. Himberger, J, Himberger, L. Accuracy of drawing blood through infusing intravenous lines. Heart Lung.
2001; 30:66–73.
9. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006; 29:S1–S92.
10. Infusion Nurses Society. Policies and procedures for infusion nursing, ed 3. Norwood, MA: Author INS; 2006,.
11. Johnson, K. Power injectable portal systems. J of Radiol Nurs. 2009; 28:27–31.
12. Mayo, DJ, Dimond, EP, Framer, W, et al. Discard volumes necessary for clinically useful coagulations studies
from heparinized Hickman catheters. Oncol Nurs Forum. 1996; 23(4):671–675.
13. Polovich, M, Whitford, J, Olsen M: Oncology Nurses Society. Chemotherapy and biotherapy guidelines and
recommendations for practice, ed 3. Pittsburgh: Oncology Nursing Press, Inc; 2009.
14. Pinto, KM. Accuracy of coagulation values obtained from a heparinized central venous catheter. Oncol Nurs
Forum. 1994; 21(3):573–575.
15. Schummer, W, Schummer, C, Schelenz, C, Case Report. The malfunction of implanted venous access devices.
Brit J of Nurs. 2009; 12(4):210–214.
16. Yucha, C, DeAngelo, E, The minimum discard volume. J Intraven Nurs 1996; 19:141–146.
Additional Readings
Camp-S orrell, D, Mermel, L, Kluger, D, et al, The effic ac y of c hlorhexidine-impregnated sponge (BioPatc h) for the prevention of intravasc ular c atheter related
infec tion. a prospec tive, randomized, c ontrolled multi-c enter trial. abstrac t of the 40th Intersc ienc e Conferenc e on Antimic robial Agents and Chemotherapy.
2000:422.
Rosenthal, K, Pinpointing intravasc ular devic e c omplic ations. Nurs Manage, 2003:37–42. [June].
S abel, M, S mith, J, Princ iples of c hronic venous ac c ess. rec ommendations based on the Roswell Park experienc e. S urg Onc ol 1988; 6:171–177.
S eemann, S , Reinhardt, A. Blood sample c ollec tion from a -peripheral c atheter system c ompared with phlebotomy. -J Intra ven Nurs. 2000; 23:290–297.
S terba, K. Controversial issues in the c are and maintenanc e -of vasc ular ac c ess devic es in the long-term/subac ute c are c lient. J Infus Nurs. 2001; 24:249–254.
Wu P-y, Yeh Y-C, Huang C-H, et al. S pontaneous migration of a Port-A-Cath c atheter into ipsilateral jugular vein in two patients with severe c ough. Ann Va sc Surg.
2005; 19:734–736.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 8 4
Intraosseous Devices
Robin S c ott and Mic hael W. Day
PURPOSE:
Intraosseous access is indicated when intravenous access cannot be obtained or cannot be obtained in a timely
manner (within 90 seconds10) and access to venous circulation is needed for the administration of medications or
fluids.
FIGURE 84-1 IO Circulation. (From Day MW: Intraossesous devices in the adult trauma patient,Crit Care Nurs. In press.)
• Insertion devices are available for insertion of IO needles.6 These devices include the bone injection gun (BIG;
Waismed, a Persys Medical Co, Houston, TX; Fig. 84-2), the FAST1 adult intraosseous infusion system (Pyng Medical
Corp, Vancouver, BC, Canada, Fig. 84-3), and the EZ-IO (Vidacare Corp, Shavano Park, TX; Fig. 84-4). These three
devices are approved by the US Food and Drug Administration (FDA) for IO access in adult patients. Two of the
devices (BIG, EZ-IO) use a specially designed needle with a stylet or trocar. The third device (FAST1) uses a metal-
tipped plastic catheter.
FIGURE 84-2 Bone injection gun (BIG; adult). (From Day MW: Intraosseous devices in the adult trauma patient, Crit Care Nurs. In press.)
FIGURE 84-3 The FAST1 infusion set. (From Day MW: Intraosseous devices in the adult trauma patient, Crit Care Nurs. In press.)
FIGURE 84-4 EZ-IO pow er driver. (From Day MW: Intraosseous devices in the adult trauma patient, Crit Care Nurs. In press.)
• In adults, the available IO access sites, depending on the specific device and following each manufacturer’s guidelines,
include:
Tibial plateau: 1 to 2 cm distal to the tibial tuberosity3,5,8
Distal tibia: 1 to 2 cm above the medial malleolus7
Sternum: 1.5 cm below the sternal notch5,8
Greater tubercle of the proximal humerus8
• IO blood can be used for many laboratory tests, including typing and screening, electrolyte values, chemistries, blood
gas values, drug levels, and hemoglobin levels.2 However, specimen samples from the marrow have a lower
correlation to serum levels after 30 minutes of resuscitation.3 In addition, drawing of blood from an IO device may not
be recommended by specific manufacturers and has the potential of occluding the device.
• The onset of action for medications is similar to that of intravenous (IV) medications.13 However, administration via
the IO route may result in lower serum concentrations versus the IV route for the following medications: ceftriaxone,
chloramphenicol, phenytoin, tobramycin, and vancomycin.5
• Marrow-toxic medications should not be infused via the IO route.8
• All resuscitation medications, isotonic fluids, and blood products may be given via the IO route2,3,5,14 ; however,
myonecrosis has been reported with the infusion of hypertonic saline solution via the IO route.10,12
• Medications administered via the IO route should be followed by a 5- to 10-mL flush of normal saline solution.4
• Fluids running into an IO line should be administered with a pressure bag because the pressure needed to push the
fluid into the bone marrow may exceed that of volumetric IV pumps.
• Complications of IO access include compartment syndrome, osteomyelitis, fracture, extravasation,5 necrosis,5 and
infection.7
• A syringe should not be attached directly to the hub of the IO needle because it could cause dislodgment, increase the
size of the hole, and cause extravasation or loss of the IO site. To extend access to the IO needle, attach extension
tubing to the hub of the IO needle and secure it to the skin.11 Some device insertion kits come with extension tubing.
• Absolute contraindications to attempting an IO access include previous attempts or fractures of the targeted bone.
• Relative contraindications to IO access include infection at the access site, previous bone surgery at the insertion site,
fractures above the insertion site,9 and bone disorders, such as osteoporosis and osteogenesis imperfecta.3 Another
relative contraindication to the FAST1 is skin damage at the insertion site, which may preclude the adherence of the
target patch used to secure the device.
• IO access in obese patients may be more difficult. The EZ-IO has a needle set specifically designed for the patient with
“excessive tissue” at the insertion site.
• IO access is meant to be a temporary venous access; IO lines should be removed as soon as other venous access is
obtained or within 24 hours of insertion.
EQUIPMENT
• Nonsterile gloves
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• IO insertion device (follow manufacturer’s guidelines for information that may be age or weight based)
• Tape
• IV tubing
• Isotonic crystalloid fluid, as prescribed
• Two 5- to 10-mL syringes
• Prescribed medications
• Pressure bag for IV solution
• Dressing supplies
Additional equipment as needed includes the following:
• Blood specimen tubes
• 1% lidocaine without epinephrine
• 2% lidocaine without epinephrine
• Sterile 2 × 2 gauze pads
• Large needle forceps
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
Procedure for Intraosseous Access
FIGURE 84-5 EZ-IO needle sets. (From Day MW: Intraossesous devices in the adult trauma patient, Crit Care Nurs. In press.)
References
1. American Heart Association, Access for medication, part 3 . intraosseous access. 2006. In Advanced cardiac life
support provider manual, student CD: AHA.
2. Bailey, P, Intraosseous cannulation, UpToDate database. www.uptodate.com/online/content/topic.do?
topicKey=ped_proc/4947&view=print# retrieved July 15, 2009. Waltham, MA, 2008.
3. Blumberg, SM, Gorn, M, Crain, EF, Intraosseous infusion. a review of methods and novel devices. Pediatr Emerg
Care 2008; 24:50–59.
4. Bosomworth, NJ. The occasional intraosseous infusion. Can J Rural Med. 2008; 13:80–83.
5. Buck, ML, Wiggins, BS, Sesler, JM. Intraosseous drug administration in children and adults during
cardiopulmonary -resuscitation. Ann Pharmacother. 2007; 41:1679–1686.
6. Day MWIntraosseous devices in the adult trauma patient Crit Care Nurs. In press.
7. Gluckman, W, Forti, RJ. Intraosseous cannulation, emedicine. http://emedicine.medscape.com/article/908610-
overview . 2003. [retrieved June 29, 2009].
8. Holleran, RS. Procedure 67 intraosseous access. In Proehl J, ed. : Emergency nursing procedures, ed 4, St Louis:
Elsevier, 2009.
9. Infusion Nurses Society. The role of the registered nurse in the insertion of intraosseous (IO) access devices, INS Position
Statement. INS, Norwood, MA: Infusion Nurses Society; 2009.
10. Langley, DM, Moran, M, Intraosseous needles. not just for kids anymore. J Emerg Nurs 2007; 34:318–319.
11. MacKinnon, KA. Intraosseous vascular use at Signature Healthcare Brockton Hospital Department of Emergency
Services. J Emerg Nurs: In press; 2009.
12. Ong, MEH, Chan, YH, Oh, JJ, et al. An observational, prospective study comparing tibial and humeral
intraosseous access using the EZ-IO. Am J Emerg Med. 2009; 27:8–15.
13. Von Hoff DD, Kuhn, JG, Burris, HA, et al. Does intraosseous equal intravenous? A pharmacokinetic study. Am J
Emerg Med. 2008; 26:31–38.
14. Vreede, E, Bulatovic, A, Rosseel, P, et al. Article 10 intraosseous infusion, update in anesthesia, 12.
www.nda.ox.ac.uk/wfsa/html/u12/u1210_01.htm, June 29, 2009.
Additional Readings
Brenner, T, Bernhard, M, Helm, M, et al. Comparison of two intraosseous infusion systems for adult emergenc y medic al use. Resuscita tion. 2008; 78:314–319.
Gunal, I, Kose, N, Gurer, D, Compartment syndrome after -intraosseous infusion. an experimental study in dogs. J Pediatr S urg. 1996; 31(11):1491–1493.
Rosetti, VA, Thompson, BM, Miller, J, et al, Intraosseous infusion. an alternative route of pediatric intravasc ular ac c ess. Ann Emerg Med 1985; 14:885–888.
P R OC E D UR E 8 5
PURPOSE:
Peripherally inserted central catheters are used to deliver central venous therapy for up to 1 year and to provide
venous access for patients who need multiple venipunctures. Peripherally inserted central catheters are used
for administration of long-term antibiotic therapy, chemotherapy, total parenteral nutrition, analgesia, blood
products, intermittent inotropic (e.g., dobutamine) therapy, power injections, and fluids. The length and type of
therapy should determine the type of central venous access device selected.
• Patient indications for the insertion of a PICC are not limited to inpatient therapies. A PICC is used increasingly for
patients receiving intravenous (IV) therapy in the home setting for chronic heart failure, cancer treatment, chronic
pain management, nutritional support, and fluid replacement (e.g., hyperemesis gravidarum).
• PICCs may be preferred over percutaneously inserted central venous catheters for patients with trauma of the chest
(e.g., burns) or certain pulmonary disorders (e.g., chronic obstructive pulmonary disease, cystic fibrosis).7 PICCs
eliminate the risks associated with insertion of percutaneously inserted central venous catheters in the neck or chest
(e.g., pneumothorax).2
• PICCs are contraindicated in patients with sclerotic veins and a history of renal disease and in extremities affected by
mastectomy, arteriovenous graft, fistula, or radial artery surgery.
• IV therapy via the PICC poses fewer and less severe complications (including infections) compared with
percutaneously inserted central venous catheters. The most common complications associated with the PICC are
phlebitis and catheter occlusion.1,7
• A variety of PICCs are available for use. PICCs are flexible catheters that are made of silicone or polyurethane.
Catheter diameters range from 23 gauge to 16 gauge, and catheter length ranges from 40 cm (16 inches) to 60 cm (24
inches). For adults, 18- or 20-gauge catheters that are 60 cm in length are the standard. PICCs are available as single-
lumen, double-lumen, and triple-lumen catheters, with and without valves. Some PICCs are designed to handle
power injections (e.g., contrast media for computed tomographic [CT] scans).
• A PICC can be inserted with or without the use of a guidewire. When a guidewire is used, venous access is achieved
with a small gauge (20- or 22-gauge) peripheral IV catheter. Once the IV catheter is inserted, the stylet is removed and
the guidewire is threaded through the IV catheter. The IV catheter is then removed, and the dilator/introducer is
inserted over the guidewire. The dilator and guidewire are removed, leaving the introducer in the vein to allow for
passage of the PICC into the vein. Once the PICC is in place, the introducer is removed. This approach is referred to
as the modified Seldinger method.2 Care must be taken with the use of a guidewire. Although advancement of the
introducer is enhanced by the firmness provided by the guidewire, the guidewire can inadvertently traumatize the
vessel.7
• A PICC can also be inserted through a cannula. This insertion involves a venipuncture with a short peripheral IV
catheter. The stylet is removed, and the PICC is threaded into the vein. The short peripheral IV catheter is removed
by pulling it over the end of the PICC.2
• Ultrasound scan technology is available to assist with vein assessment and PICC insertion (Fig. 85-2). Successful
completion of specialized education is needed.
FIGURE 85-2 Use of ultrasound scan technology to assist w ith vein location. A, Ultrasound scan probe is positioned over the insertion site. B, Depiction of
ultrasound scan–assisted catheter insertion. (Courtesy of Bard Access Systems, Salt Lake City.)
• A variety of safety-engineered introducers are available and should be used to reduce the risk for blood exposure and
needle-stick injury.5,6,9
• Verification of the PICC tip placement requires a chest radiograph after insertion.2,5,6,11
• PICCs can be placed at the patient’s bedside, in interventional radiology, or in specialized rooms dedicated for PICC
insertion.
EQUIPMENT
• Catheter insertion kit
• PICC catheter of choice
• Single-use tourniquet or blood pressure cuff
• Sterile and nonsterile measuring tape
• Waterproof underpad/linen saver
• Sterile gown
• Head cover
• Mask
• Goggles
• Two pairs of nonpowdered sterile gloves
• Sterile drapes and towels, including one fenestrated drape
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• 10-mL vial of heparin (concentration and use per institution policy)
• 30-mL vial of normal saline (NS) solution
• Luer-Lok injection port (cap) with short extension tubing
• One to three 10-mL, 20-gauge, 1-inch needle syringes (blunt needles recommended), depending on the number of
lumens
• Sterile 4 × 4 gauze pads or sponges
• 1% lidocaine without epinephrine, or 1 to 2 mL of eutectic mixture of local anesthetics (EMLA) cream (optional)
• Sterile 2 × 2 gauze pads or sponges
• Sterile, transparent, semipermeable dressing
Additional equipment as needed includes the following:
• One 1-mL, 25-gauge, 5/8-inch needle syringe (if intradermal lidocaine is used)
• One 3-0 or 4-0 nylon suture on a small, curved cutting needle (if suturing is used)
• Alternative catheter securement device (e.g., sterile wound closure strips; if suturing is not used)
FIGURE 85-3 Measurement of the catheter length for placement in the superior vena cava. A, First, measure the distance from the selected insertion site to
the shoulder. B, Continue measuring from the shoulder to the sternal notch and add 3 inches (7.5 cm) to this number.
• Measure the mid–upper arm circumference of the selected extremity. Rationale: Measurement provides a baseline
for evaluation of suspected thrombosis. Increases of greater than 2 cm over baseline are supportive of venous
occlusion.
• Stabilize the position of the arm with a towel or pillow. Rationale: Stabilization increases patient comfort, secures
the work area, and facilitates access to the selected vein.
• Instruct the patient on proper head positioning. The head is positioned to the contralateral side (away from the
insertion site) throughout the procedure, except when the catheter is advanced from the axillary vein to the superior
vena cava. At this point, the patient is instructed to position his or her head toward the ipsilateral side (toward the
insertion site) with the chin dropped to the shoulder. Rationale: Proper positioning limits the risk for the catheter
being inadvertently directed into the jugular vein.
Procedure for Peripherally Inserted Central Catheter
FIGURE 85-4 Modified Seldinger technique. 1, Insertion of the peripheral intravenous catheter. 2, Advancement of the guidew ire through the catheter. 3,
Small skin nick to facilitate the advancement of the dilator/introducer. 4, Insertion of the dilator/introducer over the guidew ire. 5, Advancement of the
dilator/introducer. 6, Removal of the dilator and guidew ire. 7, Insertion of the catheter using sterile forceps. 8, Removal of the introducer. 9, Introducer peeled
apart and removed. (Courtesy Bard Access Systems, Salt Lake City, UT.)
FIGURE 85-5 PICC Statlock device. 1, Insertion of the w ings of the PICC onto the device. 2, Placement of the device on the forearm. 3, Application of the
sterile, transparent, semipermeable dressing over the device. 4, Device properly secured. (Courtesy Bard Access Systems, Salt Lake City UT.)
References
1. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related
infections. MMWR. 2002; 51(RR-10):2–29.
2. Eddins, J. Central venous access. In Phillips L, ed. : Manual of I. V. therapeutics, ed 4, Philadelphia: F. A. Davis,
2005.
3. Fetzer, SJ, Reducing venipuncture and intravenous -insertion pain with eutectic mixture of local anesthetic. -a
meta-analysis. Nurs Res 2002; 51:119–124.
4. Hussey, VM, Poulin, MV, Fain, JA. Effectiveness of -lidocaine hydrochloride on venipuncture sites. AORN J.
1997; 66:472–475.
5. Infusion Nurses Society. Policies and procedures for -infusion nursing,, ed 3. Norwood, MA: INS; 2006.
6. Intravenous Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006; 29(1S):S1–S90.
7. Josephson, DL. Intravenous infusion therapy for nurses,, ed 2. Clifton Park, NY: Thomson Delmar Learning;
2004.
8. Lander, J, et al, Evaluation of a new topical anesthetic agent. a pilot study. Nurs Res 1996; 45:50–52.
9. National Committee on Safer Needle Devices, Using safer needle devices. the time is now,. National
Committee on Safer Needle Devices, Washington, DC, 1997.
10. Nott, M, Peacock, J, Relief of injection pain in adults. EMLA cream for 5 minutes before venipuncture.
Anaesthesia 1990; 45:772–774.
11. Oncology Nursing Society (ONS), Access device guidelines. recommendations for nursing practice and
education,. ed 2. ONS, Pittsburgh, 2004.
Additional Readings
Alexander M, Corrigan A, Gorski L, Hankins J, Peruc c a R, eds. Infusion Nurses S oc ietyInfusion NursingAn evidenc e-based approac h, ed 3, S aunders, 2010.
Potter PA, Perry AG, eds.. Basic nursing. a c ritic al thinking approac h. ed 5. Mosby, S t Louis, 2003.
Weinstein, S M. Plumer’s principles a nd pra ctice of intra venous thera py, ed 8. Philadelphia: Lippinc ott -Williams & Wilkins; 2006.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institution standard.
UNIT III
Neurologic System
S E C T I O N T W E LV E
Neurologic Monitoring
P R OC E D UR E 8 6
PURPOSE:
The bispectral index is a processed electroencephalogram-based parameter used in critically ill adults for
assessment of level of consciousness and response to sedative, hypnotic, and anesthetic agents.1-4,10,13,16 The
bispectral index also may indicate an arousal response to painful stimulation.2 Information derived from
bispectral index monitoring may be used to guide sedative, hypnotic, and analgesic therapy.2,4,10,16
Table 86-1
Bispectral Index Monitoring Terminology
Bispectral Index (BIS) Processed EEG that assesses level of consciousness and response to sedative, hypnotic, and analgesic therapy.
Digital Signal Converter Amplifies, filters, and digitizes the patient’s EEG signals.
(DSC)
Electroencephalogram Measures electrical activity of the brain.
(EEG)
Electromyelograph (EMG) Measures the presence of muscle activity or detects high frequency artifact from patient care devices.
Signal Quality Index A measure of the signal quality for the EEG channel source and is calculated based on impedance to electronic signal, electrode contact
(SQI) artifact and other variables.
Suppression Ratio (SR) Percentage of EEG suppression (isoelectric EEG) over the past 63 seconds of collected data.
• The close relationship between BIS and EEG activity should be understood.25,33,35,36
• When BIS monitoring is initiated, a sensor is placed across the patient’s forehead per manufacturer recommendations
to detect one channel of EEG activity (Fig. 86-1).
FIGURE 86-1 BIS sensor in place illustrating anatomic landmarks for optimal sensor placement. BIS Extend sensor in place. Sensor may be placed on right
or left side.
Table 86-2
BIS Values, Corresponding Level of Sedation, and EEG State 3,13,17,20
100 Awake state; patient able to respond appropriately to verbal stimulation Baseline state before sedation
Anxiolysis
80 Patient able to respond to loud verbal, limited tactile stimulation, such as mild prodding/shaking High-frequency EEG activity
(Beta augmentation)
Moderate sedation
60 Low probability of explicit recall; patient unresponsive to verbal stimulation Low-frequency EEG activity
Deep sedation
40 Patient unresponsive to verbal stimulation, less responsive to physical stimulation Deep hypnotic state
Drug-induced coma; burst-suppression EEG pattern
20 Minimal responsiveness
0 No responsiveness mediated by brain function; spinal reflexes may be present Isoelectric or completely suppressed EEG
Note: Levels of sedation and responsiveness, and corresponding BIS value and EEG state, occur on a continuum.
(Adapted from Arbour R: Continuous nervous system monitoring: EEG, the bispectral index and neuromuscular transmission, AACN Clin Iss 14(2):192, 2003.)
EQUIPMENT
• BIS monitor
• Digital signal converter
• Patient interface cable
• BIS sensor
• Detachable power cord
• Alcohol pads
• Gauze pads
• Nonsterile gloves
Additional equipment includes the following:
• Soap and water
• Emergency equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Determine anatomic landmarks for the BIS sensor placement. Rationale:
Procedure for Bispectral Index Monitoring
Landmarks provide for accurate placement of the sensor.
FIGURE 86-5 BIS sensor check at start of monitoring.4 Circle 1 is positioned at center of forehead approximately 2 inches (5 cm) above nose. Circle 4 is
placed directly above and parallel to the eyebrow . Circle 3 is placed on the temple area betw een the hairline and the outer canthus of the eye. Circle 2 is
placed betw een circles 1 and 4 on the patient’s forehead. (Courtesy Aspect Medical Systems, Norwood, MA.)
FIGURE 86-6 Setup menu for selection of monitor settings optimal to specific patient needs.4 Display of specific monitoring parameters such as BIS trend
and smoothing rate may be adjusted on this display. (Courtesy Aspect Medical Systems, Norwood, MA.)
FIGURE 86-7 Advanced setup menu enabling the operator to select secondary monitoring parameters to be displayed w ith BIS trend and other, less
frequently changed settings. Secondary parameters that may be selected include electromyography (EMG), suppression ratio (SR), and signal quality index
(SQI).4 (Courtesy Aspect Medical Systems, Norwood, MA.)
FIGURE 86-8 Documentation of BIS values over time and after medication administration in critically ill patient. At 7:30 AM, the patient w as still receiving
neuromuscular blockade w ith a BIS value of 68. Additional sedation/analgesia w as administered (fentanyl and midazolam), w ith resulting BIS decline to 52.
After stimulation, BIS value elevated to 76, necessitating supplemental dosing w ith analgesics (fentanyl). BIS value remained at less than 60, and
neuromuscular blockade w as discontinued. The upw ard trend in the BIS value tracked recovery of consciousness to baseline mental status. (Courtesy Aspect
Medical Systems, Norwood, MA.)
FIGURE 86-9 An illustration of BIS trend recording of sedation/analgesia management in critically ill patient. BIS monitoring w as initiated at approximately
10:00 AM. Sedation w as managed initially w ith fentanyl and lorazepam. Decline in BIS from betw een 90 and 97 to betw een 55 and 65 occurred over 25 to 30
minutes in response to therapy. Decline in BIS value matched clinical assessment of increased level of sedation. The patient had periods of breakthrough
agitation and ventilator dyssynchrony beginning at 12:15 PM. Agitation w as refractory to current therapy despite upw ard titration of sedation and analgesia.
The sedation management w as changed to propofol at approximately 14:05 PM. The precipitous drop in BIS value indicated increased sedation. Propofol w as
titrated back in a controlled, incremental manner. Sedation w as more closely and optimally managed w ith application of BIS monitoring and avoiding, in a
controlled manner, extremes of excessive sedation and inadequate sedation/risk of agitation and ventilator dyssychrony. This tracing has been used in
electronic format beginning in June 2003 for educational purposes on behalf of Aspect Medical Systems. (Courtesy Aspect Medical Systems, Norwood, MA.)
References
1. Arbour, R, Impact of bispectral index monitoring on sedation and outcomes in critically ill patients. a case series.
Crit Care Nurs Clin North Am 2006; 18:227–241.
2. Arbour, R, Using bispectral index monitoring to detect -potential breakthrough awareness and limit duration
of neuromuscular blockade. case report and discussion. Am J Crit Care 2004; 13:66–73.
3. Arbour, R. Continuous nervous system monitoring, EEG, the bispectral index and neuromuscular
transmission. AACN Clin Issues. 2003; 14:185–207.
4. Aspect Medical Systems. A-2000™ Bispectral Index™ (BIS) monitoring system operating manual,. Norwood, MA:
Aspect Medical Systems, Inc; 2006.
5. Aspect Medical Systems. BIS VIEW™ monitoring system operating manual,. Norwood, MA: Aspect Medical
Systems, Inc; 2007.
6. Aspect Medical Systems. BIS VISTA monitoring system operating manual. Norwood, MA: Aspect Medical
Systems, Inc; 2008.
7. Aspect Medical Systems. BIS VISTA monitoring -system bilateral monitoring addendum operating -manual,.
Norwood, MA: Aspect Medical -Systems Inc; 2008.
8. Aspect Medical Systems, Overview. the effects of electromyography (EMG) and other high-frequency signals
on the bispectral index (BIS),. Aspect Medical Systems, Inc, Norwood, MA, 2000.
9. Azim, N, Wang, CY, Case report. the use of bispectral index during a cardiopulmonary arresta potential
indicator of cerebral perfusion. Anesthesiology 2004; 59:610–612.
10. Bader, MK, Arbour, R, Palmer, S, Refractory increased intracranial pressure in severe traumatic brain injury .
barbiturate coma and bispectral index monitoring. AACN Clin Issues 2005; 16:526–541.
11. Brunh, J, Myles, PS, Sneyd, R, et al, Depth of anesthesia monitoring. what’s available, what’s validated and what’s
next. Br J Anaesth 2006; 97:85–94.
12. Chisholm, CJ, Zurica, J, Mironov, D, et al. Comparison of electrophysiologic monitors with clinical assessment of
sedation. Mayo Clin Proc. 2006; 81:46–52.
13. Chiu, CL, Ong, G, Majid, AA. Impact of bispectral index monitoring on propofol administration in patients
undergoing cardiopulmonary bypass. Anaesth Intensive Care. 2007; 35:342–347.
14. Consales, G, Chelazzi, C, Rinaldi, S, et al. Bispectral index compared to Ramsay score for sedation monitoring in
intensive care units. Minerva Anestesiol. 2006; 72:329–336.
15. Courtman, SP, Wardurgh, A, Petros, AJ. Comparison of the bispectral index monitor with the Comfort score
in assessing level of sedation of critically ill children. Intens Care Med. 2003; 29:2239–2246.
16. Dahaba, AA, Lischnig, U, Kronthaler, R, et al, Bispectral-index-guided versus clinically guided
remifentanyl/propofol analgesia/sedation during interventional radiological procedures. an observer-blinded
randomized study. Anesth Analg 2006; 103:378–384.
17. Dahaba, AA. Different conditions that could result in the bispectral index indicating an incorrect hypnotic
state. Anesth Analg. 2005; 101:765–773.
18. Escudero, D, Otero, J, Muniz, G, et al, The bispectral index scale. its use in the detection of brain death.
Transplant Proc 2005; 37:3661–3663.
19. Fraser, GL, Riker, RR. Bispectral index monitoring in the intensive care unit provides more signal than noise.
Pharmacotherapy. 2005; 25(5 Pt 2):19S–27S.
20. Gambrell, M, Using the BIS monitor in palliative care. a case study. J Neurosci Nurs 2005; 37:140–143.
21. Hashimoto, H, Nakamura, H, Hirota, K. Marked reduction in bispectral index with severe bradycardia without
hypotension in a diabetic patient undergoing ophthalmic surgery. J Anesth. 2008; 22:300–303.
22. Honan, D, Doherty, D, Frizelle, H. A comparison of the effects on bispectral index of mild vs. moderate
hypothermia during cardiopulmonary bypass. Eur J Anaesthesiol. 2006; 23:385–390.
23. Inoue, S, Kawaguchi, M, Sasaoka, N, et al. Effects of neuromuscular block on systemic and cerebral
hemodynamics and bispectral index during moderate or deep sedation in critically ill patients. Intens Care Med.
2006; 32:391–397.
24. Jacobi, J, Fraser, GL, Coursin, DB, et al. Clinical practice guidelines for the sustained use of sedatives and
analgesics in the critically ill adult. Crit Care Med. 2002; 30:119–141.
25. Kelly, SD, Monitoring level of consciousness during anesthesia and sedation. a clinician’s guide to the
bispectral indexAspect Medical Systems. http://www.aspectmedical.com/resources/handbook/default.mspx,
June 4, 2004 [2003, retrieved].
26. Kin, N, Konstadt, SN, Sato, K, et al, Reduction of bispectral index value associated with clinically significant
cerebral air embolism. J Cardiothorac Vasc Anesth 2004; 18 :82–84.
27. Kosik, TM, Induced hypothermia for patients with cardiac arrest. role of the clinical nurse specialist. Crit Care
Nurs 2007; 27:36–42.
28. Lauwick, S, English, M, Hemmerling, TM, An unusual case of cerebral hypoperfusion detected by bispectral
index monitoring. Can J Anaesth. 2007; 54:680–681.
29. LeBlanc, JM, Dasta, JF, Kane-Gill SL. Role of the bispectral index in sedation monitoring in the ICU. Ann
Pharmacother. 2006; 40:490–500.
30. Misis, M, Raxach, JG, Molto, HP, et al. Bispectral index monitoring for early detection of brain death. Transplant
Proc. 2008; 40:1279–1281.
31. Morimoto, Y, Monden, Y, Ohtake, K, et al. The detection of cerebral hypoperfusion with bispectral index
monitoring during general anesthesia. Anesth Analg. 2005; 100:158–161.
32. Prins, SA, de Hoog, M, Blok, JH, et al. Continuous noninvasive monitoring of barbiturate coma in critically ill
children using the bispectral index monitor. Crit Care. 2007; 11:R108.
33. Rampil, IJ. A primer for EEG signal processing in anesthesia. Anesthesiology. 1998; 89:980–1002.
34. Rhoney, DH, Parker, D, Use of sedative and analgesic agents in neurotrauma patients. effects on cerebral
physiology. Neurol Res 2001; 23:237–259.
35. Riker, RR, Fraser, GL, Wilkins, ML. Comparing the bispectral index and suppression ratio with burst
suppression of the electroencephalogram during pentobarbital infusions in adult intensive care patients,.
Pharmacotherapy. 2003; 23:1087–1093.
36. Rosow, C, Manberg, PJ. Bispectral index monitoring. Anesth Clin North Am. 2001; 19:946–966.
37. Sackey, PV, Radell, PJ, Granath, F, et al. Bispectral index as a predictor of sedation depth during isoflurane or
midazolam sedation in ICU patients. Anaesth Intens Care. 2007; 35:348–356.
38. Sen, I, Puri, GD, Bapuraj, JR. Early detection of cerebral vasospasm during a neurointerventional procedure
using the BIS. Anaesth Intens Care. 2005; 33:691–692.
39. Tobias, JD, Grindstaff, R. Bispectral index monitoring during the administration of neuromuscular blocking
agents in a pediatric intensive care unit patient. J Intens Care Med. 2005; 20:233–237.
40. Vivien, B, Di Maria, S, Quattera, A, et al. Overestimation of bispectral index in sedated intensive care unit
patients revealed by administration of muscle relaxant. Anesthesiology. 2003; 99:9–17.
41. Vretzakis, G, Draguomanis, C, Argiriadou, H, et al. Inaccuracy of BIS values produced by the cardiopulmonary
bypass machine during operative repair of an aortic dissection. J Cardiothorac Vasc Anesth. 2006; 20:68–70.
42. Zanner, R, Schneider, G, Kochs, EF. Falsely increased bispectral index values caused by the use of a forced-air-
warming device. Eur J Anaesthesiol. 2006; 23:618–619.
Additional Readings
Arbour, R, Elec troenc ephalograph-derived monitoringInAACN-AANN protoc ols for prac tic e. monitoring tec hnologies in c ritic ally ill patients. Littlejohns, LR.
Bader, MK. Jones and Bartlett, S udbury, MA, 2009:175–197.
Claassen, J, Mayer, S A, Kowalski, RG, et al. Detec tion of elec trographic seizures with c ontinuous EEG monitoring in c ritic ally ill patients. Neurology. 2004;
62:1743–1748.
Deogaonkar, A, Gupta, R, DeGeorgia, M, et al. Bispec tral index monitoring c orrelates with sedation sc ales in brain-injured patients. Crit Ca re Med. 2004; 32:2403–
2406.
Marc h, K, Wellwood, J, Arbour, R. Tec hnology. In: Littlejohns LR, Bader MK, eds. AANN core curriculum for neuroscience nursing. S t Louis: S aunders; 2004:199–
204.
Markand, ON. Pearls, perils and pitfalls in the use of the elec troenc ephalogram. Semin Neurol. 2003; 23:7–46.
Nasraway, S A, The bispec tral index. expanded performanc e for everyday use in the intensive c are unit. Crit Care Med 2005; 33:685–687.
Parker, BM, Anesthetic s and anesthesia tec hniques. impac ts on perioperative management and postoperative outc omes. Clev Clin J Med. 2006; 73(S uppl 1):S 13–
S 17.
Tonner, PH, Wei, C, Bein, B, et al. Comparison of two bispec tral index algorithms in monitoring sedation in postoperative intensive c are patients. Crit Ca re Med.
2005; 33:580–584.
Watson, BD, Kane-Gill, S L, S edation assessment in c ritic ally ill adults. 2001-2004 update. Ann Pharmac other 2004; 38:1898–1906.
Welsby, IJ, Ryan, M, Booth, JV, et al, The bispec tral index in the diagnosis of perioperative stroke. a c ase report and disc ussion. Anesth Analg 2003; 96:435–437.
P R OC E D UR E 8 7
PURPOSE:
Brain tissue oxygen monitoring is performed in the patient with severe brain injury for measurement and
continuous monitoring of regional brain tissue oxygenation. Monitoring of brain tissue oxygen provides
important information relative to the delivery of oxygen to cerebral tissue of the injured brain.
Table 87-1
Management of Increased or Decreased PbtO2 Values
• PbtO2 probe placement: The physician placing the probe device determines the catheter placement location after
review of the CT scan and after consideration of the most appropriate monitoring area based on diagnosis and
pathology, avoiding areas of infarct or hematoma.4,17 Placement of the probe may be ipsilateral or contralateral to the
pathology.26
The probe may be placed in the nondominant hemisphere (e.g., right frontal region) to minimize risk of injury from
catheter insertion.6,12,29 The right hemisphere is a safer location for probe placement than the left hemisphere
because speech function is located in the left hemisphere in most individuals.
Placement may be near a lesion when the clinical goal is to monitor oxygen availability to damaged but salvageable
tissue.
If a patient has a subarachnoid hemorrhage, the probe may be placed in the area of the brain expected to develop
vasospasm. Placement is determined by the distribution of subarachnoid blood on CT scan and by aneurysm
location.16,21
Manufacturer’s recommended guidelines for probe device removal manufacturer’s guidelines or replacement is 5 to
7 continuous days per device. Drift may affect accuracy after 5 days.9 Practice may vary based on institutional
guidelines.
EQUIPMENT
• Sterile gowns, sterile drapes, sterile gloves, nonsterile gloves, caps, goggles, and face masks
• Shave preparation kit
• Antiseptic solution
• PbtO2 monitor (Fig. 87-1) or module
FIGURE 87-1 A, Model IM3 triple-lumen introducer. B, Smart card w here calibration data for the oxygen probe is electronically stored. C, Licox CMP monitor,
AC 3.1. (Courtesy Integra Neurosciences, Plainsboro, NJ.)
• Connecting cables
• Cranial access tray
• PbtO2 probe
• Scalpel
• Dressing supplies, including 4 × 4 gauze and tape
• Sterile dry gauze; may be placed at the insertion site
Additional equipment to have available as needed includes the following:
• An intravenous (IV) arm board may be used to stabilize the monitor probe and cable
• Intracranial bolt system
• Extra transparent and soft cloth adhesive dressing or any appropriate dry, sterile occlusive dressing
• A compatible fiberoptic ICP catheter may be inserted through the intracranial bolt system as well and will require a
separate monitor to measure ICP
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand the procedure teaching. Answer questions as they arise, and reinforce
information as needed. Most patients who need brain tissue oxygen monitoring are in an altered level of
consciousness with a Glasgow Coma Scale score of eight or less. Rationale: Information previously taught is
evaluated and reinforced.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient; however, in emergency circumstances, time may not allow for
the consent form to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Administer sedation or analgesia as prescribed before beginning the insertion procedure. Rationale: Sedation or
analgesia facilitates the insertion process.
• Assist the patient to the semi-Fowler’s position with the head in the neutral position and the head of bed elevated 30 to
45 degrees. Rationale: Patients who are candidates for brain tissue oxygen monitoring may have increased ICP.
Elevating the head of the bed and placing the head in the neutral position act to decrease intracranial pressure by
enhancing jugular venous outflow and provides for optimal insertion accessibility.
Procedure for Brain Tissue Oxygen Monitoring: Insertion (Assist), Care, and Troubleshooting
FIGURE 87-2 Demonstration of securing the IM3 hyphenate triple-lumen system (oxygen probe, temperature probe, and ICP catheter). (Courtesy University of
Pennsylvania: Brain oxygen monitor clinical practice guidelines.)
References
1. Bardt, TF, et al, Monitoring of brain tissue Po2 in traumatic brain injury. effect of cerebral hypoxia on
outcome. Acta Neurochir (Wien). 1998; 71(Suppl):153–156.
2. Bhatia, A, Gupta, AK, Neuromonitoring in the intensive care unit. IIcerebral oxygenation monitoring and
microdialysis. Intens Care Med 2007; 33:1322–1328.
3. Bratton, SL, et al, Guidelines for the management of severe traumatic brain injury. Xbrain oxygen monitoring
and thresholds. J Neurotrauma 2007; 24:S65–S70.
4. De Georgia, MA, Deogaonkar, A. Multimodal monitoring in the neurological intensive care unit. Neurologist.
2005; 11:45–54.
5. Dings, J, Meixenberger, J, Roosen, K, Brain tissue -PO2 monitoring. catheter stability and complications.
Neurol Res 1997; 19:241–245.
6. Dings, J, et al. Clinical experience with 118 brain tissue oxygen partial pressure catheter probes. Neurosurgery.
1998; 43:1082–1095.
7. Haitsma, IK, Maas, AIR, Advanced monitoring in the -intensive care unit. brain tissue oxygen tension. Curr
Opin Crit Care 2002; 8:115–120.
8. Hebl, JR. The importance and implications of aseptic -techniques during regional anesthesia. Reg Anesth Pain
Med. 2006; 31:311–323.
9. Integra, NeuroSciences. LICOX®IMC complete neuromonitoring directions for use. model IP2. P* complete brain
IMC-PROBE KIT,. Plainsboro, NJ: Integra NeuroSciences; 2004.
10. Integra, NeuroSciences. LICOX CMP brain oxygen monitoring system operations manual,. Plainsboro, NJ: Integra
Neurosciences; 2004.
11. Integra, NeuroSciences. MRI safety of the Licox IT2 complete brain tunneling probe kit, including the model CC1. P1
oxygen and temperature probe and model VK5. 2 parenteral probe guide at 1. 5 Tesla,. Plainsboro, NJ: Integra
Neurosciences; 2006.
12. Lang, EW, et al, Direct cerebral oxygenation monitoring. a systematic review of recent publications. Neurosurg
Rev 2007; 30:99–106.
13. Maas, AIR, et al, Monitoring cerebral oxygenation. experimental studies and preliminary clinical results of
continuous monitoring of cerebrospinal fluid and brain tissue oxygen tension. Acta Neurochir. 1993;
59(Suppl):50–57.
14. Mazzeo, AT, Bullock, R, Monitoring brain tissue oximetry. will it change management of critically ill neurologic
patients. J Neurol Sci 2007; 261:1–9.
15. Meixensberger, J, et al. Brain tissue oxygen guided treatment supplementing ICP/CPP therapy after traumatic
brain injury. J Neurol Neurosurg Psychiatry. 2003; 74:760–764.
16. Meixensberger, J, et al. Monitoring of brain tissue oxygenation following severe subarachnoid hemorrhage.
Neurol Res. 2003; 25:445–450.
17. Mulvey, JM, et al, Multimodality monitoring in severe traumatic brain injury. the role of brain tissue
oxygenation monitoring. Neurocrit Care 2004; 1:391–402.
18. Sarrafzadeh, AS, et al, Cerebral oxygenation in contusioned vs. nonlesioned brain tissue. monitoring of Ptio2
with Licox and Paratrend. Acta Neurochir (Wien). 1998; 71(Suppl):186–189.
19. Stewart, C, et al, The new licox combined brain tissue oxygen and brain temperature monitor. assessment of in
vitro accuracy and clinical experience in severe traumatic brain injury. Neurosurgery 2008; 63:1159–1165.
20. Stiefel, MF, et al. Cerebral oxygenation following decompressive hemicraniectomy for the treatment of
refractory intracranial hypertension. J Neurosurg. 2004; 101(2):241–247.
21. Stiefel, MF. The effect of nimodipine of cerebral oxygenation following subarachnoid hemorrhage. J
Neurosurg. 2004; 101(4):594–599.
22. Stiefel, MF, et al, Multi-modality monitoring in the management of refractory intracranial hypertension. a case
report. J Trauma. 2005; 59(3):757–761.
23. Stiefel, MF, et al. Reduced mortality rate in patients with severe traumatic brain injury treated with brain
tissue oxygen monitoring. J Neurosurg. 2005; 103(5):805–811.
24. Tisdall, MM, Smith, M, Mulimodal monitoring in traumatic brain injury. current status and future directions. Br
J Anaesth 2007; 99:61–67.
25. Valadka, AB, et al. Relationship of brain tissue Po2 to outcome after severe head injury. Crit Care Med. 1998;
26:1576–1581.
26. Valadka, AB, et al, Brain tissue Po2. correlation with cerebral blood flow. Acta Neurochirurgica. 2002;
81(Suppl):299–301.
27. van den Brink WA, et al, Monitoring brain oxygen tension in severe head injury. the Rotterdam experience.
Acta Neurochir. 1998; 71(Suppl):190–194.
28. van den Brink WA, et al. Brain oxygen tension in severe head injury. Neurosurgery. 2000; 46:868–878.
29. van Santbrink, H, et al. Continuous monitoring of partial pressure of brain tissue oxygen in patients with
severe head injury. Neurosurgery. 1996; 38:21–31.
30. Wartenberg, KE, Schmidt, JM, Mayer, SA. Multimodality monitoring in neurocritical care. Crit Care Clin. 2007;
23:507–538.
Additional Readings
Bader, MK, Littlejohns, LR, Marc h, K, Brain tissue oxygen monitoring II. implic ations for c ritic al c are teams and c ase study. Crit Care Nurse 2003; 23:29–44.
Blissitt, PA. Brain oxygen monitoring. In: Bader MK, Littlejohns LR, eds. AACN AANN protocols for pra ctice: monitoring technologies in critica lly ill neuroscience -
pa tients. Boston: Jones and Bartlett; 2009:103–144.
Grac ias, VH, et al, Cerebral c ortic al oxygenation. a pilot study. J Trauma Injury Infec t Crit Care. 2004; 56(3):469–474.
Maloney Wilensky, E, et al. Brain tissue oxygen prac tic e guidelines using the LICOX CMP monitoring system. J Neurosci Nurs. 2005; 37(5):278–288.
Littlejohns, LR, Bader, MK, Guidelines for the management of severe head injury. c linic al applic ation and c hanges in prac tic e. Crit Care Nurse 2001; 21:48–65.
Littlejohns, LR, Bader, MK, Marc h, K, Brain tissue -oxygen monitoring in severe brain injury. Iresearc h -and usefulness in c ritic al c are. Crit Care Nurse 2003;
23:17–25.
Patterson, J, et al, S uc c essful outc ome in severe traumatic brain injury. a c ase study. J Neurosc i Nurs. 2005; 37(5):236–242.
S mith, MJ, et al. Pac ked red blood c ell transfusion inc reases loc al c erebral oxygenation. Crit Ca re Med. 2005; 33:1104–1108.
S tiefel, MF, et al. Conventional neuroc ritic al c are does not ensure c erebral oxygenation after traumatic brain injury. J Neurosurg. 2006; 105:568–575.
P R OC E D UR E 8 8
PURPOSE:
The fiberoptic catheter is a device utilized for continuous measurement of intracranial pressure (ICP). The
fiberoptic catheter is placed in the brain parenchyma and reflects pressure exerted by the intracranial contents,
brain tissue, blood, and cerebrospinal fluid (CSF), within the skull. The fiberoptic catheter is inserted through a
bolt. Unlike a ventricular catheter, which is attached to an external transducer and drainage system, the
fiberoptic catheter does not allow for CSF drainage.
• The normal ICP waveform has three or four peaks with P1 of greater amplitude than P2 and P3. P1 is thought to reflect
arterial pressure; P2 and P3 and P4 (when present) have been described as choroid plexus or venous in origin (Fig. 88-
2).13 The amplitude of P2 may exceed P1 with increased ICP or decreased intracranial compliance (Fig. 88-3).
FIGURE 88-2 Components of the intracranial pressure w aveform: P1, P2 and P3.
FIGURE 88-3 Example of intracranial pressure w aveforms w ith P2 elevation indicating decreased cerebral compliance.
• ICP waveform trends include a, b, and c waves. The a waves, also referred to as plateau waves, are associated with ICP
values of 50 to 100 mm Hg and last 5 to 20 minutes. The a waves (Fig. 88-4) are associated with abrupt neurologic
deterioration and herniation. The b waves (Fig 88-5), with ICP values of 20 to 50 mm Hg and lasting 30 seconds to 2
minutes, may become a waves. The c waves (Fig. 88-6) may coincide with ICPs as high as 20 mm Hg but are short
lasting and without clinical significance.1
FIGURE 88-4 a or plateau w aves. Open arrows indicate plateau elevations in intracranial pressure. Note that w hen intracranial pressure falls, it does not
return to baseline preceding the first w ave (closed arrow). (From Marshall SB, et al: Neuroscience critical care: pathophysiology and patient management, Philadelphia, 1990,
Saunders.)
FIGURE 88-5 Elevations in intracranial pressure represent b w aves. The intracranial pressure rise is steep and rapid but to heights less than those
observed w ith a w aves and much briefer. (From Marshall SB, et al: Neuroscience critical care: pathophysiology and patient management, Philadelphia, 1990, Saunders.)
FIGURE 88-6 c w aves. The intracranial pressure changes are much less impressive than those in a or b w aves and reflect changes in arterial blood
pressure. (From Marshall SB, et al: Neuroscience critical care: pathophysiology and patient management, Philadelphia, 1990, Saunders.)
• Cerebral perfusion pressure (CPP) is the pressure at which the brain is perfused. CPP is calculated by subtracting the
ICP from the mean arterial pressure (MAP). Normal CPP is thought to be approximately 80 mm Hg.11 In severe
traumatic brain injury, the CPP for adults should range between 50 and 70 mm Hg.2 Patients with other neurologic
injuries may require individualized CPP parameters reflective of the neuropathology and brain perfusion needs.
Research continues regarding the relationship between cerebral blood flow and CPP.
• ICP and CPP must be considered together in management of the patient. Cerebral autoregulation is the intrinsic
ability of the cerebral vessels to constrict and dilate as needed to maintain adequate cerebral perfusion. Cerebral
autoregulation is impaired with brain injury and the cerebral blood flow becomes passively dependent on the
systemic blood pressure. The cerebral blood vessels are no longer able to react to maintain CPP in response to a
change in blood pressure.3
• Sustained ICP elevations of 20 mm Hg or greater necessitate immediate reporting and intervention. ICP waveform
changes that indicate loss of cerebral compliance or cerebral autoregulation should be reported immediately.8,10,13
• ICP monitoring is indicated for the following:
Traumatic brain injury with a Glasgow Coma Scale score of less than or equal to 8 and abnormal computed
tomography (CT) scan results or normal CT scan results with two of the following: hypotension; greater than 40
years of age; and motor posturing2
Intracranial hemorrhage13
Subarachnoid hemorrhage13
Hydrocephalus13
Fulminant hepatic failure with encephalopathy13
Ischemic stroke with massive edema13
Meningitis13
Cysts13
• Contraindications for ICP monitoring include infection and coagulopathies.
• Concerns with accuracy of ICP monitoring values primarily relate to displacement, misplacement, or breakage of the
catheter and drift (especially after 5 days).11,13
• Management of the patient with increased ICP and decreased CPP is a multi-tiered approach that includes
positioning, maintaining normothermia, administration of pharmacologic agents, and surgical procedures.6,9
EQUIPMENT
• Antiseptic solution
• Sterile gloves, surgical caps, masks, goggles or face shields, and sterile surgical gowns
• Sterile towels, half-sheets, and drapes
• Local anesthetic (lidocaine 1% or 2% without epinephrine), 5-ml or 10-mL Luer-Lok syringe with 18-gauge needle (for
drawing up lidocaine), and 23-gauge or 25-gauge needle (for administration of lidocaine)
• Shave preparation kit
• Cranial access tray
Scalpel
Scalpel retractor
Forceps
Needles/needle holders
• Monitoring equipment
Pressure box (bedside monitor)
Pressure cable
Stand-alone monitor (for interpretation of fiberoptic data)
Preamp fiberoptic catheter connector cable
Monitoring cable to connect to bedside monitor
• Sterile dressing supplies
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient; however, in emergency circumstances, time may not allow for
the consent form to be signed.
• Administer preprocedural analgesia or sedation as prescribed. Rationale: The patient needs to remain still during
fiberoptic catheter insertion. In an emergency situation, the patient may already be receiving continuous analgesia and
sedation.
• Assist the patient to a supine position with the head of the bed at 30 to 45 degrees and the neck in a midline, neutral
position. Rationale: This position provides access for fiberoptic catheter insertion and enhances jugular venous
outflow, contributing to possible reduction in intracranial pressure.
Procedure for Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), Intracranial Pressure Monitoring, Care,
Troubleshooting, and Removal
References
1. Bershad, EM, Humphreis, WE, Suarez, JI. Intracranial hypertension. Semin Neurol. 2008; 28:690–702.
2. Bratton, SL, Chesnut, RM, Ghajar, J, et al, Guidelines for the management of severe traumatic brain injury. a
joint project of the Brain Trauma Foundation, American Association of Neurological Surgeons (AANS), Congress
of Neurological Surgeons (CNS), AANS/CNS Joint Section on Neurotrauma and Critical Care. J Neurotrauma.
2007; 24(Suppl 1):S1–S106.
3. Davis, JW, Davis, IC, Bennink, LD, et al, Placement of intracranial pressure monitors. are “normal”
coagulation parameters necessary. J Trauma 2004; 57:1173–1177.
4. Fan J-Y, Kirkness, C, Vicini, P, et al. Intracranial pressure waveform morphology and intracranial adaptive
capacity. Am J Crit Care. 2008; 17:545–554.
5. Hebl, JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med.
2006; 31:311–323.
6. Hickey, JV, Olson, DM, Intracranial hypertension. theory and management of increased intracranial pressure
Hickey JV, ed.. The clinical practice of neurological and neurosurgical nursing. ed 6. Lippincott Williams &
Wilkins, Philadelphia, 2009:270–307.
7. Josephson, L. Management of increased intracranial pressure. Dimens Crit Care Nurs. 2004; 23:194–207.
8. Kirkness, CJ, Mitchell, PH, Burr, RL, et al, Intracranial pressure waveform analysis. clinical and research
implications. J Neurosci Nurs 2000; 32:271–277.
9. March, K. Application of technology in the treatment of traumatic brain injury. Crit Care Nurs Q. 2000;
23:26–37.
10. March, K. Intracranial pressure monitoring and assessing intracranial compliance in brain injury. Crit Care
Nurs Clin North Am. 2002; 12:429–436.
11. March, K. Technology. In: Bader MK, Littlejohns LR, eds. AANN core curriculum for neuroscience nursing. ed 4.
St Louis: Saunders; 2004:199–202.
Marc h, K, Intrac ranial pressure monitoring. why monitor. AACN Clin Issues 2005; 16:456–475.
13. March, K, Madden, L. Intracranial pressure management. In: Littlejohns LR, Bader MK, eds. AACN-AANN
protocols for practice: monitoring technologies in critically ill neuroscience patients. Sudbury, MA: Jones and Bartlett;
2009:35–69.
14. O’Grady, NP, Alexander, M, Dellinger, EP, et al. Guidelines for the prevention of intravascular catheter-related
infections. Am J Infect Control. 2002; 30:476–489.
15. Reynolds, F. Neurologic infection after neuraxial anesthesia. Anesthesiol Clin. 2008; 26:23–52.
16. Sahuqillo, J, Poca, M, Arribas, M, et al, Interhemispheric supratentorial intracranial pressure gradients in
head-injured patients. are they clinically important. J Neurosurg 1999; 90:16–26.
17. Slavin, KV, Misra, M, Infratentorial intracranial pressure monitoring in the neurosurgical intensive care unit.
Neurol Res 2003; 25:880–884.
18. Wolfla, CE, Luerssen, TG, Bowman, RM, et al. Brain tissue pressure gradients created by expanding frontal
epidural mass lesion. J Neurosurg. 1996; 84:642–647.
Additional Reading
Zhong, J, Dujovny, M, Park, HK, et al. Advanc es in ICP monitoring tec hniques. Neurol Res. 2003; 25:339–350.
P R OC E D UR E 8 9
PURPOSE:
The combination intraventricular/fiberoptic catheter combines the capability of external ventricular drainage of
cerebrospinal fluid with monitoring of intracranial pressure. This hybrid device can be used to monitor
intracranial pressure intermittently or continuously and to drain cerebrospinal fluid intermittently or
continuously.16
EQUIPMENT
• Antiseptic solution
• Sterile gloves, surgical caps, masks, goggles or face shields, and sterile surgical gowns
• Sterile towels, half-sheets, and drapes
• Local anesthetic (lidocaine 1% or 2% without epinephrine), 5- or 10-mL Luer-Lok syringe with 18-gauge needle (for
drawing up of lidocaine), and 23-gauge or 25-gauge needle (for administration of lidocaine)
• Shave preparation kit
• Cranial access tray
Scalpel
Scalp retractor
Forceps
Needles/needle holders
Intraventricular/fiberoptic catheter
Calibration screwdriver (single-use)
• Monitoring equipment
Pressure module (bedside monitor)
Pressure cable
Stand-alone monitor (for interpretation of fiberoptic data)
Preamp cable connector cable
Monitoring cable to connect to bedside monitor
• External ventricular drainage system
• Sterile dressing supplies
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient; however, in emergency circumstances, time may not allow for
the consent form to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Administer preprocedural analgesia or sedation as prescribed. Rationale: The patient needs to remain still during
catheter insertion. In an emergency situation, the patient may already be receiving continuous analgesia and sedation.
• Assist the patient to a supine position with the head of the bed at 30 to 45 degrees and the neck in a midline, neutral
position. Rationale: This position provides access for intraventricular/fiberoptic catheter insertion and enhances
jugular venous outflow, contributing to possible reduction in intracranial pressure.
Procedure for Combination Intraventricular/Fiberoptic Catheter Insertion (Assist), Monitoring, Nursing Care,
Troubleshooting, and Removal
References
1. Arabi, Y, Memish, ZA, Balkhy, HH, et al, Ventriculostomy-associated infections. incidence and risk factors.
Am J Infect Control 2005; 33:137–143.
2. Arbour, R, Intracranial hypertension. monitoring and nursing assessment. Crit Care Nurs 2004; 24:19–32.
3. Bershad, EM, Humphreis, WE, Suarez, JI. Intracranial hypertension. Semin Neurol. 2008; 28:690–702.
4. Bratton, SL, Chesnut, RM, Ghajar, J, et al, Guidelines for the management of severe traumatic brain injury. a
joint project of the Brain Trauma Foundation, American Association of Neurological Surgeons (AANS), Congress
of Neurological Surgeons (CNS), AANS/CNS Joint Section on Neurotrauma and Critical Care. J Neurotrauma.
2007; 24(Suppl 1):S1–S106.
5. Lo, CH, Spelman, D, Bailey, M, et al, External ventricular drain infections are dependent of drain duration. an
argument against elective revision. J Neurosurg 2007; 106:378–383.
6. Davis, JW, Davis, IC, Bennink, LO, et al, Placement of intracranial pressure monitors. are “normal”
coagulation parameters necessary. J Trauma 2004; 57:1173–1176.
7. Fan, JY, Kirkness, C, Vicini, P, et al. Intracranial pressure waveform morphology and intracranial adaptive
capacity. Am J Crit Care. 2008; 17:545–554.
8. Hebl, JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med.
2006; 31:311–323.
9. Hetherington, NJ, Dooley, MJ. Potential for patient harm from intrathecal administration of preserved
solutions. Med J Aust. 2000; 173:141–143.
10. Hickey, JV, Olson, DM, Intracranial hypertension. theory and management of increased intracranial
pressureHickey JV, ed.. The clinical practice of neurological and neurosurgical nursing. ed 6. Lippincott Williams
& Wilkins, Philadelphia, 2009:270–307.
11. Kirkness, CJ, Mitchell, PH, Burr, RL, et al, Intracranial pressure waveform analysis. clinical and research
implications. J Neurosci Nurs 2000; 32:271–277.
12. Leeper, B, Lovasik, D, Cerebrospinal drainage systems. external ventricular and lumbar drainsLittlejohns LR,
Bader MK, eds.. AACN-AACN protocols for practice: monitoring technologies in critically ill neuroscience
patients. Jones and Bartlett: Sudbury, MA, 2009 :71–82.
13. Littlejohns, LR, Trimble, B. Our policy on external ventricular drainage systems includes the procedure for
priming the system. Does it really have to be primed. Crit Care Nurse. 2005; 25:57–59.
14. Lozier, AP, Sciacea, RR, Romagnoli, MF, et al, Ventriculostomy-related infections. a critical review of the
literature. Neurosurgery 2002; 51:170–181.
15. March, K. Application of technology in the treatment of traumatic brain injury. Crit Care Nurs Q. 2000; 23:26–
37.
16. March, K. Intracranial pressure monitoring and assessing intracranial compliance in brain injury. Crit Care
Nurs Clin North Am. 2000; 12:429–436.
17. March, K. Technology. In: Bader MK, Littlejohns LR, eds. Core curriculum for neuroscience nursing. ed 4.
Chicago, American Association of Neuroscience Nurses, St Louis: Saunders; 2004:199–226.
18. March, K, Madden, L. Intracranial pressure management. In: Littlejohns LR, Bader MK, eds. AACN-AANN
protocols for practice: monitoring technologies in critically ill neuroscience patients. Sudbury, MA: Jones and Bartlett;
2009:35–69.
19. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
20. Reynolds, F. Neurologic infections after neuraxial anesthesia. Anesthesiol Clin. 2008; 26:23–52.
21. Wilkinson, HA, et al, Erroneous measurement of intracranial pressure caused by simultaneous ventricular
drainage. a hydrodynamic model study. Neurosurgery 1989; 24:348–354.
22. Woodward, S, Addison, C, Shah, S, et al. Benchmarking best practice for external ventricular drainage. Br J
Nurs. 2002; 11:47–53.
P R OC E D UR E 9 0
PURPOSE:
Jugular venous oxygen saturation (SjVO2) catheters detect the oxygen saturation of hemoglobin in the blood after
cerebral perfusion. The direct and derived parameters obtained from jugular venous oxygen saturation
catheters reflect global cerebral oxygenation. Inclusion of jugular venous oxygen saturation data in the clinical
management of the patient may prevent the secondary brain injury that occurs as a result of an imbalance
between cerebral oxygen delivery and cerebral oxygen demand.2,43
• A decrease in Sj VO2 (55%) may be due to increased demand as a result of pain, hyperthermia, shivering, agitation, or
seizures. It may also be due to decreased delivery as a result of hyperventilation (hypocarbia), decreased cardiac
output, hypotension, hypovolemia, anemia, hypoxia, and sepsis.4
• An increase in Sj VO2 (70%) may be due to decreased demand as the result of hypothermia, anesthesia, paralytics, and
sepsis. It may also be due to increased delivery.4
• Derived Sj VO2 parameters include arteriovenous jugular oxygen content difference (Avj DO2 ), the cerebral extraction of
oxygen (CEO2 ), and the cerebral metabolic rate of oxygen consumption (CMRO2 ).
Avj DO2 reflects the relationship between cerebral blood flow (CBF) and CMRO2 .27,28,35,41,42
Normal range: 4.0 to 8.0 mL/dL
Calculation requires data obtained from both systemic arterial and jugular venous blood gas analysis
CEO2 reflects the influence of cerebral blood volume change (CBV ) and its effect on CBF and CMRO2 . Blood volume
flow is not equal to blood volume.27,35,41,45
Normal range: 24% − 42%
Equation: SaO2 − Sj VO2
CMRO2 is the energy needed for cellular function.35,41 This parameter includes knowledge of the cerebral blood flow
and Avj DO2 and is less frequently calculated in the clinical setting. Normal CMRO2 is 3.2 mL/100 g/min.
• The technology used for continuous Sj VO2 monitoring is oximetry, which is based on the unique light absorption
spectrum of oxyhemoglobin.40 Oximetry requires calibration, either in vivo, within the patient’s jugular vein, or in
vitro, calibration before insertion, outside the body. Formulas and normal ranges for Sj VO2 catheter data and
calculations are included in Tables 90-1 and 90-2. Clinical interventions based on Sj VO2 data are shown in Table 90-3.
Table 90-1
Formulas for Calculations Using SjVO2 Data
Calculations Formula
Avj DO2, Arteriovenous jugular oxygen content difference; SaO2, oxygen saturation in arterial blood; Sj VO2, jugular venous oxygen saturation; CEO2, cerebral extraction
of oxygen; CBF, cerebral blood flow ”
Table 90-2
Normal Ranges for SjVO2 Data and Calculations
Sj VO2 Data Normal Ranges
Avj DO2, arteriovenous jugular oxygen content difference; Sj VO2, jugular venous oxygen saturation; CEO2, cerebral extraction of oxygen.
Table 90-3
Clinical Interventions Based on SjVO2 Data
EQUIPMENT
• Antiseptic solution (e.g., 2% chorhexidine-based preparation)
• Surgical caps, gowns, goggles, sterile gloves, and gowns
• Sterile towels, half-sheets, and drapes
• Local anesthetic (lidocaine 1% or 2% without epinephrine)
• 5- or 10-mL Luer-Lok syringe with an 18-gauge needle (for drawing up of the lidocaine) and a 23-gauge needle (for
administration of the lidocaine)
• Introducer set and sheath.
In addition, the following are needed (if they are not included in the kit):
Sterile needle driver
Sutures
5 Fr percutaneous transvenous introducer catheter
4 Fr fiberoptic oximetric Sj VO2 catheter
• Optical module and connecting fiberoptic cable
• Oximetric monitor (typically a stand-alone monitor or module)
• Pressure bag setup
500 mL 0.9% sodium chloride
Pressure tubing
Pressure bag
A pressure waveform is not generated from these catheters; therefore, display of a bedside waveform is not
necessary. The system provides 3 mL of fluid an hour to prevent clotting of the catheter.
• Pressure module and cable to interface the oximetric monitor to the bedside monitor
• Sterile occlusive central venous catheter dressing
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure that informed consent is obtained. Rationale: Informed consent protects the rights of the patient and makes
competent decision making possible for the patient; however, in emergency circumstances, time may not allow for
the consent form to be signed.
• Administer preprocedural analgesia or sedation as prescribed. Rationale: Patients need to remain still during Sj VO2
catheter insertion. Usually patients are unconscious and may be receiving continuous intravenous analgesia and
sedative medications.
Procedure for Assisting with SjVO2 Catheter Insertion
Procedure for Troubleshooting SjVO2 Catheter
References
1. Bankier, AA, et al, Position of jugular oxygen saturation catheter in patients with head trauma. assessment by
use of plain films. Am J Roentgenol 1995; 164:437–441.
2. Bayir, H, et al. Promising strategies to minimize secondary brain injury after head trauma. Crit Care Med.
2003; 31(Suppl):S112–S117.
3. Bhutra, S, et al. Jugular venous oxygen saturation monitoring in comatose neurosurgical patients. JACP. 1999;
15(2):143–147.
4. Blissitt, PA. Brain oxygen monitoring. In: Littlejohns LR, Bader MK, eds. AACN-AANN protocols for practice:
monitoring technologies in critically ill neuroscience -patients. Sudbury, MA: Jones and Bartlett; 2009:103–144.
5. Bouma, GJ, et al, Cerebral circulation and metabolism -after severe traumatic brain injury. the elusive role of -
ischemia. J Neurosurg 1991; 75:683–685.
6. Bratton, SL, Chesnut, RM, Ghajar, J, et al, Brain oxygen monitoring and thresholds. guidelines for the
management of -severe traumatic brain injuryA joint project of the Brain Trauma Foundation, American
Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), AANS/CNS Joint
Section on Neurotrauma and -Critical Care. J Neurotrauma. 2007; 24(Suppl 1):S65–S70.
7. Chan, MT, Re-defining the ischemic threshold for jugular venous oxygen saturation. a microdialysis study in -
patient with severe head injury. Acta Neurochir 2005; 95:63–66. [(Suppl)].
8. Chieregato, A, et al, Detection of early ischemia in severe head injury by means of arteriovenous lactate
differences and jugular bulb oxygen saturation. relationship with CPP, severity indexes and outcomepreliminary
analysis. Acta Neurochirurgica. 2002; 81(Suppl):289–293.
9. Citerio, G, et al. Jugular saturation (SjVO2) monitoring in subarachnoid hemorrhage (SAH). Acta
Neurochirugica. 1998; 71:316–319. [(Suppl)].
10. Cormio, MA, et al. Elevated jugular venous oxygen saturation after severe head injury. J Neurosurg. 1999;
90:9–15.
11. Dearden, NM, Midgley, S. Technical considerations in continuous jugular venous oxygen saturation
measurement. Acta Neurochirurgica. 1993; 59(Suppl):91–97.
12. Fandino, J, et al. Cerebral oxygenation and systemic trauma related factors determining neurological outcome
after brain injury. J Clin Neurosci. 2000; 7:226–233.
13. Feldman, Z, Robertson, CS. Monitoring of cerebral hemodynamics with jugular bulb catheters. Crit Care Clin.
1997; 13:51–77.
14. Ferris, EB, et al. The validity of the internal jugular venous blood in studies of cerebral metabolism and blood
flow in man. Am J Physiol. 1946; 147:517–521.
15. Gibbs, EL, et al. The cross section areas of the vessels that form the torcular and the manner in which flow is
distributed to the right and left lateral sinus. Anat Rec. 1934; 59:419–426.
16. Gibbs, EL, et al, Arterial and cerebral venous blood. arterial-venous differences in man. J Biol Chem 1942;
144:325–332.
17. Gibbs, FA, et al. Cerebral blood flow preceding and accompanying epileptic seizures in man. Arch Neurol
Psychiatry (Chicago). 1934; 32:257–272.
18. Gopinath, SP. Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psychiatry. 1994;
57:717–723.
19. Graham, D, et al. Brain damage in fatal non-missile head injuries with high intracranial pressure. J Clin Pathol.
1988; 41:34–37.
20. Gupta, AK, et al. Measuring brain tissue oxygenation compared with jugular venous oxygenation after
traumatic brain injury. Anesth Analg. 1999; 88:549–553.
21. Imberti, R, et al. Cerebral tissue PO2 and SjVO2 changes during moderate hyperventilation in patients with
severe traumatic brain injury. J Neurosurg. 2002; 96:91–102.
22. Iwata, M, Kawaguchi, M, Inoue, S, et al. Effects of increasing concentrations of propofol on jugular venous bulb
oxygen saturation in neurosurgical patients under normothermic and mildly hypothermic conditions.
Anesthesiology. 2006; 104:33–38.
23. Jakobsen, M, Enevoldsen, E. Retrograde catheterization of the right internal jugular vein for serial
measurements of cerebral venous oxygen content. J Cereb Blood Flow Metab. 1989; 9:717–720.
24. Keller, E, et al, Jugular venous oxygen saturation thresholds in trauma patients may not extrapolate to
ischemic stroke patients. lessons from a preliminary study. J Neurosurg Anesthesiol 2002; 14:130–136.
25. Kidd, KC, Criddle, L. Using jugular venous catheters in patients with traumatic brain injury. Crit Care Nurse.
2001; 21(6):16–22.
26. Kiening, KL, et al, Monitoring of cerebral oxygenation in patients with severe head injuries. brain tissue PO2
versus jugular vein oxygen saturation. J Neurosurg 1996; 85:751–757.
27. Komiyama, M, et al. Marked regional heterogeneity in venous oxygen saturation in severe head injury studied
by superselective intracranial venous sampling. Neurosurgery. 1999; 45(6):1469–1472.
28. LeRoux, PD, Cerebral arteriovenous oxygen difference. a predictor of cerebral infarction and outcome in
patients with severe head injury. J Neurosurg 1997; 87:1–8.
29. Lubbers, DW, et al. Heterogeneity and stability of local PO2 distribution within the brain tissue. Adv Exp Med
Biol. 1994; 345:567–574.
30. March, K, Retrograde jugular catheter. monitoring SjO2. J Neurosci Nurs. 1994; 26(1):48–51.
31. Matta, BF, Lam, AM. The rate of blood withdrawal affects the accuracy of jugular venous bulb saturation
measurements. Anesthesiology. 1997; 86:806–808.
32. Matta, BF, et al. The influence of arterial oxygenation on cerebral venous oxygen saturation during
hyperventilation. Can J Anaesth. 1994; 41:1041–1046.
33. McLeod, AD, et al, Measuring cerebral oxygenation during normobaric hyperoxia. a comparison of tissue
microprobes, near-infrared spectroscopy, and jugular venous oximetry in head injury. Anesth Analg 2003;
97:851–856.
34. Metz, C, et al, Monitoring of cerebral oxygen metabolism in the jugular bulb. reliability of unilateral
measurements in severe head injury. J Cereb Blood Flow Metab 1998; 18:332–343.
35. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30:476–489.
36. Robertson, CS, et al. Prevention of secondary ischemic insults after severe head injury. Crit Care Med. 1999;
27:2086–2095.
37. Robertson, CS, et al. Cerebral blood flow, arteriovenous oxygen difference, and outcome in head injured
patients. J Neurol Neurosurg Psychiatry. 1992; 55:594–603.
38. Ross, DT, et al. Selective loss of neurons from the thalamic reticular nucleus following severe head injury. J
Neurotrauma. 1993; 10:151–165.
39. Rossi, S, et al. Brain oxygen tension, oxygen supply, and consumption during arterial hyperoxia in a model of
progressive cerebral ischemia. J Neurotrauma. 2001; 18:163–174.
40. Schell, RM, Cole, DJ, Cerebral monitoring. jugular venous oximetry. Anesth Analg 2000; 90:559–566.
41. Sheinberg, M, et al. Continuous monitoring of jugular venous oxygen saturation in head injured patients. J
Neurosurg. 1992; 76:212–271.
42. Sikes, PJ, Segal, J. Jugular bulb oxygen saturation monitoring for evaluating cerebral ischemia. Crit Care Nurs
Q. 1994; 17(1):9–20.
43. Stocchetti, N, et al. Cerebral venous oxygen saturation studied with bilateral samples in internal jugular veins.
Neurosurgery. 1994; 34:38–43.
44. Stocchetti, N, et al. Arterio-jugular difference of oxygen content and outcome after head injury. Anesth Analg.
2004; 99:230–234.
45. Struchen, MA, et al. The relation between acute physiological variables and outcomes on the Glasgow
Outcomes Scale and Disability Rating Scale following severe traumatic brain injury. J Neurotrauma. 2001; 18:115–
125.
46. van Santbrink, H, et al. Continuous monitoring of partial pressure of brain tissue oxygen in patients with
severe head injury. Neurosurgery. 1996; 38:21–31.
47. White, H, Baker, A, Continuous jugular venous oximetry in the neurointensive care unit. a brief review. Can J
Anaesth 2002; 49:623–629.
Additional Readings
DeGeorgia, MA, Deogaonkar, A. Multimodal monitoring in the neurologic al intensive c are unit. Neurologist. 2005; 11:45–54.
Kawano, Y, Kawaguc hi, M, Inoue, S , et al. Jugular bulb oxygen saturation under propofol or sevoflurane/nitrous oxide -anesthesia during deliberate mild
hypothermia in -neurosurgic al patients. J Neurosurg Anesthesiol. 2004; 16:6–10.
Marc h, K. Tec hnology. In: Bader MK, Littlejohns LR, eds. Core curriculum for neuroscience nursing. ed 4. Chic ago, Americ an Assoc iation of Neurosc ienc e
Nurses, S t Louis: S aunders; 2004:199–226.
S mythe, PR, S amra, S K. Monitors of c erebral oxygenation. Anesthesiol Clin North Am. 2002; 20:293–313.
Wartenberg, KE, S c hmidt, JM, Mayer, S A. Multimodality -monitoring in neuroc ritic al c are. Crit Ca re Clin. 2007; 23:507–538.
Yoshitani, K, Kawaguc hi, M, Iwata, M, et al. Comparison of c hanges in jugular venous bulb oxygen saturation and c erebral oxygen saturation during variations
of haemoglobin c onc entration under propofol and sevoflurane anaesthesia. Br J Ana esth. 2005; 94:341–346.
P R OC E D UR E 9 1
PURPOSE:
Patients with a variety of central nervous system conditions and thoracoabdominal aneurysms may benefit from
monitoring of intraspinal pressure and maintenance of therapeutic levels of cerebrospinal fluid drainage. Lumbar
subarachnoid catheters are used for cerebrospinal fluid pressure monitoring and drainage.23,40
EQUIPMENT
• Antiseptic solution
• Caps, masks with face shields, sterile gowns, and sterile gloves
• Sterile towels, half-sheets, and drapes
• Local anesthetic (lidocaine 1% or 2% without epinephrine)
• 5- or 10-mL Luer-Lok syringe with 18-gauge needle for drawing of lidocaine and 23-gauge needle for administration
of lidocaine
• Sutures (2-0 nylon, 3-0 silk)
• Forceps
• Sterile scissors
• Sterile needle holder
• Preservative-free sterile normal saline solution (vial, bag, or prefilled syringe)
• Lumbar catheter tray
• Lumbar puncture tray
• Sterile occlusive dressing
• Tape (1- and 2-inch rolls)
• External transducer with three-way stopcock
• Pressure cable
• External CSF drainage system
• Nonvented sterile caps
Additional supplies as needed include the following:
• Leveling device
• Rolled towels or small pillows to support the patient during positioning
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that informed consent is obtained. Rationale: Informed consent protects the rights of the patient and makes
competent decision-making possible for the patient; however, in emergency circumstances, time may not allow for
the consent form to be signed.
• Administer preprocedural analgesia or sedation as prescribed. Rationale: The patient must be correctly positioned
and immobile during lumbar subarachnoid catheter insertion and monitoring and therefore may need sedation or
analgesia to tolerate the procedure.
• Administer preprocedural antibiotics as prescribed. Rationale: Prophylactic intravenous antibiotics may reduce the
risk of infection.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
Procedure for Lumbar Subarachnoid Catheter Insertion (Assist)
FIGURE 91-1 Drip chamber at the level of the transducer and the external auditory meatus.
FIGURE 91-2 Top of the drip chamber w ith reference line.
Additional Readings
Marc h, K, Wellwood, J, Arbour, R. Tec hnology. In: Bader MK, Littlejohns LR, eds. AANN core curriculum for neuroscience nursing. S t Louis: S aunders;
2004:199–204.
Greenberg, MS . Ha ndbook of Neurosurgery, ed 6. New York: NY, Thiem; 2006.
P R OC E D UR E 9 2
PURPOSE:
An intraventricular catheter with an external transducer is used to monitor intracranial pressure and, in the
presence of pathology, to alleviate increased intracranial pressure by draining cerebrospinal fluid (CSF) from the
ventricular system.
EQUIPMENT
• Cranial access tray with drill
• Ventricular catheter
• Pressure monitor tubing kit, including pressure tubing, transducer, a three-way stopcock, or a flushless transducer
with stopcock
• Nonvented sterile caps
• External drainage system, including tubing, collection chamber, and drainage bag
• Preservative-free normal saline solution
• Pressure monitoring cable and module
• Sterile syringes
• Shave preparation kit
• Sterile towels, drapes
• Antiseptic solution
• Local anesthetic (lidocaine 1% or 2% without epinephrine)
• Sutures or staples
• Sterile dressing
• Tape
• Laboratory forms and specimen labels (for CSF specimens)
• Sterile CSF specimen tubes (for collection of CSF)
• Caps, masks, sterile drapes, gloves, and gowns
• Suction
• Cautery as required by institutional standard (for bedside insertion)
• Leveling device (e.g. carpenter, laser, or line level)
• IV pole
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient. However, in emergency circumstances, time may not allow for
the consent form to be signed.
• Initiate intravenous (IV) access or assess the patency of the IV. Rationale: Readily available IV access is necessary if
the patient needs to be sedated or paralyzed or needs other medications.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
Procedure for Pressure Monitoring and Drainage
FIGURE 92-1 External ventricular drainage system w ith flushless transducer at zero reference level. (Courtesy of Integra Lifesciences Corporation, Plainsboro,
NJ.)
FIGURE 92-2 External ventricular drainage system. (Drawing by Paul Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 92-3 Distal stopcock turned off to the distal tip of the pressure monitor tubing. (Drawing by Paul Schiffmacher, Thomas Jefferson University, Philadelphia,
PA.)
FIGURE 92-4 Distal stopcock turned off to the external drainage system tubing. (Drawing by Paul Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 92-5 Distal stopcock turned off to the transducer. (Drawing by Paul Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
FIGURE 92-6 CSF sampling port. (Drawing by Paul Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)
References
1. Arabi, Y, Memish, ZA, Balkhy, HH, et al, Ventriculostomy-associated infections. incidence and risk factors.
Am J Infect Control 2005; 33:137–143.
2. Bederson, JB, Connolly, ES, Batjer, HH, et al, Guidelines for the management of aneurysmal subarachnoid
hemorrhage. a statement for healthcare professionals from a special writing group of the Stroke Council,
American Heart Association. Stroke. 2009; 40:994–1025.
3. Bershad, EM, Humphreis, WE, Suraz, JI. Intracranial hypertension. Semin Neurol. 2008; 28:690–702.
4. Bisnaire, D, Robinson, L. Accuracy of levelling intraventricular collection drainage systems. J Neurosci Nurs.
1997; 29:261–268.
5. Blumenfeld, H, Ventricles and cerebrospinal fluid in neuroanatomy through clinical cases,. Sinauer
Associates, Sunderland, MA, 2002:128–133.
6. Bratton, SL, Chesnut, RM, Ghajar, J, et al, Guidelines for the management of severe traumatic brain injury. a join
project of the Brain Trauma Foundation, American Association of Neurological Surgeons (AANS), Congress of
Neurological Surgeons (CNS), AANS/CNS Joint Section on Neurotrauma and Critical Care. J Neurotrauma.
2007; 24(Suppl 1):S1–S106.
7. Brodbelt, A, Stoodley, M, CSF pathways. a review. Br J Neurosurg 2007; 21:510–520.
8. Broderick, J, Connolly, S, Feldman, E, et al, Guidelines for the early management of spontaneous intracerebral
hemorrhage in adults. guidelines from the American Heart Association/American Stroke Association Stroke
Council, High Blood Pressure Research Council, and the Quality of Care Outcomes in Research Interdisciplinary
Working Groups. Stroke 2007; 38:2001–2023.
9. Czosnyka, M, Pickard, JD. Monitoring and interpretation of intracranial pressure. J Neurol Neurosurg
Psychiatry. 2004; 75:813–821.
10. Czosnyka, M, Czosnyka, ZA, Richards, HK, et al. Hydrodynamic properties of extraventricular drainage
systems. Neurosurgery. 2003; 52:619–623.
11. Dasic, D, Hanna, SJ, Bojanic, S, et al, External ventricular drain infection. the effect of a strict protocol on infection
rates and a review of the literature. Br J Neurosurg 2006; 20:296–300.
12. Dennis, LJ, Mayer, SA. Diagnosis and management of increased intracranial pressure. Neurol India. 2001;
49(Suppl 1):S37–S50.
13. Dunn, LT. Raised intracranial pressure. J Neurol Neurosurg Psychiatry. 2002; 73(Suppl I):i23–i27.
14. Fountas, KN, Kapsalaki, EZ, Machinis, T, et al. Review of the literature regarding the relationship of rebleeding
and external ventricular drainage in patients with subarachnoid hemorrhage of aneurysmal origin. Neurosurg Rev.
2006; 29:14–18.
15. Hebl, JR. The importance and implications of aseptic techniques during regional anesth. Reg Anesth Pain Med.
2006; 31:311–323.
16. Hetherington, NJ, Dooley, MJ. Potential for patient harm from intrathecal administration of preserved
solutions. Med J Aust. 2000; 173:141–143.
17. Kinirons, B, Mimoz, O, Lafendi, L, et al. Chlorhexidine versus povidone iodine in preventing colonization of
continuous epidural catheters in children. Anesthesiology. 2001; 94:239–244.
18. Kirkness, CJ, Mitchell, PH, Burr, RL, et al, Intracranial pressure waveform analysis. clinical and research
implications. J Neurosci Nurs 2000; 32:271–277.
19. Kirkness, CJ, March, K. Intracranial pressure management. In: Bader MK, Littlejohns LR, eds. AANN core
curriculum for neuroscience nursing. St Louis: Saunders; 2004:249–267.
20. Komotar, R, Zacharia, BE, Mocco, J, et al, Controversies in the surgical treatment of ruptured intracranial
aneurysms. the first annual J. Lawrence Pool Memorial Research Symposium-Controversies in the management
of cerebral aneurysms. Neurosurgery 2008; 62:396–407.
21. Leeper, B, Lovasik, D, Cerebrospinal drainage systems. external ventricular and lumbar drains. Littlejohns LR,
Bader MK, editors. AACN-AANN protocols for practice: monitoring technologies in critically ill patients. 2009.
Jones and Bartlett: Sudbury, MA:71–82.
22. Littlejohns, LR, Trimble, B, Ask the experts. our policy on external ventricular drainage systems includes the
procedure for priming the system. Does it really have to be primed. Crit Care Nurse 2005; 25:57–59.
23. Lozier, AP, Sciacca, RR, Romagnoli, MFet al. Ventriculostomy-related infections. a critical review of the
literature. Neurosurgery. 2002; 51:170–182.
24. Maniker, A, Vaynman, AY, Karimi, RJ, et al, Hemorrhagic complications of external ventricular drainage.
Neurosurgery . 2006; 59(ONS Suppl 4 ):ONS419–424.
25. March, K. Intracranial pressure monitoring and assessing intracranial compliance in brain injury. Crit Care
Nurs Clin North Am. 2000; 12:429–436.
26. March, K, Intracranial pressure monitoring. why monitor. AACN Clin Issues 2005; 16:456–475.
27. March, K, Madden, L. Intracranial pressure management. In: Littlejohns LR, Bader MK, eds. AACN-AANN
protocols for practice: monitoring technologies in critically ill patients. Sudbury, MA: Jones and Bartlett; 2009:35–69.
28. March, K, Wellwood, J, Arbour, R. Technology. In: Bader MK, Littlejohns LR, eds. AANN core curriculum for
neuroscience nursing. St Louis: Saunders; 2004:199–204.
29. Ng, I, Lim, J, Wong, HB, Effects of head posture on cerebral hemodynamics. its influences on intracranial
pressure, cerebral perfusion pressure, and cerebral oxygenation. Neurosurgery 2004; 54:593–598.
30. O’Grady, NP, Alexander, M, Dellinger, Pet al. Guidelines for the prevention of intravascular catheter-related
infections. Am J Infect Control. 2002; 30:476–489.
31. Reynolds, F. Neurologic infections after neuraxial anesthesia. Anesthesiol Clin. 2008; 26:23–52.
32. Vincent, JL, Berre, J. Primer on medical management of severe brain injury. Crit Care Med. 2005; 33:1392–
1399.
Additional Reading
Dunham, CM, Ransom, KJ, Flowers, LL, et al. Cerebral hypoxia in severely brain-injured patients is assoc iated with admission Glasgow Coma S c ale sc ore,
c omputed tomographic severity, c erebral perfusion pressure, and survival. J Tra uma . 2004; 56:482–489.
P R OC E D UR E 9 3
PURPOSE:
Transcranial Doppler scan measures blood flow velocities in the major branches of the circle of Willis through an
intact skull. This measurement supports the grading of vasospasm severity, localization of intracranial stenoses
or occlusions, detection of cerebral emboli, monitoring of hemodynamic changes with impaired intracranial
perfusion, and assessment of the impact of therapeutic interventions on intracranial hemodynamics.7-9,18,24
FIGURE 93-1 Four w indow s of transcranial Doppler insonation (left image, clockwise): orbital, temporal, submandibular, and foraminal. The temporal
w indow has three aspects (right image): 1, middle; 2, posterior; 3, anterior. (From Alexandrow AV: Transcranial Doppler ultrasonography, Houston, 1998, University of
Texas Medical School.)
• The transtemporal window allows insonation of the middle cerebral artery (MCA), the anterior cerebral artery (ACA),
the posterior cerebral artery (PCA), and the anterior and posterior communicating arteries (AComA and PComA).1-4
• The transorbital window allows insonation of the ophthalmic artery (OA) and the internal carotid artery (ICA)
siphon.1-4
• The transforaminal window allows insonation of the vertebral arteries (VAs) and the basilar artery (BA).1-4
• The submandibular window allows insonation of the ICA as it enters the skull.1-4 TCD scan locates both the depth and
direction of arterial blood flow relative to the transducer position and the ultrasonic beam direction. Flow moving
toward the transducer is displayed as a waveform with a positive velocity spectrum, whereas flow moving away from
the transducer is displayed as a waveform with a negative velocity spectrum.1-4,12,16
• The TCD scan measures cerebral blood flow velocities that should not be equated to cerebral blood flow (CBF)
volume. TCD is an indirect reflection of CBF.4,15,21
• The examination should begin with maximal power and gate settings (e.g., power, 100%; gate, 10 to 15 mm) to
expedite identification of the temporal window and various arterial segments. Once a good temporal window is
established, the power may be reduced to adhere to the U.S. Food and Drug Administration (FDA) principles of (1)
“as low as reasonably achievable” (ALARA) and (2) minimization of overall time of patient exposure to ultrasound
scan. Transorbital examination should always be performed with minimal power (e.g., 10%) to avoid potential side
effects from the heating of orbital structures.1-4
• The highest velocity signals for each arterial segment studied, and any abnormal or unusual waveforms, should be
measured and stored in the system’s computer.3
• Criteria for normal insonation depths, flow direction, and mean flow velocities are used for appropriate identification
of arteries and diagnosis of abnormalities (Fig. 93-2 and Table 93-1).2,15,18,21
Table 93-1
Depth, Direction, and Mean Flow Velocities for Circle of Willis Arteries*
M1 MCA, First segment of the middle cerebral artery; A1 ACA, first segment of the anterior cerebral artery; ICA, internal carotid artery; OA, ophthalmic artery; PCA,
posterior cerebral artery; BA, basilar artery; VA, vertebral artery.
*Depth and MFV ranges may vary slightly betw een reference studies.
†Tow ard the probe indicates a positive (+) w aveform; aw ay from the probe indicates a negative (–) w aveform.
(Adapted with permission from Alexandrov AV: Transcranial Doppler sonography: principles, examination technique and normal values, Vasc Ultrasound Today
10:141-160, 1998.)
FIGURE 93-2 Typical MCA w aveforms. Vertical scale is in centimeters per second; horizontal scale is in seconds. Direction of flow : (+), tow ard the probe;
(–), aw ay from the probe. Velocity and pulsatility values (left to right): peak systolic, mean, pulsatility index (PI), end-diastolic (ED), resistance index (RI).
Depth indicates depth of insonation in centimeters. Gate is the diameter of sample volume in millimeters. Pow er and gain settings are given in percentages.
Table 93-2
Criteria for Normal TCD Scan Findings
(Reprinted with permission from Alexandrov AV: Transcranial Doppler sonography: principles, examination technique and normal values, Vasc Ultrasound Today
10:141-160, 1988.)
Table 93-3
Differential Diagnosis
Arterial Focal MFV increase above normal values, turbulence, bruits Primary arterial stenosis
stenosis Flow diversion to adjacent arteries Compensatory flow increase
Flow alteration distal to site of stenosis (deceleration, low PIs) Adjacent artery occlusion
Hyperemia
Arterial near Blunted waveform Near occlusion at the site of insonation
occlusion Focal decrease in MFV Arterial occlusion proximal to insonation site
Slow systolic acceleration Incorrect vessel identification
Slow flow deceleration
Flow diversion to adjacent arteries
Arterial No detectable flow Primary arterial occlusion
occlusion Good unilateral window of insonation Incorrect vessel identification
High-resistance flow proximal to occlusion Mass effect
Flow diversion to adjacent arteries
Arterial Proximal vasospasm: Vasospasm
vasospasm * Focal or diffuse elevation of MFV without parallel FV Hyperemia
increase in feeding extracranial arteries; HI greater than 3 Vasospasm with hyperemia
Distal vasospasm: Altered cerebral autoregulation
Focal increase in flow pulsatility (PI greater than or equal to Increased intracranial pressure
1.2), indicating increased resistance distal to site of
insonation
Increase in MFV in the involved and adjacent arteries may
not be present
Increased Decreased EDV or absent end-diastolic flow The presence of PI greater than or equal to 1.2 and positive end-diastolic flow in all
intracranial Rapid flow deceleration arteries may be caused by the following:
pressure PI greater than or equal to 1.2 Hyperventilation
Note that these findings may be present in patients with Hypertension
increased cardiac output or elevated blood pressure and in Increased ICP
elderly individuals Unilateral PI greater than or equal to 1.2 may be caused by the following:
Compartmental ICP increase
Stenoses distal to the site of insonation
PI greater than or equal to 2.0 associated with absent end-diastolic flow is caused
by extreme elevations in ICP and possible cerebral circulatory arrest
Cerebral Reversed end-diastolic flow or reverberating flow pattern or Possible or probable circulatory arrest; measure both MCA and BA for 30 minutes;
circulatory Minimal systolic flow acceleration with no end-diastolic flow then reassess (transient arrest may occur during transient ICP increase or low blood
arrest or pressure values)
Absent flow signals in all intracranial arterial systems
BA, Basilar artery; EDV, end-diastolic velocity; FV, flow velocity; HI, hemispheric index; ICP, intracranial pressure; MCA, middle cerebral artery; MFV, mean flow
velocity; PI, pulsatility index.
*Vasospasm criteria have been w ell established for the proximal MCA.9,14,15 Few er criteria and validation studies are available for the posterior circulation vessel and
the anterior cerebral artery.2,14,15 Institutions may set other ranges for possible vasospasm in these vessels.
• Hemispheric index (HI, also known as the Lindegaard ratio) helps to differentiate vasospasm severity and
hyperdynamic blood flow changes (HI = mean flow velocity [MFV] ipsilateral MCA/MFV ipsilateral ICA). Normal
values are less than 3.11,15,18,21
• The diameter of the vasospastic artery in aneurysmal subarachnoid hemorrhage is inversely related to the mean flow
velocity. MCA vasospasm may be further classified as mild, moderate, severe, or critical.1,12,18,21 Severity of cerebral
vasospasm is assessed by MFV value (cm/s) or MCA/ICA ratio10 :
Mild vasospasm has an MFV value of less than 120 or an MCA/ICA ratio of less than 3.
Moderate vasospasm has an MFV value from 120 to 150 or an MCA/ICA ratio from 3 to 5.
Severe vasospasm has an MFV value from 151 to 200 or an MCA/ICA ratio greater than 6.
Critical vasospasm has an MFV value greater than 200 or an MCA/ICA ratio greater than 6.
• Pulsatility of flow refers to vessel resistance and is measured with the pulsatility index (PI); normal range for PI is 0.6
to 1.1.2,4,15,21 PI (Gosling-King) = [velocity (peak systole) − velocity (end diastole)] ÷ velocity (mean).4,15,21
• Hyperventilation increases the PI and decreases mean flow velocity.4,15,21
• Hypercapnia decreases PI and increases mean flow velocity.4,15,21
• Anatomic variations in the circle of Willis are common (Fig. 93-3).2,4,15,21 Inability to find an artery with the TCD scan
should not be interpreted as arterial occlusion in the absence of other abnormal flow findings (e.g., secondary signs
such as high resistance and flow diversion).4,15,21
FIGURE 93-3 Variants of the circle of Willis. (Redrawn from Eftekhar B, Dadmehr M, Ansari S, et al: Are the distributions of variations of circle of Willis different in different
populations? Results of an anatomical study and review of literature, BMC Neurol 6:22, 2006.)
• Clinical conditions, neurologic findings, and the effects of medications (dehydration or increased blood viscosity,
hypertension or hypotension) should correlate with examination findings.2,4,15,21
• Although subjective, differentiation of Doppler sounds assists with identification of arterial segments and altered flow
patterns.2,4
• Proximal extracranial, focal intracranial, and distal circulatory conditions are determinants of waveform patterns.2,4
Waveform classification in patients with ischemic strokes is standardized with use of the Thrombolysis in Brain
Ischemia (TIBI) grading scale (Fig. 93-4 and Table 93-4).9 The TIBI grading system was prospectively validated against
angiography; it has excellent reproducibility with greater than 90% agreement in waveform interpretation among
expert TCD scan users.7,8,22 The TIBI system was implemented in a multicenter randomized clinical trial of ultrasound
scan–enhanced thrombolysis for acute ischemic stroke to demonstrate superior recanalization rates when systemic
tissue plasminogen activator (TPA) therapy was monitored with TCD scan compared with TPA given without
ultrasound scan.5,7-9,18
Table 93-4
TIBI Flow Grade Definitions
(© 2000 Health Outcomes Institute, Inc. Table 93-3.)
FIGURE 93-4 Thrombolysis in Brain Ischemia (TIBI) grading scale. (Copyright Health Outcomes Institute, Fountain Hills, AZ)
• New technology using power motion Doppler (PMD or M-mode) scan can be used to facilitate window and vessel
identification and guide spectral Doppler sampling and may reduce the time and effort necessary to learn TCD
scanning (see Fig. 93-5).14,17,19,20,23
FIGURE 93-5 Pow er motion Doppler (M-mode). Top frame of each Doppler w aveform identifies flow moving tow ard the probe (above the baseline) and
flow moving aw ay from the probe (below ); depth is used to denote vessel insonated. (Copyright Futura/Blackwell Sciences.)
EQUIPMENT
• A pulse-wave TCD scan system
• A 2-MHz probe (single or bilateral)
• Acoustic transmission gel
• Nonsterile gloves
• Tissues or washcloth
• Headphones (optional)
Additional equipment, as needed, includes the following:
• Smaller monitoring transducer with removable handles
• Head frame for monitoring transducer fixation
• Sterile plastic drape
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teaching. Answer questions as they arise, and reinforce information
as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Assist the patient with positioning. The supine position is best for insonation via the transtemporal, transorbital, or
submandibular windows. If the patient is alert with a hemodynamically and neurologically stable condition, assist the
patient to a sitting position for insonation through the transforaminal window. If the patient is unable to sit for
transforaminal insonation, assist the patient to turn his or her head laterally; if this is not feasible, examine the patient
supine with a smaller transducer with a removable handle or a monitoring probe. Rationale: The transtemporal,
transorbital, and submandibular windows are accessible with the patient in the supine position, whereas the
transforaminal window requires a sitting position for proper probe angulation (see Fig. 93-1).
• Ask the patient to close his or her eyes for insonation via the transorbital window. Rationale: The probe is placed
lightly, without pressure, on the eyelid and angled slightly medially to detect OA and ICA siphon flow signals.
• If necessary, ask the patient to hold his or her breath during insonation via the submandibular window. Rationale:
Breathing may produce audible and visual artifacts, obstructing assessment of the waveform.
Procedure for Transcranial Doppler Monitoring
References
1. Aaslid, R, Markwalder, TM, Nornes, H. Noninvasive transcranial Doppler ultrasound recording of flow
velocity in basal cerebral arteries. J Neurosurg. 1982; 57:769–774.
2. Alexandrov, AV, Transcranial Doppler sonography. principles, examination technique and normal values.
Vasc -Ultrasound Today 1998; 10:141–160.
3. Alexandrov, AV, Demchuk, AM, Burgin, WS. Insonation method and diagnostic flow signatures for
transcranial power motion (M-mode) Doppler. J Neuroimaging. 2002; 12:236–244.
4. Alexandrov, AV. Cerebrovascular ultrasound in stroke -prevention and treatment,. Oxford: Blackwell--Futura
Publishing; 2004.
5. Alexandrov, AV, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med.
2004; 351:2170–2178.
6. Alexandrov, AV, et al, Practice standards for transcranial Doppler (TCD) ultrasound. part Itest performance. J
Neuroimaging 2007; 17:11–18.
7. Burgin, WS, et al. Transcranial Doppler criteria for recanalization after thrombolysis for middle cerebral artery
stroke. Stroke. 2000; 31:1128–1132.
8. Burgin, WS, et al. Validity and reliability of the thrombolysis in brain infarction (TIBI) flow grades. Stroke.
2001; 32:324–325.
9. Demchuk, AM, et al. Thrombolysis in brain ischemia (TIBI) Doppler flow grades predict clinical severity,
early recovery, and mortality in patients treated with intravenous tissue plasminogen activator. Stroke. 2001;
32:89–93.
10. Kassah, MY, Majid, A, Farooq, FU, et al, Transcranial Doppler. an introduction for the primary care physician. J
Am Board Fam Med 2007; 20:65–71.
11. Lindegaard, KF, et al. Cerebral vasospasm diagnosis by means of angiography and blood velocity
measurements. Acta Neurochir (Wien). 1989; 100:12–24.
12. Lindegaard, KF, The role of transcranial Doppler in the management of patients with subarachnoid
haemorrhage. a review. Acta Neurochir. 1999; 72(Suppl):59–71.
13. Lupetin, AR, et al, Transcranial Doppler sonography . part 1principles, technique, and normal appearances.
Radiographics 1995; 15:179–191.
14. McCartney, JP, Thomas-Lukes, KM, Gomez, CR. Handbook of transcranial Doppler. New York: Springer; 1997.
15. Moehring, MA, Spencer, MP. Power M-mode Doppler (PMD) for observing cerebral blood flow and tracking
emboli. Ultrasound Med Biol. 2002; 28:49–57.
16. Moppet, IK, Mahajan, RP, Transcranial Doppler ultransonography in anaesthesia and intensive care. Br J
Anaesth 2004; 93:710–724.
17. Ringelstein, EB, et al, Transcranial Doppler sonography. anatomical landmarks and normal velocity values.
Ultrasound Med Biol 1990; 16:745–761.
18. Saqqur, M, et al. Derivation of power M-Mode transcranial Doppler criteria for angiographic proven MCA
occlusion. J Neuroimaging. 2006; 16:323–328.
19. Sloan, MA, Transcranial Doppler monitoring of vasospasm after subarachnoid hemorrhageTegeler CH,
Baikian VL, Gomez CR, eds.. Neurosonology. 1996. Mosby: St Louis:156–171.
20. Sloan, MA, et al, Assessment. transcranial Doppler ultrasonographyreport of the Therapeutics and Technology
Assessment Subcommittee of the American Academy of Neurology. Neurology 2004; 62:1468–1481.
21. Tegeler, CH, Babikian, VL, Gomez, CR. Neurosonology. St Louis: Mosby; 1996.
22. Tsivgoulis, G, et al. Validation of transcranial Doppler with computed tomography angiography in acute cerebral
ischemia. Stroke. 2007; 38:1245–1249.
23. Tsivgoulis, G, et al. Applications and advantages of power motion-mode Doppler in acute posterior circulation
cerebral ischemia. Stroke. 2008; 39:1197–1204.
24. White, H, Venkatesh, B, Applications of transcranial Doppler in the ICU. a review. Intensive Care Med. 2006;
32(7):981–994.
Additional Readings
Kirkness, C. Cerebral blood flow monitoring. In: Littlejohns LR, Bader MK, eds. AACN-AANN Protocols for Pra ctice: monitoring technologies in critica lly ill neuroscience
pa tients. Boston: Jones and Bartlett; 2009:145–174.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
SECTION THIRTEEN
Special Neurologic Procedures
P R OC E D UR E 9 4
PURPOSE:
An external surface or hydrogel pad temperature management device may be used to increase or decrease the
body temperature. An intravascular warming and cooling device may be inserted to increase and decrease the
body temperature. External surface cooling devices or intravascular cooling catheters are also used as a
therapeutic treatment modality to reduce the body temperature after acute injury (such as cardiac arrest) to
decrease cellular metabolism.19
Table 94-1
Terms Associated with Temperature
Term Definition
Induced hypothermia Intentional reduction of body temperature to slow metabolic processes. This may be accomplished by surface means (transfer of heat from the
skin to the cooling device) or central means (circulatory heat exchange in a cardiopulmonary bypass machine or cooling catheter)
Fever Response to a pyrogen; the hypothalamus either resets its range higher, maintaining thermoregulation, or a change occurs in the sensitivity of
the hypothalamus neuron activity to warmth and coldness.4
Hyperthermia Dysfunction of thermoregulation caused by an injury to the hypothalamus or by a person’s heat loss mechanisms being overwhelmed by high
environmental heat.
• The hypothalamus regulates temperature in the range of approximately 36.4° to 37.3°C (97.5° to 99.4°F). By initiating
physiologic responses to changes above or below this range, the hypothalamus coordinates heat loss or gain.
Vasoconstriction and vasodilation control the distribution and flow of blood to the organs, viscera, and skin surface;
thus, the amount of heat loss to the environment is influenced by vasomotor activity. In response to heat loss,
shivering and vasoconstriction occur, muscles tense and the extremities are drawn closer to the body, and the person
conserves heat. In response to heat gain, sweating and vasodilation occur, muscles relax, and heat is lost through
evaporative cooling and to the environment.12
• Heat flows from a higher temperature to a lower temperature until the gradient between the two temperatures
diminishes. Mechanisms of heat loss include conduction, convection, radiation, and evaporation.5,9,12,22
Conduction occurs when heat is lost by direct transfer from one surface to a second adjacent surface of a lower
temperature.5,9,12,22
Convection occurs when heat is lost by transfer from a surface to the surrounding air.5,9,12,22
Radiation occurs when heat (thermal energy) is transferred through air or space between separated surfaces without
direct contact.9,12,22
Evaporation occurs when heat loss accompanies water loss from the skin to the surrounding air.9,12,22
• Alteration in thermoregulation can result from a primary central nervous system injury or disease (e.g., subarachnoid
hemorrhage, traumatic brain injury, spinal cord injury, or neoplasm) and metabolic conditions (e.g., diabetes
mellitus; toxic levels of ethanol alcohol or other drugs, such as barbiturates and phenothiazines).
• Body temperature is the measurement of the presence or absence of heat. Body heat is generated, conserved,
redistributed, or dissipated during all physiologic processes. Factors such as age, circadian rhythm, and hormones
influence body temperature.
• Body temperature may be measured with a variety of thermometers and at several body sites. Electronic or digital
thermometers are used to obtain rectal, oral, and axillary temperatures. Thermistors within catheters or probes
measure rectal, nasopharyngeal, esophageal, bladder, brain, and pulmonary artery temperatures. Infrared
thermometers measure tympanic membrane and temporal artery temperatures. Choose the method of temperature
monitoring that best meets the patient’s clinical condition. The most accurate temperature monitoring methods are
intravascular (e.g., pulmonary artery catheter), esophageal, and bladder, followed by rectal, oral, and tympanic
membrane methods.9,13,21
• Variations in temperatures normally occur in the body (Table 94-2).
Table 94-2
Normal Variations in Body Temperature Based on a Rectal Temperature of 37°C
Esophageal 0.2°C8
• Site choice for temperature monitoring is based on the clinical data needed; the patient’s condition, safety, and
comfort; environmental factors (e.g., room temperature); the indication for a catheter or a probe (e.g., pulmonary
artery catheter); and the availability of equipment.
• An esophageal temperature probe can be inserted down the esophageal tract. Accurate placement of the temperature
probe is necessary to obtain results similar to monitoring the temperature from the pulmonary artery.
• A consistent temperature site must be monitored during the application of warming or cooling therapy.
• Shivering is an involuntary shaking of the body generated to maintain thermal homeostasis. Shivering causes
rhythmic tremors that result in skeletal muscle contraction and is a normal physiologic mechanism to generate heat
production.4,11
• Early detection of shivering can be accomplished by palpating the mandible and feeling a humming vibration.
Electrocardiographic (ECG) artifact from skeletal muscle is seen on the bedside monitor. If not detected early,
shivering can progress from visible twitching of the head or neck to visible twitching of the pectorals or trunk, and
then to generalized shaking of the entire body and teeth chattering.
• Shivering may be visible on the Bispectral Index Monitor (BIS) in the form of an increase in EMG activity (see
Procedure 86).
• Shivering increases the metabolic rate, carbon dioxide (CO2 ) production, oxygen consumption (by 40% to 100%),22
and myocardial work. If cardiopulmonary compensation does not occur to meet these demands, anaerobic
metabolism occurs, resulting in acidosis.11,17,22
• Shivering is counterproductive to strategies intended to lower temperature.
• At a body temperature below 35°C, the basal metabolic rate can no longer supply sufficient body heat and an
exogenous source of heat is needed.
• Table 94-3 outlines techniques to increase heat gain.
Table 94-3
Techniques to Increase Heat Gain
• Hypothermia may be categorized as mild (32° to 35°C), moderate (28° to 31.9°C), severe (<28°C), or profound
(<16.9°C).3 In severe to profound hypothermia, attempts at defibrillation are usually unsuccessful until the core
temperature is above 28°C. The American Heart Association recommends only one attempt at defibrillation and then
active rewarming should occur before reattempts at defibrillation.1
• Hypothermia may be caused by an increase in heat loss, a decrease in heat production, an alteration in
thermoregulation, and a variety of clinical conditions.
• An increase in heat loss may occur from the following:
Accidental (e.g., cold water drowning)
Environmental exposure
Induced vasodilation caused by high levels of ethanol alcohol, barbiturates, phenothiazines, or general anesthesia
Central nervous system dysfunction (e.g., spinal cord injury)
Dermal dysfunction (e.g., burns)
Iatrogenic conditions (e.g., administration of cold intravenous fluids, hemodialysis, cardiopulmonary bypass)
Trauma
• A decrease in heat production is associated with the following:
Endocrine conditions (e.g., hypothyroidism)
Malnutrition
Diabetic ketoacidosis
Neuromuscular insufficiency (e.g., resulting from a pharmacologic paralysis caused by a neuromuscular blocking
agent or anesthetic agents)
• Clinical conditions associated with hypothermia are sepsis, hepatic coma, prolonged cardiac arrest, and systemic
inflammatory response syndrome (SIRS).
• Severe hypothermia may mimic death; resuscitative efforts should be initiated despite the absence of vital signs.
• Rewarming for cardiac arrest survivors who have undergone therapeutic hypothermia should not occur faster than
0.25° to 0.50°C per hour.20 Rapid rewarming can cause rewarming acidosis, electrolyte shifts, shivering, hypovolemic
shock, temperature afterdrop, and temperature overshoot.9,16
• Afterdrop is a decrease in core temperature after rewarming is discontinued.
• Overshoot occurs when the thermoregulator mechanisms rebound or overcompensate.
• Termination of active external rewarming at 36° to 36.5°C may prevent temperature overshoot.
• Rewarming acidosis results from the increase in CO2 production associated with the temperature increase and from
the return of accumulated acids in the peripheral circulation to the heart.
• Rewarming shock occurs when hypothermic vasoconstriction masks hypovolemia. If the patient’s circulating volume
is insufficient during rewarming vasodilation, sudden decreases in blood pressure, systemic vascular resistance (SVR),
and preload occur. In cases of severe to profound hypothermia, peripheral rewarming with external devices should be
used with extreme caution. Core methods of rewarming should be considered.
• Hyperthermia occurs when the thermoregulator system of the body absorbs or produces more heat than it is able to
release.
• Malignant hyperthermia is a rare, hereditary condition of the skeletal muscle that occurs on exposure to a triggering
agent or agents.2,15 The triggering agents most commonly associated with malignant hyperthermia are anesthetic
agents, particularly inhalation anesthetics and succinylcholine. Malignant hyperthermia involves instability of the
muscle cell membrane, which causes a sudden increase in myoplasmic calcium and skeletal muscle contractures.
• The earliest indication of malignant hyperthermia is an increase in end-tidal carbon dioxide (Petco2 ) of 5 mm Hg more
than the patient’s baseline. If the Petco2 is not being monitored, the earliest sign is tachycardia, which occurs within
30 minutes of anesthesia induction. Tachycardia is followed by ventricular ectopy, which may progress to ventricular
tachycardia and ventricular fibrillation. Muscle rigidity usually begins in the extremities, chest, or jaws.2,15
• A cooling device is used to treat malignant hyperthermia after administration of the triggering agent is stopped and a
muscle relaxant (e.g., dantrolene sodium) is given. The muscle relaxant blocks the release of calcium from the
sarcoplasmic reticulum without affecting calcium uptake.15
• Heat stroke occurs when the outdoor temperature and humidity are excessive and heat is transferred to the body.
Increased humidity prevents the body from cooling by evaporation. Other signs of heat stroke include hypotension,
tachycardia, tachypnea, mental status changes from confusion to coma, and possibly seizures. The skin is hot and dry,
and sweating may occur. The rectal temperature is greater than 40.0° to 41.1°C (104°F to 106°F). Initial interventions
include support of airway, breathing, and circulation. Rapid cooling of the patient is the main treatment priority, with
a goal of reducing the temperature to 38.3° to 38.9°C (101° to 102°F) within 1 hour.
• Fever occurs in response to a pyrogen and is defined as a temperature more than 38°C.21 During fever, the
hypothalamus retains its function, and shivering and diaphoresis occur to gain or lose body heat. Fever may be an
adaptive response and may be considered beneficial in the absence of neurologic disease processes. However, a febrile
state increases the heart rate and metabolic rate and may be detrimental to a critically ill patient. The decision to
reduce a fever needs to be based on the patient’s physical and hemodynamic stability during the fever.7,21
• Some external warming or cooling devices transfer warmth or coolness to the patient via conduction. Warmed or
cooled fluids circulate through coils or channels in a thermal blanket or pad that is commonly placed under the
patient.
• Additional warming and cooling systems are available. Hydrogel pads or external wraps can be placed on the patient’s
skin in the trunk and upper leg regions. These external systems are controlled through a feedback loop system with a
core temperature (e.g., a bladder probe, an esophageal probe) that is attached to a central console and automatically
regulates temperature according to programmed temperature target points. The feedback of patient temperature is
compared to the set target temperature and the circulating water temperature is adjusted to ensure the target
temperature is maintained.
• Other external devices transfer warmth to the patient via convection. A device used for warming blows warm air
through microperforations on the underside of a blanket that is placed over the patient. The air is directed through
the blanket onto the patient’s skin.3,12
• Intravascular cooling and warming devices currently in use include central venous catheters with temperature-
controlled saline solution balloons or distal metallic heat transfer elements that cool the blood as it flows by the
catheter. The saline solution is not in direct contact with the systemic circulation. These devices may be inserted in the
subclavian, internal jugular, or femoral vein.24 They are attached to a console with an automatic temperature control
device that adjusts the pressure, temperature, and flow rate of the circulating saline solution based on the patient’s
continuously monitored temperature (e.g., rectal, bladder, esophageal) and the set-points established by the
healthcare provider).22
• Specific information about controls, alarms, troubleshooting, and safety features is available from each manufacturer
and must be understood by the nurse before using the equipment.
EQUIPMENT
• Warming or cooling device
• Sheet or bath blanket
• Nonsterile gloves
• Temperature probe, cable, and module to monitor the patient’s temperature (varies based on the type of site and
thermometer selected and available)
• Pads or blankets needed by the equipment which is going to be used
• Cardiac monitoring (see Procedure 57)
Additional equipment to have available as needed includes the following:
• Hemodynamic monitoring (see Procedure 76)
• Distilled water
• Intravascular cooling/warming central venous catheter
• Console, including cable for monitoring temperature
• Central line insertion tray
• Antiseptic (e.g., chlorhexidine)
• Sterile towels, drapes
• Masks with eye shields, sterile gloves, and sterile gowns
• Occlusive dressing
• Normal saline solution
• Water-soluble lubricant
Patient Preparation
• Ensure that the patient and family understand preprocedural education. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• If a warm air device will be used, remove the patient’s gown and top sheet. Rationale: The warm air device works
via convection and should be in direct contact with the patient’s skin for optimal results.
• If the patient is unintentionally hypothermic, cover the patient’s head with a blanket or towel or an aluminum cap.
Rationale: This action minimizes additional heat loss.
• Ensure that informed consent has been obtained for insertion of intravascular catheters. Rationale: Informed
consent protects the rights of the patient and makes a competent decision possible for the patient; however, in
emergency circumstances, time may not allow for the consent form to be signed.
• Perform a pre-procedure verification and time out with placement of intravascular catheters, if non-emergent.
Rationale: Ensures patient safety.
Procedure for External Warming/Cooling Devices
Procedure for Intravascular Warming/Cooling Devices
References
1. American Heart Association. 2005 Guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulaton. 2005; 112(Suppl 24):1–203. [IV].
2. Anderson-Pompa K, Foster, A, Parker, L, et al. Genetics and susceptibility to malignant hyperthermia. Crit Care
Nurse. 2008; 28:32–36.
3. Aslam, AF, Aslam, AK, Vasavada, BC, et al, Hypothermia. evaluation, electrocardiographic manifestations and
management. Am J Med 2006; 119:297–301.
4. Biddle, C. The neurobiology of the human febrile response. AANA J. 2006; 74:145–150.
5. Creechan, T, Vollman, K, Kravutske, ME. Cooling by convection vs cooling by conduction for treatment of
fever in critically ill adults. Am J Crit Care. 2001; 10:52–59.
6. Gentilello, L, Moujaes, S, Treatment of hypothermia in trauma victims. thermodynamic considerations. J
Intensive Care Med 1995; 10:5–14.
7. Goheen, MSL, Ducharme, MB, Kenny, GP, et al. Efficacy of forced-air and inhalation rewarming by using a
human model for severe hypothermia. J Appl Physiol. 1997; 83:1635–1640.
8. Henker, R, Shaver, J. Understanding the febrile state according to an individual adaptation framework. AACN
Clin Issues Crit Care Nurs. 1994; 2:186–193.
9. Holtzclaw, B. Monitoring body temperature. AACN Clin Issues Crit Care Nurs. 1993; 4:44–55.
10. Hooper, VD, Andrews, JO, Accuracy of noninvasive core temperature measurement in acutely ill adults. the state
of the science. Biol Res Nurs 2006; 8:24–34.
11. Iampietro, P, Vaughn, JA, Goldman, RF, et al. Heat production from shivering. J Appl Physiol. 1960; 15:632–
634.
12. Keresztes, PA, Brick, K. Therapeutic hypothermia after cardiac arrest. Dimens Crit Care Nurs. 2006; 25:71–76.
13. Lawson, L, Bridges, EJ, Ballou, I, et al. Accuracy and precision of noninvasive temperature measurement in adult
intensive care patients. Am J Crit Care. 2007; 16:485–496.
14. Lefrant, JY, Muller, L, de La Coussaye JE, et al, Temperature measurement in intensive care patients.
comparison of urinary bladder, oesophageal, rectal, axillary, and inguinal methods versus pulmonary artery core
method. Intensive Care Med 2003; 29:414–418.
15. Litman, RS, Flood, CD, Kaplan, RF, et al, Postoperative malignant hyperthermia. an analysis of cases from the
North American Malignant Hyperthermia Registry. Anesthesiology 2008; 109:825–829.
16. Loke, AY, Chan, HC, Chan, TM. Comparing the effectiveness of two types of cooling blankets for febrile
patients. Nurs Crit Care. 2005; 10:247–254.
17. Mahmood, MA, Zweifler, RM. Progress in shivering control. J Neurol Sci. 2007; 261:47–54.
18. McIlvoy, L, Comparison of brain temperature to core temperature. a review of the literature. J Neurosci Nurs
2004; 36:23–31.
19. Moore, K, Hypothermia in trauma. J Trauma Nurs 2008; 15 :62–64.
20. Neumar, RW, Nolan, JP, Adrie, C, et al, Post cardiac arrest syndrome. epidemiology, pathophysiology, treatment,
and prognosticationa consensus statement from the International Liaison Committee on Resuscitation.
Circulation 2008; 118:2452–2483.
21. O’Grady, NP, Barie, PS, Bartlett, JG, et al, Guidelines for evaluation of new fever in critically ill adults patients.
2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America.
Crit Care Med 2008; 36:1330–1349.
22. Polderman, KH, Application of therapeutic hypothermia in the ICU. opportunities and pitfalls of a promising
treatment modality: part 2: practical aspects and side effects. Intensive Care Med 2004; 30:757–769.
23. Polderman, K. H, Ingeborg, H., Therapeutic hypothermia and controlled normothermia in the intensive care unit.
Practical considerations, side effects, and cooling methods. Critical Care Medicine, 2009; 37:1101–1119.
24. Simosa, HF, Petersen, DJ, Agarwal, SK, et al. Increased risk of deep venous thrombosis with endovascular cooling
in patients with traumatic brain injury. Am Surg. 2007; 73:461–464.
25. Zoll Medical Corporation (2009), Intravascular Temperature Management. Products/Catheter Family, 2009.
http://www.alsius.com/products/catheters.html [Text available from].
P R OC E D UR E 9 5
PURPOSE:
A lumbar puncture is performed for access to the subarachnoid space to obtain a cerebrospinal fluid sample,
measure cerebrospinal fluid pressure, drain cerebrospinal fluid, infuse medications or contrast agents, or place
a cerebrospinal fluid drainage catheter.1-3,7
EQUIPMENT
• Sterile gloves, caps, masks with eye shields or goggles, and sterile gowns
• Sterile drapes
• Sterile gauze pads
• Antiseptic solution
• Fenestrated drape
• Manometer with three-way stopcock
• Lidocaine, 1% to 2% (without epinephrine)
• 3- to 5-mL syringe
• 20-, 22-, and 25-gauge needles
• 18-, 20-, or 22-gauge spinal needles
• Four numbered capped test tubes
• Adhesive strip or sterile dressing supplies
• Specimen labels
• Laboratory forms
• Glucometer/phlebotomy equipment for serum or whole blood glucose
Many supplies are available in a lumbar tray.
Additional equipment, as needed, includes the following:
• Rolled towels or small pillows to support the patient during positioning
FIGURE 95-1 The lateral decubitus position appropriate for lumbar puncture. The patient flexes the neck, hips, and knees, and the knees are draw n up
tightly to the chest. This increases the intraspinous space for facilitation of needle insertion.
• Explain that the procedure may produce some discomfort and that local anesthesia is injected to minimize pain. Also,
explain that the patient may receive some mild analgesic and anxiolytic agents as prescribed and needed. Rationale:
The patient and family are prepared for what to expect.
• Explain that the patient may find it helpful to lie flat for 1 to 4 hours after the LP. Rationale: A flat position may
promote dural closure; the position was previously thought to reduce the possibility of postprocedural headache, but
studies suggest it is not helpful in the prevention of a headache after the procedure.1,5,12
Patient Preparation
• Verify correct patient using two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Obtain informed consent. Rationale: Informed consent protects the rights of the patient and makes competent
decision-making possible for the patient; however, in emergency circumstances, time may not allow for the consent
form to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Obtain the patient’s history of allergic reactions. Rationale: History can rule out an allergy to lidocaine, the
antiseptic solution, and the analgesia or sedation.
• Prescribe an analgesic medication and/or an anxiolytic medication. Rationale: These medications may be needed to
promote comfort and to decrease anxiety so that positioning can be achieved during the procedure.
Procedure for Lumbar Puncture (Perform)
FIGURE 95-2 The body of the spinal cord ends at L2-L3. The region below , L4-L5, encloses the cauda equina (a bundle of lumbar and sacral nerve roots)
w ithin the subarachnoid space. It is this area that is appropriate for lumbar puncture.
References
1. Ahmed, SV, Jayawarna, C, Jude, E, Post-lumbar puncture headache. diagnosis and management. Postgrad Med J
2006; 82:713–716.
2. Armon, C, Evans, RW, Addendum to assessment. prevention of post-lumbar puncture headachesreport of
the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology
2005; 65:510–512.
3. Boon, JM, Abrahams, PH, Meiring, JH, et al, Lumbar puncture. anatomical review of a clinical skill. Clin Anat
2004; 17:544–553.
4. Ellenby, MS, Tegtmeyer, K, Lai, S, et al. Lumbar puncture. N Engl J Med. 2006; 355:e12.
5. Euerle, B. Spinal puncture and cerebrospinal fluid examination. In: Roberts JR, Hedges JR, Chanmugam AS,
eds. Clinical procedures in emergency medicine. ed 4. St Louis: Elsevier; 2003:1197–1222.
6. Evans, RW, Armon, C, Frohman, EM, et al, Assessment. prevention of post-lumbar puncture
headachesreport of the Therapeutics and Technology Assessment Subcommittee of the American Academy of
Neurology. Neurology 2000; 55:909–914.
7. Farley, A, McLafferty, FA. Lumbar puncture. Nurs Stand. 2008; 22:46–48.
8. Frank, RL, Lumbar puncture and post-dural puncture headaches. implications for the emergency physician. J
Emerg Med 2008; 35:149–157.
9. Gaiser, R. Postdural puncture headache. Curr Opin Anaesthesiol. 2006; 19:249–253.
10. Hebl, JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med.
2006; 31:311–323.
11. Kinirons, B, Mimoz, O, Lafendi, L, et al. Chlorhexidine versus povidone iodine in preventing colonization of
continuous epidural catheters in children. Anesthesiology. 2001; 94:239–244.
12. Levine, DN, Rapalino, O. The pathophysiology of lumbar puncture headache. J Neurol Sci. 2001; 192:1–8.
13. Lowery, S, Oliver, A. Incidence of postdural puncture headache and backache following diagnostic/therapeutic
lumbar puncture using a 22G cutting spinal needle, and after introduction of a 25G pencil point spinal needle.
Paediatr Anaesth. 2008; 18:230–234.
14. Luostarinen, L, Heinonen, T, Luostarinen, M, et al, Diagnostic lumbar puncture. comparative study between
22-gauge pencil point and sharp bevel needle. J Headache Pain 2005; 6:400–404.
15. Manthous, CA, DeGirolamo, A, Haddad, C, et al, Informed consent for medical procedures. local and national
practices. Chest 2003; 124:1978–1984.
16. Milstone, AM, Passaretti, CL, Perl, TM, Chlorhexidine. expanding the armamentarium for infection control and
prevention. Clin Infect Dis 2008; 46:274–281.
17. Reynolds, F. Neurological infections after neuraxial anesthesia. Anesthesiol Clin. 2008; 26:23–52.
18. Roos, KL. Lumbar puncture. Semin Neurol. 2003; 23:105–114.
19. Ropper, AH, Samuel, MA, Special techniques for neurological diagnosisRopper AH, Samuels MA, eds.. Adams
and Victor’s principles of neurology. ed 9. McGraw-Hill, New York, 2009..
www.accessmedicine.com.offcampus.lib.washington.edu/content.aspx?aID=3630099 [Text available at].
20. Seehusen, DA, Reeves, MM, Fomin, DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003; 68:1103–1108.
21. Shah, KH, McGillicuddy, D, Spear, J, et al. Predicting difficult and traumatic lumbar punctures. Am J Emerg Med.
2007; 25:608–611.
22. Stiffler, KA, Jwayyed, S, Wilber, ST, et al. The use of ultrasound to identify pertinent landmarks for lumbar
puncture. Am J Emerg Med. 2007; 25:331–334.
23. Straus, SE, Thorpe, KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to
diagnose bacterial meningitis. JAMA. 2006; 296:2012–2022.
24. Sudlow, CL, Warlow, CC. Epidural blood patching for preventing and treating post-dural puncture headache.
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26. Turnbull, DK, Shepherd, DB, Post-dural puncture headache. pathogenesis, prevention, and treatment. Br J
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Additional Readings
Allen, S H. How to perform lumbar punc ture with the patient in a seated position. Br J Hosp Med. 2006; 67:M46–M47.
Mc Quillan, KA. The neurologic system. In: Alspac h JA, ed. Core curriculum for critica l ca re nursing. ed 6. Philadelphia: S aunders; 2006:381–524.
Wilson, RK, Williams, MA. Normal pressure hydroc ephalus. Clin Geria tr Med. 2006; 22:935–951.
Ziai, WC, Lewin, JJ. Update in the diagnosis and management of c entral nervous system infec tions. Neurol Clin. 2008; 26:427–468.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 9 6
PURPOSE:
A lumbar puncture is performed for access to the subarachnoid space to obtain a cerebrospinal fluid sample,
measure cerebrospinal fluid pressure, drain cerebrospinal fluid, infuse medications or contrast agents, or place
a cerebrospinal fluid drainage catheter.1-3,7
EQUIPMENT
• Sterile gloves, caps, masks with eye shield, and sterile gowns
• Sterile drapes
• Sterile gauze pads
• Antiseptic solution
• Fenestrated drape
• Manometer with a three-way stopcock
• Lidocaine, 1% to 2% (without epinephrine)
• 3- to 5-mL syringe
• 18-, 20-, 22-, and 25-gauge needles
• 18-, 20-, or 22-gauge spinal needles
• Four consecutively numbered, capped test tubes
• Adhesive strip or sterile dressing supplies
• Specimen labels
• Laboratory forms
• Glucometer/phlebotomy supplies for concurrent testing of serum or whole blood glucose
Additional equipment, as needed, includes the following:
• Alcohol pads or swab sticks
• Two over-bed tables (one for sterile field; one to position patient, if necessary)
• Rolled towels or small pillows to support the patient during positioning
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent is obtained. Rationale: Informed consent protects the rights of the patient and makes
competent decision making possible for the patient; however, in emergency circumstances, time may not allow for
the consent form to be signed.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
Procedure for Lumbar Puncture (Assist)
FIGURE 96-1 Proper positioning of the patient for a lumbar puncture. (From Ellenby MS, Tegtmeyer K, Lai S, et al: Lumbar puncture: New Engl J Med 355:e12, 2006.
Copyright © 2006, Massachusetts Medical Society. All rights reserved.)
References
1. Ahmed, SV, Jayawarna, C, Jude, E, Post-lumbar puncture headache. diagnosis and management. Postgrad Med J
2006; 82:713–716.
Armon, C, Evans, RW, Addendum to assessment. prevention of post-lumbar punc ture headac hesreport of the Therapeutic s and Tec hnology Assessment
S ubc ommittee of the Americ an Ac ademy of Neurology. Neurology 2005; 65:510–512.
3. Boon, JM, Abrahams, PH, Meiring, JH, et al, Lumbar puncture. anatomical review of a clinical skill. Clin Anat
2004; 17:544–553.
4. Ellenby, MS, Tegtmeyer, K, Lai, S, et al. Lumbar puncture. N Engl J Med. 2006; 355:e12.
5. Euerle, B. Spinal puncture and cerebrospinal fluid examination. In: Roberts JR, Hedges JR, Chanmugam AS,
eds. Clinical procedures in emergency medicine. ed 4. St Louis: Elsevier; 2003:1197–1222.
6. Evans, RW, Armon, C, Frohman, EM, et al, Assessment. prevention of post-lumbar puncture
headachesreport of the Therapeutics and Technology Assessment Subcommittee of the American Academy of
Neurology. Neurology 2000; 55:909–914.
7. Farley, A, McLafferty, E. Lumbar puncture. Nurs Stand. 2008; 22:46–48.
8. Frank, RL, Lumbar puncture and post-dural puncture headaches. implications for the emergency physician. J
Emerg Med 2008; 35:149–157.
9. Gaiser, R. Postdural puncture headache. Curr Opin Anaesthesiol. 2006; 19:249–253.
10. Hebl, JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med.
2006; 31:311–323.
11. Kinirons, B, Mimoz, O, Lafendi, L, et al. Chlorhexidine versus povidone iodine in preventing colonization of
continuous epidural catheters in children. Anesthesiology. 2001; 94:239–244.
12. Levine, DN, Rapalino, O. The pathophysiology of lumbar puncture headache. J Neurol Sci. 2001; 192:1–8.
13. Lowery, S, Oliver, A. Incidence of postdural puncture headache and backache following diagnostic/therapeutic
lumbar puncture using a 22G cutting spinal needle, and after introduction of a 25G pencil point spinal needle.
Paediatr Anaesth. 2008; 18:230–234.
14. Luostarinen, L, Heinonen, T, Luostarinen, M, et al, Diagnostic lumbar puncture. comparative study between
22-gauge pencil point and sharp bevel needle. J Headache Pain 2005; 6:400–404.
15. Manthous, CA, DeGirolamo, A, Haddad, C, et al, Informed consent for medical procedures. local and national
practices. Chest 2003; 124:1978–1984.
16. Milstone, AM, Passaretti, CL, Perl, TM, Chlorhexidine. expanding the armamentarium for infection control and
prevention. Clin Infec Dis 2008; 46:274–281.
17. Reynolds, F. Neurological infections after neuraxial anesthesia. Anesthesiol Clin. 2008; 26:23–52.
18. Roos, KL. Lumbar puncture. Semin Neurol. 2003; 23:105–114.
19. Ropper, AH, Samuel, MA, Special techniques for neurological diagnosis. Adams and Victor’s principles of
neurology. ed 9. McGraw-Hill, New York, 2009.
20. Seehusen, DA, Reeves, MM, Fomin, DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003; 68:1103–1108.
21. Shah, KH, McGillicuddy, D, Spear, J, et al. Predicting difficult and traumatic lumbar punctures. Am J Emerg Med.
2007; 25:608–611.
22. Stiffler, KA, Jwayyed, S, Wilber, ST, et al. The use of ultrasound to identify pertinent landmarks for lumbar
puncture. Am J Emerg Med. 2007; 25:331–334.
23. Straus, SE, Thorpe, KE, Holroyd-Leduc J. How do I perform a a lumbar puncture and analyze the results to
diagnose bacterial meningitis. JAMA. 2006; 296:2012–2022.
24. Sudlow, CL, Warlow, CC. Epidural blood patching for preventing and treating post-dural puncture headache.
Cochrane Database Syst Rev. 2, 2002. [CD001791].
25. Sudlow, CL, Warlow, CC. Posture and fluids for preventing post-dural puncture headache. Cochrane Database
Syst Rev. 2, 2002. [CD001790].
26. Turnbull, DK, Shepherd, DB, Post-dural puncture headache. pathogenesis, prevention, and treatment. Br J
Anaesth 2003; 91:718–729.
27. van Kooten F, Oedit, R, Bakker, SL, et al, Epidural blood patch in post dural puncture headache. a randomised,
observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry 2008; 79:553–558.
28. Weaver, JP. Cerebrospinal fluid aspirationIrwin RS, Rippe JM, eds.. Irwin and Rippe’s intensive care medicine. ed
6. Lippincott Williams & Wilkins, Philadelphia, 2008:151–158.
29. Williams, J, Lye, DCB, Umapathi, T, Diagnostic lumbar puncture. minimizing complications. Intern Med J 2008;
38:587–591.
Additional Readings
Allen, S H. How to perform lumbar punc ture with the patient in a seated position. Br J Hosp Med. 2006; 67:M46–M47.
Mc Quillan, KA. The neurologic system. In: Alspac h JA, ed. Core curriculum for critica l ca re nursing. ed 6. Philadelphia: S aunders; 2006:381–524.
Wilson, RK, Williams, MA. Normal pressure hydroc ephalus. Clin Geria tr Med. 2006; 22:935–951.
Ziai, WC, Lewin, JJ. Update in the diagnosis and management of c entral nervous system infec tions. Neurol Clin. 2008; 26:427–468.
SECTION FOURTEEN
Traction Management
P R OC E D UR E 9 7
PURPOSE:
Cervical tongs or a halo ring are inserted into the skull so that weighted traction can be applied to the cervical
spine. Cervical traction decompresses the spinal cord and immobilizes and realigns the cervical spine.
Realignment and immobilization of the cervical spine decrease the risk of secondary spinal cord injury. Spinal
realignment and immobilization allow spinal fractures and supportive structures to heal properly.
• Tongs consist of a body with one pin attached at each end (Fig. 97-2). Tong pins are applied to the outer table of the
skull on both sides of the skull. Cervical tongs are available in a variety of types, such as Crutchfield, Gardner-Wells,
and Vinke tongs.
FIGURE 97-2 All three types of cervical tongs consist of a stainless steel body and a pin w ith a sharp tip attached to each end. A, Crutchfield tongs are
placed about 5 inches apart in line w ith the long axis of the cervical spine. B, Vinke tongs are placed on the parietal bones, near the w idest transverse
diameter of the skull. C, Gardner-Wells tongs are inserted slightly above the patient’s ears.
• The shape, features, insertion site, and placement vary slightly, but the purpose, principles, and care are the same.
Physician preference is an important deciding factor in choosing the specific device to be used.2,11
• The insertion of Crutchfield and Vinke tongs necessitates an incision to expose the skull. Two holes are made in the
outer table of the skull with a twist drill, and the pins are inserted and tightened until there is a firm fit.2,11
• Gardner-Wells tongs are inserted by placing the razor-sharp pin edges to the prepared areas of the scalp and
tightening the screws until the spring-loaded mechanism indicates that the correct pressure has been achieved. To
decrease the possibility of tong displacement, all types of pins are well seated into the outer table of the skull and
angled inward.2,6,11
• Tongs are made of stainless steel or a graphite body with titanium pins. The graphite body with titanium pins is
compatible with magnetic resonance imaging (MRI).
• Traction can be applied with the use of a rope and pulley system or a cable and alignment bracket. Weights are added
gradually and followed with radiographic imaging. The physician uses serial radiographs of the cervical spine to assist
in determining the optimal amount of traction (measured in pounds) needed to reduce a fracture and provide optimal
alignment. Excessive traction may result in stretching of the spinal cord and subsequent damage.2-4 The addition of
traction is managed by the physician.
• Cervical traction also may be applied with a halo ring device. This is a stainless steel or graphite ring that is attached to
the skull by four stabilizing pins (two anterior and two posterolateral; Fig. 97-3). Skull pins can be made of stainless
steel, titanium, or ceramic material.1,2,5,7 Pins are threaded through holes in the ring, screwed into the outer table of
the skull, and locked into place. Traction can be applied to the ring device with the use of a rope and pulley system or
a cable and bracket alignment system. Weights are added gradually. After alignment of the cervical spine is achieved,
the spine can be immobilized by attaching the ring to a body vest or a custom molded body jacket. The patient then
is able to move while the head and neck remain immobile.
FIGURE 97-3 Placement of halo pins and ring. The anterior pins are placed anterolaterally 1 cm above the orbital ridge. This “safe zone” avoids the
temporalis muscle laterally and an orbital nerve plexus and frontal sinus medially. (From Batte M, et al: The halo skeletal fixator: principles of applications and
maintenance, Clin Orthop 239:14, 1989.)
EQUIPMENT
• Tongs or halo ring
• Insertion tray, including either the specific type of tongs to be used or the halo ring with insertion pins
• Local anesthetic: lidocaine, 1% to 2% (with or without epinephrine, depending on physician preference)
• Needles (18- and 23-gauge)
• Sterile and nonsterile gloves
• Gowns, masks, and eye shields
• Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
• Sterile sponges
• Sterile drill and bits (for insertion of Crutchfield and Vinke tongs)
• Rope and traction assembly for the bed (If a KCI RotoRest Delta Kinetic Therapy™ bed is used, a cable and bracket
alignment system is needed; see Procedure 100.)
• S and C hooks (to attach to the distal end of the rope for weight application)
• Weights to attach to the traction
• Torque wrench for the halo apparatus
Additional equipment, as needed, includes the following:
• Hair clippers
• Emergency equipment
Patient Preparation
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Ensure that the head of the bed is flat and that the patient’s head is in a neutral position by whatever approved means
(e.g., hard/rigid collar) have been instituted. Rationale: This measure prevents mobilization of neck, which may
increase the risk of injury or extension of spinal cord injury.
Procedure for Assisting with Application of Tongs or Halo Ring for Cervical Traction
References
1. Bono, CM. The halo fixator. J Am Acad Orthop Surg. 2007; 15:728–737.
2. Canale, ST, Beaty, JH. Cervical spine injuries. In: Canale ST, Beaty JH, eds. Campbell’s operative orthopaedics. ed
11. Philadelphia: Mosby; 2008:1776–1777. [[electronic resource]].
3. Congress of Neurological Surgeons. Initial closed reduction of cervical spine fracture-dislocation injuries.
Neurosurgery. 2002; 50(Suppl 3):S44–S50.
4. Congress of Neurological Surgeons. Treatment of -subaxial cervical spine injuries. Neurosurgery. 2002;
50(Suppl 3):S156–S165.
5. Hayes, VM, Silber, JS, Siddiqu, FN, et al. Complications -of halo fixation of the cervical spine. Am J Orthop.
2005; 34:271–276.
6. Hickey, JV. Vertebral and spinal cord injuries. In: Hickey JV, ed. The clinical practice of neurological and
neurosurgical nursing. ed 6. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009:410–453.
7. Kang, M, Vives, MJ, Vaccaro, AR, The halo vest. principles of application and management of complications. J
Spinal Cord Med 2003; 26:186–192.
8. Osmond, T. Principles of traction. Aust Nurs J. 1999; 6:1–4. [(Suppl)].
9. Styrcula, L, Traction basics. part I. Orthop Nurs. 1994; 13(2):71–74.
10. Styrcula, L, Traction basics. part II. Orthop Nurs. 1994; 13(3):55–59.
11. Styrcula, L, Traction basics. part III. Orthop Nurs. 1994; 13(4):34–44.
Additional Readings
Davis, A. S ensory and motor disorders. In: Kinney MR, et al, eds. AACN clinica l reference for critica l ca re nursing. ed 4. S t Louis: Mosby; 1998:711.
Jerome Cervic al S pine S ystem. Applica tion instructions for Jerome Ha lo Tra ction Systems. Morristown, NJ: Jerome Cervic al S pine S ystem; 2003.
Lee, TT, Green, BA. Advanc es in the management of ac ute spinal c ord injury. Orthop Clin North Am. 2002; 33:311–315.
Maher, AB, S almond, S W, Pellino, TA, Orthopedic nursing. ed 3. S aunders, Philadelphia, 2002:296.
Mc Closkey JC, Bulec hek GM, eds.. Iowa Intervention Projec t. nursing interventions c lassific ation (NIC). ed 3. Mosby, S t Louis, 2000.
Mollabashy, A, Immobilization tec hniques in c ervic al spine injury. c ervic al orthoses, skeletal trac tion, and halo devic es. Top Emerg Med 1997; 19:3.
P R OC E D UR E 9 8
PURPOSE:
A halo ring attached to a halo vest (commonly referred to as a halo) is designed to immobilize and stabilize the
cervical spine. A halo ring and vest may be used alone or in conjunction with surgery for the patient with an
unstable cervical spine, as a result of spinal fracture or dislocation; degenerative processes, such as C1-C2
changes from rheumatoid arthritis; or spinal surgery. With the use of the halo ring and vest, vertebral column
movement is prevented and subsequent risk of the injury to the spinal cord is reduced.2 The halo ring and vest
may be used as a primary definitive treatment to stabilize the cervical spine, before surgery to reduce spine
deformity, or after surgery as an adjunct to interval cervical fixation. This procedure focuses on the management
of the patient who needs immobilization with a halo ring and vest.
• With the halo ring and pins in place, traction can be discontinued and a halo vest and struts added for long-term
immobilization of the cervical neck (see Fig. 98-1). The advantage of this approach is that the patient can sit upright,
mobilize out of bed, and ambulate, if able, while the cervical spine remains stable.
• The nurse must be familiar with the components of the halo-vest device, including the halo ring and pins, anterior and
posterior posts, vest screws, front and back panels of the vest, and shoulder and side buckles.
• Basic cardiac life support knowledge and skills are essential.
• It is important that the nurse knows how to access the patient’s anterior chest to administer cardiopulmonary
resuscitation (CPR) if cardiac arrest occurs. Refer to information from the manufacturer of the halo vest for specific
information on emergency access to the chest. Some vests have a hinged closure; the vest can be lifted up at the hinge
to allow quick access to the chest. Other vests are not hinged and require a wrench. The wrench must be available at
all times and, depending on institution policy, may be maintained on the front of the vest for instant access to the
chest. If the patient needs defibrillation, avoid touching the bars of the traction with the defibrillator.
• The halo-vest side panels may be opened only when the patient is flat and supine.2,5,8 Unbuckling of the halo vest may
result in loss of spine alignment and neurologic compromise.8 Follow manufacturer’s recommendations and
institution policies for opening the vest.
• Because the halo vest limits movement of the head, patients must be taught to scan the environment for objects in
their path that could lead to falls.
• The halo vest changes the center of gravity and limits movement, thus requiring adaptations for performing activities
of daily living (ADLs).8
EQUIPMENT
• Halo device (in place)
• Soap and a basin of warm water
• Washcloth and towel
• Alcohol
• Nonsterile gloves
• Flashlight
Additional equipment to have as needed include the following:
• Sheepskin liner
• Emergency wrench
PATIENT AND FAMILY EDUCATION
• Explain that the reason for the halo ring and vest device is to maintain cervical immobilization. Rationale: Patient
and family anxiety is decreased.
• Describe turning, positioning, and skin care procedures before performing them. Rationale: Patient and family
anxiety is decreased.
• If the patient is ambulatory, explain modifications in meeting basic needs such as bathing, toileting, eating, dressing,
ambulation precautions, and safety needs. Rationale: Self-care skills and awareness of special safety precautions are
developed.
• For patients who will be discharged home wearing a halo-vest device, begin a comprehensive teaching program with
the patient and family. Rationale: The patient and family are prepared for care in the home environment.
• Explain to the patient and family that the patient cannot be turned with the struts (posts) of the halo-vest device.
Rationale: The patient and family are prepared for care in the home environment.
• Explain that precautions must be used when the ambulatory patient with a halo-vest device gets in and out of a car
and walks up and down stairs. Rationale: The patient cannot move the head in the halo-vest device to look down.
• Explain that driving, riding a motorcycle or bicycle, and operating machinery are unsafe with a halo-vest device.
Rationale: Patients recognize that they cannot turn their head.
• Explain that the pins of the halo transmit vibration and cold sensation to the patient’s skull. Rationale: The patient
and family are alerted to possible sensations during ADLs.
• Explain that if the pins or screws become loose, the patient should contact the physician immediately. Inform the
patient and family not to adjust the pins or screws. Rationale: The patient and family are prepared for care in the
home and can identify when emergency care may be needed.
• Explain that if the patient has any decline in neurologic function (i.e., decreased or abnormal sensory function; decline
in motor ability; or increase in pain), the physician should be contacted immediately. Rationale: Decline in
neurologic function may indicate extension of spinal cord injury and the need for immediate interventions.
Table 98-1
Assessment of Muscle Strength
5 Normal muscle strength; can maintain high degree of function against maximal resistance.
4 The muscle can go through its normal range of motion, but it can be overcome by increased resistance.
3 The muscle can go through its normal range of motion against gravity only; it cannot tolerate external resistance.
2 The muscle contracts weakly; it does not have sufficient strength to overcome gravity.
1 Visible or palpable muscle contractions may be seen or felt, but no movement is found in the limb.
0 Complete paralysis; no evidence of motor function.
(Adapted from Hickey J: The clinical practice of neurological and neurosurgical nursing, ed 4, Philadelphia, 1997, JB Lippincott.)
FIGURE 98-2 Sample of flow sheet documentation form for motor and sensory testing. (From University of California–San Diego Medical Center.)
FIGURE 98-3 Sensory dermatomes: guidelines for sensory testing. (From Barr ML, Kiernan JA: The human nervous system: an anatomical viewpoint, ed 5, Philadelphia,
1988, JB Lippincott, 81.)
• Obtain vital signs before halo ring and vest placement. Rationale: Baseline data are provided.
• Assess for difficulty swallowing and risk for aspiration.4,11 Rationale: Assessment identifies a patient at high risk and
the need to modify oral intake.
• Assess the skin at the edges of the vest and where the vest may overlap for redness or abrasion, especially over bony
prominences.8,11 Rationale: Skin irritation related to the halo-vest device is identified.
• Check the fit of the vest for tightness or looseness. Rationale: The need for change or modification of the vest is
identified. Patient weight loss may contribute to vest looseness.
• Check the halo vest for loose straps or screws, dirt, odor, or evidence of the need to repair the vest. Rationale: The
vest may need to be repaired or the sheepskin liner changed.
Patient Preparation
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Assist patients as they lie supine in a neutral position with proper body alignment for the purpose of halo vest
application, liner change, and routine skin care. Rationale: Patients are kept safe and accessible for inspection.
• Observe the sides and back of the vest and adjacent skin with the patient standing, if possible. Rationale:
Observation provides an opportunity to inspect all areas in which the skin and vest come in contact.
Procedure for Halo Ring and Vest Care
References
1. Blissitt, PA. Spinal cord injury. In: Carlson KK, ed. Advanced critical care nursing. Philadelphia: Saunders;
2009:637–680.
2. Bono, CM. The halo fixator. J Am Acad Orthop Surg. 2007; 15:728–737.
3. Canale, ST, Beaty, JH, Cervical spine injuries Canale ST, Beaty JH, eds.. Campbell’s operative orthopaedics. ed 11.
Mosby, Philadelphia, 2008:1776–1777.
4. Hayes, VM, Silber, JS, Siddiqi, FN, et al. Complications of halo fixation of the cervical spine. Am J Orthop.
2005; 34:271–276.
5. Jerome, Medical. Application instructions for Jerome halo traction systems. Moorestown, NJ: Jerome Medical;
2003.
6. Kang, M, Vives, MJ, Vaccaro, AR, The halo vest. principles of application and management of complications. J
Spinal Cord Med 2003; 26:186–192.
7. Lethaby, A, Temple, J, Santy, J. Pin site care for preventing infections associated with external bone fixators and
pins. Cochrane Database Syst Rev. 4, 2008. [CD004551].
8. Patchen, SJ, Timyan, L, Atherton, S. Your life in a halo made easier,. Miami and Moorestown, NJ: University of
Miami School of Medicine and Jerome Medical; 2002.
9. Patterson, MM. Multicenter pin care study. Orthop Nurs. 2005; 24:349–360.
10. Saeed, MU, Dacuycuy, MA, Kennedy, DJ, Halo pin insertion-associated brain abscess. case report and review of
the literature. Spine 2007; 32:E271–E274.
11. Taitsman, LA, Altman, DT, Hecht, AC, et al. Complications of cervical halo-vest orthoses in elderly patients.
Orthopedics. 2008; 31:446.
Additional Readings
Bernardo, LM. Evidenc e-based prac tic e for pin site c are in -injured c hildren. Orthop Nurs. 2001; 20:29–34.
Mc Kenzie, LL. In searc h of a standard for pin site c are. Orthop Nurs. 1999; 18:73–78.
P R OC E D UR E 9 9
PURPOSE:
Tong and halo pin site care is provided to cleanse and remove exudate from pin sites in an effort to minimize the
risk of infection. In addition, pin site care allows assessment of the pin sites for signs and symptoms of infection
and pin loosening or displacement.
EQUIPMENT
• Approximately eight cotton-tipped applicators
• Nonsterile gloves
• Cleansing or antiseptic solution
• Sterile container for cleansing solution
• Rinsing solution (as needed)
• Second sterile container for rinsing solution (as needed)
Additional equipment, to have available as needed, includes the following:
• Hair clippers
• Dressing supplies
• Light source to assist with visualization of posterior pin sites
Patient Preparation
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Assist the patient to a supine position. The patient in a halo vest may be sitting up in a position of comfort.
Rationale: Access to the pins is facilitated for care.
Procedure for Pin Site Care: Cervical Tong and Halo Pins
References
1. Bell, A, Leader, M, Lloyd, H. Care of pin sites. Nurs Stand. 2008; 22:44–48.
2. Bono, CM. The halo fixator. J Am Acad Orthop Surg. 2007; 15:728–737.
3. Canale, ST, Beaty, JH. Campbell’s operative orthopaedics,. In: Canale ST, Beaty JH, eds. Cervical spine injuries. ed
11. Philadelphia: Mosby; 2008:1776–1777.
Hayes, VM, S ilber, JS , S iddiqi, FN, et al. Complic ations of halo fixation of the c ervic al spine. Am J Orthop. 2005; 34:271–276.
5. Holmes, SB, Brown, SJ, Skeletal pin site care. National Association of Orthopaedic Nurses guidelines for
orthopaedic nursing. Orthop Nurs 2005; 24:99–107.
Kang, M, Vives, MJ, Vac c aro, AR, The halo vest. princ iples of applic ation and management of c omplic ations. J S pinal Cord Med 2003; 26:186–192.
7. Lethaby, A, Temple, J, Santy, J. Pin site care for preventing infections associated with external bone fixators and
pins. Cochrane Database Syst Rev. 4, 2008. [CD004551].
Patterson, MM. Multic enter pin c are study. Orthop Nurs. 2005; 24:349–360.
9. Saeed, MU, Dacuycuy, MA, Kennedy, DJ, Halo pin insertion-associated brain abscess. case report and review of
the literature. Spine 2007; 32:E271–E274.
10. Wu, SC, Crews, RT, Zelen, Cet al. Use of chlorhexidine-impregnated patch at pin site to reduce local morbidity.
the ChiPPS pilot trial,. Int Wound J 2008; 5:416–422.
Additional Readings
Bernardo, LM. Evidenc e-based prac tic e for pin site c are in injured c hildren. Orthop Nurs. 2001; 20:29–34.
Davis, P, Lee-S mith J, Booth, J, et al, Pin site management . towards a c onsensuspart 2. J Orthop Nurs 2001; 5:125–130.
Lee-S mith J, S anty, J, Davis, P, et al, Pin site management . towards a c onsensuspart 1. J Orthop Nurs. 2001; 5:37–42.
Mc Kenzie, LL. In searc h of a standard for pin site c are. Orthop Nurs. 1999; 18:73–78.
P R OC E D UR E 1 0 0
PURPOSE:
Once cervical traction has been established, the nurse cares for the patient who is immobilized on complete bed
rest. Traction must be maintained on a continuous basis until realignment and stabilization with surgical
management or orthoses is attained or healing is completed.
• The principles of skeletal traction are the foundation of management of any patient in cervical traction. One must
follow such key points as (1) never raising the traction weights, (2) never disconnecting the traction, (3) never
allowing the traction weights to rest on the floor, and (4) never allowing other objects to compromise freely hanging
weights.
EQUIPMENT
• Cervical traction system in place, including rope and pulley system or cable and bracket alignment device and weights
for the Rotating Kinetic Treatment Table (Roto-kinetic) (Fig. 100-1) or RotoRest™ Delta Kinetic™ Therapy Bed (Fig
123-1).
• Pillows
Additional equipment, as needed, may include the following:
• Positioning devices
• Specialty bed (e.g., Stryker frame)
Table 100-2
High-Risk Focus Area Skin Assessment Guide
References
1. Blissitt, PA. Spinal cord injury. In: Carlson KK, ed. -Advanced critical care nursing. Philadelphia: -
Saunders/Elsevier; 2009:637–680.
2. Consortium for Spinal Cord Medicine, Early acute management in adults with spinal cord injury. a clinical -
practice guideline for health-care professionals. Paralyzed Veteran’s Association, -Washington, DC, 2008.
3. Gupta MC, Benson, DR, Keenen, TL. Initial evaluation and emergency treatment of the spine-injured patient. In:
Browner BD, Green NE, Jupiter JB, et al, eds. Skeletal trauma. ed 4. Philadelphia: Saunders; 2008:794–798.
4. Harvey, CV, Challenges of traction in critical care. a case study. Crit Care Nurs Q 1998; 21:1–13.
5. Lethaby, A, Temple, J, Santy, J. Pin site care for preventing infections associated with external bone fixators and
pins. Cochrane Database of Syst Rev. 2008; 4:CD004551.
6. Osmond, T, Clinical update. principles of traction. Aust Nurs J 1999; 6:S1–S4.
7. Patterson, MM. Multicenter pin care study. Orthop Nurs. 2005; 24:349–360.
8. Styrcula, L, Traction basics. part I. Orthop Nurs 1994; 13:71–74.
9. Wood, G. Cervical spine injuries. In: Canale ST, Beaty JH, eds. Campbell’s operative orthopaedics. ed 11. St Louis:
Mosby; 2008:1761–1810.
10. Wuermser, LA, Ho, CH, Chiodo, AE, et al, Spinal cord injury medicine. 2acute care management of traumatic
and nontraumatic injury. Arch Phy Med Rehabil 2007; 88 :S55–S61.
Additional Reading
Hic key, JV. Vertebral and spinal c ord injuries. In: Hic key JV, ed. The clinica l pra ctice of neurologica l a nd neurosurgica l nursing. ed 6. Philadelphia: Wolters Kluwer
Health/Lippinc ott Williams & Wilkins; 2009:410–453.
S ponseller, PD, Takenaga, RK, Newton, P, et al. The use of trac tion in the treatment of severe spinal deformity. -Spine. 2008; 33:2305–2309.
SECTION FIFTEEN
Pain Management
P R OC E D UR E 1 0 1
PURPOSE:
Epidural catheters are used to provide regional anesthesia and analgesia by delivering medications directly into
the epidural space surrounding the spinal cord. Medications injected into the epidural space are capable of
providing dose-related site-specific anesthesia and analgesia. Epidural catheters can be used effectively for
short-term (e.g., acute, obstetric, postoperative, trauma) or long-term (e.g., chronic, advanced cancer) pain
management.7,20
• The epidural space (potential space) contains fat, large blood vessels, connective tissue, and spinal nerve roots.
• Analgesia via an epidural catheter may be given with a continuous, intermittent, or patient-controlled epidural
analgesia (PCEA) pump system.17,29
• A variety of medication options are available, including local anesthetics, opiates, mixtures of local anesthetics and
opiates, α2 -adrenergic agonists (e.g., clonidine), and other agents.13,17 All medications should be preservative-free for
epidural administration.4,7,12,13
• The pharmacology of agents given for epidural analgesia, including side effects and duration of action, must be
understood.22
• Knowledge of the signs and symptoms of profound motor and sensory blockade or overmedication is essential.
Intravenous (IV) access, IV volume loading, and immediate availability of an opioid antagonist and vasopressors are
necessary.4,12,22
• According to the American Pain Society (APS), the most common reason for unrelieved pain in hospitals is the failure
of staff to routinely and adequately assess pain and pain relief. Many patients silently tolerate unrelieved pain if not
specifically asked about it.1
• The Agency for Health Care Policy and Research (AHCPR) urges healthcare professionals to accept the patient’s self-
report as “the single most reliable indicator of the existence and intensity” of pain. Behavioral observations are
unreliable indicators of pain levels.1
• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.1,7
• No matter how successfully or deftly conducted, surgical operations produce tissue trauma. Trauma caused by
surgery or injury initiates a series of biochemical events that release numerous endogenous chemicals, which
potentiate mediators of inflammation and pain.16
• Pain is just one response to the trauma of surgery. In addition to pain, the substances released from injured tissue
evoke stress hormone responses in the patient. Such responses promote pain transmission, breakdown of body
tissues, increased metabolic rate, blood clotting, water retention, and impaired immune function and trigger a fight-
or-flight alarm reaction with autonomic nervous system stimulation features (e.g., rapid pulse).1,4,13
• The psychologic effects of pain include depression, anxiety, and other negative emotions.1,6,7
• The patient may attempt to “splint” the injured site, resulting in shallow breathing and cough suppression followed by
retained pulmonary secretions and pneumonia.12,13 Unrelieved pain also may delay the return of normal gastric
emptying and cause development of an ileus, impairment of bowel function, and reductions in respiratory tidal
volumes, all of which may predispose patients in pain to infection after surgery.7,8,19,30
• Epidural analgesia provides a number of well-documented advantages in the postoperative period, including
attenuation of the surgical/trauma stress response, excellent analgesia, earlier extubation, less sedation, decreased
incidence of pulmonary complications, earlier return of bowel function, decreased deep venous thrombosis, earlier
ambulation, earlier discharge from high-acuity units,12,14,20,30 and possibly shorter hospital stays.20,32
EQUIPMENT
• One epidural catheter kit or the following supplies:
One 25-gauge, ⅝-inch (0.5 × 16 mm) injection needle
One 23-gauge, 1¼-inch (0.6 × 30 mm) injection needle
One 18-gauge, 1½-inch (1.2 × 40 mm) injection needle
One 5-mL Luer-Lok syringe
One 20-mL Luer-Lok syringe
One Luer-Lok loss-of-resistance syringe
One 18-gauge, 3¼-inch (1.3 × 80 mm) epidural needle (pink)
One 0.45 × 0.85 inch epidural catheter
• One introducer stabilizing catheter guide
• One screw-cap Luer-Lok catheter
• One screw-cap Luer-Lok catheter connector
• One 0.2 × m epidural flat filter
• Topical skin antiseptic, as prescribed (e.g., 2% chlorhexidine non–alcohol-based preparation)
• Sterile towels
• Sterile forceps
• Sterile gauze 4 × 4 pads
• Sterile gloves, face masks with eye shields, sterile gowns
• 20 mL normal saline solution
• 5 to 10 mL local anesthetic as prescribed (e.g., 1% lidocaine; local infiltration)
• 5 mL local anesthetic as prescribed to establish the block
• Test dose (e.g., 3 mL 2% lidocaine with epinephrine, 1:200,000)
• Gauze or transparent dressing to cover the epidural catheter entry site
• Tape to secure the epidural catheter to the patient’s back and over the patient’s shoulder
• Labels stating “Epidural only” and “Not for intravenous injection”
• Pump for administering analgesia (e.g., volumetric pump, dedicated for epidural use with rate and volume limited,
which has the ability to be locked to prevent tampering and preferably is a color-coded [e.g., yellow] or patient-
controlled epidural analgesia pump)
• Dedicated epidural portless administration set
• Specific observation chart for patient monitoring of the epidural infusion
• Prescribed medication analgesics and local anesthetic medications
• Equipment for monitoring blood pressure, heart rate, and pulse oximetry
Additional equipment, as needed, includes the following:
• Ice or alcohol swabs for demonstrating level of block
• Capnography equipment desired
• Emergency medications
• Bag-valve-mask device and oxygen
• Intubation equipment
Patient Preparation
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Wash the patient’s back with soap and water and open the gown in the back. Rationale: This action cleanses the
skin and allows easy access to the patient’s back.
• Consider nothing by mouth (NPO), especially if sedation or general anesthesia is to be used. Rationale: NPO status
decreases the risk for vomiting and aspiration.
• Establish IV access, or ensure the patency of IV lines, and administer IV fluids as prescribed before epidual catheter
insertion. Rationale: IV access ensures that medications can be given quickly if needed. The administration of IV
fluids may decrease hypotension that may occur during epidural infusions.4,12
• Reassure the patient. Rationale: Anxiety and fears may be reduced.
Procedure for Pain Management: Epidural Catheters (Assisting with Insertion and Initiating Continuous Infusion)
FIGURE 101-2 Patient positioning for placement of epidural catheter. (Courtesy Astra Pharmaceuticals, London.)
FIGURE 101-3 Dermatomes. Segmental dermatome distribution of spinal nerves to the front, back, and side of the body. Dermatomes are specific skin
surface areas innervated by a single spinal nerve or group of spinal nerves. Dermatome assessment is done to determine the level of spinal anesthesia for
surgical procedures and postoperative analgesia w hen epidural local anesthetics are used. C, Cervical segments; T, thoracic segments; L, lumber segments;
S, sacral segments; CX, coccygeal segment. (From McCaffery M, Pasero C: Pain: clinical manual, St Louis, 1999, Mosby.)
Procedure for Epidural Catheter (Bolus Dose Administration) Without a Continuous Infusion
Procedure for Assisting with Removal of the Epidural Catheter
References
1. Agency for Health Care Policy and Research Acute Pain Management Guideline Panel. Clinical practice
guidelines: acute pain management: operative or medical procedures and trauma, AHCPR pub 92-0032. Rockville,
MD: Public Health Service, US Department of Health and Human Services; 1992.
2. Ashburn, MA, Caplan, RA, Carr, DB, et al, Practice guidelines for acute pain management in the
perioperative setting. an updated report by the American Society of Anesthesiologists Task Force on Acute Pain
Management. Anesthesiology 2004; 100:1573–1581.
3. Bedforth, NM, Aitkenhead, AR, Hardman, JG. Haematoma and abscesses after epidural analgesia an updated
report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Br J Anesth. 2008;
101:291–293.
4. Burkard, J, Olson, RL, Vacchiano, CA. Regional anesthesia. In: Nagelhout JJ, Zaglaniczny KL, eds. Nurse
anesthesia. ed 3. St Louis: Elsevier Saunders; 2004:977–1030.
5. Chan, L, Bailin, MT, Spinal epidural hematoma following central neuraxial blockade and subcutaneous
enoxaparin. a case report. J Clin Anesth 2004; 16:382–385.
6. Dunwoody, CJ, Krenzischek, DA, Pasero, C, et al. Assessment, physiological monitoring, and consequences of
inadequately treated acute pain. J Perianesth Nurs. 2008; 23(Suppl 1):S15–S27.
7. Faut-Callahan M, Hand, WR. Pain management. In: Nagelhout JJ, Zaglaniczny KL, eds. Nurse anesthesia. ed 3.
St Louis: Elsevier Saunders; 2004:1157–1182.
8. Gendall, KA, Kennedy, RR, Watson, AJ, et al. The effect of epidural analgesia on postoperative outcome after
gastrointestinal surgery. Colorectal Dis. 2007; 9:584–598.
9. Gordon, DB, Dahl, JH, Miaskowski, C, et al. American Pain Society recommendations for improving the
quality of acute and cancer pain management. Arch Intern Med. 2005; 165:1574–1580.
10. Hebl, JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain
Med. 2003; 31:311–323.
11. Horlocker, TT, Burton, AW, Connis, RT, et al. Practice guidelines for the prevention, detection, and management
of respiratory depression associated with neuroaxial opioid administration. Anesthesiology. 2009; 110:218–230.
12. Kleinman, W, Mikhail, MS, Spinal, epidural and caudal blocksMorgan GE, Mikhail MS, Murray MJ, eds..
Clinical anesthesiology. ed 4. McGraw- Hill, New York, 2006:289–323.
13. Mahlmeister, L, Nursing responsibilities in preventing, preparing for, and managing epidural emergencies. J
Perinat Neonatal Nurs 2003; 17:19–32.
14. Marret, E, Remy, C, Bonnet, F, Postoperative pain forum group. meta-analysis of epidural local analgesia versus
parenteral opioid analgesia after colorectal surgery. Br J Surg 2007; 94:665–673.
15. Meikle, J, Bird, S, Nightingale, JJ, et al, Detection and management of epidural haematomas related to anesthesia
in the UK. a national survey of current practice. Br J Anaesth 2008; 101:400–404.
16. Mertin, S, Sawatzky, JA, Diehl-Jones WL, et al, Roadblock to recovery. the surgical stress response. Dynamics
2007; 18:14–20.
17. Miaskowski, C, Bair, M, Chou, R, et al. Principles of analgesic use in the treatment of acute and cancer pain, ed 6.
Glenview, IL: American Pain Society; 2008.
18. Milstone, AM, Passaretti, CL, Perl, TM, Chlorhexidine . expanding the armamentarium for infection control and
prevention. Clin Infect Dis 2008; 46:274–281.
19. Morgan, GE, Mikhail, MS, Murray, MJ. Pain management. In: Morgan GE, Mikhail MS, Murray MJ, eds. Clinical
anesthesiology. ed 4. New York: McGraw-Hill Company; 2006:359–412.
20. Pasero, C. Improving postoperative outcomes with epidural analgesia. J Perianesth Nurs. 2005; 20:51–55.
21. Pasero, C, McCaffery, M. Orthopaedic postoperative pain management. J Perianesth Nurs. 2007; 22:160–172.
22. Pasero, C, Eksterowicz, N, Primeau, M, et al. The registered nurse’s role in the management of analgesia by
catheter techniques. J Perianesth Nurs. 2008; 23:53–56.
23. Ranasinghe, JS, Lee, AJ, Birnbach, DJ, Infection associated with central venous or epidural catheters. how to
reduce it. Curr Opin Anaesthesiol 2008; 21:386–390.
24. Reynolds, F. Neurologic infections after neuroaxial anesthesia. Anesthesiol Clin. 2008; 26:23–52.
25. Rowlingson, JC, Hanson, PB. Neuraxial anesthesia and low-molecular-weight heparin prophylaxis in major
orthopedic surgery in the wake of the latest American Society of Regional Anesthesia guidelines. Anesth Analg.
2005; 100:1482–1488.
26. Ruppen, W, Derry, S, McQuay, HJ, et al, Incidence of epidural haematoma and neurological injury in
cardiovascular patients with epidural analgesia/anaesthesia. systematic review and meta analysis. BMC
Anesthesiol. 2006; 6(10). www.biomedcentral.com/1471-2253-6-10 [accessed September 1, 2009, from].
27. Ruppen, W, Derry, S, McQuay, HJ, et al, Infection rates associated with epidural indwelling catheters for seven
days or longer. systematic review and meta-analysis. BMC Palliat Care. 2007; 3(6).
www.biomedcentral.com/1472-684X/6/3 [accessed September 1, 2009, from].
28. Schulz-Stubner S. The critically ill patient and regional anesthesia. Curr Opin Anaesthesiol. 2006; 19:538–544.
29. St. Marie B. Pain management. In: Weinstein SM, ed. Plumer’s principles and practice of intravenous therapy. ed 8.
Philadelphia: Lippincott Williams & Wilkins; 2007:576–607.
30. Tenenbein, PK, Debrouwere, R, Maguire, D, et al. Thoracic epidural analgesia improves pulmonary function in
patients undergoing cardiac surgery. Can J Anaesth. 2008; 55:344–350.
31. Wedel, DJ, Horlocker, TT. Regional anesthesia in the febrile or infected patient. Reg Anesth Pain Med. 2006;
31:324–333.
32. Weetman, C, Allison, W. Use of epidural analgesia in post-operative pain management. Nurs Stand. 2006; 20:54–
64.
Additional Readings
Additional Readings
Ballantyne, JC, Mc Kenna, JM, Ryder, E. Epidural analgesia-experienc e of 5628 patients in a large teac hing hospital derived through audit. Acute Pa in. 2003;
4:89–97.
P R OC E D UR E 1 0 2
Patient-Controlled Analgesia
Lorie Ann Meek
PURPOSE:
Intravenous patient-controlled analgesia empowers patients to manage their pain by allowing them to administer
smaller analgesic doses more frequently. Nurses are responsible for ensuring appropriate patient selection,
maintaining the intravenous delivery system, and ensuring that patients are able to safely meet their own needs
for pain management through frequent assessment and patient education.
Table 102-1
Guidelines for Patient-Controlled Intravenous Opioid Administration for Opioid-Naive Adults and Children with
Acute Pain
*Typical concentrations are listed in parentheses.
(Miaskowski C, Blair M, Chou R, et al: Principles of analgesic use in the treatment of acute pain and cancer pain, ed 6, Glenview, IL, 2008, American Pain Society,
42).
Table 102-2
Patient Controlled Analgesia: Considerations in Opioid Selection
(Institute for Safe Medication Practices: Patient-controlled analgesia: making it safer for patients, Horsham, PA, 2006, Institute for Safe Medication Practices.)
• Unrelieved postoperative pain may result in clinical and psychologic changes, an increase in morbidity and mortality,
an increase in costs, and a decrease in quality of life. Negative clinical outcomes related to ineffective pain
management for patients after surgery include deep vein thrombosis, pulmonary embolism, coronary ischemia,
myocardial infarction, pneumonia, poor wound healing, impairment of the immune system, insomnia, and negative
emotions.25 Unrelieved pain may delay recovery and prolong hospital stays.1,3
• The Agency for Healthcare Research and Quality (AHRQ) urges healthcare professionals to accept the patient’s self-
report as “the single most reliable indicator of the existence and intensity” of pain.1
• Studies and meta-analyses have shown an increase in patient satisfaction with pain management and an improvement
in pain control.5,18,23,34,38 Intravenous (IV) patient-controlled analgesia (PCA) may be used for both acute and chronic
pain.26
• Intravenous PCA can be an effective method of pain relief for pediatric and adult patients.14,18,34,38 Table 102-1 lists
dosing guidelines.
• Intravenous PCA can be administered as a continuous (basal) infusion along with patient-initiated boluses or as
intermittent patient-initiated boluses exclusively.
• Patient assessment at frequent, regular intervals (at least every 4 hours) should include an evaluation of the patient’s
vital signs, sedation level with a valid and reliable scale, pain level with a valid and reliable scale, and common opioid
side effects, such as pruritus, nausea,9,12 constipation, and urinary retention.13 Table 102-2 lists side effects associated
with PCA opioids. Patients need more frequent assessments during the first 24 hours after initiation of IV PCA and
during the night.10,11,14,19 Systematic evaluation of agitation and pain can lead to a reduction in pain levels and
agitation.9
• PCA pump settings should be confirmed at regular intervals.10,11,19 See Box 102-1 for common terms used when
administering patient-controlled analgesia. Adverse events during IV PCA may include respiratory depression and
hypoxemia. Opioid anatagonists should be readily available.
B O X 102-
1 K ey Ter m s for P a t ient - C ont r olled A na lges ia1 3 , 2 5 , 2 6 , 3 5
Basal rate: The amount of analgesic administered continuously.
Break-through dose: A bolus dose administered by the nurse, similar to a loading dose when pain is
inadequately managed with the current PCA settings.
Cumulative dose limit: The predetermined maximum drug amount that can be delivered over either 1 or
more (usually 4) hours.
Demand or PCA dose: The amount of drug administered each time the patient activates the pump.
Loading dose: A bolus dose given before initiation of PCA therapy, usually higher than the dose
administered when the patient activates the pump.
Lockout interval: Predetermined period during which the patient cannot initiate doses.
• Adjunctive medications can be used to improve pain management7,14,15,27,39 or to improve opioid side effects.7,15,23,24
• The Joint Commission does not support PCA by proxy (someone other than the patient pushing the PCA button) on
the recommendation of the Institute of Safe Medication Practices (ISMP). According to ISMP, patients have
experienced oversedation, increased respiratory depression, and death from PCA by proxy.11,19,21
• PCA by authorized user (typically nurse or designated family member of patient) is a potential alternative to PCA by
proxy. Healthcare institutions that use PCA by authorized user need to have the following in place before this practice
is initiated.2,11,19,21,22,37,41
Policies that guide the practice, including the patient population
Definition of PCA by an authorized user
Education plan for the authorized user
Documentation of the authorized user and education given
• Patients with an increased risk for complications during IV PCA use include those with:
Age more than 65 years (greater incidence of desaturation)29
Morbid obesity (greater incidence of desaturation)8,29,36
Sleep apnea or asthma8,11,20,36
Concurrent medications that potentiate opiates (e.g., sedation)11,19
Impaired organ function25
• Careful patient selection is imperative for effective pain management. Patients who may be poor candidates for PCA
include the following:
Anyone with cognitive abilities that prohibit understanding and following directions for IV PCA (e.g., infants, young
children, patients with a decreased level of consciousness or with developmental disabilities)11,19
Anyone without the physical ability to push the PCA button that controls the dose administration11,19
Anyone with a psychologic reason that prohibits using the PCA button for pain management (e.g., psychologic
disability, refusal to operate the PCA administration button)11,19
• Patients can have as effective or better pain control with epidural analgesia than with IV PCA after various surgical
procedures.6,16,32,33,40
• A number of medication errors have been reported with IV PCA. Factors associated with errors include improper
patient selection, inadequate monitoring, inadequate patient education, medication product mix-ups, programming
errors, PCA by proxy, inadequate medical and nursing staff education, prescription errors, and PCA pump design
flaws.11,17,19
• PCA is available in various routes, including IV, epidural (patient-controlled epidural analgesia [PCEA]; see Procedure
101), subcutaneous, peripheral nerve catheter (see Procedure 103), oral, intranasal, and transdermal.14,15,25,26,31 The
focus of this procedure is IV PCA.
EQUIPMENT
• PCA pump
• PCA tubing with antisiphon valve (may also include a plunger for insertion into PCA medication syringe barrel)
• IV pump
• IV tubing
• Prescribed medication (may be in a syringe, bag, or cassette)
• Alcohol wipes
• Non-sterile gloves
• ECG and blood pressure monitoring equipment
• Pulse oximetry equipment
• Normal saline solution or other compatible IV fluid
Additional equipment as needed includes:
• Emergency medications, including naloxone
• Bag-valve-mask device and oxygen
• End-title carbon dioxide monitoring equipment
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands the teaching. Answer questions as they arise, and reinforce information as
needed.31 Rationale: Understanding of previously taught information is evaluated and reinforced.
• Obtain IV access or ensure patency of the IV. Rationale: Analgesia is delivered intravenously.
Procedure for Initiating Intravenous Patient-Controlled Analgesia
References
1. Agency for Health Care Policy and Research, Acute Pain Management Guideline Panel: . Clinical practice
guidelines acute pain managementoperative or medical -procedure and trauma, AHCPR pub. 92-0032. Agency
for Health Care Policy and Research, Public Health Service, US Department of Health and -Human Services,
Rockville, MD, 1992.
2. Anghelescu, DL, Burgoyne, LL, Oakes, LL, et al. The safety of patient-controlled analgesia by proxy in
pediatric oncology patients. Anesth Analg. 2005; 101:1623–1627.
3. Apfelbaum, JL, Chen, C, Mehta, SS, et al, Postoperative pain experience. results from a national survey
suggest postoperative pain continues to be undermanaged. Anesth Analg 2003; 97:534–540.
4. Ashburn, MA, Caplan, RA, Carr, DB, et al, Practice guidelines for acute pain management in the
perioperative setting. an updated report by the American Society of Anesthesiologists Task Force on Acute Pain
Management. Anesthesiology 2004; 100:1573–1581.
5. Ballantyne, JC, Carr, DB, Chalmers, TC, et al, Postoperative patient-controlled analgesia. a meta-analysis of
initial randomized control trials. J Clin Anesth 1993; 5:182–193.
6. Bauer, C, Hentz, JG, Ducrocq, X, et al, Lung function after lobectomy. a randomized, double-blinded trial
comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia.
Anesth Analg 2007; 105:238–244.
7. Capdevila, X, Dadure, C, Bringuier, S, et al, Effect of -patient-controlled perineural analgesia on rehabilitation and
pain after ambulatory orthopedic surgery. a multicenter randomized trial. Anesthesiology 2006; 105:566–573.
8. Cashman, JN, Dolin, SJ, Respiratory and haemodynamic effects of acute postoperative pain management.
evidence from published data. Br J Anesth 2004; 93:212–223.
9. Chanques, G, Jaber, S, Barbotte, E, et al. Impact of systematic evaluation of pain and agitation in an intensive care
unit. Crit Care Med. 2006; 34:1691–1699.
10. Cohen, MR, Smetzer, J. Patient-controlled analgesia safety issues. J Pain Palliat Care Pharmacother. 2005;
19:45–50.
11. Cohen, MR, Weber, RJ, Moss, J, Patient-controlled analgesia. making it safer for patients. 2006. Institute for Safe
Medication Practices. Text available at: Horsham, PA.
http://www.ismp.org/profdevelopment/PCAMonograph.pdf
12. Culebras, X, Corpataux, J, Gaggero, G, et al, The antiemetic efficacy of droperidol added to morphine patient-
controlled analgesia. a randomized controlled multicenter dose-finding study. Anesth Analg 2003; 97:816–821.
13. Gallo, S, DuRand, J, Pshon, N. A study of naloxone effect on urinary retention in the patient receiving morphine
patient-controlled analgesia. Orthop Nurs. 2008; 27:111–115.
14. Grass, JA. Patient-controlled analgesia. Anesth Analg. 2005; 101:S44–S61.
15. Grond, S, Hall, J, Spacek, A, et al. Iontophoretic transdermal system using fentanyl compared with patient-
controlled intravenous analgesia using morphine for postoperative pain management. Br J Anaesth. 2007;
98(6):806–815.
16. Gupta, A, Fant, F, Axelsson, K, et al, Postoperative analgesia after radical retropubic prostatectomy. a double-blind
comparison between low thoracic epidural and patient-controlled intravenous analgesia. Anesthesiology 2006;
105:784–793.
17. Hicks, RW, Sikirica, V, Nelson, W, et al. Medication errors involving patient-controlled analgesia. Am J Health
Syst Pharm. 2008; 65:429–440.
18. Hudcova, J, McNicol, ED, Quah, CS, et al. Patient controlled opioid analgesia versus conventional opioid analgesia
for postoperative pain. Cochrane Database Syst Rev. 4, 2006. [CD003348].
19. Institute for Safe Medication Practices, Safety issues with patient-controlled analgesia. part 1how errors occur,.
Institute for Safe Medication Practices, Horsham, PA, 2003..
http://www.ismp.org/newsletters/acutecare/articles/20030710.asp [accessed September 28, 2009, from].
20. Institute for Safe Medication Practices, Safety issues with patient-controlled analgesia. part IIhow to prevent
errors,. Institute for Safe Medication Practices, Horsham, PA, 2003..
http://www.ismp.org/newsletters/acutecare/articles/20030724.asp [accessed September 28, 2009, from].
21. Joint Commission on Accreditation of Healthcare Organizations, Sentinel event alert. patient controlled
analgesia by proxy,. Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL,
2004.. www.jointcommission.org/sentinelevents/sentineleventalert/sea_33.htm
22. Krane, EJ, Patient-controlled analgesia. proxy-controlled analgesia. Anesth Analg 2008; 107:15–17.
23. Lee, Y, Lai, HY, Lin, PC, et al, A dose ranging study of dexamethasone for preventing patient-controlled
analgesia-related nausea and vomiting. a comparison of droperidol with saline. Anesth Analg 2004; 98:1066–
1071.
24. Maxwell, LG, Kaufmann, SC, Bitzer, S, et al, The effects of a small-dose naloxone infusion on opioid-induced
side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia. a
double-blind, prospective, randomized, controlled study. Anesth Analg 2005; 100:953–958.
25. Miaskowski, C. Patient-controlled modalities for acute postoperative pain management. J Perianesth Nurs.
2005; 20:255–267.
26. Miaskowski, C, Bair, M, Chou, R, et al. Principles of analgesic use in the treatment of acute pain and cancer pain,.
Glenview, IL: American Pain Society; 2008.
27. Michelet, P, Guervilly, C, Hélaine, A, et al, Adding ketamine to morphine for patient-controlled analgesia after
thoracic surgery. influence on morphine consumption, respiratory function, and nocturnal desaturation. Br J
Anaesth 2007; 99:396–403.
28. National Institutes of Health, Pain management. fact sheet. National Institutes of Health, Bethesda, MD, 2007.
29. Overdyk, FJ, Carter, R, Maddox, RR, et al. Continuous oximetry/capnometry monitoring reveals frequent
desaturation and bradypnea during patient-controlled analgesia. Anesth Analg. 2007; 105:412–418.
30. Pasero, C, McCaffery, M. Safe use of a continuous infusion with IV PCA. J Perianesth Nurs. 2004; 19:42–45.
31. Pasero, C, McCaffery, M. Orthopaedic postoperative pain management. J Perianesth Nurs. 2007; 22:160–172.
32. Roussier, M, Mahul, P, Pascal, J, et al. Patient-controlled cervical epidural fentanyl compared with patient-
controlled i. v. fentanyl for pain after pharyngolaryngeal surgery. Br J Anaesth. 2006; 96:492–496.
33. Schenk, MR, Putzier, M, Kugler, B, et al, Postoperative analgesia after major spine surgery. patient-controlled
epidural analgesia versus patient-controlled intravenous analgesia. Anesth Analg 2006; 103:1311–1317.
34. Schiessl, C, Gravou, C, Zernikow, B, et al. Use of patient-controlled analgesia for pain control in dying children.
Support Care Cancer. 2008; 16:531–536.
35. St. Marie B. Pain management. In: Weinstein SM, ed. Plumer’s principles and practice of intravenous therapy. ed 8.
Philadelphia: Lippincott Williams & Wilkins; 2006:576–607.
36. Stone, JG, Cozine, KA, Wald, A. Nocturnal oxygenation during patient-controlled analgesia. Anesth Analg.
1999; 89:104–110.
37. Voepel-Lewis T, Marinkovic, A, Kostrzewa, A, et al. The prevalence of and risk factors for adverse events in
children receiving patient-controlled analgesia by proxy or patient-controlled analgesia after surgery. Anesth
Analg. 2008; 107:70–75.
38. Walder, B, Schafer, M, Henzi, I, Tramèr, MR, Efficacy and safety of patient-controlled opioid analgesia for
acute postoperative pain. a quantitative systematic review. Acta Anaesth Scand 2001; 45:795–804.
39. Webb, AR, Skinner, BS, Leong, S, et al, The addition of a small-dose ketamine infusion to tramadol for
postoperative analgesia. a double-blinded, placebo-controlled, randomized trial after abdominal surgery. Anesth
Analg 2007; 104:912–917.
40. Werawatganon, T, Charuluxanun, S. Patient controlled intravenous opioid analgesia versus continuous
epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev. 1, 2005. [CD004088].
41. Wuhrman, E, Cooney, MF, Dunwoody, CJ, et al, Authorized and unauthorized (“PCA by proxy”) dosing of
analgesic infusion pumps. position statement with clinical practice recommendations. Pain Manag Nurs 2006;
8:4–11.
Additional Readings
Helfand, M, Freeman, M, Assessment and management of ac ute pain in adult medic al inpatients. a systematic review. Pain Med 2009; 10:1183–1199.
Hic ks, RW, Heath, WM, S ikiric a, V, et al. Medic ation -errors involving patient-c ontrolled analgesia. Jt Comm -J Qua l Pa tient Sa f. 2008; 43:734–742.
Kim, HS , Czuc zman, GJ, Nic holson, WK, et al, Pain levels within 24 hours after UFE. a c omparison of morphine -and fentanyl patient-c ontrolled analgesia.
Cardiovas Interv Radiol 2008; 31:1100–1107.
Leung, JM, S ands, LP, Paul, S , et al. Does postoperative -delirium limit the use of patient-c ontrolled analgesia -in older surgic al patients. Anesthesiology. 2009;
111:625–631.
S c hein, JR, Hic ks, RW, Nelson, WW, et al, Patient-c ontrolled analgesia-related errors in the postoperative period. c auses and prevention. Drug S afety 2009;
32:549–559.
Weitz, JW, Witkowski, TA, Visc usi, ER. new and emerging analgesic s and analgesic tec hnologies for ac ute pain management. Curr Opin Ana esthesiol. 2009;
22:608–617.
P R OC E D UR E 1 0 3
PURPOSE:
Peripheral nerve blocks are administered as single local anesthetic injections or continuously through a catheter
placed into a precise anatomic area to provide site-specific (e.g., femoral, brachial plexus, axillary, intrapleural,
extrapleural, paravertebral, tibial, sciatic, and lumbar plexus) prolonged anesthesia or analgesia for
postoperative and trauma pain management.7,33,34 The use of peripheral nerve blocks requires skilled and
knowledgeable health care providers.7,33,34 Catheter placement and the continuing treatment of the patient
should be under the direct supervision of an anesthesiologist, nurse anesthetist, or the acute pain service.22,33
Table 103-1
Single-Shot and Continuous Peripheral Nerve Blocks in the Critically Ill
Combination of femoral and sciatic Unilateral leg pain (e.g., femoral neck fracture [femoral], tibial and ankle Patient positioning
block fractures [sciatic])* Interference of femoral nerve catheters with
femoral lines
*Caution: Compartment syndrome.
(Modified from Schulz-Stubner S: The critically ill patient and regional anesthesia, Curr Opin Anaesthesiol 19:538-544, 2006.)
FIGURE 103-1 Location for needle insertion for an axillary block. (From Sinatra RS: Acute pain: mechanisms & management, St Louis, 1992, Mosby.)
FIGURE 103-2 Needle insertion for an axillary block. (From Sinatra RS: Acute pain: mechanisms & management, St Louis, 1992, Mosby.)
FIGURE 103-3 Landmarks for interscalene brachial plexus block. (From Sinatra RS: Acute pain: mechanisms & management, St Louis, 1992, Mosby.)
• A three-in-one peripheral nerve block can be used for analgesia after proximal lower limb orthopedic surgery. A three-
in-one peripheral nerve block provides analgesia to block three nerves, including the lateral femoral cutaneous,
femoral, and obturator nerves.24 This block is as effective as epidural analgesia, with fewer side effects than epidural
analgesia (e.g., urinary retention, nausea, and risk for epidural hemorrhage in patients with anticoagulation).5,6,13,18,24
Some forms of plexus analgesia (e.g., brachial plexus analgesia) in the postoperative setting may serve two purposes:
pain relief and sympathetic blockade, the latter of which increases blood flow and may improve outcomes in some
cases (i.e., digit reimplantation).4,13,21,31
• Analgesia via a catheter may be administered as a continuous infusion with the use of a volumetric pump system, a
patient-controlled regional infusion system, or a disposable pump device (e.g., elastomeric). Elastomeric pumps are
one type of disposable infusion pump designed to provide a constant rate of infusion from a filled reservoir. The
infusion rates are not adjustable (Fig. 103-4.)19,27,31 Medication administered is usually a local anesthetic (e.g.,
bupivacaine, ropivacaine). Other agents have been used on an adjunctive basis as a bolus, including opioids,
clonidine, epinephrine,13,14 and neostigmine.15
FIGURE 103-4 An elastomeric infusion pump. Parts include: 1, filling port; 2, elastomeric balloon (drug-containing reservoir); and 3, outer protective shell.
(Originally published in Skryabina E, Dunn TS: Disposable infusion pumps, Am J Health Syst Pharm 63:1260-1268, 2006.) © 2006, American Society of Health-System Pharmacists, Inc.
All rights reserved. Reprinted with permission (R1002).
• The pharmacokinetics and pharmacodynamics of local anesthetics and other agents used, including side effects and
duration of action, should be clearly understood. Local anesthetic medications used for peripheral nerve blocks
provide surgical analgesia (i.e., loss of pain sensation) and anesthesia (i.e., loss of all sensation). The duration of action
for each anesthetic medication depends on several factors, including the volume injected, concentration of the
medication, site of injection, and absorption. The addition of a vasoconstrictor, such as epinephrine, constricts blood
vessels and reduces vascular uptake, which further prolongs the duration of action of the local anesthetic.13,14
Epinephrine should not be used in peripheral nerve blocks in areas with end arteries, such as ear lobes, the nose,
digits, and the penis.35 Vasoconstrictor medications may cause spasm of blood vessels, resulting in necrosis.7
Knowledge of signs and symptoms of profound motor and sensory blockade, or overmedication, is essential.4,7,8,14
• Sensory and motor blockade may be acceptable or desirable, depending on the physician’s goals and preference. The
loss of sensation at the site is often the primary goal of blocks, and although motor loss is often acceptable, it is not
desirable.3
• According to the American Pain Society, the most common reason for unrelieved pain in hospitals is failure of health
care providers to routinely and adequately assess pain and pain relief.2 Many patients silently tolerate unrelieved pain
if not specifically asked about it.1,2,14 Patient self report is considered the best indicator of pain.2,30 Behavioral
observations are unreliable indicators of pain levels.1,2
• Contraindications to peripheral nerve blockade include a history of coagulopathy, preexisting neuropathies, anatomic
or pathologic deviations at the injection site, and systemic disease or infection.4-6,8,18,20,35
EQUIPMENT
• One peripheral nerve catheter kit
• Infusion set for continuous plexus anesthesia with or without an adaptor for a nerve stimulator
• Topical skin antiseptic, as prescribed (e.g., 2% chlorhexidine-based preparation or povidone-iodine)
• Sterile towels
• Sterile forceps
• Sterile gauze 4 × 4 pads
• Sterile gloves, fluid shield face masks, sterile gowns
• 20 mL normal saline solution
• 5 to 10 mL local anesthetic as prescribed (1% lidocaine) for local infiltration
• Local anesthetic as prescribed (to establish the block)
• Occlusive dressing supplies to cover the catheter entry site
• Gauze and tape to secure the catheter to the patient’s body
• Labels stating “Local anesthetic only” and “Not for intravenous injection”
• Pump for administration of analgesia (e.g., volumetric pump, dedicated for peripheral nerve block infusion with rate
and volume limited, and preferably a different color from the epidural and intravenous infusion pumps; patient-
controlled analgesic pump or a portable infusion device such as an elastomeric [PCA]) pump
• Specific observation chart for patient monitoring of the peripheral nerve block infusion
• Prescribed analgesics and local anesthetics
• Equipment for monitoring blood pressure, heart rate, and pulse oximetry
Additional equipment, as needed, includes the following:
• Ice or alcohol swabs for demonstrating sensory block
• Emergency medications
• Bag-valve-mask device and oxygen
• Equipment for end-tidal carbon dioxide monitoring
• Intubation equipment
• Peripheral nerve stimulator
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand the planned procedure. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Wash the specific anatomic area of the patient’s body with soap and water and open the gown to expose the site for
injection while maintaining the patient’s privacy and dignity. Rationale: This action cleanses the skin and allows
easy access to the specific anatomic area of the patient’s body.
• Consider nothing by mouth (NPO), especially if sedation or general anesthesia is to be used. Rationale: The risk for
vomiting and aspiration is decreased.
• Establish intravenous (IV) access or ensure the patency of IV lines. Rationale: The need to treat hypotension or
respiratory depression may occur.
• Position the patient as appropriate, according to which anatomic area of the body is to be blocked. Rationale:
Prepares the patient for the procedure.
• Reassure the patient. Rationale: Anxiety and fears may be reduced.
Procedure for Peripheral Nerve Blocks
References
1. Agency for Health Care Policy and Research, Acute Pain Management Guideline Panel, Clinical practice
guidelines. acute pain managementoperative or medical -procedures and trauma,AHCPR pub. 92-0032. Public
Health Service, US Department of Health and Human Services, Rockville, MD, 1992.
2. American Pain Society. Principles of analgesic use in the treatment of acute and cancer pain, ed 6. Glenview, IL:
American Pain Society; 2008.
3. Barnes, S, Russell, S. Interscalene blocks in the -ambulatory setting. J Perianesth Nurs. 2004; 19:352–354.
4. Bergman, BD, Hebl, JR, Kent, J, et al. Neurologic complications of 405 consecutive continuous axillary
catheters. Anesth Analg. 2003; 96:247–252.
5. Bickler, P, Brandes, J, Lee, M, et al. Bleeding complications from femoral and sciatic nerve catheters in patients
receiving low molecular weight heparin. Anesth Analg. 2006; 103:1036–1037.
6. Buckenmaier, CC, Bleckner, LL. Continuous peripheral nerve blocks and anticoagulation. Br J Anaesth. 2008;
101:139–140.
7. Burkard, J, Vacchiano, CA. Regional anesthesia. In: Nagelhout JJ, Plaus K, eds. Nurse anesthesia. ed 4. St Louis:
Elsevier Saunders; 2009:977–1030.
8. Capdevila, X, Pirat, P, Bringuler, S, et al, Continuous peripheral nerve blocks in hospital wards after
orthopedic surgery. a multicenter prospective analysis of the quality of postoperative analgesia and complications
in 1,416 patients. Anesthesiology 2005; 103:1035–1045.
9. Capdevila, X, Dadure, C, Bringuier, S, et al, Effect of patient-controlled perineural analgesia on rehabilitation and
pain after ambulatory orthopedic surgery. a multicenter randomized trial. Anesthesiology 2006; 105:566–573.
10. Capdevila, X, Jaber, S, Pesonen, P, et al. Acute neck cellulitis and mediastinitis complicating a continuous
interscalene block. Anesth Analg. 2008; 107:1419–1421.
11. Capdevila, X, Ponrouch, M, Choquet, O. Continuous peripheral nerve blocks in clinical practice. Curr Opin
Anaesthesiol. 2008; 21:619–623.
12. Chelly, JE, Ben-David B, Williams, BA, et al, Anesthesia and postoperative analgesia. outcomes following
orthopedic surgery. Orthopedics. 2003; 26(8 Suppl):S865–S871.
13. Couture, DJ, Cuniff, HM, Mave, JP, et al. The addition of clonidine to bupivacaine in combined femoral-sciatic
nerve block for anterior cruciate ligament reconstruction. AANA J. 2004; 72:273–278.
14. Cox, B, Durieux, ME, Marcus, MA. Toxicity of local anesthetics. Best Pract Res Clin Anaesthesiol. 2003; 17:111–
136.
15. Grossi, PA, Allegri, MB, Continuous peripheral nerve blocks. state of the art. Curr Opin Anaesthesiol 2005;
18:522–526.
16. Hadzic, A, Sala-Blanch X, Xu, D. Ultrasound guidance may reduce but not eliminate complications of peripheral
nerve blocks. Anesthesiology. 2008; 108:557–558.
17. Hebl, JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med.
2006; 31:311–323.
18. Horlocker, TT, Wedel, DJ, Benzon, H, et al, Regional anesthesia in the anticoagulated patient. defining the
risks. Reg Anesth Pain Med 2003; 28:172–197.
19. Kamming, D, Chung, F, Williams, D, et al. Pain management in ambulatory surgery. J Perianesth Nurs. 2004;
19:174–182.
20. Marhofer, P, Greher, M, Kapral, S. Ultrasound guidance in regional anaesthesia. Br J Anaesth. 2005; 94:7–17.
21. McCamant, KL, Peripheral nerve blocks. understanding the nurse’s role. J Perianesth Nurs 2006; 21:16–24.
22. McDonnell, A, Nicholl, J, Read, SM, Acute pain teams and the management of postoperative pain. a
systematic review and meta-analysis. J Adv Nurs 2003; 41:261–273.
23. Mertin, S, Sawatzky, JA, Diehl-Jones WL, et al, Roadblock to recovery. the surgical stress response. Dynamics
2007; 18:14–20.
24. Morau, D, Lopez, S, Biboulet, P, et al, Comparison of continuous 3-in-1 and fascia iliaca compartment blocks
for postoperative analgesia. feasibility, catheter migration, distribution of sensory block, and analgesic efficacy.
Reg Anesth Pain Med 2003; 28:309–314.
25. Pasero, C, Eksterowicz, N, Primeau, M, et al, Registered nurse management and monitoring of analgesia by
catheter techniques. position statement. Pain Manag Nurs 2007; 8:48–54.
26. Pham-Dang C, Kick, O, Collet, T, et al. Continuous peripheral nerve blocks with stimulating catheters. Reg
Anesth Pain Med. 2003; 28:83–88.
27. Remerand, F, Vuitton, AS, Palud, M, et al, Elastomeric pump reliability in postoperative regional anesthesia. a
survey of 430 consecutive devices. Anesth Analg 2008; 107:2079–2084.
28. Salinas, FV, Location, location, location. continuous peripheral nerve blocks and stimulating catheters. Reg
Anesth Pain Med 2003; 28:79–82.
29. Schulz-Stubner S. The critically ill patient and regional anesthesia. Curr Opin Anaesthesiol. 2006; 19:538–544.
30. Sessler, CN, Grap, MJ, Ramsay, MA, Evaluating and monitoring analgesia and sedation in the intensive care unit
available at. Crit Care. 2008; 12(Suppl 3):S2. http://ccforum.com/content/12/S3/S3 [accessed October 15, 2009].
31. Shinaman, RC, Mackey, S. Continuous peripheral nerve blocks. Curr Pain Headache Rep. 2005; 9:24–29.
32. Skryabina, E, Dunn, TS. Disposable infusion pumps. Am J Health Syst Pharm. 2006; 63:1260–1268.
33. Tsui, BCH, Rosenquist, RW. Peripheral nerve blockade. In: Barash PG, Cullen BF, Stoelting RK, et al, eds. Clinical
anesthesia. ed 6. Philadelphia: Lippincott Williams & Wilkins; 2009:955–1002.
34. Wedel, DJ, Horlocker, TT. Nerve blocks. In: Miller RD, Eriksson LI, Fleisher LA, et al, eds. Miller’s anesthesia. ed 7.
London: Churchill Livingstone; 2009:1639–1674.
35. Wiegel, M, Gottschaldt, U, Hennebach, R, et al. Complications and adverse effects associated with continuous
peripheral nerve blocks in orthopedic patients. Anesth Analg. 2007; 104:1578–1582.
Additional Readings
Mulroy, MF, Bernards, CM, Mc Donald, S B, et al. A pra ctica l a pproa ch to regiona l a nesthesia , ed 4. Philadelphia: Lippinc ott Williams & Wilkins; 2008.
Ric hman, JM, Liu, S S , Courpas, G, et al. Does c ontinuous peripheral nerve bloc k provide superior pain c ontrol to opioids? A meta-analysis. Anesth Ana lg. 2006;
102:248–257.
Turjanic a, MA. Postoperative c ontinuous peripheral nerve bloc kade in the lower extremity total joint arthroplasty population. Medsurg Nurs. 2007; 16:151–154.
UNIT IV
Gastrointestinal System
SECTION SIXTEEN
Special Gastrointestinal Procedures
P R OC E D UR E 1 0 4
PURPOSE:
Esophagogastric tamponade therapy is used to provide temporary control of bleeding from gastric or esophageal
varices.2
FIGURE 104-2 Minnesota four-lumen tube. (From Swearingen PL: Photo atlas of nursing procedures, Reading, MA, 1991, Addison-Wesley.)
• Esophagogastric tamponade tubes may be introduced via either the nasogastric or the orogastric route. The tubes are
then advanced through the oropharynx and esophagus and into the stomach.
• Contraindications include esophageal strictures or recent esophageal surgery, congestive heart failure, respiratory
failure, hiatal hernia, and cardiac dysrhythmias.3 Because of the risk for aspiration, the patient may need endotracheal
intubation for airway protection.
• Sedation should be considered, but dosing should be individualized on the basis of the likelihood of liver injury with
its concomitant alteration in the metabolism of medications. The plan for sedation is individualized with the goal of
achieving patient comfort through a safe use of medications if needed.
• Head of bed (HOB) should be at least 30 to 45 degrees at all times to reduce risk of aspiration.6
EQUIPMENT
• Tamponade tube (Sengstaken-Blakemore, Minnesota, or Linton-Nachlas)
• Irrigation kit (or catheter-tip, 60-mL syringe and basin)
• Nasogastric (NG) tubes (one for Sengstaken-Blakemore tube)
• Normal saline (NS) solution for irrigation
• NS solution, 500 mL (provides weight for traction on the tube)
• Water-soluble lubricant
• Topical anesthetic agent
• Sphygmomanometer or pressure gauge
• Four rubber-shod clamps
• Adhesive tape
• Two suction setups and tubing
• Endotracheal suction equipment
• Cardiac monitor
• Emergency medications, including atropine
• Emergency equipment, including transcutaneous pacemaker and intubation equipment
• Scissors, to be kept at bedside
Additional equipment (to have available based on patient need) includes the following:
• Rubber cube sponge (used for nasal tamponade tube placement)
• Balanced suspension traction apparatus with 1 pound of weights, 500 mL of NS solution (Fig. 104-3), or football
helmet with face mask (Figs. 104-4)
FIGURE 104-3 Balanced suspension traction securing tamponade tube and placement. (From DeGroot KD, Damato M: Critical care skills, Norwalk, CT, 1987, Appleton
& Lange.)
FIGURE 104-4 Tamponade tube secured in position w ith helmet.
• Lopez enteral valve (Fig. 104-5)7 (ICU, Medical, San Clemente, CA), a three-way stopcock used to attach a 60-mL
catheter-tip syringe and the handheld manometer to the Minnesota tube
FIGURE 104-5 Lopez valve. (Courtesy of ICU Medical, Inc. San Clemente, CA.)
Patient Preparation
• Ensure that the patient and family understand preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Measure the tube from the bridge of the nose to the earlobe to the tip of the xiphoid process. Mark the length of tube
to be inserted. Rationale: Estimating the length of tube to be inserted helps place the distal tip in the stomach.
• If the patient is alert, place the patient in high Fowler’s or semi-Fowler’s position. If the patient is unconscious or
obtunded, place the patient head down in the left lateral position. Rationale: Positioning facilitates the passage of
the tube into the stomach and reduces the risk for aspiration.
Procedure for Inserting Esophagogastric Tamponade Tube
FIGURE 104-6 Inflation of esophageal balloon. (Courtesy of Davol, Inc. Warwick, RI)
FIGURE 104-7 Measuring nasogastric tube. (From Luckmann J: Saunders manual of nursing care, Philadelphia, 1997, Saunders, 1262.)
References
1. Bard MedicalBard Medical DivisionCovington. GAInstructions for passing Minnesota four lumen esophagogastic
tamponade tube for the control of bleeding from esophageal varicies. 8195 Industrial Boulevard, 30014; 2006.
2. Christensen, T, Christensen, M. The implementation for guideline of care for patients with Sengstaken-
Blakemore tube in situ in a general intensive care unit using transitional change theory. Intensive Crit Care Nurs.
2007; 23:234–242.
3. Day, M. Gastrointestinal bleeding. In: Carlson K, ed. Advanced critical care nursing. St Louis: Saunders; 2009:748–
751.
4. Hilinski, A, Stark, ML. Memory aide to reduce the incidence of ventilator-associated pneumonia. Crit Care Nurse.
2006; 26(5):80–81.
5. Isaacs, KL, Balloon tamponade. handbook of gastroenterologic procedures. ed 4. Lippincott Williams & Wilkins,
Philadelphia, 2005:119–120. www.findarticles.com/p/articles/mi [retrieved August 17, 2009, from].
6. Mallinckrodt Inc, Tyco Health Care Group, 154 fareham road gosport, hampshire, UK, po 13 oas. Linton-Nachlas
tube. April 19, 2009 retrieved. www.gpnotebook.co.uk/simplepage.cfm [from].
7. Martin, RK, Hassanein, T, Liver dysfunction and failure Carlson KK, ed.. Advanced critical care nursing.
Saunders/Elsevier: Philadelphia, 2009:759–764.
8. Treger, R, Graham, TP, Dea, SK, Sengstaken-Blakemore tube. treatment & medication,.
http//emedicine.medscape.com/article/-81020-treatment, 2008 [retrieved April1, 2009, from].
Additional Reading
Garc ia-Tsao G. Portal hypertension. Curr Opin Ga stroenterol. 2006; 22(3):254–262.
P R OC E D UR E 1 0 5
PURPOSE:
With suspected gastric hemorrhage, gastric lavage can be used for the initial assessment of upper
gastrointestinal bleeding to potentially identify the severity of bleeding and clear the stomach of blood and clots.
Gastric lavage may improve visualization of the gastric fundus in preparation for endoscopy or endoscopic
treatments. In overdose, gastric lavage can be used to evacuate drugs or toxins within 1 hour of ingestion,
potentially minimizing the consequences of systemic absorption of drugs or toxins.
EQUIPMENT
• Adult lavage tube, external diameter 12 to 13.3 mm 9
No. 36 to 40 Fr gastric tube or
No. 30 English gastric tube
• 60-mL irrigating syringe
• Water-soluble lubricant
• Lavage fluid (warm normal saline solution or tap water)
• Measurable container for lavage fluid
• Disposable basin or suction canister for aspirate
• Suction source and connecting tubing
• Rigid pharyngeal suction-tip (Yankauer) catheter
• Endotracheal suction equipment
• Tape for securing nasogastric (NG) or OG tube
• Stethoscope
• Cardiac monitor
• Pulse oximeter
• Automatic blood pressure cuff
• Nonsterile gloves
• Eye and face protection
• Barrier gowns
Additional equipment, to have available based on patient need, includes the following:
• Specimen container for aspirate (for overdose)
• Absorptive agent for instillation (for overdose, if prescribed)
• Emergency intubation and cardiac equipment
• Bite block or oral airway (if patient needs intubation for procedure)
• Emergency medications
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Place the patient on a cardiac monitor, automatic blood pressure cuff, and pulse oximeter. Set up oropharyngeal
suction. Rationale: This action allows for close cardiovascular and respiratory system monitoring during the
procedure and ensures suction is available for the procedure.
• Establish and maintain intravenous (IV) access. For the patient with GI hemorrhage, place a minimum of two large-
bore IVs or provide central access. Rationale: IV access is necessary for emergency IV medication administration
and volume resuscitation in the case of GI hemorrhage.5
• Position patient in left lateral decubitus position.7,8 Rationale: This position facilitates passage of the tube into the
stomach. The left lateral position is the position of choice to prevent aspiration if the patient should vomit.
• Apply oxygen via nasal prongs or mask as needed. Continue to evaluate the patient for possible need of airway
intubation. Rationale: Supplemental oxygen may optimize the patient’s oxygen saturation.
Procedure for Gastric Lavage in Hemorrhage and Overdose
References
References
1. American Association of Critical-Care Nurses, AACN practice alert. verification of feeding tube placement.
www.aacn.org/WD/Practice/Docs/PracticeAlerts/Verification_of_Feeding_Tube_Placement_05-2005.pdf, 2005
[retrieved April 26, 2009 from].
2. Caravati, EM, Erdman, AR, Scharman, EJ, et al, Long-acting anticoagulant rodenticide poisoning. an -evidence-
based consensus guideline for out-of hospital management. Clin Toxicol. 2007; 45(1):1–22.
3. Criddle, LM. An overview of pediatric poisonings. AACN Adv Crit Care. 2007; 18(2):109–118.
4. Garcia-Tsao G, Sanyal, AJ, Grace, ND, et al, Practice -guidelines. prevention and management of gatroesophageal
varices and variceal hemorrhage in cirrhosis. Am J -Gastroenterol. 2007; 102(9):2086–2102.
5. Gralnek, IM, Barkun, AN, Bardou, M. Management of acute bleeding from a peptic ulcer. N Engl J Med. 2008;
359(9):928–937.
6. Greene, S, Harris, C, Singer, J. Gastrointestinal decontamination of the poisoned patient. Pediatr Emerg Care.
2008; 24(3):176–189.
7. Heard, K. Gastrointestinal decontamination. Med Clin North Am. 2005; 89(6):1067–1078.
8. Heard, K. The changing indications of gastrointestinal decontamination in poisonings. Clin Lab Med. 2006;
26(1):1–12.
9. Kulig, K, Position paper. gastric lavageAmerican Academy of Clinical Toxicology; European Association of
Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 2004; 42(7):933–943.
10. Lee, SD, Kearney, DJ. A randomized controlled trial of gastric lavage prior to endoscopy for acute upper
gastrointestinal bleeding. J Clin Gastroenterol. 2004; 38(10):861–865.
11. Madden, M. Responding to pediatric poisoning. Nursing. 2008; 52–55. [August].
12. Palmer, K, Nairn, M, Management of acute gastrointestinal blood loss. summary of SIGN guidelines. BMJ. 2008;
337(a1832):928–933.
Additional Readings
Li, Y, Tse, ML, Gawarammana, I, et al. S ystematic review -of c ontrolled c linic al trials of gastric lavage in ac ute -organophosphorus pestic ide poisoning. Clin
Toxicol. 2009; 47(3):179–192.
Larkin, GL, Claassen, C. Trends in emergenc y department use of gastric lavage for poisoning events in the United S tates, 1993-2003. Clin Toxicol. 2007; 45(2):164–
168.
S c ottish Interc ollegiate Guidelines Network, Ma na gement of a cute upper a nd lower ga strointestina l bleeding. a na tiona l clinica l guideline.
www.sign.ac .uk/guidelines/fulltext/105/index.html, 2008 [retrieved April, 26, 2009 from].
P R OC E D UR E 1 0 6
PURPOSE:
Intraabdominal hypertension and abdominal compartment syndrome occur when the abdominal contents expand
in excess of the capacity of the abdominal cavity, compromising abdominal organ perfusion and resulting in
organ dysfunction or failure and associated mortality.3,5,9,13,14,17,20,23,25
Table 106-1
Patients at Risk for Development of Intraabdominal Hypertension and Abdominal Compartment Syndrome 3,17
(Levels C, D, E*)
*Level C: Qualitative studies, descriptive or correlational studies, integrative review s, systematic review s, or randomized controlled trials w ith inconsistent results
*Level D: Peer-review ed, professional organizational standards w ith clinical studies to support recommendations
*LevelE: Multiple case reports, theory-based evidence from expert opinions, or peer-review ed professional organizational standards w ithout clinical studies to
support recommendations
or
• APP should be maintained at more than 50 to 60 mm Hg to maintain adequate perfusion to the abdominal organs and
reduce the chance of organ dysfunction.3,6,7,17
• Measurement of bladder pressure via an indwelling urinary bladder catheter is considered the reference standard for
the measurement of IAP and may be performed with equipment readily available in the critical care environment
(Fig. 106-1).2,3,8,15,17,22 Commercially prepared kits designed for measurement of IAP are also available and may
provide advantages in efficiency, standardization of measurement technique, and data reproducibility. Instructions
for specific setup and operation of commercially prepared devices are provided by the manufacturer. Note that
regardless of the device used, a standardized procedure for measurement should be used to prevent measurement
variability between practitioners.12,15,22
• The bladder acts as a passive reservoir and accurately reflects IAP when intravesicular volumes of 25 mL or less are
used. Larger volumes previously suggested (50 to 100 mL) are not necessary and may in fact overdistend the bladder,
falsely elevating measured bladder pressure (IAP).3,11,18
• Normal IAP is 0 mm Hg and may even be subatmospheric. In patients who are critically ill, it may rise to 5 to 7 mm
Hg.3,17
• IAP should be measured with the patient in the supine position. The transducer should be leveled or zeroed at the iliac
crest in the midaxillary line (Fig. 106-2).2,3,17,24
FIGURE 106-2 Correct position of the transducer for bladder pressure measurement. (Illustration by John J. Gallagher.)
• IAP should be measured at end expiration. Wait an appropriate time (10 to 60 seconds) after saline solution instillation
to allow for equilibration of the monitor to a steady state pressure reading.3,17
• IAP should be expressed in millimeters of mercury (mm Hg; 1 mm Hg = 1.36 cm H2 O).3,17
• Serial monitoring of bladder pressures is useful in detection of the onset of IAH and the progression to the more
severe condition of ACS. Recommendations are that measurements be repeated every 2 to 4 hours in patients with
IAP more than or equal to 12 mm Hg so a trend may be established and increases in pressure are detected.3,17
• Bladder pressure measurement may be contraindicated in certain conditions, such as bladder trauma, bladder
surgery, and neurogenic bladder. Risks and benefits of measurement should be discussed with the physician before
the procedure is performed in these patients.
• In patients who do not have a urinary catheter in place, the risks and benefits of catheter placement for the purpose of
bladder pressure measurement should be considered.
EQUIPMENT
• Nonsterile gloves
• Cardiac monitor and pressure cable for interface with the monitor
• 500- or 1000-mL intravenous (IV) bag of normal saline (NS) solution
• Pressure transducer system, including pressure tubing with flush device, transducer, and two stopcocks
• 25-mL Luer-Lok syringe
• Clamp
• Chlorhexidine swab sticks
Note: Commercial bladder pressure monitoring system may be substituted for the previous list.
Table 106-2
Physiologic Changes Associated with Intraabdominal Hypertension and Abdominal Compartment
Syndrome 3,5-7,9,13,16,17,25 (Levels C, D, E*)
Cardiovascular Increased abdominal pressure prevents venous return (preload reduction) and impedes arterial outflow (increase in afterload). Transmitted
↑ CVP, PAP, PCWP, backpressure from the abdominal cavity falsely elevates CVP, PAP, PCWP, PVR, and SVR. CVP and PCWP may be corrected for the
SVR influence of increased IAP as follows5:
↓ CO (more CVP corrected = CVP measured – IAP/2
pronounced with PCWP corrected = PCWP measured – IAP/2
hypovolemia)
↓ Venous return from
lower extremities (risk
for DVT)
Renal Increased IAP reduces cardiac output to the kidney, thereby reducing perfusion pressure to the glomerulus. Simultaneously IAP increases the
↑ Renal blood flow → pressure within the renal parenchyma, leading to reduction in filtration. The combination leads to a marked reduction in GFR and urine
↓GFR → ↓urine output production.
Pulmonary Increased IAP causes an increase in intrathoracic pressure and limits diaphragm excursion, resulting in hypoventilation and hypoxia.
↑ Intrathoracic pressures
↑ Peak inspiratory
pressures
↓ Tidal volume →
hypercarbia + ↓PaO2
↓ Compliance
Neurologic Increased IAP impedes venous outflow from the brain, increasing cerebral venous congestion.
↑ICP
↓CPP
Gastrointestinal/hepatic Increased IAP reduces perfusion to the abdominal organs. Capillary blood flow becomes obstructed as the IAP rises. When the IAP achieves
effect and surpasses the venous capillary pressure, capillary blood flow is reduced or ceases. Transfer of oxygen/nutrients stops leading to
↓Celiac and portal anaerobic metabolism.
blood flow
↓Lactate clearance
↓Mucosal blood flow →
↓ pHi
CO, Cardiac output; CPP, cerebral perfusion pressure; CVP, central venous pressure; DVT, deep venous thrombosis, GFR, glomerular filtration rate; IAP,
intraabdominal pressure; ICP, intracranial pressure; PaO2, partial pressure of arterial oxygen; PAP, pulmonary artery pressure; PCWP, pulmonary capillary w edge
pressure; pHi, intramucosal pH; PVR, pulmonary vascular resistance; SVR, systemic vascular resistance.
*Level C: Qualitative studies, descriptive or correlational studies, integrative review s, systematic review s, or randomized controlled trials w ith inconsistent results
*Level D: Peer-review ed, professional organizational standards w ith clinical studies to support recommendations
*LevelE: Multiple case reports, theory-based evidence from expert opinions, or peer-review ed professional organizational standards w ithout clinical studies to
support recommendations
Patient Preparation
• Ensure that the patient and family understand preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure the presence of a conventional (single-lumen) urinary catheter connected to a drainage system. Rationale: A
urinary catheter with a drainage system is required to obtain bladder pressure measurements. Multilumen irrigation
urinary catheters also may be used but are not required.
• Place the patient in the supine flat position (if this can be tolerated) in preparation for bladder pressure measurement.
The transducer should be placed at the iliac crest at the level of the midaxillary line (see Fig. 106-2).3,17 Rationale:
The supine flat position reduces the effect of downward pressure from the abdominal organs on the bladder, reducing
the chance that IAP is falsely elevated. Patients who cannot tolerate the supine position (head injury, respiratory
compromise) may have measurements taken with the head of the bed (HOB) elevated.3,17 If the patient must remain
with the HOB elevated, the transducer must be placed at the level of the bladder (iliac crest; see Fig. 106-2).
• Documentation should reflect the degree of reverse Trendelenburg’s or HOB elevation when measurements are not
obtained in the supine position.2,3,17,24 Rationale: IAP results can be evaluated in light of the patient’s position at the
time of measurement. Note that the phlebostatic axis should not be used to level the transducer for bladder pressure
measurement.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
Procedure for Intraabdominal Pressure Monitoring2,3,10,11,15,17,22,24 (see Fig. 106-1)
FIGURE 106-3 IAP w aveform. The IAP read at end expiration is 16 mm Hg in this patient on mechanical ventilation.
FIGURE 106-4 Commercially prepared bladder pressure measurement system (AbViser). (Courtesy of Wolfe Tory Medical, Salt Lake City, UT.)
Procedure for Intraabdominal Pressure Monitoring with the Wolfe Tory Medical AbViser (Wolfe Tory Medical, Salt
Lake City, Utah) Bladder Pressure Monitoring System with AutoValve (Fig. 106-4)
FIGURE 106-5 AbViser® Bladder Pressure Monitoring System. (Courtesy of Wolfe Tory Medical, Salt Lake City, UT.)
Procedure for Intraabdominal Pressure Monitoring with the Holtech Abdo-Pressure System, Charlottenlund,
Denmark
FIGURE 106-6 Commercially prepared Abdo-Pressure bladder pressure monitoring system. (Redrawn with permission from Holtech Medical.)
FIGURE 106-7 The urine fills the Abdo-Pressure and flow s on to the urine collection device. (Redrawn with permission from Holtech Medical.)
References
1. Balogh, Z, et al. Secondary abdominal compartment syndrome is an elusive early complication of traumatic
shock resuscitation. Am J Surg. 2002; 184:538–543.
2. Cheatham, ML, et al, The impact on body position on intra-abdominal pressure measurement. a multicenter
analysis. Crit Care Med 2009; 37:2187–2190.
3. Cheatham, ML, et al, Results from the International Conference of Experts on Intra-abdominal Hypertension and
Abdominal Compartment Syndrome. IIrecommendations. Intensive Care Med. 2007; 33(6):951–962.
4. Cheatham, ML, Safcsak, K. Is the evolving management of IAH/ACS improving survival. Acta Clinica Belgica.
2007; 62(Suppl 1):268. [Abstract 061].
5. Cheatham, ML, Malbrain, MLNG. Cardiovascular implications of abdominal compartment syndrome. Acta
Clinica Belgica. 2007; 62(Suppl 1):98–112.
6. Cheatham, ML, Malbrain, MLNG. Abdominal perfusion pressure. In: Cheatham ML, Malbrain MLNG, Sugrue
M, eds. Abdominal compartment syndrome. Georgetown, TX: Landes Biomedical; 2006:69–81.
7. Cheatham, ML, et al, Abdominal perfusion pressure . a superior parameter in the assessment of
intraabdominal hypertension. J Trauma 2000; 56:237–242.
8. Cheatham, ML, Safcak, K, Intraabdominal pressure. a revised method for measurement. J Am Coll Surg
1998; 186:594–595.
9. Cullen, D, et al. Cardiovascular, pulmonary, and renal effects of massively increased intraabdominal pressure
in critically ill patients. Crit Care Med. 1989; 17:118–122.
10. De Potter TJ, Dits, H, Malbrain, MLNG. Intra- and interobserver variability during in vitro validation of two
novel methods for intra-abdominal pressure monitoring. Intensive Care Med. 2005; 31(5):747–751.
11. De Waele JJ, et al, Saline volume in transvesical intra-abdominal pressure measurement. enough is enough.
Intensive Care Med. 2006; 32(3):455–459.
12. Gracias, VH, et al. Abdominal compartment syndrome in the open abdomen. Arch Surg. 2002; 137:1298–
1300.
13. Kashtan, J, et al. Hemodynamic effects of increased intraabdominal pressure. J Surg Res. 1981; 30:249–255.
14. Kimball, EJ, et al. Clinical awareness of intra-abdominal hypertension and abdominal compartment syndrome in
2007. Acta Clinica Belgica. 2007; 62(Suppl 1):66–73.
15. Kimball, EJ, et al. Reproducibility of bladder pressure measurements in critically ill patients. Intensive Care Med.
2007; 33(7):98–1195.
16. Kron, I, Harman, K, Nolan, SP. The measurement of intraabdominal pressure as a criterion for abdominal re-
exploration. Ann Surg. 1984; 199:28–30.
17. Malbrain, MLNG, Delaet, I, Cheatham, ML, Consensus conference definitions and recommendations on
intraabdominal hypertension (IAH) and the abdominal compartment syndrome (ACS). the long road to the final
publicationshow did we get there. Acta Clinica Belgica. 2007; 62(Suppl 1):44–59.
18. Malbrain, MLNG, Deeren, D, Effect of bladder volume on measuring intravesical pressure. a prospective cohort
study. Crit Care Forum. 2006; 10(4):1–6.
19. Malbrain, MLNG, Jones, F, et al. Intra-abdominal pressure measurement techniques. In: Ivatury RR, Cheatham
ML, Malbrain M, eds. Abdominal compartment syndrome. Georgetown, TX: Landis Bioscience, 2006.
20. Malbrain, MLNG, et al, Incidence and prognosis of intraabdominal hypertension in a mixed population of
critically ill patients. a multiple-center epidemiological study. Crit Care Med. 2005; 33(2):315–322.
21. Malbrain, MLNG, et al, Prevalence of intra-abdominal hypertension in critically ill patients. a multicentre
epidemiological study. Intensive Care Med. 2004; 30(5):822–829.
22. Malbrain, MLNG, Different techniques to measure intra-abdominal pressure (IAP). time for a critical re-
appraisal. Intensive Care Med. 2004; 30(3):357–371.
23. Malbrain, MLNG. Abdominal perfusion pressure as a prognostic marker in intraabdominal hypertension. In:
Vincent JL, ed. Yearbook of intensive care and emergency medicine. Berlin, Heidelberg, New York: Springer;
2002:792–814.
24. Vasquez, DG, Berg-Copas GM, Wetta-Hall R. Influence of semi-recumbent position on intra-abdominal pressure
as measured by bladder pressure. J Surg Res. 2007; 139(2):280–285.
25. Wolfe, TR, Kimball, EJ, McLean, B. The interrelationship of severe sepsis, sepsis resuscitation and the abdominal
compartment syndrome. Int J Intensive Care. 2008; 87–91. [Spring].
Additional Readings
Ivatury, RR, Cheatham, ML, Malbrain, M, et al, Abdominal c ompartment syndrome. Landis Biosc ienc e, Georgetown, TX, 2006.
World S oc iety of the Abdominal Compartment S yndrome. World S oc iety of the Abdominal Compartment S yndrome. Ac c essed June 10, 2009 www.wsac s.org.
[(website)].
Abdominal Compartment S yndrome, Abdominal Compartment S yndrome. org. S ponsored by Wolfe Tory Medic al (website).
www.abdominalc ompartmentsyndrome.org [Ac c essed June 10, 2009].
Intra-abdominal Pressure Monitoring. Holtec h Medic al. (website) www.holtec h-medic al.c om. [Ac c essed June 10, 2009].
Wolfe Tory Medic al. Wolfe Tory Medic al. (website) www.wolfetory.c om. [Ac c essed June 10, 2009].
P R OC E D UR E 1 0 7
Paracentesis (Perform)
Eleanor Fitzpatric k
PURPOSE:
Abdominal paracentesis is performed to remove fluid from the peritoneal cavity for diagnostic or therapeutic
purposes.
• Ultrasound scan can be used before paracentesis to locate fluid and during the procedure to guide insertion of
catheter. The ultrasound scan may be performed by the practitioner performing the procedure or by other personnel
trained to conduct the study. Ultrasound scan–guided paracentesis has a higher success rate when compared with the
procedure performed with physical examination as the lone assessment tool.8 Endoscopic transgastric ultrasound scan
has also been used in the diagnosis of malignant ascites.12
• A semipermanent catheter or a shunt may be an option for patients with rapidly reaccumulating ascites.13,15,16
• When large-volume paracentesis (>5 L) is performed in patients with cirrhosis and other disorders, the infusion of
albumin, 6 to 8 g/L of fluid removed, may prevent the onset of circulatory compromise associated with massive fluid
shifting.1,3,6,7,18
EQUIPMENT
• Commercially prepared kit or the following:
Personal protective equipment, including sterile gloves, mask, goggles, and gown
Skin-cleansing solution (povidone-iodine or chlorhexidine preparation)
Sterile marking pen
Sterile towels or sterile drape
Local anesthetic for injection: 1% or 2% lidocaine with epinephrine
5- or 10-mL syringe with 21- or 25-gauge needle for anesthetic
Trocar with stylet, needle (16-, 18- or 20-gauge), or angiocatheter, depending on abdominal wall thickness
25- or 27-gauge 1½-inch needle
20- or 22-gauge spinal needles
20-mL syringe for diagnostic tap
50-mL syringe if using stopcock technique
Four sterile tubes for specimens
Scalpel and no. 11 knife blade
Three-way stopcock
Sterile 1-L collection bottles with connecting tubing
Nylon skin suture material on cutting needle (4-0 or 5-0) and needle holder
Mayo scissors and straight scissors
Four to six sterile 4 × 4 gauze pads
Sterile gauze dressing with tape or adhesive strip
Stoma bag
Soft wrist restraints
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Obtain a written informed consent form. Rationale: Paracentesis is an invasive procedure that requires a signed
informed consent form.
• Decompress the bladder either by having the patient void or by inserting a Foley catheter. Rationale: A distended
bladder increases the risk for bladder perforation during the procedure.
• Obtain plain and upright radiographs of the abdomen before the procedure is performed. Rationale: Air is
introduced during the procedure and may confuse the diagnosis later.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Check that all relevant documents and studies are available before the procedure is started. Rationale: This measure
ensures that the correct patient receives the correct procedure.
• Place the patient in the supine position (may tilt to side of collection slightly for improved fluid positioning).
Rationale: Fluid accumulates in the dependent areas.
• Examine abdomen for areas of shifting dullness. Find landmarks and mark appropriately. Rationale: Shifting
dullness indicates fluid.
• If the patient has altered mental status, soft wrist restraints may be needed. Rationale: The patient must not move
his or her hands into the sterile field once it has been established.
Procedure for Performing Paracentesis
FIGURE 107-2 A, Z-track method of paracentesis. The skin is pulled approximately 2 cm caudal in relation to the deep abdominal w all by the non–needle-
bearing hand w hile the paracentesis needle is slow ly being inserted directly perpendicular to the skin. B, After the peritoneum is penetrated and fluid return
obtained, the skin is released. Note that the needle is angulated caudally. (From Roberts JR, Hedges JR: Clinical procedures in emergency medicine, ed 4, Philadelphia,
2004, Saunders.)
References
1. Arora, G, Keeffe, EB, Management of chronic liver failure until liver transplantation. Med Clin North Am. 2008;
92(4):839–860.
2. Dib, N, Oberti, F, Cales, P, Current management of the complications of portal hypertension. variceal bleeding
and ascites. Can Med Assoc J. 2006; 174(10):1433–1443.
3. Dong, MH, Saab, S. Complications of cirrhosis. Disease-A-Month. 2008; 54(7):445–456.
4. Edmiston, CE, Seabrook, GR, Johnson, CP, et al. Comparative of a new and innovative 2% chlorhexidine
gluconate-impregnated cloth with 4% chlorhexidine gluconate as topical antiseptic for preparation of the skin
prior to surgery. Am J Infect Control. 2007; 35(2):89–96.
5. Ferri, FF. Paracentesis. In Ferri F, ed. : Practical guide to the care of the medical patient, ed 7, Philadelphia:
Mosby/Elsevier, 2007.
6. Gines, P, Arroyo, V, Quintero, E, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics
with tense ascites-results of a randomized study. Gastroenterology. 1987; 93(2):234–241.
7. Grewal, P, Martin, P. Pretransplant management of the cirrhotic patient. Clin Liver Dis. 2007; 11(2):431–439.
8. Han, MK, Hyzy, R. Advances in critical care management of hepatic failure and insufficiency. Crit Care Med.
2006; 34(9 Suppl):S225–S231.
9. Hauser, SC, Mayo Clinic gastroenterology and hepatology board review. ed 2. Mayo Clinic Scientific Press,
Rochester, MN, 2006.
10. Heidelbaugh, JJ, Sherbondy, M, Cirrhosis and chronic liver failure. part IIcomplications and treatment. Am Fam
Physician. 2006; 74(5):767–776.
11. Hibbard, JS, Analyses comparing the antimicrobial activity of current antiseptic agents. a review. J Infusion
Nurs. 2005; 28(3):194–207.
12. Kaushik, N, Khalid, A, Brody, D, et al. EUS-guided paracentesis for the diagnosis and management of malignant
ascites. Gastrointest Endosc. 2006; 64(6):908–913.
13. McGibbon, A, Chen, G, Peltekian, K, et al. An evidence-based manual for abdominal paracentesis. Dig Dis Sci.
2007; 52(12):3307–3315.
14. Pare, P, Talbot, J, Hoefs, JC, Serum-ascites albumin concentration gradient. a physiologic approach to the
differential diagnosis of ascites. Gastroenterology. 1983; 85(2):240–244.
15. Rodes, J, Textbook of hepatology. from basic science to clinical practice. ed 3. Blackwell Publishing Ltd, Malden,
MA, 2007.
16. Rosenberg, SM. Palliation of malignant ascites. Gastroenterol Clin. 2006; 35(1):189–199.
17. Saab, S, Nieto, JM, Lewis, SK, et al. TIPS versus paracentesis for cirrhotic patients with refractory ascites.
Cochrane Database Syst Rev. 3, 2008.
18. Sanchez, W, Talwalkar, JA. Palliative care for patients with end-stage liver disease ineligible for liver
transplantation. Gastroenterol Clin. 2006; 35(1):201–219.
19. Schiff, ER, Sorrell, MF, Maddrey, WC. Schiff’s diseases of the liver, ed 10. Philadelphia: Lippincott Williams &
Wilkins; 2007.
Additional Readings
Garc ia-Tsao G. Portal hypertension. Curr Opin Ga stroenterol. 2006; 22(3):254–262.
Hou W, S anyal, A. J, Asc ites. Diagnosis and -management,. Med Clin North Am. 2009; 93(4):801–817.
Minor, MA, Grac e, ND. Pharmac ologic therapy of portal -hypertension. Clin Liver Dis. 2006; 10(3):563–581.
Thomsen, TW, S haffer, RW, White, B, et al, Videos in c linic al medic ine. parac entesis. N Engl J Med. 2007; 355(19):e21.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 1 0 8
Paracentesis (Assist)
Eleanor Fitzpatric k
PURPOSE:
Abdominal paracentesis is performed to remove fluid from the peritoneal cavity for diagnostic or therapeutic
purposes.
EQUIPMENT
• Commercially prepared kit or the following:
Personal protective equipment, including sterile gloves, mask, goggles, and gown
Skin-cleansing solution (povidone-iodine or chlorhexidine preparation)
Sterile marking pen
Sterile towels or sterile drape
Local anesthetic for injection: 1% or 2% lidocaine with epinephrine
5- or 10-mL syringe with 21- or 25-gauge needle for anesthetic
Trocar with stylet, needle (16-, 18-, or 20-gauge), or angiocatheter, depending on abdominal wall thickness
25- or 27-gauge 1½-inch needle
20- or 22-gauge spinal needles
20-mL syringe for diagnostic tap
50-mL syringe if using stopcock technique
Four sterile tubes for specimens
Scalpel and no. 11 knife blade
Three-way stopcock
Sterile 1-L collection bottles with connecting tubing
Nylon skin suture material on cutting needle (4-0 or 5-0) and needle holder
Mayo scissors and straight scissors
Four to six sterile 4 × 4 gauze pads
Sterile gauze dressing with tape or adhesive strip
Stoma bag
Soft wrist restraints
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that a written informed consent form has been obtained by the practitioner performing the procedure. The
assisting practitioner may be a witness to the signing of the consent if needed. Rationale: Paracentesis is an invasive
procedure and requires a signed informed consent form.
• Decompress the bladder either by having the patient void or by inserting a Foley catheter. Rationale: A distended
bladder increases the risk for bladder perforation during the procedure.
• The physician or advanced practice nurse orders plain and upright radiographs of the abdomen before the procedure
is performed. Rationale: Air is introduced during the procedure and may confuse the diagnosis later.
• Perform a pre-procedure verification and time out with the physician or advanced practice nurse, if non-emergent.
Rationale: Ensures patient safety.
• Check that all relevant documents and studies are available before the procedure is started. Rationale: This measure
ensures that the correct patient receives the correct procedure.
• Place the patient in the supine position (may tilt to side of collection slightly for improved fluid positioning).
Rationale: Fluid accumulates in the dependent areas.
• The physician or advanced practice nurse will examine the abdomen for areas of shifting dullness, find landmarks,
and mark appropriately. Rationale: Shifting dullness indicates fluid.
• If the patient has altered mental status, soft wrist restraints may be needed. Rationale: The patient must not move
his or her hands into the sterile field once it has been established.
Procedure for Assisting with Paracentesis
References
1. Arora, G, Keeffe, EB. Management of chronic liver failure until liver transplantation. Med Clin North Am. 2008;
92(4):839–860.
2. Dib, N, Oberti, F, Cales, P, Current management of the complications of portal hypertension. variceal bleeding
and ascites. Can Med Assoc J. 2006; 174(10):1433–1443.
3. Dong, MH, Saab, S. Complications of cirrhosis. Disease A-Month. 2008; 54(7):445–456.
4. Edmiston, CE, Seabrook, GR, Johnson, CP, et al. Comparative of a new and innovative 2% chlorhexidine
gluconate-impregnated cloth with 4% chlorhexidine gluconate as topical antiseptic for preparation of the skin
prior to surgery. Am J Infect Control. 2007; 35(2):89–96.
5. Ferri, FF. Paracentesis. In Ferri F, ed. : Practical guide to the care of the medical patient, ed 7, Philadelphia:
Mosby/Elsevier, 2007.
6. Gines, P, Arroyo, V, Quintero, E, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics
with tense ascites-results of a randomized study. Gastroenterology. 1987; 93(2):234–241.
7. Grewal, P, Martin, P. Pretransplant management of the cirrhotic patient. Clin Liver Dis. 2006; 11(2):431–439.
8. Han, MK, Hyzy, R. Advances in critical care management of hepatic failure and insufficiency. Crit Care Med.
2006; 34(9 Suppl):S225–S231.
9. Hauser SC, ed. Mayo Clinic gastroenterology and hepatology board review, ed 2, Rochester, MN: Mayo Clinic
Scientific Press, 2006.
10. Heidelbaugh, JJ, Sherbondy, M, Cirrhosis and chronic liver failure: part II. complications and treatment. Am Fam
Physician. 2006; 74(5):767–776.
11. Hibbard, JS, Analyses comparing the antimicrobial activity of current antiseptic agents. a review. J Infusion
Nurs. 2005; 28(3):194–207.
12. Kaushik, N, Khalid, A, Brody, D. EUS-guided paracentesis for the diagnosis and management of malignant
ascites. Gastrointest Endosc. 2006; 64(6):908–913.
13. McGibbon, A, Chen, G, Peltekian, K, et al. An evidence-based manual for abdominal paracentesis. Dig Dis Sci.
2007; 52(12):3307–3315.
14. Pare, P, Talbot, J, Hoefs, JC, Serum-ascites albumin concentration gradient. a physiologic approach to the
differential diagnosis of ascites. Gastroenterology. 1983; 85(2):240–244
15. Rodes J, ed.. Textbook of hepatology. from basic science to clinical practice. ed 3. Blackwell Publishing Ltd,
Malden, MA, 2007.
16. Rosenberg, SM. Palliation of malignant ascites. Gastroenterol Clin. 2006; 35(1):189–199.
17. Saab, S, Nieto, JM, Lewis, SK, et al. TIPS versus paracentesis for cirrhotic patients with refractory ascites.
Cochrane Database Syst Rev. 3, 2008.
18. Sanchez, W, Talwalkar, JA. Palliative care for patients with end-stage liver disease ineligible for liver
transplantation. Gastroenterol Clin. 2006; 35(1):201–219.
19. Schiff, ER, Sorrell, MF, Maddrey, WC. Schiff’s diseases of the liver, ed 10. Philadelphia: Lippincott Williams &
Wilkins; 2007.
Additional Readings
Garc ia-Tsao G. Portal hypertension. Curr Opin Ga stroenterol. 2006; 22(3):254–262.
Hou, W, S anyal, AJ, Asc ites. diagnosis and management. Med Clin of North Amer. 2009; 93(4):801–817.
Minor, MA, Grac e, ND, Pharmac ologic therapy of portal hypertension . Clin Liver Dis. 2006; 10(3):563–581.
Thomsen TW, S haffer RW, White B, et al, eds.. Videos in c linic al medic ine. parac entesis, N Engl J Med 355( 19). 2007:e21.
P R OC E D UR E 1 0 9
PURPOSE:
Percutaneous peritoneal lavage is performed for both therapeutic and diagnostic purposes.
EQUIPMENT
• Commercially prepared kit or the following:
Personal protective equipment, including sterile gloves, mask, goggles, and gown
Skin cleansing solution (chlorhexidine or povidone-iodine)
Sterile marking pen
Sterile towels or sterile drape
Razor to shave area, if necessary
Local anesthetic for injection: 1% or 2% lidocaine with epinephrine
5- or 10-mL syringe with 25- or 27-gauge needle for anesthetic
Scalpel and no. 11 knife blade
Trocar with stylet; needle (16-, 18-, or 20-gauge) or angiocatheter; depending on abdominal wall thickness may use
guidewire with floppy tip and 9 to 18 Fr peritoneal lavage catheter
20-mL syringe for diagnostic tap
Sterile intravenous (IV) tubing (without valves) with appropriate sterile connectors for lavage catheter and IV bags
Sterile tubes for specimens
Warmed Ringer’s lactate (RL), normal saline (NS), or antibiotic solution for infusion into abdomen
Three-way stopcock for therapeutic lavage
Nylon skin suture material on cutting needle (4-0 or 5-0) and needle holder
Four to six sterile 4 × 4 gauze pads
Sterile gauze dressing with tape or adhesive strip
Soft wrist restraints
Pressure bag
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Obtain signed informed consent from the patient or decision maker, if possible. In a trauma situation or unresponsive
patient, this may be implied consent. Rationale: Peritoneal lavage is an invasive procedure that requires a signed
consent form.
• Have patient void or insert a urinary drainage catheter. Rationale: A distended bladder increases the risk for
bladder perforation during the procedure.7
• Insert a nasogastric tube unless contraindicated (e.g., in significant facial trauma) and attach to low intermittent
suction. Rationale: A distended stomach increases the risk for perforation during the procedure.6
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the physician or advanced
practice nurse should ensure the correct identification of the patient for the intended intervention.
• Check that all relevant documents and studies are available before starting the procedure. Rationale: This measure
ensures that the correct patient receives the correct procedure.
• Place the patient in the supine position (may tilt to side of collection slightly for improved fluid positioning).
Rationale: Fluid accumulates in the dependent areas.
• Examine abdomen for landmarks and mark appropriately. Shave area, if necessary. Rationale: Correct placement
of catheter for peritoneal lavage minimizes complications.
• For the patient with pain or agitation who is unable to cooperate with the procedure, consider analgesia or sedation. If
sedation is needed for the procedure, institution-specific moderate sedation monitoring should be performed.
Rationale: Analgesia and sedation provide for patient comfort and safety during procedure.
• If the patient has altered mental status, soft wrist restraints may be needed. Rationale: The patient must not move
his or her hands into the sterile field once it has been established.
Procedure for Performing Peritoneal Lavage
FIGURE 109-1 The plastic catheter is placed over the guidew ire and inserted into the peritoneal cavity by means of a tw isting motion at the skin level. After
the catheter has been advanced, the guidew ire is removed. (From Pfenninger JL, Fowler GC, editors: Pfenninger and Fowler’ s procedures for primary care, ed 2, St Louis,
2003, Mosby.)
References
1. Brakenridge, SC, et al. Detection of intra-abdominal injury using diagnostic peritoneal lavage after shotgun
wound to the abdomen. J Trauma. 2003; 54:329–331.
2. Crandall, M, West, MA, Evaluation of the abdomen in the critically ill patient. opening the black box. Curr Opin
Crit Care 2006; 12:333–339.
3. Ferri, FF. Paracentesis. In Ferri FF, ed. : Practical guide to the care of the medical patient, ed 7, Philadelphia:
Mosby/Elsevier, 2007.
4. Griffin, XL, Pullinger, R. Are diagnostic peritoneal lavage or focused abdominal sonography for trauma safe
screening interventions for hemodynamically stable patients -after blunt abdominal trauma? A review of the
literature. J Trauma. 2007; 62:779–784.
5. Jansen, JO, Yule, SR, Loudon, MA. Investigation of blunt abdominal trauma. BMJ. 2008; 336:938–942.
Marx, JA. Peritoneal proc edures. In: Roberts JR, Hedges JR, eds. Clinica l procedures in emergency medicine. ed 4. Philadelphia: S aunders; 2004:733–749.
7. Proehl J, ed.. Diagnostic peritoneal lavage. Emergency nursing procedures. ed 4. Elsevier, St Louis, 2008.
S ato, T, Hirose, Y, S aito, H, et al, Diagnostic peritoneal -lavage for diagnosing blunt hollow visc eral injury. the -ac c urac y of two different c riteria and their
c ombination. S urg Today 2005; 35:935–939.
9. Thacker, LK, Parks, J, Thal, ER, Diagnostic peritoneal -lavage. is 100,000 RBC’s a valid figure for penetrating -
abdominal trauma. J Trauma Injury Infect Crit Care 2007; 62:853–857.
Additional Readings
Bode, PJ, van Vugt, AB. Ultrasound in the diagnosis of injury. Injury. 1996; 27:379–383.
Brown, MA, et al, Blunt abdominal trauma. sc reening US in 2,693 patients. Radiology 2001; 218:352–358.
Goletti, O, et al, The role of ultrasonography in blunt abdominal trauma. results in 250 c onsec utive c ases. J Trauma 1994; 36:178–181.
Gonzalez, RP, et al, Complementary roles of diagnostic peritoneal lavage and c omputed tomography in the evaluation of blunt abdominal trauma. J Tra uma . 2001;
51:1128–1134.
Liu, A, Kaufmann, C, Ritc hie, R. A c omputer-based simulator for diagnostic peritoneal lavage. Stud Hea lth Technol Inform. 2001; 81:278–285.
Marx, JA, et al, Limitations of c omputed tomography in the evaluation of ac ute abdominal trauma. a prospec tive c omparison with diagnostic peritoneal lavage. J
Trauma 1985; 25:933–937.
Maxwell-Armstrong, C, et al, Diagnostic peritoneal lavage analysis. should trauma guidelines be revised. Emerg Med J 2002; 19:524–525.
Root, HD, et al. Diagnostic peritoneal lavage. Surgery. 1965; 57:633–637.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 11 0
PURPOSE:
Percutaneous peritoneal lavage is performed for both therapeutic and diagnostic purposes.
EQUIPMENT
• Commercially prepared kit or the following:
Personal protective equipment, including sterile gloves, mask, goggles, and gown
Skin cleansing solution (chlorhexidine or povidone iodine)
Sterile marking pen
Sterile towels or sterile drape
Razor to shave area, if necessary
Local anesthetic for injection: 1% or 2% lidocaine with epinephrine
5- or 10-mL syringe with 25- or 27-gauge needle for anesthetic
Scalpel and no. 11 knife blade
Trocar with stylet; needle (16-, 18-, or 20-gauge) or angiocatheter; depending on abdominal wall thickness may use
guidewire with floppy tip and 9 to 18 Fr peritoneal lavage catheter
20-mL syringe for diagnostic tap
Sterile intravenous (IV) tubing (without valves) with appropriate sterile connectors for lavage catheter and IV bags
Sterile tubes for specimens
Warmed Ringer’s lactate (RL), normal saline (NS), or antibiotic solution for infusion into abdomen
Three-way stopcock for therapeutic lavage
Nylon skin suture material on cutting needle (4-0 or 5-0) and needle holder
Four to six sterile 4 × 4 gauze pads
Sterile gauze dressing with tape or adhesive strip
Soft wrist restraints
Pressure bag
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that a written informed consent form has been obtained by the practitioner performing the procedure (if
possible). The healthcare provider who is assisting may be a witness to the signing of the consent if needed. In a
trauma situation or with an unresponsive patient, this consent may be implied. Rationale: Peritoneal lavage is an
invasive procedure that requires a signed consent form.
• Have the patient void or insert a urinary drainage catheter. Rationale: A distended bladder increases the risk for
bladder perforation during the procedure.7
• Insert a nasogastric tube unless contraindicated (e.g., in significant facial trauma) and attach to low intermittent
suction. Rationale: A distended stomach increases the risk for perforation during the procedure.6
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the physician or advanced
practice nurse and the healthcare provider assisting in the procedure should ensure the correct identification of the
patient for the intended intervention.
• Check that all relevant documents and studies are available before starting the procedure. Rationale: This measure
ensures that the correct patient receives the correct procedure.
• Place the patient in the supine position (may tilt to side of collection slightly for improved fluid positioning).
Rationale: Fluid accumulates in the dependent areas.
• The physician or advanced practice nurse examines the abdomen for landmarks and marks appropriately.
Rationale: Correct placement of the catheter for peritoneal lavage minimizes complications.
• For the patient with pain or agitation who is unable to cooperate with the procedure, consider analgesia or sedation. If
sedation is needed for the procedure, institution-specific moderate sedation monitoring should be performed.
Rationale: Analgesia or sedation provides for patient comfort and safety during the procedure.
• If the patient has altered mental status, soft wrist restraints may be needed. Rationale: The patient must not move
his or her hands into the sterile field once it has been established.
Procedure for Assisting with Peritoneal Lavage
References
1. Brakenridge, SC, et al. Detection of intra-abdominal injury using diagnostic peritoneal lavage after shotgun
wound to the abdomen. J Trauma. 2003; 54:329–331.
2. Crandall, M, West, MA, Evaluation of the abdomen in the critically ill patient. opening the black box. Curr Opin
Crit Care 2006; 12:333–339.
3. Ferri, FF. Paracentesis. In Ferri, ed. : Practical guide to the care of the medical patient, ed 7, Philadelphia:
Mosby/Elsevier, 2007.
4. Griffin, XL, Pullinger, R. Are diagnostic peritoneal lavage or focused abdominal sonography for trauma safe
screening interventions for hemodynamically stable patients after blunt abdominal trauma? A review of the
literature. J Trauma. 2007; 62:779–784.
5. Jansen, JO, Yule, SR, Loudon, MA. Investigation of blunt abdominal trauma. BMJ. 2008; 336:938–942.
6. Marx, JA. Peritoneal procedures. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. ed
4. Philadelphia: Saunders; 2004:733–749.
7. Proehl J, ed.. Diagnostic peritoneal lavage. Emergency nursing procedures. ed 4. Elsevier, St Louis, 2008.
8. Sato, T, Hirose, Y, Saito, H, et al, Diagnostic peritoneal lavage for diagnosing blunt hollow visceral injury. the
accuracy of two different criteria and their combination. Surg Today . 2005; 35:935–939.
9. Thacker, LK, Parks, J, Thal, ER, Diagnostic peritoneal lavage. is 100,000 RBC’s a valid figure for penetrating
abdominal trauma. J Trauma Injury Infect Crit Care 2007; 62:853–857.
Additional Readings
Bode, PJ, van Vugt AB. Ultrasound in the diagnosis of injury. Injury. 1996; 27:379–383.
Brown, MA, et al, Blunt abdominal trauma. sc reening US in 2,693 patients. Radiology 2001; 218:352–358.
Goletti, O, et al, The role of ultrasonography in blunt abdominal trauma. results in 250 c onsec utive c ases. J Trauma 1994; 36:178–181.
Gonzalez, RP, et al. Complementary roles of diagnostic peritoneal lavage and c omputed tomography in the evaluation of blunt abdominal trauma. J Tra uma . 2001;
51:1128–1134.
Liu, A, Kaufmann, C, Ritc hie, R. A c omputer-based simulator for diagnostic peritoneal lavage. Stud Hea lth Technol Inform. 2001; 81:278–285.
Marx, JA, et al, Limitations of c omputed tomography in the evaluation of ac ute abdominal trauma. a prospec tive c omparison with diagnostic peritoneal lavage. J
Trauma 1985; 25:933–937.
Maxwell-Armstrong C, et al, Diagnostic peritoneal lavage analysis. should trauma guidelines be revised. Emerg Med J 2002; 19:524–525.
Root, HD, et al. Diagnostic peritoneal lavage. Surgery. 1965; 57:633–637.
P R OC E D UR E 111
Endoscopic Therapy
Eleanor Fitzpatric k
PURPOSE:
Endoscopic therapy is performed to control or prevent bleeding from esophageal or gastric varices, gastric or
duodenal ulcer sites, or other selected causes of upper gastrointestinal bleeding.
Table 111-1
Sclerosing Agents
Sclerosants Used for Bleeding Varices 4 Sclerosants Used for Other Causes of Upper GI Bleeding2
• Endoscopic therapy can combine a number of interventions to promote hemostasis, including esophageal band
ligation, injection therapy, laser therapy, thermal coagulation, and transjugular intrahepatic portosystemic shunt
(TIPS), a radiologic intervention.2,11,12
• Ablative therapies, such as the use of a heater probe or bipolar electrocoagulation, are other endoscopic techniques for
the management of bleeding from peptic ulcer disease and other nonvariceal causes of upper GI bleeding. These
therapies are effective as they result in coagulation of a bleeding vessel.2,8
• Passage of the large-bore therapeutic endoscope may stimulate the vagal response in the patient and precipitate
bradydysrhythmias.
• As a result of the sedation and topical anesthetic used, the patient’s gag reflex may be diminished or absent, putting
the patient at risk for aspiration.
• Sedation can put the patient at risk for respiratory depression. A moderate sedation protocol is recommended for use
to guide monitoring of the patient. This protocol should include the use of recommended monitoring and emergency
equipment.
EQUIPMENT
• Therapeutic large-caliber endoscope (rigid or flexible; however, the flexible scope is the usual type used for upper
endoscopy)
• Endoscopic injector needle (23- to 26-gauge, 2- to 5-mm needle; as ordered by physician)
• Three 10-mL syringes filled with sclerosing agent, as prescribed by physician
• Additional therapeutic equipment should be available for management of nonvariceal upper GI bleeding (i.e., laser or
thermal equipment, endoloops or endoclips)
• Esophageal bands should be available for management of known or suspected variceal upper GI bleeding
• Suction setup with connecting tubing
• Rigid pharyngeal suction-tip (Yankauer) catheter
• Safety goggles for each healthcare provider and the patient
• Nonsterile gloves
• Barrier gowns
• Nonsterile 4-inch gauze or washcloth
• Water-soluble lubricant
• Topical anesthesia
• Premedications (as prescribed by physician)
• Two 30- to 60-mL syringes
• Normal saline (NS) solution or tap water for irrigation
• Oral airway or bite block
• Cardiac monitor
• Pulse oximeter
• Automatic blood pressure cuff
• Emergency intubation equipment
Additional equipment, to have available as needed, includes the following:
• Nasogastric (NG) tube, Minnesota tube, or Sengstaken-Blakemore tube for esophagogastric tamponade (see Procedure
104)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient.
• Check that all relevant documents and studies are available before starting the procedure. Rationale: This measure
ensures that the correct patient receives the correct procedure.
• Place the patient on a cardiac monitor and apply a pulse oximeter and automatic blood pressure cuff. Rationale:
This allows for close cardiovascular and respiratory monitoring during the procedure.
• Ensure venous access is in place. Rationale: Venous access is needed for premedications and emergency
medications.
• Ensure that the patient has been on nothing-by-mouth (NPO) status for at least 4 hours before the procedure.
Rationale: Undigested material in the stomach increases the risk for aspiration and decreases visualization of the GI
tract.
• Have sedatives (common sedatives used include midazolam, diazepam, meperidine, and fentanyl) available (as
prescribed) and administer when requested. Naloxone and flumazenil should be available for narcotic or sedative
reversal. Rationale: Sedation decreases patient anxiety and facilitates cooperation during the procedure.
• Set up the suction with connecting tubing and rigid pharyngeal suction tip attached and a catheter ready.
Rationale: This set up is necessary for suctioning the patient’s oral secretions during the procedure.
• Have atropine available at the bedside. Rationale: Atropine is necessary if a vagal reaction occurs with the insertion
and passage of the endoscope.
• Remove the patient’s dentures. Rationale: Dentures interfere with safe passage of the endoscope.
• Protect the patient’s eyes with goggles or a waterproof covering. Rationale: Protection is provided against accidental
exposure to blood or the sclerosing agents. Sclerosing agents are eye irritants.
Procedure for Assisting with Endoscopic Therapy
FIGURE 111-1 Injection of sclerosing agent into engorged varix. (From Pierce JD, Wilkerson E, Griffiths SA: Acute esophageal bleeding and endoscopic injection therapy,
Crit Care Nurse 10:67-72, 1990.)
FIGURE 111-2 Endoscopic variceal ligation (EVL). A, Endoscope placement over varix. B, The varix is draw n into the distal portion of the endoscope. C, A
rubber band is dropped over the varix. D, The rubber band contracts around the varix, causing it to sclerose and eventually slough. (Drawings by Paul
Schiffmacher, Medical Illustrator, Medical Media Services at Thomas Jefferson University Hospital, Philadelphia.)
References
1. Abraldes, JG, Bosch, J. The treatment of acute variceal bleeding. Clin Gastroenterol. 2007; 41:S312–S317.
[(Suppl)].
2. Cappell, MS, Friedel, D, Acute nonvariceal upper gastrointestinal bleeding. endoscopic diagnosis and therapy.
Med Clin North Am. 2008; 92(3):511–550.
3. Cappell, MS, Friedel, D, Initial management of acute upper gastrointestinal bleeding. from initial evaluation up
to gastrointestinal endoscopy. Med Clin North Am. 2008; 92(3):491–509.
4. Dib, N, Oberti, F, Cales, P, Current management of the complications of portal hypertension. variceal bleeding.
Can Med Assoc J. 2006; 174(10):1433–1443.
5. Di Mario F, Battaglia, G, Leandro, G, et al, Short-term treatment of gastric ulcer. a meta analytical evaluation
of blind trials. Dig Dis Sci. 1996; 41(6):1108–1131.
6. Ferri, FF. Paracentesis. In Ferri F, ed. : Practical guide to the care of the medical patient, ed 7, Philadelphia:
Mosby/Elsevier, 2007.
7. Gisbert, JP, Gonzalez, L, Calvet, X, et al, Proton pump inhibitors versus H2 antagonists. a meta analysis of
their efficacy in treating bleeding peptic ulcer. Aliment Pharm Ther. 2001; 15(7):917–926.
8. Hauser SC, ed. Mayo Clinic Gastroenterology and Hepatology Board review, ed 2, Rochester, MN: Mayo Clinic
Scientific Press, 2006.
9. Longacre, AV, Garcia-Tsao G. A commonsense approach to esophageal varices. Clin Liver Dis. 2006; 10(3):613–
625.
10. Messori, A, Trippoli, S, Vaiani, M, et al, Bleeding and pneumonia in intensive care patients given ranitidine
and sulcralfate in the prevention of stress ulcer. a meta analysis of randomized controlled trials. BMJ. 2003;
321(7):1103–1106.
11. Tariq, SH, Mekhjian, G. Gastrointestinal bleeding in older adults. Clin Geriatr Med. 2007; 23(4):769–784.
12. Toubia, N, Sanyal, AJ. Portal hypertension and variceal hemorrhage. Med Clin North Am. 2008; 92(3):551–574.
13. Tryba, M, Prophylaxis of stress ulcer bleeding. a meta analysis. J Clin Gastroenterol. 1991; 13(Suppl 2):S44–
S55.
Additional Readings
DiMaio, CJ. Nonvaric eal upper gastrointestinal bleeding. Ga strointest Endosc Clin North Am. 2007; 17(2):253–272.
Heidelbaugh, JJ, S herbondy, M, Cirrhosis and c hronic liver failure. part II, c omplic ations and treatment. Am Fam Physic ian. 2006; 74(5):767–776.
Khan, S , Tudur S mith C, Williamson, P, et al. Portosystemic shunts versus endosc opic therapy for varic eal rebleeding in patients with c irrhosis. Cochra ne Da ta ba se
Syst Rev. 3, 2008.
Leung, JW, Chung, S C. Endosc opic injec tion of adrenaline in bleeding peptic ulc ers. Ga strointest Endosc. 1987; 33(2):73–75.
Lim, CH, Vani, D, S hah, S G, et al, The outc ome of suspec ted upper gastrointestinal bleeding with 24-hour ac c ess to upper gastrointestinal endosc opy. a
prospec tive c ohort study. Endosc opy. 2006; 38(6):581–585.
Marmo, R, Rotondano, G, Pisc opo, R, et al, Dual therapy versus monotherapy in the endosc opic treatment of high-risk bleeding ulc ers. a meta-analysis of
c ontrolled trials. Am J Gastroenterol. 2007; 102(2):279–289.
S hibli, AB, Tac hauer, A, S mruti, R. Outpatient management of c irrhosis. South Med J. 2006; 99(6):559–561.
S iersema, PD. Therapeutic esophageal interventions for dysphagia and bleeding. Curr Opin Ga stroenterol. 2006; 22(4):442–447.
Talwalkar, JA. Cost effec tiveness of treating esophageal varic es. Clin Liver Dis. 2006; 10(3):679–689.
Zaman, A, Portal hypertension-related bleeding. management of diffic ult c ases. Clin Liver Dis. 2006; 10(3):353–370.
UNIT V
Renal System
SECTION SEVENTEEN
Renal Replacement
P R OC E D UR E 11 2
PURPOSE:
Continuous renal replacement therapies are used in the critical care unit setting for volume regulation, acid-
base control, electrolyte regulation, drug intoxications, management of azotemia, and immune modulation. These
methods are most often used in critically ill patients whose hemodynamic status does not tolerate the rapid fluid
and electrolyte shifts associated with hemodialysis or who need continuous removal or regulation of solutes and
intravascular volume.
Table 112-1
Continuous Renal Replacement Therapies
Adapted from Giuliano K, Pysznik E: Renal replacement therapy in critical care: implementation of a unit-based CVVH program, Crit Care Nurse 18:40-45, 1998.
FIGURE 112-2 Continuous venovenous hemofiltration (CVVH). Fluid removal and fluid replacement. (Copyright Rhonda K. Martin. All rights reserved. Used with
permission.)
FIGURE 112-3 Continuous venovenous hemodialysis (CVVHD). Fluid and solute removal w ith dialysate. (Copyright Rhonda K. Martin. All rights reserved. Used with
permission.)
FIGURE 112-4 Continuous venovenous hemodiafiltration (CVVHDF). Fluid replacement w ith dialysate. (Copyright Rhonda K. Martin. All rights reserved. Used with
permission.)
• A blood pump provides the pressure that drives the system; the blood circuit consists of blood lines, a blood pump,
and various monitoring devices. The blood lines carry the blood to and from the patient. The blood pump controls
the speed of the blood through the circuit. The monitoring devices include arterial and venous pressure monitors and
an air detection monitor to prevent air that may have entered the circuit from being returned to the patient.
Anticoagulant, dialysate, and replacement fluids can also be added to the system.
Integrated pump systems have separate pumps for blood, dialysate, ultrafiltrate/effluent, and replacement fluids
(Fig. 112-5). The pumps are controlled by a computerized control module. Blood flow rate, dialysate flow rate,
anticoagulation rate, and fluid removal rates are entered by the nurse per medical guidelines. Dialysate,
ultrafiltrate/effluent, and replacement fluids are measured by weight or volumetric scales on the unit. The module
calculates and adjusts pump speeds to achieve the selected fluid goal. The module also records and displays
treatment data.
FIGURE 112-5 Gambro Prismaflex CRRT machine. (Courtesy Gambro USA, Lakewood, Colo.)
• SCUF (see Fig. 112-1) is used primarily to remove plasma water. A hemofilter with a large surface area, high sieving
coefficient, and low resistance is used to facilitate slow continuous fluid removal.
• CVVH (see Fig. 112-2) removes fluids and solutes via convection. Replacement solution is part of the setup; the
replacement solution creates a solute drag effect.
• CVVHD (see Fig. 112-3) is used to remove solutes primarily via diffusion. Dialysate solution is part of the setup; flow
of the dialysate is countercurrent to the blood flow.
• CVVHDF (see Fig. 112-4) removes fluids and solutes via diffusion and convection. Dialysate runs countercurrent to
the blood flow. Intravenous or blood circuit replacement fluid is used continuously based on the amount of UF
removed each hour and net fluid goals for the patient.
• Other extended renal replacement therapy techniques or “hybrid” techniques (sustained low-efficiency dialysis
[SLED], extended daily dialysis [EDD]) generally use standard hemodialysis equipment with reduced blood flow and
dialysate rates to gradually remove plasma water and solutes. They are used from 4 to 12 hours a day.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• When CRRT is initiated, ensure that informed consent has been obtained. Rationale: Informed consent protects the
rights of the patient and makes a competent decision possible for the patient.
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Position the patient in a comfortable position (that also facilitates optimal blood flow through the vascular access).
Rationale: The patient and family must understand that movement during the procedure may affect the blood flow
through the system and that a comfortable position before the initiation of therapy is important. They should also
understand that different access sites may require different patient positions to facilitate optimal blood flow. Choose a
position that allows for setup of the sterile field. The nurse who sets up the sterile field and initiates therapy must be
able to easily reach all the necessary supplies.
Procedure for Initiation and Termination of Continuous Renal Replacement Therapy
References
1. Bellomo, R, Ronco, C, Mehta, R. Nomenclature for continuous renal replacement therapies. Am J Kidney Dis.
1996; 28:S2–S7.
2. Bouman, CS, High-volume hemofiltration as adjunctive therapy for sepsis and systemic inflammatory response
syndrome. background, definition and a descriptive analysis of animal and human studies. Adv Sepsis 2007;
6:57–74.
3. Craig, M. Slow extended daily dialysis (SLEDD) and continuous renal replacement therapies (CRRT). In: Counts
C, ed. Core curriculum for nephrology nursing. ed 5. Pitman, NJ: American Nephrology Nurses’ Association;
2008:132–229.
4. Dirkes, S, Hodge, K, Continuous renal replacement therapy in the adult intensive care unit. history and current
trends. Crit Care Nurse 2007; 27:61–81.
5. Fiore, GB, Ronco, C. Principles and practice of internal hemodiafiltration. Contrib Nephrol. 2007; 158:177–184.
6. Gibney, N, et al. Volume management by renal replacement therapy in acute kidney injury. Int J Artif Organs.
2008; 31:145–155.
7. Giuliano, K, Pysznik, E, Renal replacement therapy in critical care. implementation of a unit-based CVVH
program. Crit Care Nurse 1998; 18:40–45.
8. Goldstein-Fuchs J. Nutrition and chronic kidney disease. In: Molzahn A, Butera E, eds. Contemporary nephrology
nursing: principles and practice. ed 2. Pitman, NJ: American Nephrology Nurses’ Association; 2006:371–391.
9. Jones, S. Heat loss and continuous renal replacement therapy. AACN Clin Issues. 2004; 15:223–230.
10. National Kidney Foundation (NKF), KDOQI clinical practice guidelines for vascular access. update 2006. Am J
Kidney Dis 2006; 48:S176–S307.
11. Ricci, Z, Ronco, C, Dose and efficiency of renal replacement therapy. continuous replacement therapy versus
intermittent hemodialysis versus extended daily dialysis. Crit Care Med 2008; 36:S229–S237.
12. Rickard, C, et al, Preventing hypothermia during continuous veno-venous haemodiafiltration. a randomized
controlled study. J Adv Nurs 2004; 47:393–400.
13. Ronco, C, et al. Potential interventions in sepsis-related acute kidney injury. Clin J Am Soc Nephrol. 2008; 3:531–
544.
14. Ronco, C, et al, Outcome comparisons of intermittent and continuous therapy in acute kidney injury. what do
they mean. Int J Artif Organs 2008; 31:213–220.
15. Pannu, N, et al. Renal replacement therapy in patients with acute renal failure. JAMA. 2008; 299:793–805.
16. Pronovost, P, et al. An intervention to decrease catheter-related blood stream infections in the ICU. N Engl J Med.
2006; 355:2725–2734.
17. Tolwani, AJ, et al. Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol.
2008; 19:1233–1238.
18. Uchino, S, et al, Continuous renal replacement therapy . a worldwide practice survey. Intensive Care Med 2007;
33 :1563–1570.
19. White, RB, Vascular access for hemodialysisMolzahn A, Butera E, eds.. Contemporary nephrology nursing:
principles and practice. ed 2. 2006 . American Nephrology Nurses’ Association: Pitman, NJ:559–578.
20. Young, E, et al. Incidence and influencing factors associated with exit site infections in temporary catheters for
hemodialysis and apheresis. Nephrol Nurs J. 2005; 32:41–50.
Additional Readings
Clark, WR, et al. Rec ent c linic al advanc es in the management of c ritic ally ill patients with ac ute renal failure. Blood -Purifica tion. 2006; 24:487–498.
Oudemans-van S traaten HM, et al, Antic oagulation strategies in c ontinuous renal replac ement therapy. c an the c hoic e be evidenc e based. Intensive Care Med
2006; 32:188–202.
Palsson, R, et al. Choic e of replac ement solution and -antic oagulation in c ontinuous venovenous hemofiltration. Clin Nephrol. 2006; 65:34–42.
P R OC E D UR E 11 3
Hemodialysis
S onia M. Astle
PURPOSE:
Hemodialysis is performed for volume regulation, acid-base control, electrolyte regulation, management of
azotemia, and the treatment of drug intoxications.
FIGURE 113-1 Components of a typical hemodialysis system. (From Thompson JM, et al, editors: Mosby’ s manual of clinical nursing, St Louis, 1989, Mosby.)
• Requirements for ensuring adequate therapy include: 1, an appropriate prescription; 2, a high level of nursing
expertise; 3, an efficiently operating hemodialysis machine; 4, satisfactory access; 5, an informed patient; and 6,
ongoing data review.11
• Knowledge of the principles of diffusion, ultrafiltration (UF), osmosis, oncotic pressure, and hydrostatic pressure as
they pertain to fluid and solute management during dialysis is neccessary.2,4,5
Diffusion is the passive movement of solutes through a semipermeable membrane from an area of higher to lower
concentration until equilibrium is reached.
Ultrafiltration is the bulk movement of solute and solvent through a semipermeable membrane with a pressure
movement. This movement is usually achieved with positive pressure in the blood compartment of the hemofilter
and negative pressure in the dialysate compartment. Blood and dialysate run countercurrent to each other (in
opposite directions). The size of the solute molecules as compared with the size of molecules that can move through
the semipermeable membrane determines the degree of UF.
Osmosis is the passive movement of solvent through a semipermeable membrane from an area of higher to lower
concentration.
Oncotic pressure is the pressure exerted by plasma proteins that favors intravascular fluid retention and movement of
fluid from the extravascular to the intravascular space.
Hydrostatic pressure is the force exerted by arterial blood pressure that favors the movement of fluid from the
intravascular to the extravascular space.
Absorption is the process by which drug molecules pass through membranes and fluid barriers and into body fluids.
Adsorption is the adhesion of molecules (solutes) to the surface to the hemofilter, charcoal, or resin.
Convective transport is the rapid movement of fluid across a semipermeable membrane from an area of high pressure
to an area of low pressure with transport of solutes. When water moves across a membrane along a pressure
gradient, some solutes are carried along with the water and do not require a solute concentration gradient (also
called solute drag). Convective transport is most effective for the removal of middle-molecular-weight and large-
molecular-weight solutes.
• Vascular access is needed to perform hemodialysis and can be provided with a double-lumen vascular access catheter
(VAC), an external arteriovenous (AV) shunt, or a surgically created AV anastomosis (e.g., fistula or graft). Common
sites for the VAC include the internal jugular or subclavian vein. Common sites for the external shunt include the
forearm (radial artery to cephalic vein) or the leg (posterior tibial artery to long saphenous vein). The AV fistula or
graft is used for long-term dialysis management.
• The subclavian vein is not recommended for temporary access because of the increased incidence of vascular stenosis,
which makes the vein of the ipsilateral arm unsuitable for chronic dialysis if needed. The internal jugular or leg veins
are more commonly used.
• Hemodialysis uses an artificial kidney (hemofilter, dialyzer) with a semipermeable membrane to create two separate
compartments: the blood compartment and the dialysis solution (dialysate) compartment. The semipermeable
membrane allows the movement of small molecules (e.g., electrolytes, urea, drugs) and middle-weight molecules
(creatinine) from the patient’s blood into the dialysate but is impermeable to larger molecules (blood cells, plasma
proteins).
• Each dialyzer has four ports: two end ports for blood (in one end and out the other) and two side ports for dialysis
solution (also in one end and out the other). In most cases, the blood and dialysate are run through the dialyzer in
opposite or countercurrent directions.
• The hollow-fiber dialyzer is the most commonly used dialyzer. With this dialyzer, the blood flows through the center
of hollow fibers and the dialysate flows around the outside of the hollow fibers. The advantages of hollow-fiber filters
include a low priming volume, low resistance to flow, and high amount of surface area. The major disadvantage is the
potential for clotting because of the small fiber size.
• Parallel-plate dialyzers are designed as sheets of membrane over supporting structures. Blood and dialysate pass
through alternate spaces of the dialyzer. The major disadvantages of this type of filter are the increase in allergic
dialyzer reactions and lower filter surface area.
• All dialyzers have UF coefficients; thus, the dialyzer selected varies in different clinical situations. The higher the UF
coefficient, the more rapid the fluid removal. UF coefficients are determined with in vivo measurements done by each
dialyzer manufacturer.
• Clearance refers to the ability of the dialyzer to remove metabolic waste products from the patient’s blood. The blood
flow rate, the dialysate flow rate, and the solute concentration affect clearance. Clearance occurs by the processes of
diffusion, convection, and UF.2-4,8-10
• The blood circuit consists of blood lines, a blood pump, and various monitoring devices. The blood lines carry the
blood to and from the patient. The blood pump controls the speed of the blood through the circuit. The monitoring
devices include arterial and venous pressure monitors and an air detection monitor to prevent air entering the circuit
from being returned to the patient.
• The dialysate is composed of water, a buffer (e.g., acetate or bicarbonate), and various electrolytes. Most solutions also
contain glucose. The buffer helps neutralize acids that are generated as a result of normal cellular metabolism and
usually are excreted by the kidney. The concentration of electrolytes is usual normal plasma concentrations, which
help to create a concentration gradient for removal of excess electrolytes. The glucose, available in various
concentrations, promotes the removal of plasma water.
• Heparin is usually used during dialysis to prevent clotting of the circuit. In patients with coagulopathies, normal saline
solution flushes can be used to keep the blood circuit patent.5 Heparin should be avoided in patients with a history of
heparin-induced thrombocytopenia (HIT).2,10
• Because large volumes of water are used during treatments to generate the dialysate, the water must be purified before
patient use to prevent patient exposure to potentially harmful substances present in the water supply (e.g., calcium
carbonate, sodium chloride, and iron).
• Other extended renal replacement therapy techniques or “hybrid” techniques (sustained low-efficiency dialysis
[SLED], extended daily dialysis [EDD]) generally use standard hemodialysis equipment and techniques with reduced
blood flow and dialysate rates to gradually remove plasma water and solutes in the critically ill patient. They are used
from 4 to 12 hours a day.8
• The adequacy of dialysis and assessment of the patient’s residual renal function should be evaluated on a periodic
basis. Adequacy of dialysis can be measured with urea kinetic modeling (Kt/V) or urea clearance.2,4,14,15 Residual renal
functioning can be monitored with urine creatinine clearance.14,15 Collaboration with the nephrology team is
necessary to monitor these parameters.2,4,5
EQUIPMENT
• Fluid shield face masks or goggles
• Sterile and nonsterile gloves
• Sterile gowns
• Sharps container
• Sterile normal saline (NS) solution, 3 L
• Two 10-mL syringes with blunt-tip cannulas
• Two 3-mL syringes
• Dressing supplies (sterile barrier, 4 × 4 gauze pads, transparent dressing, tape)
• Povidone-iodine, hypochlorite, or chlorhexidine bactericidal solution (follow institution standard)
• Heparin (1000 units/mL; for both priming and infusion, as ordered)
• Sterile bowl for soaking of 4 × 4 pads with bactericidal solution
• Antiseptic solution
• Hemostats
• Replacement fluid, as ordered
• Dialysate fluid, as ordered
• Alcohol wipes
Additional equipment for graft cannulation includes the following:
• Two 10-mL syringes with blunt-tip cannulas
• NS solution for injection
• Two fistula needles
• Chlorhexidine swabs
• 1% lidocaine and two tuberculin syringes with 25-gauge needles
• Two hemostats
Additional equipment for initiation of hemodialysis includes the following:
• Dialysis machine, tubing, dialyzer, and dialysate solution/water treatment setup
• Two hemostats
• One 30-mL syringe
Additional equipment, to have available depending on patient need, includes the following:
• One tourniquet (AV fistula only)
• Loading dose of heparin (if ordered)
• Equipment for termination of hemodialysis includes the following:
Four hemostats
2 × 2 gauze pads
NS solution, 1000 mL
Four bandages, tape
Fluid shield face masks or goggles
Nonsterile gloves
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure the patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Position the patient in a comfortable position (that also facilitates optimal blood flow through the access site and allows
for the setup of a sterile field). Rationale: Facilitation of patient comfort helps to minimize the amount of patient
movement during treatment, which can change the amount of blood flow through the access site. Different access
sites may require different patient positions to facilitate optimal blood flow.
• With AV fistula use, ask the patient whether he or she wants lidocaine used on the access site before the fistula is
accessed. Rationale: Patient comfort is promoted, and anxiety may be reduced.
Procedure for Hemodialysis
References
1. Allon, M, Dialysis catheter-related bacteremia. treatment and prophylaxis. Am J Kidney Dis 2004; 44:779–
791.
2. Amato, RL. Hemodialysis. In: Counts CS, et al, eds. Core curriculum for nephrology nursing. ed 5. Pitman, -NJ:
American Nephrology Nurses Association; 2008,:-657–681.
3. Bouman, CS, High-volume hemofiltration as adjunctive therapy for sepsis and systemic inflammatory response -
syndrome. background, definition and a descriptive analysis of animal and human studies. Adv Sepsis 2007;
6:74–77.
4. Burrows-Hudson S, Prowant, B. Nephrology nursing standards of practice and guidelines for care,. Pitman, NJ:
American Nephrology Nurses Association; 2005,.
5. Challinor, P. Hemodialysis. In: Thomas N, ed. Renal nursing. ed 3. Edinburg: Ballierre Tindall; 2008:181–222.
6. Dinwiddie, LC, Managing catheter dysfunction for better patient outcomes. a team approach. Nephrol Nurs J
2004; 31:653–660.
7. Goldstein-Fuchs, J, Contemporary nephrology nursing. principles and practice. Molzahn, A. Butera, E. Nutrition
and chronic kidney disease. ed 2. American Nephrology Nurses’ Association, Pitman, NJ, 2006:371–391.
8. Golper, T, Hybrid renal replacement therapies in critically ill patients. sepses, kidney and multiple organ
dysfunction. Contrib Nephrol 2004; 114:278–283.
9. Kellum, JA, et al. The 3rd International Consensus -Conference of the Acute Dialysis Quality Initiative
(ADQI). Int J Artif Organs. 2005; 28:441–444.
10. Kraus, MA, Renal replacement therapy, part 1. indications and modalitiesMolitoris BA, ed.. Critical care -
nephrology. Remedica: London, 2005,:151–156.
11. Latham, CE. Hemodialysis technology. In: Molzahn A, Butera E, eds. Contemporary nephrology nursing: principles
and practice. ed 2. Pitman, NJ: American Nephrology Nurses’ Association; 2006:548.
12. MacRae, JM, et al, The cardiovascular effects of -arteriovenous fistulas in chronic kidney disease. a cause for
concern. Semin Dialysis 2006; 19:349–352.
13. National Kidney Foundation (NKF), KDOQI clinical practice guidelines for vascular access. update 2006. Am J
Kidney Dis 2006; 48:S176–S307.
14. Palevsky, PM, et al, Design of the VA/NIH Acute Renal Failure Trial Network (AN) Study. intensive versus
conventional renal support in acute renal failure. Clin Trials 2005; 2:423–435.
15. Palevsky, PM, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med.
2008; 359:7–20.
16. Robins, DC, Hemodialysis. prevention and management of treatment complicationsMolzahn A, Butera E, eds..
Contemporary nephrology nursing: principles and practice. ed 2. American -Nephrology Nurses’ Association,
Pitman, NJ, 2006:581–623.
17. White, RB. Vascular access for hemodialysis. In: Molzahn A, Butera E, eds. Contemporary nephrology nursing:
principles and practice. ed 2. Pitman, NJ: American Nephrology Nurses’ Association; 2006:559–578.
18. Young, EJ, et al. Incidence and influencing factors associated with exit site infections in temporary catheters for
hemodialysis and apheresis. Nephrol Nurs J. 2005; 32:41–50.
Additional Readings
Ball, L. The buttonhole tec hnique for arteriovenous fistula c annulation. Nephrol Nurs J. 2006; 33:299–304.
Bellomo, R, et al, Ac ute renal failure. definition, outc ome measures, animal models, fluid therapy and information tec hnology needsthe S ec ond International
Consensus Conferenc e of the Ac ute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8:R204–R212.
Burrowes, JD, Van Houten, G. Herbs and dietary supplement use in patients with stage 5 c hronic kidney disease. Nephrol Nurs J. 2006; 33:85–88.
Fry, AC, Farrington, K. Management of ac ute renal failure. Postgra d Med J. 2006; 82:106–116.
Desai, AA, et al, Identifying best prac tic es in dialysis c are. results of c ognitive interviews and a national survey of dialysis providers. Clin J Am S oc Nephrol 2008;
3:1066–1076.
Denhaerync k, K, et al. Prevalenc e and c onsequenc es of nonadherenc e to hemodialysis regimens. Am J Crit Ca re. 2007; 16:222–235.
Gomez, N, Prac tic e issues in nephrology nursing. foc us on -issues from ANNA’s spec ial interest groupsNational S ymposium S pec ial Interest Group
presentations. Nephrol Nurs J/J Am Nephrol Nurs Assoc 2003; 30:333–341.
Liangos, O, Epidemiology and outc omes of ac ute renal failure in hospitalized patients. a national survey. Clin J Am S oc Nephrol 2006; 1:43–51.
Metta, R, et al, S pec trum of ac ute renal failure in the intensive c are unit. the PICARD experienc e. Kidney Int 2004; 66:-1613–1621.
Ostermann, M, et al. Ac ute kidney injury in the intensive c are unit ac c ording to RIFLE. Crit Ca re Med. 2007; 35:1837–1843.
Overberger, P, et al, Management of renal replac ement therapy in ac ute kidney injury. a survey of prac titioner presc ribing prac tic es. Clin J Am S oc Nephrol 2007;
2:623–630.
Pupim, LB, et al. Nutrition and metabolism in kidney disease. Semin Nephrol. 2006; 26:134–157.
Rauf, AA, et al. J Intensive Ca re Med. 2008; 23:195–203.
Uc hino, S , et al, Ac ute renal failure in c ritic ally ill patients . a multinational, multic enter study. JAMA 2005; 294:813–818.
P R OC E D UR E 11 4
Peritoneal Dialysis
S onia M. Astle
PURPOSE:
Peritoneal dialysis is used for the removal of fluid and toxins, the regulation of electrolytes, and the management
of azotemia.
FIGURE 114-1 Tenckhoff catheter used in peritoneal dialysis. (From Lewis SM et al (2007). Medical-surgical nursing: Assessment and management of clinical problems, ed
7, Mosby.)
• A small-framed adult can usually tolerate 2 to 2.5 L of dialysate, whereas a large-framed adult may be able to tolerate
up to 3 L in the abdominal cavity. The larger the volume of dialysate, the more effective the removal of blood urea
nitrogen (BUN) and creatinine6,9,11 ; however, peritoneal clearance may be improved with more frequent exchange
rather than an increase in the exchange volume.5 The most limiting factor of the volume of dialysate is that it may
cause direct pressure on the diaphragm and cause a compromise of respiratory excursion.4,14,15 The PD dialysate
contains higher concentrations of glucose than normal serum levels. These higher concentrations aid in the removal of
water via osmosis and small-to-middle-weight molecules (urea, creatinine) via diffusion. Several concentrations of
glucose are available in commercially prepared dialysate solutions. The higher the concentration of glucose in the
dialysate, the greater the amount of fluid removal. Icodextrin, a relatively new alternative to glucose solutions, may be
used as the osmotic agent. This glucose polymer is metabolized to maltose and is not readily absorbed.6,8,12,13
• PD involves repeated fluid exchanges or cycles. Each cycle has three phases: instillation, dwell, and drain.
During the instillation phase, the dialysate is infused via gravity into the patient’s peritoneal cavity through a
peritoneal catheter.1,2,12
During the dwell phase, the dialysate remains in the patient’s peritoneal cavity, allowing osmosis and diffusion to
occur. Dwell time varies based on the patient’s clinical need.
During the drain phase, the dialysate and excess extracellular fluid, wastes, and electrolytes are drained via gravity
from the peritoneal cavity via the catheter.
• PD can be performed either manually with a dialysis administration set with a drainage bag or with a cycler machine
(Fig. 114-2). With a cycler machine, multiple exchanges are programmed into the machine and run automatically.
Cycler machines are infrequently found in the hospital setting but are often used by outpatients for evening and night
exchanges.
FIGURE 114-2 Baxter HomeChoice Pro PD Cycler. (Courtesy Baxter International, Inc, Deerfield, IL.)
• PD catheters can become clogged with the build-up of fibrin. Heparin is sometimes added to the dialysate or used as a
separate flush to prevent occlusion.1,4,9,14,15
• PD dialysate should be warmed to the appropriate temperature in a commercial warmer. Never warm the solution in a
standard microwave oven, which heats unevenly and does not regulate the fluid temperature.14,15
• After each cycle of PD, assess the patient’s vital signs, fluid balance, and any signs of infection and communicate
abnormal findings to the physician.
• The adequacy of dialysis and assessment of the patient’s residual renal function should be evaluated on a periodic
basis. Adequacy of dialysis can be measured with urea kinetic modeling (Kt/V) or urea clearance.6,11 Residual renal
functioning can be monitored with urine creatinine clearance. Collaboration with the nephrology team is necessary to
monitor these parameters.
EQUIPMENT
• Masks
• Goggles or fluid shield face masks
• Sterile and nonsterile gloves
• Sterile 4 × 4 gauze pads
• Sterile containers
• Povidone-iodine, chlorhexidine, or hypochlorite solutions
• Tape
• Sterile barriers
• Plastic hemostats
Additional equipment, to have available depending on patient need, includes the following:
• Equipment for culture
• Equipment for cell count/hematocrit
Additional equipment for initiation of PD includes the following:
• PD administration set with drainage bag
• Warmed dialysate solution
• Cycler with tubing (if being used)
Additional equipment for termination of PD includes the following:
• Sterile catheter caps
• Labels for catheter
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Assist the patient in applying a mask. Rationale: The risk for airborne and nasal pathogens is decreased.
• Reposition patient to a comfortable position. Rationale: Proper positioning is important to ensure patient comfort,
optimize respiratory status, and facilitate optimal flow through the abdominal catheter.
Procedure for Peritoneal Dialysis
References
1. Ash, SR, Chronic peritoneal dialysis catheters. procedures for placement, maintenance and removal. Semin
Nephrol 2002; 22:221–236.
2. Ash, SR, Chronic peritoneal dialysis catheters. challenges and design solutions. Int J Artif Organs 2006; 29:85–94.
3. Bernardini, J, et al. Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site
infection in peritoneal dialysis patients. J Am Soc Nephrol. 2005; 16:539–545.
4. Burrows-Hudson S, Prowant, B. Nephrology nursing standards of practice and guidelines for care,. Pitman, NJ:
American Nephrology Nurses’ Association; 2005.
5. Churchill, DN. Impact of peritoneal dialysis dose guidelines on clinical outcomes. Perit Dial Int. 2005; 25:S95–
S98.
6. Crabtree, JH. Rescue and salvage procedures for mechanical and infectious complications of peritoneal dialysis.
Int J Artif Organs. 2006; 29:67–84.
7. Diaz-Buxo JA. Complications of peritoneal catheters: early and late. Int J Artificial Organs. 2006; 29:50–58.
8. Goffin, E. Aseptic peritonitis and icodextrin. Perit Dial Int. 2006; 26:314–316.
9. Luongo, M, Biel, L. Peritoneal dialysis in the acute care setting. In: Counts C, ed. Core curriculum for -nephrology
nursing,. ed 5. Pitman, NJ: American Nephrology Nurses’ Association; 2008:215–230.
10. McIntyre, CS. Update on peritoneal dialysis solutions. Kidney Int. 2007; 71:486–490.
11. National Kidney Foundation (NKF), KDOQI clinical practice guidelines for vascular access. update 2006. Am J
Kidney Dis 2006; 48:S176–S307.
12. Negoi, D, et al. Current trends in the use of peritoneal dialysis catheters. Adv Perit Dial. 2006; 22:147–152.
13. Piraino, B. Peritoneal Dialysis infections recommendations [review]. Contrib Nephrol. 2006; 150:181–186.
14. Prowant, BF, et al, Peritoneal dialysis Counts CS, ed.. Core curriculum for nephrology nursing. ed 5. American
Nephrology Nurses’ Association, Pitman, NJ, 2008:657–681.
15. Wild, J. Peritioneal dialysis. In: Thomas N, ed. Renal nursing. ed 3. Edinburg: Ballierre Tindall; 2008:223–275.
Additional Readings
Chin, AI, Yeun, JY, Enc apsulating peritoneal sc lerosis. an -unpredic table and devastating c omplic ation of peritoneal dialysis. Am J Kidney Dis 2006; 47:697–712.
Crabtree, JH, et al, Optimal peritoneal dialysis c atheter type and exit site loc ation. an anthropometric analysis. AS AIO J 2005; 51:743–747.
Erixon, M, et al, Take c are in how you store your PD fluids. ac tual temperature determines the balanc e between -reac tive and non-reac tive GDPs. Perit Dial Int
2005; 25:583–590.
S c anziani, R, et al. Imaging work-up for peritoneal ac c ess c are and peritoneal dialysis c omplic ations. Int J Artif Orga ns. 2006; 29:142–152.
UNIT VI
Hematologic System
SECTION EIGHTEEN
Fluid Management
P R OC E D UR E 11 5
PURPOSE:
A massive transfusion is defined as 10 or more units of blood within the first 24 hours of admission.3,13 Rapid
infusers are used to warm and quickly infuse multiple units of blood and intravenous fluids into patients with
hemodynamically unstable conditions. Patients with severe trauma, gastrointestinal hemorrhage, postoperative
hemorrhage, and intravascular losses, as occur in septic shock and burns, may need the rapid administration of
large volumes of blood products and intravenous fluids to restore and maintain intravascular volumes. A
pressure infusor bag is used to administer a large amount of intravenous fluid or blood products to a patient with
life-threatening hemorrhage within a prescribed period of time.
• IV catheters for aggressive fluid resuscitation should have a large bore and short diameter to facilitate the rapid
infusion of large volumes of IV fluids and blood products. Usually, multiple IVs are used, including peripheral and
central sites. Venous access may also be obtained surgically via a venous cut-down of the basilic or saphenous veins
when peripheral access cannot be obtained.12
• Both crystalloid and colloid IV solutions are used for resuscitating patients who are hypovolemic with
hemodynamically unstable conditions. Crystalloids directly increase the intravascular volume. Colloids expand
plasma volume by pulling interstitial fluid back into the vascular space via osmosis. Numerous crystalloid and colloid
preparations are available in isotonic, hypotonic, and hypertonic preparations. Crystalloids most commonly used in
aggressive fluid resuscitation are 0.9% normal saline (NS) and lactated Ringer’s (LR) solutions.
• The use of colloids such as albumin, dextran, and hetastarch allows the effective restoration of intravascular volume
with smaller amounts of fluid; however, these colloids coat red blood cells (RBCs) and platelets, which may result in
type and cross-match difficulties and clotting problems. Even slight overresuscitation with colloids increases the risk
for fluid overload and pulmonary edema.12,14
• Blood and blood products are natural colloids used to replace lost blood and restore coagulation factors. In the patient
with significant ongoing hemorrhage, infusion of blood and clotting factors is critical to restoring intravascular
volume. Type O-negative blood is the universal donor for all patients and can be given in extreme emergencies before
the completion of typing and crossmatching. PRBCs and whole blood are used to replace oxygen-carrying
components; FFP, platelets, and cryoprecipitate are used to replace essential clotting factors.2
• When large volumes of IV fluids are being infused into patients, the fluids must be warmed to prevent hypothermia.
(Although institutions vary in what constitutes large volumes, a good rule of thumb is to institute fluid rewarming
measures when more than 2 L of fluid are required in less than 1 hour.)
• Hypothermia is a common consequence of aggressive fluid resuscitation and has serious physiologic consequences. It
is correlated with mortality when the patient’s body temperature decreases below 34°C17 and significantly prolongs
coagulation times at or below 35°C.7 Moderate hypothermia (32° to 34°C) reduces coagulation factor activity
approximately 10% for each degree Celsius decrease in temperature while markedly affecting platelet function.8
Measures to prevent and treat hypothermia include solar blankets, heated blankets, body bags, warmed blood
products and fluids, continuous arteriovenous rewarming, and cardiopulmonary bypass, used in extreme cases of
hypothermia (see Procedure 94).1
• Patients who have received multiple transfusions and aggressive fluid resuscitation are at risk for multiple
complications as a result of shock and from the fluids and blood products themselves. These sequelae may include
fluid overload, adult respiratory distress syndrome, acute tubular necrosis, hypothermia, hypokalemia, hypocalcemia,
hemolytic and allergic reactions, and air embolism.14
EQUIPMENT
• Rapid infuser (see Fig. 115-1)
• Disposable fluid administration sets (Fig. 115-2)
FIGURE 115-2 Placement of tubing in Level 1 rapid infuser. (Courtesy Level 1, Inc, Rockland, MA.)
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient.
• Ensure that the patient and family understand the need and purpose for rapid infusion. Answer questions as they
arise, and reinforce information as needed. Rationale: Understanding of previously taught information is evaluated
and reinforced.
• Place additional peripheral IV sites. Rationale: Aggressive fluid resuscitation requires additional IV access besides
the one site being used with the rapid infuser. Backup IV sites can be used if other sites infiltrate or become pulled
out; extra sites may also be used to infuse medications, such as vasopressors, that should be kept separate from rapid
infusion lines. Ideal sites for large IV catheter access are the antecubital fossae, saphenous veins, and the veins of the
forearm and upper arm.
• Assist the physician or advanced practice nurse with placement of central venous access or pulmonary artery catheter
or both. Rationale: This placement allows for the assessment of volume status before and after infusion of fluids
and blood products. It also allows for assessment of core temperature with pulmonary artery catheter thermistor and
provides central venous access in the event vasoactive medications are needed.
• Place an automatic blood pressure monitor on the patient’s arm that is not being infused with the rapid infusion
device. Set it to check blood pressure every 5 minutes. Rationale: Assessment of patient’s hemodynamics and
response to fluid replacement is provided. This is used temporarily until an arterial line can be placed by the physician
or advanced practice nurse.
• Assist the physician or advanced practice nurse with placement of an arterial line. Rationale: Placement allows for
continuous assessment of the blood pressure during resuscitation and provides convenient access for blood sampling.
• Obtain a blood sample for type and cross-match. Two tubes should be sent if a large volume of blood is expected to be
transfused. Rationale: This action prepares for blood transfusion.
• Obtain baseline hematocrit, chemistry panel, and coagulation studies. Repeat, as ordered, every 15 to 60 minutes until
hemorrhage is controlled. Rationale: These studies guide proper replacement of blood products and essential
electrolytes.
• Place an indwelling urinary catheter. Rationale: Patients who need aggressive fluid resuscitation should have an
indwelling urinary catheter placed to determine volume status and end-organ perfusion.
• Cover the patient with warm cotton blankets or a warm-air blanket. Cover the patient’s head with a warmed blanket,
a towel, or an aluminum cap. Rationale: Additional heat loss is minimized.
Procedure for Use of Massive Infusion Device
Procedure for Pressure Infusor Bag Use
References
1. Beekley, AC, Damage control resuscitation. a sensible -approach to the exsanguinating patient. Crit Care Med
2008; 36:S267–S274.
2. Casey, AL, et al. A randomized, prospective clinical -trial to assess the potential infection risk associated with
the PosiFlow needleless connector. J Hosp Infection. 2003; 54:288–293.
3. Como, JJ, et al. Blood transfusion rates in the care of acute trauma. Transfusion. 2004; 44:809–813.
4. Cotton, BA, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and -
postinjury complications. J Trauma. 2009; 66:41–49.
5. Dente, CJ, et al. Improvements in early mortality and coagulopathy are sustained better in patients with blunt
trauma -after institution of a massive transfusion protocol in a civilian level 1 trauma center. J Trauma. 2009;
66:1616–1624.
6. Duchesne, JC, et al, Review of current blood transfusions strategies in a mature level 1 trauma center. were we
wrong for the last 60 years. J Trauma 2008; 65:272–277.
7. Gubler, KD, et al. The impact of hypothermia on dilutional coagulopathy. J Trauma. 1994; 36:847–851.
8. Hess, JR, Lawson, JH, The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma 2006;
60 :S12–S19.
9. Holcomb, JB, et al, Damage control resuscitation . directly addressing the early coagulopathy of trauma. J Trauma
2007; 62:307–310.
10. Holcomb, JB. Damage control resuscitation. J Trauma. 2007; 62:S36–S37.
11. Kauvar, DS, Lefering, R, Wade, CE, Impact of hemorrhage on trauma outcome. an overview of epidemiology,
clinical presentations, and therapeutic considerations. J Trauma 2006; 60:S3–S11.
12. Koran, Z, Newberry, L. Vascular access and fluid replacement. In: Emergency Nurses Association, Newberry
L, eds. Sheehy’s emergency nursing. ed 5. St Louis: Mosby; 2003:147.
13. McLaughlin, DF, et al. A predictive model for massive transfusion in combat casualty patients. J Trauma. 2008;
64:S57–S63.
14. McQuillan, KA. Initial management of traumatic shock. In: McQuillan KA, ed. Trauma nursing: from
resuscitation through rehabilitation. ed 3. Philadelphia: Saunders; 2002:151.
15. Nunez, TC, et al, Early prediction of massive transfusion in trauma. simple as ABC (assessment of blood
consumption). J Trauma 2009; 66:346–352.
16. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect
Control. 2002; 30(8):476–489.
17. Shaz, BH, et al. Transfusion management of trauma patients. Anesth Analg. 2009; 108:1760–1768.
Additional Readings
Americ an Assoc iation of Blood Banks. Primer of blood a dministra tion. Bethesda, MD: The Assoc iation; 2002. [revised 12/02,].
S nyder, CW, et al, The relationship of blood produc t ration to mortality. survival benefit or survival bias. J Trauma 2009; 66:358–364.
S tammers, AH, et al. Utilization of rapid-infusor devic es for massive transfusion. Perfusion. 2005; 20:65–69.
SECTION NINETEEN
Special Hematologic Procedures
P R OC E D UR E 11 6
PURPOSE:
Apheresis techniques are used to remove cells, plasma, and other substances from blood. These procedures
are used as adjunctive treatments in many diseases, especially in antibody-mediated conditions that produce
autoantibodies.
Filtration: A hollow-fiber cell separator, permeable to plasma proteins, is used to remove the patient’s plasma via an
apheresis machine or continuous renal replacement machines adapted for pheresis (Fig. 116-2).
FIGURE 116-2 The B. Braun Diapact CRRT system can also be used for therapeutic plasma exchange and plasma adsorption/perfusion. (Photo courtesy B.
Braun Medical, Inc.)
• Treatment length and frequency vary according to the disease being treated, rate of production of the substance being
removed, and the patient’s response to treatment. Acute conditions, such as thrombotic thrombocytopenia purpura
or graft-versus-host disease, usually require daily treatments for 5 to 7 days.6,7 Other conditions usually require plasma
exchanges two or three times weekly for up to 6 weeks.2,5-7 The total amount of plasma to be exchanged is used as a
guide for treatment. A single treatment, referred to as a plasma exchange, usually takes 2 to 3 hours with a centrifugal
machine and 2 to 6 hours with filtration methods.4
• Apheresis procedures are performed by healthcare professionals such as registered nurses or blood bank personnel,
with special knowledge and skills in apheresis. These procedures are commonly performed both in critical care units
and on an outpatient basis, depending on the type of disease being treated and on the patient’s condition.
• The most commonly used apheresis systems use two large-bore peripheral venous catheters, a double-lumen vascular
access catheter (VAC), or a dialysis graft or fistula to access the vascular system. Peripherally inserted central venous
catheters or implantable venous access ports do not provide for adequate blood flow and are not acceptable for use.4
• The system should be primed with an anticoagulant (e.g., heparin or citrate) to prevent clotting. If citrate is used, the
patient must be monitored closely for hypocalcemia. Citrate works as an anticoagulant by binding calcium (Ca++ ),
therefore decreasing the amount of Ca++ available for normal clotting.4
• Plasma exchange is used to treat antibody-mediated disorders because the pathogenic antibodies are contained in the
plasma. Removal of these antibodies through plasma exchange reduces the number of circulating antibodies,
temporarily decreasing the patient’s symptoms.
• Conditions treated by plasma exchange may include the following2,5-7 :
Myasthenia gravis
Guillain-Barré syndrome
Various hematologic disorders
Nephrologic disorders
Rhematologic disorders
Poisoning
Drug overdose/drug toxicity
Acute liver failure
Solid organ transplantation for ABO incompatibility and rejection
Cytokine-mediated injury, such as sepsis, burns, and multisystem organ dysfunction syndrome (MODS);
experimental use
• Current indication categories for therapeutic apheresis, as endorsed by the American Association of Blood Banks
(AABB) and the American Society for Apheresis (ASFA), are listed in Table 116-1.
Table 116-1
Indication Categories for Therapeutic Apheresis
I, Standard therapy, acceptable but not mandatory. II, Available evidence tends to favor efficacy; conventional therapy usually tried first. III, Inadequately tested at this
time. IV, No demonstrated value in controlled trials. P, Pending, includes diseases that can be treated w ith therapeutic apheresis using devices that are not available in
the United States or do not have US Food and Drug Administration (FDA) clearance (ASAF category).
*Indication categories as established by the American Medical Association:
From Szczepiorkowski ZM, Shaz BH, Bandarenko N, et al: The new approach to assignment of ASFA categories: introduction to the fourth special issue: clinical
applications of therapeutic apheresis, J Clin Apherisis 22:96-105, 2007.
• If the patient is taking angiotensin-converting enzyme (ACE) inhibitors, contact with certain filters or membranes in
the apheresis system can cause an anaphylactic reaction and severe hypotension as a result of increased levels of
bradykinin, a potent vasodilator. ACE inhibitors are recommended to be withheld for 48 to 72 hours before
treatment.
• Invasive procedures should be delayed until after the treatment, unless FFP is used as a replacement fluid.
• Potential complications of apheresis techniques include the following:
Bleeding
Thrombocytopenia
Red blood cell (RBC) lysis/hemolysis
Air embolism
Blood leak
Circuit clotting
Hypovolemia
Hypotension
Hypothermia
Vascular access complications
Fever/chills
Shock
Anaphylaxis
Allergic reactions
Transfusion reactions
Electrolyte imbalances
Dysrhythmias
Citrate toxicity
Infection
EQUIPMENT
• Blood cell separator machine
• Blood cell separator tubing set
• Replacement fluids
• Hemostats
• Appropriate laboratory specimen tubes
• Vascular access dressings and flushes
• Nonsterile gloves
• Fluid shield face masks or goggles
• Caps
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and
makes a competent decision possible for the patient.
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Assist the patient to a position of comfort that also facilitates optimal blood flow through the vascular access.
Rationale: Facilitating patient comfort helps to minimize the amount of patient movement during treatment.
Movement can change the blood flow through the access site. Different access sites may require different patient
positions to facilitate optimal blood flow.
Procedure for Assisting with Apheresis/Plasmapheresis
References
1. Garner, Sf, et al, Apheresis donors and platelet function. inherent platelet responsiveness influences platelet
quality. Transfusion 2008; 48:673–680.
2. McLeod, BC. Evidence based therapeutic apheresis in -autoimmune and other haemolytic anemias. Curr Opin
Hematol. 2007; 14:647–654.
3. Rahman, T, Harper, L, Plasmapheresis in nephrology. an update. Curr Opin Nephrol Hypertens 2006; 15:603–
609.
4. Rohe, RM. Therapeutic plasma exchange. In: Counts C, et al, eds. Core curriculum for nephrology nursing. ed 5.
Pitman, NJ: American Nephrology Nurses’ Association; 2008:277–308.
5. Roth, SH. Role of apheresis in rheumatoid arthritis. Drugs. 2006; 66:1903–1908.
6. Szczepiorkowski, ZM, et al, The new approach to assignment of ASFA categories. introduction to the fourth
special issueclinical applications of therapeutic apheresis. J Clin Apher 2007; 22:96–105.
7. Szczepiorkowski, ZM, et al, Guidelines on the use of -therapeutic apheresis in clinical practice. evidence-based
approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apheresis
2007; 22:106–175.
8. Tobian, AA, et al, Transfusion premedications. a growing practice not based on evidence. Transfusion 2007;
47:1089–1096.
Young, EJ, et al. Inc idenc e and influenc ing fac tors -assoc iated with exit site infec tions in temporary c atheters for hemodialysis and apheresis. Nephrol Nurs J. 2005;
32:41–50.
Additional Readings
Heddle, NM, et al, Comparing the effic ac y and safety of apheresis and whole blood-derived platelet transfusions. a systematic review. Transfusion 2008; 48:1447–
1458.
George, JN. Evaluation and management of patients with thrombotic thromboc ytopenic purpura. J Intensive Ca re Med. 2007; 22:82–91.
Greenberg, BM, Idiopathic transverse myelitis. c ortic osteroids, plasma exc hange, or c yc lophosphamide. Neurology 2007; 68:1614–1617.
Thompson, GR, et al. Rec ommendations for the use of LDL apheresis. Atherosclerosis. 2008; 198:247–255.
Van de Watering L. The intention-to-treat princ iple in c linic al trails and meta-analyses of leukoreduc ed blood transfusions in surgic al patients. Tra nsfusion. 2007;
47:573–581.
P R OC E D UR E 11 7
PURPOSE:
The acquisition of a bone marrow aspirate from the core of the bone is used in the diagnosis of hematopoietic
disorders. It is also used to follow the effectiveness of treatment in patients undergoing conventional
chemotherapy, to assess response in the post autologous blood and marrow transplant period as well as
treatment response and engraftment in the post allogeneic stem cell transplant. The preferred site for a bone
marrow aspirate and biopsy is the posterior iliac crest.1 The sternum may be used in aspiration of marrow;
however, a core biopsy cannot be obtained from the sternum because of the risk of damage to underlying
internal organs, most significantly the heart.6,8
EQUIPMENT
EQUIPMENT
• Bone marrow aspiration and biopsy kit, which includes the following:
Povidone-iodine or chlorhexidine-alcohol antiseptic preparation
Sterile fenestrated drape (2)
1 vial lidocaine (1% or 2%; 5-10mLs)
5 or 10-mL syringe for drawing up lidocaine
Filter needle (if lidocaine drawn from glass vial)
Needles of appropriate lengths to anesthetize both skin and periosteum
Sterile 4 × 4 and 2 x 2 gauze pads
Small scalpel blade
Illinois needle (for bone marrow aspirate)
Jamshidi bone biopsy needle (for core biopsy)
20-mL syringe for bone marrow aspirate
Blunt tip needles
Multiple 10-ml syringes with slip tips or adaptor for leur lock
Adhesive bandage
• Sterile gloves
• Sterile gowns
• Fluid shield face mask or goggles
• Required tubes for specimen processing: two edetate disodium (EDTA; lavender top) and two sodium heparin (green
top) tubes (follow institution standard)
• Glass slides and cover plate
• 2½- to 6-inch spinal needle (may be required for anesthetizing periosteum in the obese patient)
• Extra-long Jamshidi needle (may be needed to acquire core specimen in obese patient)
• Container for bone core biopsy specimen, including appropriate fixative (10% formalin or 2 ×2 cotton gauze soaked
with sterile saline solution to keep specimen from drying out)
• 1 vial of 100 units/mL heparin (follow institution standard)
• 1 Additional vial of lidocaine (1% or 2%; 20 mL)
Additional equipment for patients receiving conscious sedation:
• Pulse oximeter
• Automated blood pressure monitor
• Oxygen
• Suction
• Ambu bag
• IV pharmacologic agents for sedation (i.e., midazolam, 2 to 4 mg; fentanyl, 25 to 50 mcg; lorazepam, 1 to 2 mg)
• IV opiate and benzodiazepine antagonist agents (i.e., naloxone and flumazenil)
• Emergency equipment
Patient Preparation
• Ensure that the patient and family understand pre- and postprocedural teachings and discharge instructions. Answer
questions as they arise, and reinforce information as needed. Rationale: Understanding of previously taught
information is evaluated and reinforced. The patient and family understand postprocedure care.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Obtain informed consent for bone marrow aspiration and biopsy and, if indicated, conscious sedation. Rationale:
Informed consent protects the rights of the patient and makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Prescribe analgesia or sedation, if needed. Rationale: Patient may need analgesia or sedation to ensure adequate
cooperation and minimize discomfort during the procedure.
• Follow institution standard for a patient receving conscious sedation. Rationale: Preparation ensures that
appropriate emergency equipment and medical staff are available.
• Obtain IV access for patients receiving sedation. Rationale: A secure patent IV line is necessary for administration of
IV pharmacologic agents and, if necessary, emergency antagonist agents.
• Obtain a complete blood count and differential via venipuncture. Rationale: Many pathologists prefer to review a
peripheral blood sample in conjunction with the marrow to make a complete and accurate diagnostic evaluation.
• Confirm availability of personnel who will assist with the procedure. If the procedure is to be performed without
assistance, prepare all equipment and walk through the procedure for concise and accurate specimen acquisition.
Rationale: Slide preparation, specimen processing, and additional supplies require an appropriately trained assistant
for the procedure if available.
• Assist the patient to an appropriate position depending on the patient’s comfort and the practitioner’s preference.
Rationale: Positioning ensures good visualization and control of the posterior iliac crest.
• Ensure site markings have been made where appropriate. Site may be marked with sterile marking pen. Rationale:
Procedure site is identified.
Procedure for Performing Bone Marrow Biopsy and Aspiration
References
1. Bain, BJ. Bone marrow aspiration. J Clin Pathol. 2001; 54:657–663.
2. Burkle, CM, et al. Morbidity and mortality of deep sedation in outpatient bone marrow biopsy. Am J
Hematol. 2004; 77:250–256.
3. Ellis, LD, Jensen, WN, Westerman, MP. Needle biopsy of bone and marrow; an experience with 1,445
biopsies. Arch Intern Med. 1964; 114:213–221.
4. Gudgin, EJ, Besser, MW, Craig, JIO. Entonox as a sedative for bone marrow aspiration and biopsy. Int J Lab
Hematol. 2008; 30:65–67.
5. Hyun, BH, Gulati, GL, Ashton, JK, Bone marrow examination. techniques and interpretation. Hematol Oncol
Clin North Am 1988; 2:513–523.
6. Riley, RS, et al, A pathologist’s perspective on bone -marrow aspiration and biopsy. 1performing a bone -
marrow examination. J Clin Lab Anal 2004; 18:70–90.
7. Vanhelleputte, P, et al, Pain during bone marrow aspiration. prevalence and prevention. J Pain Symptom
Manage 2003; 26:860–866.
8. Van Marum RJ, Te Velde L. Cardiac tamponade following sternal puncture in two patients. Netherlands J Med.
2001; 59:39–40.
Additional Readings
Aboul-Nasr R, et al. Comparison of touc h imprints with aspirate smears for evaluating bone marrow spec imens. Am J Clin Pa thol. 1999; III(6):753–758.
Bain, BJ. Bone marrow trephine biopsy. J Clin Pa thol. 2001; 54:737–742.
Huyn, BH, S tevenson, AJ, Hanua, CA. Fundamentals of bone marrow examination. Hema tol Oncol Clin North Am. 1994; 8:651–663.
Lawson, S , et al. Trained nurses c an obtain satisfac tory bone marrow aspirates and trephine biopsies. J Clin Pa thol. 1999; 52:154–156.
Lin, EM, Advanc ed prac tic e in onc ology nursing. c ase studies and review,. S aunders, Philadelphia, 2001.
Litwac k, K. Core curriculum for peria nesthesia nursing,, ed 4. Philadelphia: S aunders; 1999.
Quinn, DMD, S c hic k, L, Perianesthesia nursing c ore c urric ulum. preoperative, phase 1 and phase II PACU nursing,. S aunders, Philadelphia, 2004.
Ryan, DH, Cohen, HJ. Bone ma rrow a spira tion a nd morphology, hema tology ba sic principles a nd pra ctice,, ed 3. New York: Churc hill Livingstone; 2000.
Trewhitt, KG. Bone marrow aspirate and biopsy c ollec tion and interpretation. Oncol Nurs Forum. 2001; 28:1409–1415.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 11 8
PURPOSE:
Bone marrow aspiration and biopsy are used for diagnosis and classification of various hematopoietic diseases,
identification of metastatic disease, monitoring of clinical response to treatment, and assessment of engraftment
after bone marrow or stem cell transplantation.
EQUIPMENT
• Bone marrow aspiration and biopsy kit, which includes the following:
Povidone-iodine or chlorhexidine-alcohol antiseptic preparation
Sterile fenestrated drape (2)
1 vial of lidocaine (1% or 2%; 5-10 mL)
5 or 10-mL syringe for drawing up lidocaine
Needles of appropriate lengths to anesthetize both skin and periosteum
Sterile 4 × 4 and 2 × 2 gauze pads
Small scalpel blade
Bone marrow aspirate needle (Illinois needle)
Jamshidi bone biopsy needle (regular or extra long)
20-mL syringe for bone marrow aspirate
10-mL syringes for marrow aspiration
Edetate disodium (EDTA) sterile solution (15 mg/mL; 2 mL total)
Blunt needles for drawing up EDTA, heparin, saline solution
Adhesive bandage
• Sterile gloves
• Filtered needle (if lidocaine drawn from glass vial)
• Fluid shield face mask or goggles
• Specimen bags and labels
• Required tubes for specimen processing: two EDTA (lavender top) and two sodium heparin (green top) tubes (follow
institution standard)
• Glass slides and cover plate
• 2½- to 6-inch spinal needle (may be required for anesthetizing periosteum in the obese patient)
• Container for bone biopsy specimen including appropriate fixative (10% formalin or sterile saline solution–soaked
sterile gauze)
• 1 additional vial of lidocaine (1% or 2%)
• 1 vial of 100 unit/mL heparin (follow institution standard)
Additional equipment for patients receiving conscious sedation:
• Pulse oximeter
• Automated blood pressure monitor
• Oxygen
• Suction
• Ambu bag
• IV pharmacologic agents (i.e., midazolam, 2 to 4 mg; fentanyl, 25 to 50 mcg; lorazepam, 1 to 2 mg)
• IV opiate and benzodiazepine antagonist agents (i.e., naloxone and flumazenil)
• Emergency equipment
Patient Preparation
• Ensure that the patient and family understand pre- and postprocedural teachings and discharge instructions. Answer
questions as they arise, and reinforce information as needed. Rationale: Understanding of previously taught
information is evaluated and reinforced. The patient and family understand postprocedure care. The patient is made a
participant in care.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Obtain informed consent for bone marrow aspiration and biopsy and, if indicated, conscious sedation. Rationale:
Informed consent protects the rights of the patient and makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures patient safety.
• Administer analgesia or sedation as prescribed. Rationale: Patient may need analgesia or sedation to ensure
adequate cooperation and minimize discomfort during the procedure.
• Follow institution standard for a patient receving conscious sedation. Rationale: Preparation ensures that
appropriate emergency equipment and medical staff are available.
• Obtain IV access for patients receiving sedation. Rationale: A secure patent IV line is necessary for administration of
IV pharmacologic agents and, if necessary, emergency antagonist agents.
• Obtain a complete blood count and differential via venipuncture. Rationale: Many pathologists prefer to review a
peripheral blood sample in conjunction with the marrow to make a complete and accurate diagnostic evaluation.
• Confirm availability of personnel who will assist with the procedure. Rationale: Slide preparation, specimen
processing, and obtaining additional supplies require an appropriately trained assistant for the procedure.
• Assist the patient to an appropriate position depending on the patient’s comfort and the practitioner’s preference.
Rationale: Positioning ensures good visualization and control of the posterior iliac crest.
Procedure for Assisting with Bone Marrow Biopsy and Aspiration
References
1. Bain, BJ. Bone marrow aspiration. J Clin Pathol. 2001; 54:657–663.
2. Burkle, CM, et al. Morbidity and mortality of deep sadation in outpatient bone marrow biopsy. Am J
Hematol. 2004; 77:250–256.
3. Ellis, LD, Jensen, WN, Westerman, MP, Needle biopsy of bone and marrow. an experience with 1,445
biopsies. Arch Intern Med 1964; 114:213–221.
4. Gudgin, EJ, Besser, MW, Craig, JIO. Entonox as a sedative for bone marrow aspiration and biopsy. Int J Lab
Hematol. 2008; 30:65–67.
5. Hyun, BH, Gulati, GL, Ashton, JK, Bone marrow examination. techniques and interpretation. Hematol Oncol
Clin North Am 1988; 2:513–523.
6. Riley, RS, et al, A pathologist’s perspective on bone marrow aspiration and biopsy. 1performing a bone
marrow examination. J Clin Lab Anal 2004; 18:70–90.
7. Vanhelleputte, P, et al, Pain during bone marrow aspiration. prevalence and prevention. J Pain Symptom
Manage 2003; 26:860–866.
8. Van Marum RJ, Te Velde L. Cardiac tamponade following sternal puncture in two patients. Netherlands J Med.
2001; 59:39–40.
Additional Readings
Aboul-Nasr, R, et al. Comparison of touc h imprints with aspirate smears for evaluating bone marrow spec imens. Am J Clin Pa thol. 1999; III(6):753–758.
Burke, JM, Dx/Rx. leukemia,. Jones and Bartlett, Boston, 2006.
Bain, BJ. Bone marrow trephine biopsy. J Clin Pa thol. 2001; 54:737–742.
DeVita, VT, et al. Ca ncer principles a nd pra ctice,, ed 3. Philadelphia: Lippinc ott Williams & Wilkins; 2001.
Huyn, BH, S tevenson, AJ, Hanua, CA. Fundamentals of bone marrow examination. Hema tol Oncol Clin North Am. 1994; 8:651–663.
Lawson, S , et al. Trained nurses c an obtain satisfac tory bone marrow aspirates and trephine biopsies. J Clin Pa thol. 1999; 52:154–156.
Lin, EM, Advanc ed prac tic e in onc ology nursing. c ase studies and review,. S aunders, Philadelphia, 2001.
Litwac k, K. Core curriculum for peria nesthesia nursing,, ed 4. Philadelphia: S aunders; 1999.
Quinn, DMD, S c hic k, L, Perianesthesia nursing c ore c urric ulum. preoperative, phase I and phase II PACU nursing,. S aunders, Philadelphia, 2004.
Ryan, DH, Cohen, HJ. Bone ma rrow a spira tion a nd morphology, hema tology ba sic principles a nd pra ctice,, ed 3. New York: Churc hill Livingstone; 2000.
Trewhitt, KG. Bone marrow aspirate and biopsy c ollec tion and interpretation. Oncol Nurs Forum. 2001; 28:1409–1415.
Watson, M, et al. Oncology,, ed 2. New York: Oxford Press; 2006.
UNIT VII
Integumentary System
SECTION TWENTY
Burn Wound Management
Introduction
Across the United S tates, diversity is found among burn units concerning policy, practice, and procedure in the care of
thermal injuries. This in no way intimates that diversity in practice corresponds with diversity in quality. The burn care
community, consisting of 127 burn units, regularly benchmarks among themselves, both formally and informally, to
compare outcomes and update practices to ensure that patients receive optimum quality of care. As with any specialty,
the effects of research and the trial of new techniques and products are always part of the search for best practice.
P R OC E D UR E 11 9
PURPOSE:
Care of the donor site is performed to promote wound healing and maintain function. Pain control is a priority
during donor site care.
• Factors that can disrupt or prolong healing include infection, desiccation, edema, adherent dressing changes, poor
nutrition, hemodynamic instability, and a variety of preexisting medical conditions.2
• The longer a partial-thickness wound takes to heal, the more significant the scarring; therefore, donor sites can
produce minimal or hypertrophic scars.2 Donor sites retain deep epidermal appendages, so they are generally capable
of sweating and bearing hair after they heal. The donor site may be reharvested once healing is complete, but skin
from the first harvest of a donor site is always of higher quality than that of repeat harvesting.
• Because the dermis is richly supplied with capillaries and nerve endings, donor sites are at risk for bleeding in the first
24 hours and are exquisitely tender to touch. They produce large volumes of serous exudate.
• Donor site treatment goals include minimizing bleeding, supporting reepithelialization, managing exudate, preventing
infection, controlling pain, and minimizing scarring.9 Epinephrine-soaked dressings, thrombin spray, or compression
dressings may be applied in the operating room to attain stasis.9 A compression dressing is usually used for the first 12
to 24 hours to ensure stasis.8 After this initial period, compression may be applied for comfort.
• Wounds epithelialize most rapidly in a moist environment. If donor sites are small enough, use of a thin-film
polyurethane or hydrocolloid dressing has been shown to promote rapid healing while providing comfort through
dressing flexibility and occlusive coverage of nerve endings.6 Occlusive dressings (sealed on all sides) can be difficult
to maintain on larger donor sites because of the substantial volume of exudate.6 A small drain (attached to a
vacutainer and collection tube Becton, Dickinson and Co., Franklin Lakes, NJ) tube can be used to remove excess
drainage from under a thin-film dressing. Calcium alginates have also been used successfully under occlusive
dressings to mange exudate.6
• Multilayer occlusive dressings may also be used, with a nonstick dressing (e.g., greasy gauze, meshed silicone) applied
next to the donor site and a bulky absorbent outer layer to maintain a moist environment and wick away excess
drainage. The outer dressing may be changed periodically, leaving the inner dressing intact until the wound heals
beneath it.
• One of the oldest and most cost-effective methods for treatment of donor sites is to apply mesh gauze, wrap with an
outer wrap for 12 to 24 hours, and then remove the outer wrap and allow the inner dressing to remain exposed and
dry until the wound heals beneath. This method has been done with fine mesh gauze and xeroform (McKesson
Brand, San Francisco, CA)/xeroflo (Kendall Healthcare, Coviden, Mansfield, MA). The technique is only effective if
the dressing dries well and becomes impermeable to bacteria, essentially acting as a scab.11 Positioning the patient for
maximal exposure of the donor sites, preventing prolonged donor site contact with sheets and clothing, and
increasing airflow across the wound are important for this technique to work.5 If the donor site is large, this procedure
creates a rather stiff and uncomfortable protective layer.
• Biobrane (UDL Laboratories, Rockford, IL), a biosynthetic product, produces a more flexible donor site dressing.
When exposed to air at 24 hours after harvesting, it dries to form a fibrous bond with the collagen in the wound. This
dressing provides improved pain control, exudate management, and rate of healing when compared with a fine-mesh
gauze dressing.12
• Antimicrobial creams or ointments have also been used on donor sites, essentially treating the wounds in the same
way as partial-thickness burns are treated. The disadvantage to this approach is that it requires daily washing of the
wound and reapplication of cream and dressings.11
• Slow-release silver dressings are gaining popularity for donor site use. These dressings are moistened twice daily with
sterile water to release the silver. In highly exudating wounds, the wound moisture may be adequate to promote silver
release without exogenously applied moisture. These dressings release silver for 3 or more days; ideally, they are
placed on the donor site in the operating room, and the wound is allowed to heal beneath with infrequent or no
dressing changes.6,11
• Donor sites need to be assessed daily for signs of infection, including periwound warmth and erythema, increased
pain, and purulent drainage. Bacteria can delay healing and increase scarring or convert a partial-thickness donor site
to a full-thickness wound.2 Erythema should be outlined to monitor progression, with consideration of either
removing the donor site dressing or applying a topical antimicrobial to penetrate the donor site dressing. Reopening
or “melting” of epithelium in previously healed donor sites is often the result of colonization with gram-positive
organisms and may require antibacterial intervention.4 Heavy hair-bearing donor sites such as the scalp provide
special challenges. Heavy hair growth can lead to matting of hair in the exudate, which can lead to accumulation of
protein, proliferation of bacteria, and ingrowth of hair, a condition referred to as chronic folliculitis.8 This problem can
lead to chronic, nonhealing, inflamed wounds or conversion of partial-thickness donor sites to full-thickness wounds.
Dressings that prevent drying and wick away the exudate work well.
• Donor sites are often very painful, with the amount of pain variable depending on the dressing technique used.
Patients with donor sites usually need scheduled round-the-clock pain medication.3,7
• The donor site should not be exposed to the sun for a year after the burn. Apply full-spectrum sunblock to donor sites
any time exposure to the sun is anticipated.10
• Protect fresh donor sites from dependent edema by wrapping with elastic bandages before sitting or ambulating.
EQUIPMENT
• Personal protective equipment (gown, mask, goggles as needed)
• Nonsterile gloves
• Scissors
• Replacement dressing as needed
• Pain and sedation medication (as prescribed)
Patient Preparation
• Ensure that the patient understands preprocedural teaching. Answer questions, and reinforce information as needed.
Rationale: Understanding of previously taught information is evaluated and reinforced.
• Premedicate the patient for pain and anxiety, as prescribed. Wait to perform the procedure until the medication has
had time to work. Rationale: Waiting allows time for the medication to take effect and promotes optimal comfort
for the patient. Medication reduces pain and anxiety and encourages patient trust and compliance with procedure.
Procedure for Care of Donor Sites
References
1. Brooks, JP, et al, Scratching the surface. managing the itch associated with burnsa review of current knowledge.
Burns 2008; 34:751–760.
2. Broughton, G, et al, Wound healing. an overview. Plast Reconstr Surg 2006; 117:1e-S–32e-S.
3. Faucher, L, et al. Practice guidelines for the management of pain. J Burn Care Res. 2006; 27:659–668.
4. Gallagher, JJ, et al. Treatment of infections in burns. In: Herndon D, ed. Total burn care. ed 3. London: Saunders
Elsevier; 2007:136–176.
5. Hedman, TL, et al. Two simple leg net devices designed to protect lower-extremity skin grafts and donor sites
and prevent decubitus ulcer. J Burn Care Res. 2007; 28:115–119.
6. Honari, S. Topical therapies and antimicrobials in the management of burn wounds. Crit Care Nurs Clin North
Am. 2004; 16:1–11.
7. Meyer, WJ, et al. Management of pain and other discomforts in burned patients. In: Herndon D, ed. Total burn
care. ed 3. London: Saunders Elsevier; 2007:797–818.
8. Mimoun, M, et al, The scalp is an adventageous donor site for thin-skin grafts. a report on 945 harvested
samples. Plast Reconstr Surg 2006; 118:369–373.
9. Muller, M, et al. Operative wound management. In: Herndon D, ed. Total burn care. ed 3. London: Saunders
Elsevier; 2007:177–195.
10. Serghiou, MA, et al. Comprehensive rehabilitation of the burn patient. In: Herndon D, ed. Total burn care. ed 3.
London: Saunders Elsevier; 2007:620–651.
11. Stout, LR. Burns. In: Carlson KK, ed. AACN advanced critical care nursing. London: Saunders Elsevier; 2009:1212–
1260.
12. Whitaker, IS, et al, A critical evaluation of the use of -Biobrane as a biologic skin substitute. a versatile tool for the
plastic and reconstructive surgeon. Ann Plastic Surg 2008; 60:333–337.
Additional Readings
Flynn MB, ed.. Burn and wound c are. Crit Care Nurs Clin North Am, 16. 2004:1–185.
Makic , MBF, Mann, E. Burn Injuries. In: Mc Quillan K, Makic MBF, Whalen E, eds. Tra uma nursing: resuscita tion through reha bilita tion. Philadelphia: Elsevier;
2009:865–888.
P R OC E D UR E 1 2 0
PURPOSE:
Burn wound care is performed to promote healing, maintain function, and prevent infection and burn wound
sepsis. A major focus must be on pain control.
FIGURE 120-1 Cross section of skin w ith areas affected by partial-thickness and full-thickness burns. (From Lewis SM, Cox IC: Medical-surgical nursing:
assessment and management of clinical problems, ed 2, New York, 1987, McGraw-Hill.)
The epidermis is the outermost layer. It is capable of rapid regeneration through division of cells closest to the dermis;
older epidermal cells are pushed outward as the epidermis is regenerated. The epidermis provides a barrier to the
environment, containing melanocytes (protection from the sun) and Langerhans cells (protection against foreign
organisms).
The dermis contains blood vessels, sensory fibers (for pain, touch, pressure, and temperature), collagen, sebaceous
glands, and sweat glands. Epidermal cells line deep dermal structures (hair follicles and sweat glands); these
epidermal elements provide the ability for the skin to regenerate (the more epidermal cells remaining in the wound
bed, the faster the healing).
• The depth of burns has historically been classified as first-degree (into epidermis), second-degree (into dermis), or
third-degree (through skin into subcutaneous tissue; Table 120-1).1,2
Table 120-1
Depth Characteristics of Burn Wounds
Full-thickness burn (third-degree): Destruction of epidermis Dry; leathery and firm to touch; pearly Incapable of self-regeneration. Preferred treatment is early
and all of dermis. Results from exposure to flames, white, brown, or charred in excision and autografting.
chemicals that are not immediately washed, electrical appearance; no blanching to pressure;
injury, or prolonged contact with heat source. no pain, may see thrombosed vessels.
First-degree, or superficial, burns extend only partially through the epidermis, thereby maintaining the barrier
function of the skin. These burns are not included when estimating the percentage of total body surface area
burned (%TBSA) because they do not result in an open wound.
Second-degree burns extend into the dermis and can be superficial (loss of the epidermis and part of the dermis) or
deep (destruction of most of the dermis). They are also referred to as partial-thickness burns because they extend
partially through the skin (Fig. 120-2). These wounds heal by epithelialization from epidermal cells remaining in the
dermis. Shallow wounds are associated with rapid healing and less scarring. Deep wounds may result in slow-
healing (more than 21 days) and fragile wounds prone to hypertrophic scarring. For that reason, surgical excision of
partial-thickness wounds that affect functional and cosmetic areas and application of skin grafts may be preferable.
A third-degree, or full-thickness, burn involves complete destruction of the dermis. Because the skin is unable to
regenerate, the dead tissue is removed and the wound is grafted with skin from another part of the patient’s own
body (autograft).2 The grafted wound loses epidermal appendages and is unable to sweat, maintain lubrication, or
protect from sun exposure after healing (Fig. 120-3).
FIGURE 120-3 A fresh burn that is a partial-thickness burn tow ard the patient’s left side and progresses to a full-thickness burn on the patient’s right side.
• The depth of a burn wound is directly related to the temperature intensity and the duration of contact with the
burning agent. The burning agent can be thermal (i.e., flame, contact, or scald), chemical, or electrical. An inhalation
injury should always be suspected if the patient was in an enclosed space with a fire; mortality rate is significantly
increased when burns are compounded by smoke inhalation.4
• The burn injury produces three zones of injury: the zone of coagulation (cellular death), zone of stasis (vascular
impairment, potentially reversible tissue injury), and zone of hyperemia (increased blood flow and inflammatory
response). Decreased perfusion of the burn wound can cause the zone of stasis to deteriorate, deepening the initial
wound. This progressive destruction can be minimized by providing adequate oxygenation and fluid resuscitation,
alleviating pressure on the injured tissue, maintaining local and systemic warmth, and decreasing edema by elevating
the burned area.1
• Assess for areas where full-thickness eschar is circumferential. Because of the inelastic nature of eschar, it may act like
a tourniquet as edema develops, requiring surgical release (escharotomy) to prevent circulatory or respiratory
compromise (Fig. 120-4).
• Monitor pulses, capillary refill, and sensation distal to circumferential eschar. Signs and symptoms that indicate a need
for escharotomy include cyanosis of distal unburned skin, unrelenting deep tissue pain, progressive paresthesias, and
progressive decrease or absence of pulse.1
• Adequacy of respiratory excursion must be assessed because circumferential eschar of the trunk can lead to decreased
tidal volume and agitation (Fig. 120-5).1
FIGURE 120-5 Full-thickness burn w ith chest escharotomy to improve chest expansion.
• Escharotomy is performed at the bedside by a physician, with a scalpel or electrocautery used to cut the eschar
longitudinally. Bleeding should be minimal because only dead tissue is cut; any bleeding can be controlled with
sutures, silver nitrate sticks, collagen packing, or electrocautery. Pain is usually managed with small intravenous doses
of opiates and benzodiazepines.
• Burn size may be determined with several methods.20
The rule of nines may be used to quickly calculate burn size. In an adult, the head and neck and each upper
extremity represent 9% of the patient’s body surface area. The anterior trunk, posterior trunk, and each leg
represent 18% of the patient’s body surface area. This rule only applies to adults; infants and young children have
much larger heads in proportion to body size.
The Lund and Browder chart (Fig. 120-6) breaks the body into smaller areas and takes into consideration the
proportional differences of persons of different ages.12
FIGURE 120-6 The Lund and Brow der chart is used to assess and graphically document size and depth of the burn w ound.
The rule of the palm notes that the patient’s hand may be used as a template to represent roughly 1% of the TBSA.
• The inflammatory response causes a massive fluid shift to the interstitial space during the first 24 hours, with
mobilization of fluid starting after 72 hours. Fluid resuscitation with a balanced salt solution is based on the patient’s
weight and burn size (partial-thickness and full-thickness wounds).17 Large wounds are prone to huge evaporative
water losses that require close monitoring of volume status.
• Effective resuscitation results in adequate urinary output (30 to 50 mL/hr or 0.5 to 1.0 mL/kg/hr) and mean arterial
blood pressure of at least 60 mm Hg as surrogate markers of end-organ perfusion and hemodynamic stability.17
• Burns of specific anatomic areas need special consideration. Assess eyes for injury and treat chemical exposure with
copious normal saline solution irrigation; treat burned ears with a topical antimicrobial cream and protect from
pressure by eliminating use of pillows or dressings about the head; elevate burned extremities; consider the need for
an indwelling urinary catheter in the patient with perineal burns; and shave hair growing through the burn wounds.
Two burned surfaces that contact each other need dressings between them to prevent fusing as they heal (e.g.,
between toes, skin folds).
• Emergency treatment of thermal injuries includes initially cooling the burned skin with tepid water (never with ice)
while recognizing the importance of preventing hypothermia.1 In preparation for transfer, the airway should be
assessed and 100% oxygen administered; large-bore intravenous (IV) access should be established and fluid
resuscitation started; patients should be on nothing by mouth (NPO) status; wounds should be wrapped with a clean,
dry sheet and possibly blanket; pain medication should be given in small IV doses, with recognition that coexisting
injuries or medical conditions exacerbate the effects of opiates; tetanus prophylaxis should be administered; and all
initial treatment should be documented.1
• Initial treatment of chemical burns includes removing saturated clothing, brushing off any powdered chemical, and
continuously irrigating involved skin with copious amounts of water for 20 to 30 minutes. Neutralizing chemical
burns with another chemical is contraindicated because the procedure generates heat. Burned eyes must be irrigated
with large volumes of normal saline solution followed by an eye examination.1 Some chemicals are absorbed
systemically through burn wounds; contact the local poison control center to determine whether further treatment is
indicated.2 Ensure all providers wear appropriate personal protective equipment to prevent unintentional chemical
exposure.
• Tar can be removed with mineral oil, a petrolatum-based ointment, or solvent.16
• Electrical injuries (Fig. 120-7) result when the body becomes part of the pathway for the electrical current. Deep burns
may occur from tissue resistance where the patient contacted the electrical source and where the patient was
grounded. Initially of greater concern than the burns is the high incidence of cardiac dysrhythmias, myoglobinuria
resulting in acute tubular necrosis, and neurologic sequelae. Monitoring electrocardiographic (ECG) results, increasing
urine output to 100 mL/hr in the presence of dark port-colored urine, assessing for associated trauma, and
establishing baseline neurologic status are vital in the treatment of the electrical injury patient.1,20
• Criteria for transferring patients to a specialized burn care facility have been adopted by the American Burn
Association and the American College of Surgeons. These criteria are listed in Table 120-2.
Table 120-2
Criteria for Patient Transfer to a Specialized Burn Care Facility
Partial-thickness burns on more than 10% TBSA
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Third-degree burns in any age group
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that could complicate management, prolong
recovery, or affect mortality
Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the
greatest risk for morbidity or mortality
Burned children in hospitals without qualified personnel or equipment to care for children
Burn injury in patients who will need special social, emotional, or long-term rehabilitative intervention
(Adopted From Committee on Tra uma , America n College of Surgeons: Guidelines for the opera tion of burn centers resources for optima l ca re of the injured pa tient,
Chica go, 2006, America n College of Surgeons, 79-86) .
• Care of the burn wound and associated healing are determined by the extent and depth of the injury and the overall
condition of the patient.
• Most burn centers use clean technique for dressing removal and wound cleansing, with sterile technique for sterile
dressing application only.2
• Wound care should be done in a warm area. Many burn units have replaced traditional hydrotherapy tanks with
shower tables for large wound care procedures to allow water run-off, thus decreasing leaching of electrolytes and
minimizing wound exposure to perineal-contaminated water. Emergency equipment must always be immediately
available during hydrotherapy procedures. As wounds decrease in size and patients approach discharge, bathtubs and
showers offer reasonable options for wound cleansing.
• Initial wound cleansing requires thorough débridement of all devitalized tissue. Blisters are generally unroofed.18 Use
of dry gauze is effective to gently remove burned tissue, with use of a slow and deliberate wiping motion. Wash the
wounds with gentle pH neutral liquid soap solution or wound cleanser and pat dry with clean towels.
• Topical antimicrobial agents limit bacterial proliferation and fungal colonization in burn wounds. The three most
commonly used agents are 1% silver sulfadiazine (Silvadene, Monarch Pharmaceuticals, Inc., Bristol, TN), 10%
mafenide acetate (Sulfamylon, UDL Laboratories, Inc., Rockford, IL), and 0.5% silver nitrate solution (Table 120-3).7
Systemic antibiotics are not routinely administered to burn patients because of the high risk for development of
antibiotic resistance.15
Table 120-3
Topical Antimicrobial Agents
*Silvadene, Monarch Pharmaceuticals, Inc., Bristol, TN
‡Sulfamylon, UDL Laboratories, Inc., Rockford, IL
• Eschar is a leathery layer of devitalized tissue that covers full-thickness burns. Bacterial action causes eschar to separate
from the wound bed. However, the use of topical antimicrobial agents and early excision has minimized the nurse’s
involvement in eschar removal.
• Survival rates for burn patients are markedly improved with early excision and grafting.6 The most important
predictors of mortality are the patient age and the extent of the burn, with the presence of inhalation injury and
comorbidity crucial factors. Although the burn wound has the most obvious potential for infection, the lower
respiratory tract is the most common site of infection and carries the highest incidence of sepsis and death.4
• An autograft (skin graft taken from the patient) is the only treatment that can heal a full-thickness burn wound.11
Wounds with higher than 105 organisms per gram of tissue impede graft adherence, so expedient grafting is
desirable.15
• Burn wound management accomplishes three primary goals: protect the wound, reduce metabolic demand, and
provide comfort.
• A débrided full-thickness wound may be protected from infection and drying through the use of biologic dressings
when donor sites are not available for autografting. Allograft, or homograft, refers to the use of “nonself” human skin
grafts; such a graft becomes vascularized by the patient and risks rejection if it stays in place too long. Xenograft, or
heterograft, is nonhuman skin obtained from commercial pigskin (porcine) processing companies; it forms a collagen
bond with the wound and protects it for a period of time until donor sites are available for autografting. Porcine
xenograft may be placed over clean partial-thickness wounds to protect the wound while it heals beneath the
xenograft.11
• Integra (Integra Lifesciences Corporation, Plainsboro, NJ) is an acellular matrix composite graft that may be placed on
débrided full-thickness burns. Capillaries and collagen grow into this matrix in about 3 weeks, forming a neodermis,
which is then grafted with the patient’s own epidermal cells. The matrix is slowly biodegradable and cannot be
detected with wound biopsy after complete healing.11 This allows for improved wound coverage and use of thinner
donor sites but requires two surgeries. Thinner autografts allow more rapid healing of donor sites and produce less
hypertrophic donor site scarring.
• Biosynthetic dressings such as Biobrane (UDL Laboratories, Inc., Rockford, IL) have been used to cover clean partial-
thickness wounds to facilitate healing.11,22 Biobrane is a two-layer, semisynthetic dressing composed of knitted-elastic
nylon fabric that is mechanically bonded to a thin, Silastic, semipermeable membrane and coated with collagen
polypeptides.22 As the wound heals beneath, the dressing can be peeled away.22
• Topical antimicrobial agents are used to reduce wound colonization. Commonly used creams include silver
sulfadiazine (Silvadene) and 10% mafenide acetate (Sulfamylon), antibacterial ointments such as bacitracin, and liquid
soaks such as mafenide acetate 5% solution and 0.5% silver nitrate.7 Creams and ointments are applied every 12 hours
or as needed to cover the wound. Dry protective dressings prevent premature removal of the topical. Damp gauze
dressings saturated with antimicrobial solution are changed every 24 hours, but dressings require moistening (“wet-
down”) every 4 to 6 hours to ensure activity of agent.
• Negative-pressure wound therapy may be used to maintain fresh graft placement, improve wound bed
vascularization, and reduce microbial activity.20
• The burn patient’s condition is hypermetabolic until burn wounds are closed and healing is complete. Increased
caloric and protein requirements for wound healing are usually met through nasogastric or nasojejunal tube feeding
to maintain mucosal integrity in large burns. Zinc and vitamin C have also been shown to be important in wound
healing. Current research is evaluating the role of arginine and fish oil in decreasing infections,13 glutamine’s role in
maintaining mucosal integrity and reducing infection,13 and insulin’s ability to preserve muscle mass.21 Additional
treatments include use of β-blockade9 to reduce metabolic demand and oxandrolone10 to increase anabolism.
• Burn patients should be encouraged to consume a high-protein diet. Supplementation with high-calorie nutritional
drinks facilitates meeting energy needs. Large quantities of free water should be discouraged because risk for
hyponatremia is high after a large burn.
• During wound care because heat lost through the wound, along with shivering, increases the metabolic rate.
• An individualized plan for pain control should be in place for both background pain (pain that is continuously
present), breakthrough pain (associated with activity of daily living), and procedural pain (intermittent pain related to
procedures).5,14 Unrelieved pain can lead to stress-related immunosuppression, an increased potential for infection,
delayed wound healing, and depression. Subcutaneous and intramuscular injections should be avoided because
absorption is poor and unreliable as a result of edema. Intravenous administration of medication is preferred in
critically ill patients; oral medication is preferred in noncritical patients with a functioning gastrointestinal system.5,14
As the wound heals, the patient has more discomfort from itchiness and less discomfort from pain.14 A moisturizing
lotion prevents drying and reduces pruritus. Nonpharmacologic techniques can be learned to assist with the
management of pain and itch.3,5,14
• Burn wounds contract during the healing phase. Self-care and range-of-motion exercises are encouraged. Stretching
exercises and proper positioning are vital to prevent contractures and loss of function.8 Static splinting is sometimes
added to maintain sustained stretch.8 Hypertrophic scar formation is countered through the use of topical silicone gel
sheeting and pressure garments worn 24 hours a day until the scars mature and soften (6 to 18 months).19 Keloids, if
they form, may require surgery, steroid injections, and pressure treatment.19
• Grafts and donor sites on the lower extremities require support during healing when the patient is out of bed.
Application of elastic bandages to extremities may prevent pooling of venous blood, permanent discoloration, or skin
breakdown.
• The burn wound should not be exposed to the sun for a year because new scars sunburn easily.
• Patients should be instructed to select clothing that blocks sun and to use sunscreen on exposed grafts, generally for
life.
EQUIPMENT
• Personal protective equipment as needed (e.g., gown, mask, goggles)
• Nonsterile gloves
• Sterile gloves
• Warm water
• Mild pH-neutral liquid soap, as ordered
• Normal saline (NS) solution
• Washcloths
• Towels
• Scissors and forceps (clean and sterile)
• Topical agents, as ordered
• Tongue depressors
• Sterile dressings as needed (e.g. gauze, Exu-dry [Smith & Nephew, St. Petersburgh, FL])
• Rolled dressing, gentle tape, or netting to secure dressings
• Pillows to elevate extremities
• Pain and sedation medication (as prescribed)
Patient Preparation
• Ensure the patient understands procedural teaching. Answer questions as they arise and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Notify other appropriate healthcare providers who need to assess the burn wound (e.g., physician) or perform a task
(e.g., quantitative wound biopsies, range-of-motion exercises by physical therapist) of time of dressing change.
Rationale: Organization of care allows important assessment and intervention to take place without causing extra pain
and stress to the patient.
• After checking previous requirements for patient comfort during the dressing change, premedicate the patient with
pain medication and any sedative as prescribed, allowing an appropriate amount of time before starting wound care.
Rationale: Premedication allows time for medication to take effect and promotes optimal comfort for the patient.
• Consider synergistic effects of opioids, sedatives, and drugs that affect the central nervous system (CNS). Closely
monitor patient 30 to 60 minutes after wound care procedure is completed. Rationale: Stimulatory effects that
counteract CNS depression are reduced after wounds are covered; decreased noxious stimuli and respiratory
depression may occur.
Procedure for Care of Burn Wounds
References
1. American Burn Association. Advanced burn life support provider course. Chicago: American Burn Association;
2005.
2. Bessey, TQ. Wound care. In: Herndon DN, ed. Total burn care. ed 3. London: Saunders Elsevier; 2007:127–135.
3. Brooks, JP, et al, Scratching the surface. managing the itch associated with burnsa review of current knowledge.
Burns 2008; 34:751–760.
4. Demling, RH, Smoke inhalation lung injury. an update. Eplasty 2008; 16:254–282.
5. Faucher, L, et al. Practice guidelines for the management of pain. J Burn Care Res. 2006; 27:659–668.
6. Guo, F, et al, Management of burns over 80% of total body surface area. a comparative study. Burns 2008;
[doi:10. 1016/j. burns. 2008. 05. 021].
7. Honari, S. Topical therapies and antimicrobials in the management of burn wounds. Crit Care Nurs Clin North
Am. 2004; 16:1–11.
8. Huang, T. Management of contractural deformities involving the axilla (shoulder), elbow, hip, knee, and ankle
joints in burn patients. In: Herndon DN, ed. Total burn care. ed 3. London: Saunders Elsevier; 2007:727–740.
9. Ipaktchi, K, Arbabi, S. Advances in burn critical care. Crit Care Med. 2006; 34:S239–S244.
10. Jeschke, MG, et al. The effect of oxandrolone on the endocrinologic, inflammatory, and hypermetabolic responses
during the acute phase postburn. Ann Surg. 2007; 246:351–362.
11. Lineen, E, et al. Biologic dressings in burns. J Craniofac Surg. 2008; 19:923–928.
12. Lund, CC, Browder, NC. The estimate of areas of burns. Surg Gynecol Obstet. 1944; 79:352–358.
13. Masters, B, Wood, F, Nutrition support in burns. is there consistency in practice. J Burn Care Res 2008; 29:561–
571.
14. Meyer, WJ, et al. Management of pain and other discomforts in burned patients. In: Herndon D, ed. Total burn
care. ed 3. London: Saunders Elsevier; 2007:797–818.
15. Polavarapu, N, et al. Microbiology of burn wound infections. J Craniofac Surg. 2008; 19:899–902.
16. Pham, TN, et al, Evaluation of the burn wound. management decisionsHerndon D, ed.. Total burn care. ed 3.
Saunders Elsevier, London, 2007:119–126.
17. Pham, TN. American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res. 2008;
29:257–266.
18. Sargent, RL, Management of blisters in the partial-thickness burn. an integrative research review. J Burn Care Res
2006; 27:66–81.
19. Serghiou, MA, et al. Comprehensive rehabilitation of the burn patient. In: Herndon D, ed. Total burn care. ed 3.
London: Saunders Elsevier; 2007:620–651.
20. Stout, LR. Burns. In: Carlson KK, ed. AACN advanced critical care nursing. London: Saunders Elsevier; 2009:1212–
1260.
21. Wanek, S, Wolf, SE. Metabolic response to injury and role of anabolic hormones. Curr Opin Clin Nutr Metab Care.
2007; 10:272–277.
22. Whitaker, IS, et al, A critical evaluation of the use of Biobrane as a biologic skin substitute. a versatile tool for the
plastic and reconstructive surgeon. Ann Plastic Surg 2008; 60:333–337.
Additional Readings
Broughton, G, et al, Wound healing. an overview. Plast Rec onstr S urg 2006; 117:1eS –32eS .
Flynn MB, ed.. Burn and wound c are. Crit Care Nurs Clin North Am, 16. 2004:1–185.
Makic , MBF, Mann, E. Burn injuries. In: Mc Quillan K, Makic MBF, Whalen E, eds. Tra uma nursing: resuscita tion through reha bilita tion. Philadelphia: Elsevier;
2009:865–888.
P R OC E D UR E 1 2 1
PURPOSE:
Skin-graft care is performed to promote perfusion to the graft and to prevent infection. Successful graft
transplant and care result in maximal function.
• Negative-pressure wound therapy (NPWT) is a mechanical wound care treatment that uses controlled negative
pressure (via a machine, tubing, and sealed dressing) to accelerate wound healing. NPWT can also be used to enhance
incorporation of a STSG mesh graft. The NPWT dressing is placed over the graft during surgery. A nonadherent
dressing is used as a barrier for the graft to protect the graft from trauma and decrease overgrowth of granulation
tissue formation.1
• Nonmeshed grafts, or sheet grafts, are used on the face, hands, and some joints because of cosmetic and functional
concerns related to appearance and increased shrinkage.
• A sheet graft covers the same amount of surface area as the donor site. Pockets of serous fluid or blood tend to
accumulate under these grafts (the interstices of meshed grafts allow the fluid to escape) and separate the graft from
the wound bed, which is vital for blood supply, resulting in failure of the graft to adhere or “take” to the wound bed.
Evacuation of this fluid is imperative. Sheet grafts on the face, neck, and hands are generally inspected within the first
12 to 24 hours to look for fluid collections or graft dislodgement. If the sheet graft has been in place for less than 48
hours and the fluid is near the edge of sheet graft, the fluid can be rolled to the edge and out (Fig. 121-2).2
FIGURE 121-2 A, A no. 11 surgical blade and cotton-tipped applicator are used to blade a new sheet graft. Note that the blade is held so that the tip of the
cutting surface comes into contact w ith only the graft. B, Cotton-tipped applicators are rolled gently over the graft tow ard the slit to express fluid that has
collected betw een the graft and the w ound bed surface. When deblebbing thick grafts, adequate-sized slits are important to avoid recurring buildup of fluid,
w hich may jeopardize graft survivability and result in scarring. C, Blebs tend to recur in the same place. Vigilance about deblebbing at least once every 8
hours until bleb formation ceases is advisable. Documentation of bleb formation and location ensures that the next caregiver is aw are of graft sites in need of
close monitoring. (From Carrougher GJ: Burn care and therapy, St Louis, 1998, Mosby.)
• Caution should be used when evacuating fluid after vascularization of the graft begins to avoid disruption of the graft
attachment endangering graft take. A more safe practice for removing fluid involves making a small nick in the sheet
graft directly over the area of fluid accumulation and gently expressing the fluid through the hole. In either case, the
fluid should be gently dabbed away with gauze dampened with sterile normal saline solution or sterile water.6
Seromas and hematomas tend to redevelop in the same areas, so careful charting should reflect location of any fluid
pockets (blebs). Close monitoring of these areas should occur at least every 8 hours until bleb formation is no longer
noted.
• In the operating room, all nonviable tissue is surgically excised to create a wound bed able to support a skin graft (Fig.
121-3); therefore, the grafted area should be observed for bleeding for the first 24 hours.
FIGURE 121-3 Meshed split-thickness skin graft covering the arm, w ith the remainder of the w ound bed ready to be grafted.
• The goals after a graft placement are to protect the wound bed from infection and desiccation and to ensure that no
movement (shearing) of the graft occurs while it is becoming vascularized. Neovascularization begins within the first
24 hours of surgery as capillaries grow up into the graft, securing the graft permanently to its new site. Either a barrier
dressing (e.g., Biobrane allograft [UDL Laboratories, Rockford, IL]) protects the wound (with or without a bulky
dressing added), or a minimal nonadherent dressing (e.g., Xeroform [McKesson Brand, San Francisco]) is used with a
bulky dressing over the grafted tissue to act as the barrier to infection, prevent drying and shearing. The newly
grafted tissue must be well protected from shearing forces for 5 to 7 days to allow for graft adherence to the wound
bed. With meshed skin grafts, the interstices of the autograft fill with granulation tissue and the epidermis of the
autograft migrates over the granulation tissues. Successful grafting is often expressed as a percentage of graft “take,”
or adherence and vascularization of the graft to the new site.1,5
• Cultured epidermal autografts, most frequently used with burn injuries, are commercially available and are an option
when the patient does not have enough unburned tissue for donor sites to cover the burn in a reasonable period of
time.1,7 Cultured epidermal autografts are grown from a sample of the patient’s own epidermal cells in a laboratory.
However, the cost is prohibitive, the grafts are extremely fragile, and successful take of the graft is much more likely if
the burn team has experience with this treatment.3
• The use of artificial skin and other options for wound coverage has expanded in recent years. Currently, the use of
these wound coverings is limited to providing temporary wound coverage or allowing for dermal regeneration while
waiting for suitable donor sites for definitive wound closure with autografting.
• Allografts, also called homografts, are fresh or cyropreserved grafts from human donors. Allografts are the gold
standard for temporary coverage of wounds. Allograft benefits include prevention of wound desiccation, promotion
of granulation tissue, and decreased water and heat loss.1
• The use of Integra® Dermal Regeneration Template (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) has been shown to
decrease length of stay (LOS) in severely injured burned adults.7 Integra® is a commercial bilayer dermal regeneration
template system that is frequently used in burn centers to treat severe burns. Integra is composed of two layers. The
first layer is made from cross-linked bovine collagen and chondroitin 6-sulfate (glycosaminoglycan) from shark
collagen, which is a permanent dermal template that provides a scaffolding for the patient’s own dermis to grow into.
The second layer, the outer layer, is a temporary synthetic polysiloxane polymer (silicone)covering that acts as an
artificial epidermis until the patient is ready for autografting, usually 2 to 3 weeks after the Integra is placed. Because
of enhanced dermal regeneration, the graft bed requires only a very thin meshed donor graft from the patient to heal
the wound. This allows quicker healing of donor sites and the ability to reharvest from the same donor site multiple
times, if necessary, in a short time period. Clinical trials have shown that the epidermal autograft over Integra usually
heals without the formation of the meshed appearance typical of meshed autografts, thereby resulting in a better
cosmetic outcome for the patient.5
• The graft is usually stapled or sutured in place, covered with a nonadherent dressing, and padded with a bulky bolster
dressing to prevent mechanical dislodgement of the graft. Recent studies have shown that the use of fibrin sealants, a
surgical hemostatic agent derived from human plasma, may be more effective than staples for adherence of sheet
grafts.4
• After surgery, the graft is delicate, and care is taken to decrease trauma to the graft. If the graft is over a joint, the
extremity may be immobilized to enhance graft take. The first dressing change is usually done after 3 to 5 days. Most
centers use clean technique for dressing removal and donor-site cleansing and use sterile technique for dressing
application only.6
• If a patient is allowed to mobilize after surgery, leg grafts must be supported with Ace wraps or other compressive
dressings when the patient’s legs are dependent for the first 3 to 5 days after surgery to prevent capillary engorgement
and hematoma formation beneath the graft. Grafted extremities should be elevated when the patient is supine.
• Initial healing of the grafted area should occur in 7 to 10 days. The graft area is immobilized for 4 to 5 days to prevent
dislocation and shearing. Splints and immobilizers are used during this time to prevent disruption of grafts and to
provide therapeutic positioning of extremities.
• Signs of successful graft take include vascularization of the graft, reepithelialization of the interstices, decreased pain,
and adherence of the graft. Signs of complications include graft necrosis, graft loss, cellulitis, purulent drainage, and
fever.
• Skin grafts contract during the healing and remodeling phases. Continuing mobility and proper positioning are vital
to prevent contractures and loss of function. Self-care and range-of-motion exercises should be encouraged as soon as
the graft is adherent. Once the wounds heal, pressure garments may be ordered to be worn at all times, except during
bathing, to reduce hypertrophic scar formation.6
• Pain related to care of wounds is complicated by several components: background pain (pain that is continuously
present), procedural pain (intermittent pain related to procedures and routine care), and anxiety. Unrelieved pain can
lead to stress-related immunosuppression, increased potential for infection, delayed wound healing, and depression.
The management of pain should be a multidimensional approach, including pharmacologic and nonpharmacologic
methods, tailored to individual patient needs.8,9
• Burns greater than 20% total body surface area (TBSA) cause a hypermetabolic response that results from a loss of
glycogen stores, increased gluconeogenesis, and increased lipid metabolism. In addition, dressing changes, loss of
normal thermoregulatory mechanisms, surgical débridement, pain, and infection exacerbate the hypermetabolic
response to injury. Therefore, estimating and meeting a patient’s nutritional needs is paramount to maximize wound
healing.3
• Exposure of the healed skin graft to the sun should be avoided. The newly healed area is extremely sensitive to
sunlight, and permanent discoloration can occur. To prevent discoloration, the patient should protect grafted areas
with clothing or sunscreen. During the first year, as the patient’s graft matures, the risk for skin discoloration slowly
decreases.
EQUIPMENT
• Personal protective equipment (i.e., gowns, mask, goggles)
• Nonsterile gloves
• Sterile gloves
• Scissors and forceps
• Warm tap water (sometimes sterile water or sterile normal saline [NS] solution is used for first dressing change)
• Clean washcloths
• Staple remover
• Nonadherent dressing/gauze (e.g., Adaptic [Johnson and Johnson, New Brunswick, NJ], Xeroform)
• Secondary dressings, as needed
• Pain and antianxiolytic medication (as prescribed)
Additional equipment, as needed, includes the following:
• Splints (to be secured with gauze roll, hook and loop closure [e.g., Velcro], elastic bandage such as ace wraps, or self-
adherent wrap (e.g., Coban, 3M, St. Paul, MN)
• Towels or waterproof pads
Patient Preparation
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Notify other appropriate healthcare providers who need to assess the graft (e.g., physician) or perform a task (e.g.,
range-of-motion exercises by physical therapist) of the time of dressing change. Rationale: Organization of care
allows important assessment and intervention to take place without causing extra pain and stress to the patient.
• Premedicate the patient with pain medication and any sedation and anxiolytic medications as prescribed. Allow an
appropriate amount of time for medications to begin to take effect before starting wound care. Rationale:
Premedication reduces pain and anxiety and allows time for medication to take effect and promote optimal comfort
for the patient. Patient trust and compliance with procedure are encouraged.
Procedure for Care of Skin Grafts
References
1. Bryant, R, Nix, D, Acute & chronic wounds,. ed 3. Mosby, St Louis, 2006:361–390.
2. Carrougher, GJ. Burn care and therapy,, ed 1. St Louis: Mosby; 1998.
3. Flynn, MB. Nutritional support for the burn-injured patient. Crit Care Nurs Clin North Am. 2004; 16(1):139–
144.
4. Gibran, N, Luterman, A, Herndon, D, et al, Comparison of fibrin sealant and staples for attaching split-thickness
-autologous sheet grafts in patients with deep partial- or full-thickness burn wounds. a phase 1/2 clinical study. J
Burn Care Res. 2007; 28(3):401.
5. Heimbach, D, et al, Artificial dermis for major burns. a multi-center randomized clinical trial. Ann Surg 1988;
208:313–320.
6. Honari, S. Topical therapies and antimicrobials in the management of burn wounds. Crit Care Nurs Clin North
Am. 2004; 16(1):1–11.
7. Jeng, JC, Fidler, PE, Sokolich, JC, et al. Seven years’ experience with Integra as a reconstructive tool. J Burn Care
Res. 2007; 28(1):120–126.
8. Makic, MBF, Mann, E. Burn injuries. In: McQuillan K, Makic MBF, Whalen E, eds. Trauma nursing: from -
resuscitation through rehabilitation. ed 4. St Louis: Elsevier; 2009:865–888.
9. Montgomery, RK. Pain management in burn injury. Crit Care Nurs Clin North Am. 2004; 16(1):39–49.
Additional Readings
Barret, JP, Herndon, DN. Effec ts of burn wound exc ision on bac terial c olonization and invasion. Pla st Reconstruct Surg. 2003; 111:744–750.
Branski, LK, Herndon, DN, Pereira, C, et al, Burn and wound c are. Crit Ca re Nurs Clin North Am. 2004; 16 (1)
Foster, K, Ric hey, K, Wound wise. the story on partial-thic kness skin grafts. Nurs Made Inc redibly Easy. 2008; 6(2):19–21.
Heimbac h, DM, et al. Multic enter postapproval c linic al trial of Integra Dermal Regeneration Template for burn treatment. J Burn Ca re Reha b. 2003; 24:42–48.
Herndon, DN, Total burn c are. ed 3. S aunders, London, 2007.
Integra Dermal Regeneration Template. www.integra-ls.c om/produc ts, January 14, 2010 [retrieved from].
Nowlin, A. The delic ate business of burn c are. RN. 2006; 69(1):52–58.
Osborn, K, Critic al c are. nursing burn injuries. Nurs Manage. 2003; 34(5):49–56.
Pham, C, Greenwood, J, Cleland, H, et al, Bioengineered skin substitutes for the management of burns. a systematic review. Burns. 2007; 33(8):946–957.
S affle, JR, Covering massive burn injuries. integra-ting and interpreting the data. Crit Care Med. 2007; 35(11):2661–2662.
Zhang, X, Jesc hke, MG, Longitudinal assessment of integra in primary burn management. a randomised pediatric c linic al trials. Crit Care Med. 2007; 35(11):2615–
2623.
S E CTION TWE NTY-ONE
Special Integumentary Procedures
P R OC E D UR E 1 2 2
PURPOSE:
Compartment syndrome can occur within any confined anatomic region when elevations in tissue pressure are
sufficient to cause neurovascular compromise of the tissues in that region or compartment. Typically, diagnosis
of this syndrome is made with serial clinical examinations of the involved extremity. However, in patients with
inconclusive physical findings or with an altered level of consciousness, direct measurement of the
intracompartmental pressure is a useful diagnostic adjunct.
• All clinicians involved with performing and assisting with the procedure should have knowledge of aseptic technique.
• Nurses should be credentialed in performing IPM. This should include supervised training in the techniques used for
IPM and opportunities to maintain clinical competence.
• Clinicians should have a high index of suspicion that the patient is at risk for developing compartment syndrome.
Etiologies can be divided into internal and external sources. Examples of internal causes include fractures, contusions,
and edema formation associated with crush injuries or reperfusion injuries. External sources are generally related to
compression of the limb and include such things as eschar from burn injuries, splints, casts, dressings, and
immobility.1 Definitive treatment may be as simple as releasing a splint, cast, or dressing. More advanced treatment
may require release of the compartment with an escharotomy or fasciotomy.
• The pathophysiology of compartment syndrome is related to compromised perfusion. Blood flow to any tissue or
organ requires a sufficient perfusion pressure, which is generally calculated as the mean arterial pressure minus the
intracompartmental pressure and should be 70 to 80 mm Hg.2 Therefore, as the mean arterial pressure decreases or
the intracompartmental pressure increases, the perfusion to the tissue is reduced. Insufficient perfusion pressure may
lead to ischemia and eventual necrosis of the tissues within the affected area.
• Normal compartment pressure within an unaffected compartment is considered less than 10 mm Hg.3,4 Clinically
significant pressure changes are generally defined in one of two ways:
An absolute value of more than 30 mm Hg in the presence of other signs and symptoms of compartment
syndrome. However, injury of the area may lead to elevations of the intracompartmental pressure in the absence of
actual compartment syndrome.5 Positioning of the extremity may also cause elevations in intracompartmental
pressure particularly when assessing dependent compartments.
A delta compartment pressure (δp) of less than 30 mm Hg: the diastolic blood pressure minus the
intracompartmental pressure. This measurement may be a more reliable indicator of the risk for development of
compartment syndrome because it takes into account blood pressure.6,7
• Acute compartment syndrome is a true orthopedic emergency. Signs and symptoms can develop in as little as 2 hours
after injury. Ischemic damage to muscles and nerves can start in 4 to 6 hours, with permanent damage occurring in
12 to 24 hours.3
EQUIPMENT
• Electronic pressure monitoring device (bedside pressure monitor or a handheld monitoring device).
• Prefilled sterile saline solution syringe
• Dedicated disposable tubing with needle
• Chlorhexidine gluconate 1%
• 1% Lidocaine without epinephrine
• Sterile gloves
• Sterile dressing
• One roll of hypoallergenic tape
Patient Preparation
• Explain steps of the procedure to the patient and family (if applicable). Answer any questions as they arise.
Rationale: Explanation reinforces understanding of previously presented information and may assist in allaying
anxiety.
• Remove constricting dressings and bandages. Assist with the modification of splints, casts, and other devices on the
affected extremity. Rationale: Removal reduces external pressure on the tissue of the affected extremity.
• Place the patient in the supine position with the extremity at the level of the heart. Rationale: Access to the affected
compartment is provided. Positioning the extremity above the heart may impede circulation, placing it in a
dependent position, and may worsen edema.
• Consider administration of short-acting analgesic and/or anxiolytic. Rationale: Analgesic and/or anxiolytic decreases
patient discomfort during procedure.
Additional Readings
Walsh, CR. Musc uloskeletal injuries. In: Mc Quillan KA, Makic MBF, Whalen E, eds. Tra uma nursing: from resuscita tion through reha bilita tion. ed 4. S t Louis:
Elsevier; 2009:735.
Whiteside, TE, Haney, TC, Morimoto, M, et al. Tissue pressure measurements as a determinant for the need of fasc iotomy. Clin Orthop Rel Res. 1975; 113:43–51.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 1 2 3
PURPOSE:
The purpose of pressure redistribution surface (i.e., support surface) is to assist in the reduction of pressure
over areas of the body and reduce the development of pressure ulcers and other skin breakdown.9 Continual
lateral rotation therapy provides dynamic rotation of a support surface to enhance mobilization and removal of
pulmonary secretions for pulmonary benefit and to assist in preventing and treating physiologic complications of
immobility. The RotoRest™ Lateral Rotation Surface is a unique kinetic therapy surface that can be perceived to
be technically challenging to use. This surface is ideal for patients with traumatic injury, unstable spine, and
traction and for patients who need aggressive rotation therapy.
FIGURE 123-1 KCI RotoRest™ Delta Kinetic™ Therapy bed. (Courtesy KCI Licensing, Inc, San Antonio, TX, 2008.)
• Noted principles in caring for a patient receiving kinetic therapy on a RotoRest™ Delta Kinetic™ Therapy bed include
technical and clinical competence in the following:
The surface below the patient and the positioning packs consist of pressure-redistributing foam and a pad of
nonliquid polymer gel with a low-friction, low-shear GORE medical fabric (KCI Licensing, Inc, San Antonio, Texas)
cover that does not absorb body fluids.
The gel pads prevent the patient from bottoming out and transfer body heat evenly; they are radiographically
transparent.
The bed provides continuous, slow, side-to-side turning of the patient by rotating the bed frame. Keeping the
patient in maximal rotation assists with prevention of skin breakdown and provides the most effective therapy for
pulmonary indications. The bed can turn up to 62 degrees on each side, either intermittently or constantly,
providing unilateral or bilateral rotation.
The amount of time the patient is held at the rotation limit before rotating in the opposite direction can be adjusted
from 7 seconds to 30 minutes.
Head and shoulder packs provide cervical stability but should not be used as the primary means of stabilizing
cervical spine fractures. Cervical traction, halo, and vest or internal fixation may be required. Lateral arm and leg
hatches facilitate range of motion.
Hatches underneath the bed (located in the cervical, thoracic, and rectal areas) provide access for skin care, catheter
maintenance, and bladder and bowel management. Do not open thoracic and sacral hatches at the same time.
The bed has a built-in scale with a maximal patient weight of 300 lbs.7
An optional vibrator pack is available to provide chest physiotherapy to further mobilize pulmonary secretions.
EQUIPMENT
• Suggested personal protective equipment: Gloves
• Sheet or slide board to assist with moving patient onto the surface
• Transparent or foam protective dressings for areas prone to friction or shear
• Appropriate pressure redistribution surface, CLRT surface, or RotoRest™ lateral rotation surface
Patient Preparation
• Ensure that the patient and family understand preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught clinical information and rationale is
evaluated and reinforced.
• Evaluate the properties of support surface to meet pulmonary needs, skin factors related to type of injury, moisture,
and need for redistribution of pressure on skin and wounds. Order and inspect the bed functions before the patient is
placed on the surface Rationale: Support surface selection should match clinical indication for patient therapy.
Relief of external pressure may decrease risk of pressure ulcer formation and facilitates wound healing.
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Organize moving the patient to the special surface, ensuring adequate personnel are available. Assist the patient to a
supine position with the head of the bed elevated to 30 degrees (if not medically contraindicated) in preparation for
move to specialty bed. Rationale: Transfer of the patient from one bed to another is potentiated. Head of bed at 30
degrees minimizes shearing forces and protects airway.
Procedure for Lateral Rotation Therapy
References
1. Ayello, EA, Lyder, CH, Protecting patients from harm. -preventing pressure ulcers in hospital patients. Nursing.
2007; 37(10):36–40.
2. Braden, BJ, Bergstrom, N. Clinical utility of the Braden scale for predicting pressure sore risk. Decubitus. 1989;
2(3):44–46,50-41.
3. Bernard, GR, Acute Respiratory distress syndrome. a -historical perspective. Am J Respir Crit Care Med 2005;
172:798–802.
4. Brienza, DM, Geyer, J. Using support surfaces to manage tissue integrity. Adv Skin Wound Care. 2005;
18(3):151–157.
5. Goldhill, DR, Imhoff, M, McLean, B, et al, Rotational bed therapy to prevent and treat respiratory complications.
a -review and meta-analysis. Am J Crit Care. 2007; 16(1):50–62.
6. Higgens Martin, A. Should continuous lateral rotation therapy replace manual turning. Nurs Manage. 2001;
32(8):41–45.
7. Kinetic, Concepts, Roto-Rest Delta. operations and maintenance manual. Kinetic Concepts, San Antonio,
1995.
8. Maklebust, J. Choosing the right support surface. Adv Skin Wound Care. 2005; 18(3):158–160.
9. National Pressure Ulcer Advisory Panel, Support surface standards initiative. terms and definitions related to -
support surfaces,. www.npuap.org/npuap_S31_TD, 2007 [retrieved August 28, 2009, from].
10. Rauen, CA, Makic, MB, Bridges, E, Evidence-based practice habits. transforming research into bedside practice.
Crit Care Nurse. 2009; 29(2):46–59.
11. Russell, T, Logsdon, A, Pressure ulcers and lateral rotation beds. a case study. J Wound Ostomy Continence
Nurs. 2003; 30(3):143–145.
12. Thompson, P, Anderson, J, Langeo, D, et al, Support surfaces. definitions and utilization for patient care. Adv
Skin Wound Care. 2008; 21(6):264–266.
13. Turpin, P, Pemberton, V, Prevention of pressure ulcers in patients being managed on CLRT. is supplemental
repositioning needed. J Wound Ostomy Continence Nurs. 2006; 33(4):381–388.
14. Washington, GT, Macness, CL, Evaluation of outcomes. the effects of continuous lateral rotation therapy. J
Nurse Care Qual. 2005; 20(3):273–282.
Additional Readings
Anderson, J, Hanson, D, Langeo, D, et al. The evolution of support surfac es. Adv Skin Wound Ca re. 2006; 19(3):130–132.
Agenc y for Health Care Polic y and Researc h (AHCPR), Pressure ulc ers in adults. predic tion and prevention,. US Department of Health and Human S ervic es,
Roc kville, MD, 1992. [AHCPR Public ation 92-0047].
Agenc y for Health Care Polic y and Researc h (AHCPR). Trea tment of pressure ulcers. Roc kville, MD: US Department of Health and Human S ervic es; 1994. [AHCPR
Public ation 95-0652].
National Pressure Ulc er Advisory Panel. www.npuap.org, S eptember 2, 2009 [Ac c essed].
P R OC E D UR E 1 2 4
Wound Closure
Trac ey Anderson*
PURPOSE:
Wound closure is the process of holding body tissues together to promote wound healing. It is used to achieve
hemostasis, approximate tissues separated by surgery or trauma, expedite healing with minimal scarring and
without infection, provide strength until the natural tensile strength of the healing wound is sufficient to maintain
closure, and maintain appropriate positioning of tubes or drains.
FIGURE 124-1 Interrupted dermal suture. A, Proper depth. B, Proper spacing (a=b). C, Proper final appearance. D, Improper final appearance. (From
Pfenninger JL, Fowler GC, editors: Pfenninger and Fowler’ s procedures for primary care, ed 2, St Louis, 2006, Mosby.)
• Subcutaneous suture with inverted knot or buried stitch (Fig. 124-2) is used for deeper wounds or wounds under
tension. Absorbable sutures are used with the knot inverted below the skin margin. Begin at the bottom of the
wound, come up and go straight across the incision to the base again, and tie. Deep, buried subcutaneous sutures are
used to reduce the tension on skin sutures, close dead space beneath a wound, and allow for early suture removal.9,13
FIGURE 124-2. Inverted subcutaneous suture. Also show n is layered closure. (From Pfenninger JL, Fowler GC, editors: Pfenninger and Fowler’ s procedures for primary
care, ed 2, St Louis, 2006, Mosby.)
• Vertical mattress suture (Fig. 124-3) promotes eversion of the skin, which promotes less prominent scarring.13
Mattress sutures are used when skin tension is present or where the skin is very thick (palms and soles of feet). This
suture is identical to a simple suture, but an additional suture is taken very close to the edge of each side of the
wound.
FIGURE 124-3 Vertical mattress suture. A, Cross section. B, Overhead view . Begin at a, and go under skin to b. Come out, go in at c, and exit at d. (From
Pfenninger JL, Fowler GC, editors: Pfenninger and Fowler’ s procedures for primary care, ed 2, St Louis, 2006, Mosby.)
• Three-point or half-buried mattress suture (Fig. 124-4) is used to close an acute corner of a laceration without
impairing blood flow to the tip. The needle is inserted into the skin on the nonflap portion of the wound, passed
transversely through the tip, and returned on the opposite side of the wound, paralleling the point of entrance. The
suture is then tied, drawing the tip snugly in place.9,13
FIGURE 124-4 Three-point or half-buried mattress. (From Pfenninger JL, Fowler GC, editors: Pfenninger and Fowler’ s procedures for primary care, ed 2, St Louis, 2006,
Mosby.)
• Subcuticular running suture (Fig. 124-5) is used for linear wounds under little or no tension and allows for edema
formation. Wound approximation may not be as meticulous as with an interrupted dermal suture. An anchor suture
is placed at one end of the wound, then continuous sutures are placed at right angles to the wound less than 3 mm
apart. The wound is pulled together and the other end secured with either another square knot or tape under slight
tension.
FIGURE 124-5 Subcuticular running suture. (From Pfenninger JL, Fowler GC, editors: Pfenninger and Fowler’ s procedures for primary care, ed 2, St Louis, 2006, Mosby.)
Sutures must be completely removed in a timely fashion to avoid further tissue inflammation and possible infection.
Sutures on extremities and the trunk should be removed in 8 to 14 days; those on the face should be removed in 3
to 5 days; and those on the palms, soles, back, and skin over mobile joints should be removed in 10 to 14 days.5,17
EQUIPMENT
• Local anesthetic (with or without epinephrine)
• Chlorhexidine solution3 and sterile normal saline (NS) solution
• 8 to 10 4 × 4 gauze sponges
• Sterile metal prep basin
• 30- or 60-mL syringe and 18-gauge needle
• Sterile drape
• Fenestrated drape
• Sterile gloves, mask, eye protection
• Electric clippers (only if hair removal necessary)
• For suturing:
6-inch needle holder
Suture material and needle
Curved dissecting scissors
Two mosquito hemostats: one curved, one straight
Suture scissors
Tissue forceps
Scalpel handle and no. 15 knife blade
Skin hooks (for atraumatic tissue handling)
• For other wound closures:
Staple gun
Steri-Strips
Skin adhesive
• Note: Some hospitals use prepackaged suture kits; thus, it may be unnecessary to assemble all of the items listed here
if such a kit is available.
Patient Preparation
• Ensure that patient understands preprocedural teachings and obtain consent. Answer questions as they arise, and
reinforce information as needed. Rationale: Suturing is an invasive procedure, so consent should be obtained
before the procedure is started. Understanding of previously taught information is evaluated and reinforced.
• Administer pain medication as necessary. Consider moderate procedural sedation for laceration repair in children.15
Consider use of LET (lidocaine, 4%; epinephrine, 0.1%; and tetracaine, 0.5%) topically for children. Rationale: Pain
medication reduces activity significantly during suturing to provide a stable field.
• Administer tetanus prophylaxis, if necessary (Table 124-1). Rationale: Possibility of tetanus from unclean wound is
prevented.
Table 124-1
Guide to Tetanus Prophylaxis in Wound Management
The appropriate use of tetanus toxoid and TIG in w ound management is also important for the prevention of tetanus.
*Such as (but not limited to) w ounds contaminated w ith dirt, feces, soil, and saliva; puncture w ounds; avulsions; and w ounds resulting from missiles, crushing, burns,
and frostbite.
†For children younger than 7 years of age, DTaP is recommended; if pertussis vaccine is contraindicated, DT is given. For persons 7 to 9 years of age or 65 years or
older, Td is recommended. For persons 10 to 64 years, Tdap is preferred to Td if the patient has never received Tdap and has no contraindication to pertussis
vaccine. For persons 7 years of age or older, if Tdap is not available or not indicated because of age, Td is preferred to TT.
‡TIG, Human tetanus immune globulin. Equine tetanus antitoxin should be used w hen TIG is not available.
§If only three doses of fluid toxoid have been received, a fourth dose of toxoid, preferably an adsorbed toxoid, should be given. Although licensed, fluid tetanus toxoid
is rarely used.
¶Yes, if it has been 10 years or longer since the last dose.
**Yes, if it has been 5 years or longer since the last dose. More frequent boosters are not needed and can accentuate side effects.
(Manual for the surveillance of vaccine-preventable diseases, ed 4, 2008, available at www.cdc.gov/vaccines/pubs/surv-manual/chpt16-tetanus.htm#9.)
FIGURE 124-7 Thumb-ring finger grip of needle holder. (Copyright © 1996, 2010, Covidien. All rights reserved. Used with permission of Covidien.)
References
1. Autio, L, Olson, KK, The four S’s of wound management. staples, sutures, Steri-Strips, and sticky stuff. Holist
Nurs Pract 2002; 16:80–88.
2. Beam, JW. Tissue adhesives for simple traumatic lacerations. J Athletic Training. 2008; 43(2):222–224.
3. Chaiyakunapruk, N, et al, Chlorhexidine compared with povidone-iodine solution for vascular catheter-site
care. a meta-analysis. Ann Intern Med 2002; 136:792–801.
4. Cole, E. Wound closure using adhesive strips. Nurs Stand. 2007; 22(9):48–49.
5. Edlich, RF, Woods, JA, Drake, DB. Scientific basis of wound closure techniques. Norwalk, CT: Auto Suture
Company; 1996.
6. Edlich, RF, et al. A scientific basis for choosing the technique of hair removal used prior to wound closure. J
Emerg Nurs. 2000; 26:134–139.
7. Farion, KJ, et al, Tissue adhesives for traumatic lacerations. a systematic review of randomized controlled
trials. Acad Emerg Med 2003; 10:110–118.
8. Farion, KJ, Russell, KF, Osmond, MH, et al, Tissue adhesives for traumatic lacerations in children and adults.
Cochrane Database Syst Rev 2004; 4:CD003326, doi: 10. 1002/14651858. [CD003326].
9. Hanasono, MM, Hotchkiss, RN. Locking horizontal mattress suture. Dermatol Surg. 2005; 31:572–573.
10. Henry, FP, Purcell, EM, Eadie, PA, The human bite injury. a clinical audit and discussion regarding the
management of this alcohol fuelled phenomenon. Emerg Med J 2007; 23:455–458.
11. Hock, MO, et al. A randomized controlled trial comparing the hair apposition technique with tissue glue to
standard suturing in scalp lacerations (HAT study). Ann Emerg Med. 2002; 40:19–26.
12. Khachemoune, A, et al, Dehisced clean wound. resuture it or steri-strip it. Dermatol Surg 2004; 30:431–432.
13. Krunic, AL, Weitzul, S, Taylor, RS, Running combined simple and vertical mattress suture. a rapid skin-
everting stitch. Dermatol Surg 2005; 31:1325–1329.
14. Mangram, AJ, et al. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;
20:247–278. [1999].
15. Moreira, ME, Markovchick, VJ. Wound management. Emerg Med Clin North Am. 2007; 25:873–899.
16. Moureau, NL. Is your skin prep technique up-to-date. Nursing. 2003; 33(11):17.
17. Reilly, J. Evidence-based surgical wound care on surgical wound infection. Br J Nurs. 2002; 11(16 Suppl):S4–
S12.
18. Singer, AJ, Dagum, AB. Current management of acute cutaneous wounds. N Engl J Med. 2008; 359:1037–1046.
19. Tanner, J, Woodings, D, Moncaster, K, Preoperative hair removal to reduce surgical site infection. Cochrane
Database Syst Rev 2006; 3:CD004122, doi: 10. 1002/1465185858. [CD004122. pub3].
20. Waterbrook, AL, Germann, CA, Southall, JC. Is epinephrine harmful when used with anesthetics for digital nerve
blocks. Ann Emerg Med. 2007; 50:472–475.
21. Zehtabchi, S. The role of antibiotic prophylaxis for prevention of infection in patients with simple hand
lacerations. Ann Emerg Med. 2007; 49(5):682–689.
Additional Readings
Broughton, G, Janis, JE, Attinger, CE, Wound healing. an -overview. Plast Rec onstruc t S urg. 2006; 117(7S ):1eS –32eS .
S nell, G. Lac eration repair. In: Pfenninger JL, Fowler GC, eds. Pfenninger a nd Fowler’s procedures for prima ry ca re. ed 2. S t Louis: Mosby; 2006:12–19.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
*Trac ey Anderson would like to ac knowledge the signific ant work done by the original c hapter author, Peggy Kirkwood.
P R OC E D UR E 1 2 5
PURPOSE:
Sutures and staples are placed to approximate tissues that have been separated. When wound healing is
sufficient to maintain closure, sutures and staples are removed.
Table 125-1
Timing of Suture Removal
EQUIPMENT
• Sterile gloves and mask
• Sterile towel or drape
• Sterile swab with antiseptic cleaning solution according to facility’s policy (typically chlorhexidine)
• 4 × 4 gauze pads
• Suture removal kit with scissors and forceps (if no kit available, obtain sterile scissor and forceps)
or
• Staple remover
• Skin tape or adhesive skin strips (Steri-Strips) of appropriate width
• Skin adherent (recommended as it helps with adherence and protects periwound area)
Patient Preparation
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Administer pain medication as prescribed. Rationale: Pain medication reduces activity during suture or staple
removal to provide a stable field.
• Provide privacy and position the patient for comfort without undue tension on the suture line or staples. Rationale:
Provides patient comfort and promotes cooperation during procedure.
• Adjust the light to shine directly on the suture line or staples. Rationale: Light is used to provide ease of removal
and patient comfort.
• Prepare sterile field. Rationale: Sterile field is used to prevent contamination.
Procedure for Suture Removal
FIGURE 125-1 Removal of plain interrupted sutures w ith sterile forceps and scissors.
FIGURE 125-2 Removal of interrupted mattress sutures w ith sterile forceps and scissors.
References
1. Hrouda, BS. How to remove surgical sutures and staples. Nursing. 2000; 30:54–55.
2. Sussman, C, Bates-Jensen, B, Wound care. a collaborative practice manual for health professionals. ed 3.
Lippincott Williams & Wilkins, Philadelphia, 2006.
Additional Readings
S inger, AJ, Dagum, AB. Current management of ac ute c utaneous wounds. N Engl J Med. 2008; 359:1037–1046.
Yaremc huk, MJ, Gallic o, GG. Princ iples and prac tic e of plastic surgery. In: Morris PJ, Wood WC, eds. Oxford textbook of surgery. ed 2. New York: Oxford University
Press, Inc ; 2000:3533–3537.
S E CTION TWE NTY-TWO
Wound Management
P R OC E D UR E 1 2 6
PURPOSE:
Cleaning, irrigating, culturing, and dressing open wounds are performed to optimize healing. Wound culturing
may be necessary to isolate and allow for treatment of organisms.
Normal wound healing is often described as a progressive process that involves three overlapping phases:
inflammation, proliferation, and maturation. The inflammatory phase is marked for hemostasis, increased
vasodilation, and migration of neutrophils and macrophages to the area. The proliferation phase begins 2 to 4 days
after injury and is the healing phase of the wound process in which epithelialization, angiogenesis, and collagen
synthesis predominate.8,9 The maturation phase involves the body remodeling collagen fiber and increasing tissue
tensile strength.8,9
Most clean wounds heal by primary intention. Suturing each layer of tissue approximates the wound edges. These
wounds typically heal quickly and require minimal wound care.
Open wounds heal by secondary intention by granulating from the base of the wound to the skin surfaces and
contracting and epithelializing from the wound edges; care must be taken to allow for uniform granulation and
prevention of open pockets or tunneling.
Tertiary intention involves a period of secondary healing to achieve edema reduction and decreased exudate
production, followed by surgical closure for primary healing.
• Clean, moist wound beds allow for effective wound healing under the support of a dressing.
Openly granulating wounds heal more slowly, may result in drying of granulating tissue and tissue death, and may
be more painful for the patient.
The presence of exudate is not synonymous with infection but is the natural result of the inflammatory response to
maintain moisture and allow movement and replication of epithelial cells necessary for healing. A change in
volume, color, or consistency of exudate may indicate impending infection.2,4,12
• Wound cleansing should be accomplished with minimal chemical or mechanical trauma.
Cytotoxic cleaning agents (i.e., chlorhexidine, iodine, hydrogen peroxide) should be limited because they can delay
healing.1,4,9,12
Wound cleaning solutions should be pH neutral.
Normal saline (NS) solution is the cleaning agent of choice; however, tap water is safe and effective for cleaning of
most acute and chronic wounds.1,5,14
The cleaning solution must be delivered with enough force to physically loosen foreign materials and bacteria
without injuring the tissue. Effective wound cleaning is best achieved when solution is delivered at 8 to 13 psi (Fig.
126-2). A 35-mL syringe attached to an 18-gauge angiocatheter tip only delivers fluid at 8 psi. A 12-mL syringe with
a 22-gauge angiocatheter tip provides 13 psi. (Increasing syringe size decreases the pressure of the stream, and
increasing the bore of the catheter tip increases the pressure.) Pressures greater than 15 psi may actually force
bacteria and debris deeper into the wound bed.2,8,9,12
• Wound infections delay wound healing. Wound cultures (obtained before antibiotic therapy) may isolate organisms
and differentiate between colonization and active infection.
Wound contamination is the presence of bacteria on the wound surface that are not actively multiplying. Signs and
symptoms of infection are not present, and healing is not impaired.4,12
Colonization is the presence of bacteria in the wound that are actively multiplying or forming colonies. Colonization
can delay healing but may not elicit signs of infection.
Wound infection is present if organisms are present at 105 colony-forming units per milliliter (103 for virulent
organisms like β-hemolytic strep4 ) in conjunction with clinical findings such as erythema, edema, pain, purulence,
fever, and leukocytosis.
With the proliferation of organisms like methicillin-resistant Staphylococcus aureus (MRSA) and aggressive bacteria
that cause necrotizing soft tissue infections (e.g., group A Streptococci and Streptococcus pyogenes), the standard of
empirically implementing antibiotic treatment without wound culture is being questioned. Knowledge of whether
resistant strains of bacteria are present at the onset of treatment is critical to provide the optimal situation for
healing and rapid intervention.4,11
Bacterial invasion of wounds is managed with cleansing, débridement (see Procedure 127), and antibiotic therapy
(local or systemic). Soaking can macerate wound and periwound tissues and may not improve bacterial counts.14
EQUIPMENT
• Nonsterile and sterile gloves (two pairs); sterile field (depending on type and age of wound)
• Personal protective equipment (as needed)
• Two or three sterile cotton-tipped applicators for use in measurement
• (NS) solution or ordered irrigation solution
• Sterile basins
• Waterproof barriers
• Sterile 35-mL slip-tip syringe and 18-gauge angiocatheter sheath for irrigation (if necessary)
• Sterile gauze (4 × 4); possibly, ABD dressings (if the wound has excessive drainage, an absorptive dressing may be
necessary; if the wound has minimal drainage, a moisture-enhancing dressing may be needed)
• Liquid skin barrier or wafer; apply around the wound edge to protect periwound tissue
• Hypoallergenic tape; tubular mesh bandage or one set of Montgomery straps
Additional equipment to have available, if needed, includes the following:
• Swab culture: two sterile serum-tipped swabs and culturettes
• Tissue biopsy: scalpel, forceps, gauze for hemostasis, and container
• Needle aspiration: 10-mL syringe, 22-gauge needle, and syringe cap
Appearance of wound bed (color, presence of debris; i.e., necrotic or darkened areas on tissue bed are black; slough
is green or cream yellow; and healthy tissue is red)
Condition of wound margins and periwound skin (intact versus maceration or xerosis; abnormal
textures/undermining)
Pain or tenderness
Presence of erythema (blanches with pressure) or ecchymosis (does not blanch with pressure)
Elevated temperature or localized warmth at wound site
White blood cell count; may be elevated or show a change from baseline
With advance age, subtle changes in activity and cognition may be the only indications of infection2,6
Nutrition assessment
Rationale: Assessment provides information about the healing process and assists in early identification of wound
infection. True wound bed assessment cannot be completed until after the wound bed has been cleansed.
Patient Preparation
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Place patient in position of optimal comfort and visualization for wound care procedures. Rationale: Proper
positioning provides for effective wound visualization and enhances patient tolerance of procedure.
• Optimize lighting in room and provide privacy for patient. Rationale: Lighting allows for optimal wound
assessment, and privacy provides patient comfort.
• Administer premedication with prescribed analgesic, if indicated. Rationale: Medication decreases patient anxiety
and increases comfort. Pain and stress are recognized deterrents for healing.3,13
Procedure for Cleaning, Irrigating, Culturing, and Dressing an Open Wound
FIGURE 126-4 Cleaning of a w ound. (From Potter PA, Perry A: Basic nursing: essentials for practice, ed 5, St Louis, 2003, Mosby.)
FIGURE 126-5 Montgomery straps.
References
1. Agency for Health Care Policy and Research, Clinical practice guideline. treatment of pressure ulcers,. US
Department of Health and Human Services, Rockville, MD, 1994.
2. Bates-Jensen BM, Ovington, LG. Management of exudate and infection. In: Sussman C, Bates-Jensen BM, eds.
Wound care: a collaborative practice manual. ed 3. Philadelphia: Wolters Kluwer; 2007:215–233.
3. Broadbent, E, Petrie, K, Alley, PG, et al. Psychological stress impairs early wound repair following surgery.
Psychosom Med. 2003; 65(5):865–869.
4. Edwards, R, Harding, KG. Bacteria and wound healing. Curr Opin Infect Dis. 2004; 17(2):91–96.
5. Fernandez, R, Griffiths, R. Water for wound cleansing. Cochrane Database Syst Rev. 2008; 23(1):CD003861.
6. Johnson, CB, Harper, GM, Landsfeld, CS. Geriatric -medicine. In: McPhee SJ, Papadakis MA, Tierney LM, Jr.,
eds. Current medical diagnosis and treatment. ed 47. New York: Lange Medical Books/McGraw-Hill; 2008:51–66.
7. Lawson, C, Juliano, L, Ratilff, CR. Does sterile or nonsterile technique make a difference in wounds healing by
-secondary intention. Ostomy Wound Manage. 2003; 49(4):56–60.
8. Makic, MB, McQuillan, KA. Wound healing and soft -tissue injuries. In: McQuillan KA, Makic MB, Whalen E,
eds. Trauma nursing: from resuscitation through -rehabilitation. ed 4. St Louis: Saunders Elsevier; 2009:306–329.
9. Rolstad, BS, Ovington, LG. Principles of wound management. In: Byrant RA, Nix CP, eds. Acute and chronic
wounds. ed 3. Philadelphia: Mosby Elsevier; 2007:-391–426.
10. Siegel, JD, Rhinehart, E, Jackson, M, et al, Healthcare Infection Control Practices Advisory Committee, guideline
for isolation precautions. preventing transmission of infectious agents in healthcare settings; transmission-based
precautions,. Centers for Disease Control and Prevention, Atlanta, 2007.
11. Storr, A, Inappropriate therapy for methicillin-resistant Staphylococcus aureus. resource utilization and cost
implications. Crit Care Med. 2008; 36(8):2335–2340.
12. Stotts, N, Wound infection. diagnosis and managementByrant RA, Nix CP, eds.. Acute and chronic wounds. ed 3.
Mosby Elsevier, Philadelphia, 2007:161–175.
13. Sussman, C, Bates-Jensen, B, Wound healing physiology. acute and chronicSussman C, Bates-Jensen B, eds..
Wound care: a collaborative practice manual for health professionals. ed 3. Wolters Kluwer, Philadelphia,
2007:21–51.
14. The Joanna Briggs Institute, Solutions, techniques and pressure for wound cleansing. www.joannabriggs.edu.au
retrieved September 10, 2008, from. Best Pract. 2006; 10(2):1–4.
Additional Readings
Baranoski, S , Choosing a wound dressing. part I. Nursing. 2008; 38(1):60–616.
Baranoski, S , Choosing a wound dressing. part II. Nursing. 2008; 38(2):14–15.
Bates-Jensen, BM, Mac Lean. Quality indic ators for the c are of pressure ulc ers in vulnerable elders. J Am Geria tr Soc. 2007; 55(S uppl 2):S 409–S 416.
Moore, Z, Cowan, S . A systematic review of wound c leansing for pressure ulc ers. J Clin Nurs. 2008; 17(15):1963–1972.
Wound Ostomy and Continenc e Nurses (WOCN) S oc iety. Guideline for prevention a nd ma na gement of pressure ulcers (series),. Glenview, IL: WOCN; 2003.
P R OC E D UR E 1 2 7
PURPOSE:
Wound débridement is the removal of necrotic nonviable tissue to promote wound healing.
EQUIPMENT
• Sharp débridement:
Personal protective equipment (gown, goggles, mask)
Sterile gloves and field
Normal saline solution
Gauze 4 × 4 pads
Sterile instrument set (scissors, forceps, no. 10 scalpel)
Wound dressing
Tape
• Chemical débridement:
Normal saline solution or water to clean wound
Clean gloves or sterile gloves (depending on type and age of wound)
Enzymatic preparation or solution (prescribed)
Tongue blade
Filler dressing if needed; secondary absorptive dressing
No. 10 scalpel for crosshatching (optional)
Tape
• Mechanical débridement (wet-to-dry gauze dressing):
Clean or sterile gloves (depending on type and age of wound)
Normal saline solution
Gauze (rolled or 4 × 4 pads)
Secondary absorptive dressing
Tape
• Autolytic débridement:
Clean gloves
Normal saline solution or water to clean wound
Moisture-retentive dressing (transparent film, hydrocolloid dressing, hydrogels)
Secondary absorptive dressing as indicated
Tape
Patient Preparation
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Verify correct patient with two identifiers. Obtain informed consent for surgical and sharp débridement.2,11
Rationale: Prior to performing a procedure, ensure the correct identification of the patient for the intended
intervention. Informed consent ensures patient knowledge of procedure.
• Before the procedure, comply with Universal Protocol requirements.11 Ensure all relevant studies and documents,
including informed consent, are available. Ensure site markings have been made where appropriate. Prior to surgical
or sharp débridement, perform a pre-procedure verification and time out, if non-emergent. Rationale: Ensures
patient safety.
• Premedicate patient with prescribed analgesic, if needed. Assess patient’s response to analgesic before start of
procedure. Reassess patient’s need for additional analgesic agents throughout débridement procedure. Consider
topical lidocaine solution. Rationale: Patient anxiety and discomfort are decreased. Pain results in vasoconstriction
of the cutaneous tissues from the increase in adrenergic activity. Adequate pain control improves tissue perfusion and
results in improved healing.3
• Place patient in position of optimal comfort and visualization for dressing the wound. Keep the patient warm while
the wound is exposed. Rationale: Positioning provides for effective wound visualization and enhances patient
tolerance of procedure. Keeping the patient warm prevents vasoconstriction that impairs wound healing.
• Optimize lighting in room and provide privacy for patient. Rationale: Optimal wound assessment and patient
comfort are provided.
Procedure for Débridement: Pressure Ulcers, Burns, and Wounds
References
1. Agency for Health Care Policy and Research. Treatment of pressure ulcers. Rockville, MD: US Department of
Health and -Human Services; 1994. [AHCPR Publication No. 95-0652].
2. Anderson, I. Debridement methods in wound care. Nurs Stand. 2006; 20(24):65–72.
3. Broughton, G, et al, Wound healing. an overview. Plast Reconstruct Surg. 2006; 117(7S):1e-s–32e-s.
4. Calianno, C, et al, Wound bed preparation. laying the foundation for treating chronic wounds, part 1. Wound
Skin Care. 2006; 36(2):70.
5. Kirshen, C, et al, Debridement. a vital component of wound bed preparation. Adv Skin Wound Care. 2006;
19(9):506–517.
6. Kravitz, S, et al, Management of skin ulcers. understanding the mechanism and selection of enzymatic debriding
agents. Adv Skin Wound Care. 2008; 21(2):72–74.
7. NPUAP. Pressure ulcer stages revised. www.npuap.org, September 24, 2008. [retrieved from].
8. Ovington, LG. Hanging wet-to-dry dressings out to dry. Adv Skin Wound Care. 2002; 15:79–89.
9. Rodeheaver, GT, Pressure ulcer debridement and cleansing. a review of current literature. Ostomy Wound
Manage 1999; 45:80–86.
10. Thomaselli, N, WOCN position statement. conservative sharp wound debridement for registered nurses. J
Wound Ostomy Continence Nurses 1995; 22:32A.
11. The Joint Commission. Universal protocol for preventing wrong site, wrong procedure, wrong person surgery.
www.jointcommission.org/PatientSafety/UniversalProtocol, 2003. [retrieved January 8, 2009, from].
Additional Readings
Dryburgh, N, S mith, F, Donaldson, J, et al, Debridement for surgic al wounds. Cochra ne Da ta ba se Syst Rev. 2008(3), doi: 10. 1002/14651858. [CD006214].
Byrant, RA, Nix, CP, Ac ute and c hronic wounds. ed 3. Mosby Elsevier, Philadelphia, 2007.
S iegel, JD, Rhinehart, E, Jac kson, M, et al. Centers for Disease Control and Prevention, Atlanta, 2007.
S ussman, C, Fowler, E, Wethe, J. Sha rp debridement of wounds [video series]. Torranc e, CA: S ussman Physic al Therapy, Inc ; 1995.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 1 2 8
PURPOSE:
Management of wound exudate is an essential step in wound healing. Pouching may be used to contain
excessive drainage. Drains may be placed in the wound for management of drainage.
EQUIPMENT
• Nonsterile and sterile gloves; sterile field
• Personal protective equipment: gowns and face protection
• Sterile gauze (4 × 4 pads); abdominal pad (e.g., ABD) or other absorptive dressings may be needed
• Sterile water or normal saline (NS) solution for cleansing
• Liquid skin barrier, skin barrier wafers, paste, powder and sealant, or hydrocolloid to protect periwound surface
• Drainage bag or pouch: ostomy-type appliance
• Clean scissors; forceps, if appropriate
• Hypoallergenic tape
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Follow institutional standard for assessing pain. Administer analgesia as prescribed. Rationale: Identifies need for
pain interventions.
• Place patient in position of optimal comfort and visualization for dressing the wound. Rationale: Positioning
provides for effective wound visualization and enhances patient tolerance of procedure.
• Optimize lighting in room and provide privacy for patient. Rationale: These measures allow for optimal wound
assessment and patient comfort.
Procedure for Management of Wound Exudate with Drains and Pouches
FIGURE 128-1 Dressing a w ound w ith a drain.
References
1. Ayello, EA, The TIME principles of wound bed preparation . Adv Skin Wound Care. 2009; 22(Suppl 1):2–5.
2. Bates-Jensen BM, Ovington, L, Management of exudate and infectionSussman C, Bates-Jensen BM, eds.. Wound
care . a collaborative practice manual. ed 3. 2007. Lippincott Williams & Wilkins: Philadelphia :215–233.
3. Bates-Jensen BM, Seaman, S, Management of malignant cutaneous wounds and fistulas. Sussman, C. Bates-
Jensen, BM. Wound care . a collaborative practice manual. ed 3. Lippincott Williams & Wilkins, Philadelphia,
2007:476–494.
4. Bovill, E, et al, Topical negative pressure wound therapy. a review of its role and guidelines for its use in the
management of acute wounds. Int Wound J. 2008; 65(3):722–731.
5. Bryant, RA, Rolstad, BS, Management of drain sites and fistulasBryant RA, Nix DP, eds.. Acute & chronic
wounds . current management concepts. ed 3. Mosby, Philadelphia, 2007:490–516.
6. Gray, M, Weir, D, Prevention and treatment of moisture-associated skin damage (maceration) in the periwound
skin. J Wound Ostomy Continence Nurs. 2007; 34(2):153–157.
7. Hanson, D, et al. Understanding wound fluid and the phases of healing. Adv Skin Wound Care. 2005;
18(1):360–362.
8. Naude, L, Exudate management. putting the patient first. Pro Nurs Today. 2008; 12(5):29–32.
9. Nix, DP, Patient assessment and evaluation of healing Bryant RA, Nix DP, eds. Acute & chronic wounds: current
management concepts, ed 3, Philadelphia: Mosby, 2007.
10. Ovington, LG, Dealing with drainage. the what, why, and how of wound exudates. Home Healthcare Nurse
2002; 20:368–374.
11. Rolstad, BS, Ovington, LG, Principles of wound management Bryant RA, Nix DP, eds.. Acute & chronic wounds:
current management concepts. ed 3. Mosby, Philadelphia, 2007:391–426.
12. Brindle, CT, Blankenship, J. Management of complex abdominal wounds with small bowel fistulae; isolation
techniques and exudate control to improve outcomes. J Wound Ostomy Continence Nurs. 2009; 36(4):396–404.
Additional Readings
Hoc evar, BJ, et al, Management of fistula in the abdominal region. J Wound Ostomy Continence Nursing . 2008; 35(4):417–423.
S kovgaard, R, Keiding, H, A c ost-effec tiveness analysis of fistula treatment in the abdominal region using a new integrated fistula and wound management system. J
Wound Ostomy Continence Nursing . 2008; 35(6):592–595.
Trevillion, N. Cleaning wounds with saline or tap water. Emerg Nurse. 2008; 16(2):24–26.
P R OC E D UR E 1 2 9
Drain Removal
Mary Beth Flynn Makic
PURPOSE:
Drain removal is performed when the drain is no longer needed for wound management.
EQUIPMENT
• Nonsterile gloves
• Personal protective equipment (e.g., gowns and face protection)
• Sterile gauze 4 × 4 pads
• Dressing for exit site based on characteristics of wound
• Suture removal kit or sterile scissors
• Hypoallergenic tape
Patient Preparation
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Premedicate patient with prescribed analgesic, if needed. Rationale: Patients may not need premedication for drain
removal; however, the patient’s pain and need for analgesia should be assessed before the procedure and treated
appropriately.
• Optimize lighting in room and provide privacy for patient. Rationale: These measures allow for optimal assessment
and patient comfort.
Procedure for Drain Removal
References
1. Bates-Jensen B, Woolfolk, N, Acute surgical wound management Sussman C, Bates-Jensen B, eds.. Wound care: a
collaborative practice manual for health professional. ed 3. Lippincott -Williams & Wilkins, Philadelphia,
2007:323–335.
2. Bovill, E, Banwell, PE, Teot, L, et al, Topical negative pressure wound therapy. a review of its role and guidelines
for its use in the management of acute wounds. Int Wound J 2008; 10:1–19.
3. Fleck, CA. Wound assessment parameters and dressing selection. Adv Skin Wound Care. 2006; 19:364–370.
4. Gray, M, Wier, D, Prevention and treatment of moisture-associated skin damage (maceration) in the periwound
skin . JWOCN 2007; 43:153–157.
5. Sussman, G, Management of the wound environment with dressings and topical agentsSussman C, Bates-Jensen
B, eds.. Wound care . a collaborative practice manual for health professionals. ed 3. Lippincott Williams &
Wilkins, Philadelphia, 2007:250–267.
6. Vuolo, JC. Assessment and management of surgical wounds in clinical practice. Nurs Stand. 2006; 20:46–56.
7. Walker, J. Patient preparation for safe removal of surgical drains. Nurs Stand. 2007; 21:39–41.
Additional Readings
Additional Readings
Flec k, CA. Managing wound pain. Adv Skin Wound Ca re. 2007; 20:138–144.
Ovington, LG. Dealing with drainage. Home Hea lthca re Nurse. 2002; 20:368–375.
Trevillion, N. Cleaning wounds with saline or tap water. Emerg Nurse. 2008; 16:24–26.
P R OC E D UR E 1 3 0
PURPOSE:
Fecal containment devices and bowel management systems may be used to divert liquid fecal matter associated
with acute diarrhea. Containment of feces may assist with the prevention or treatment of incontinence-
associated dermatitis, prevention of pressure ulcers, and contamination of perineal wounds.
FIGURE 130-1 Flexi-Seal FMS, ConvaTec, Skillman, NJ. (Copyright © 1996, 2010 Covidien. All rights reserved. Used with the permission of Covidien.)
FIGURE 130-2 ActiFlow Indw elling Bow el Catheter. (Courtesy of Hollister, Inc., Libertyville, IL.)
Manufacturer-specific contraindications for BMS include allergies to product components; children; adults with
strictured anal canals; and patients with impactions or recent rectal surgery (less than 6 weeks), severe
hemorrhoids, localized inflammatory process or disease, or an incompetent rectal sphincter.4,12
The BMS may be inserted to manage existing diarrhea or provide fecal diversion away from existing wounds;
however, the stool should be liquid or semiliquid.
Use with caution in patients on anticoagulation therapy or with rectal varices, inflammatory bowel disease, low
platelet count, or high international normalized ratio (INR).
• If blood is present in the rectum, ensure there is no evidence of pressure necrosis from the device. Discontinuation of
use of the device is recommended if evident. Notify physician for any signs of bleeding.
• Avoid use of ointments or lubricants with petroleum base because they may compromise the integrity of the BMS
device.4,12
• Transient fecal incontinence and diarrhea are common among hospitalized patients. Goals of a bowel management
program should be clearly discussed among all healthcare providers, patient, and family. Goals should include
treatment of the cause of the fecal incontinence if possible and prevention of perineal tissue injury and may not
require a containment device.
EQUIPMENT
• Nonsterile gloves
• Personal protective equipment (e.g., gowns and face protection)
• Sterile water (or normal saline solution)
• Water-soluble lubricant
• Bowel management system
• Underpads
• Skin cleansing solution
Patient Preparation
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Optimize lighting in room and provide privacy for patient. Rationale: These measures allow for optimal assessment
and patient comfort.
• Place patient in a left lateral position or position of optimal comfort and visualization for anus and rectum.
Rationale: Positioning provides for effective visualization and enhances patient tolerance of procedure.3
Procedure for Fecal Containment Device and Bowel Management System (BMS)
FIGURE 130-3 Correct placement of a bow el management system in the rectum. (Courtesy of Hollister, Inc., Libertyville, IL.)
References
1. Ayello, EA, Lyder, CH, Protecting patients from harm . preventing pressure ulcers in hospital patients . Nursing
2007; 37:36–40.
2. Beitz, JM, Fecal incontinence in acutely and critically ill patients. options in management. Ostomy Wound
Manage 2006; 52:56–66.
3. Benoit, RA, Watts, C, The effect of a pressure ulcer prevention program and the bowel management system in
reducing pressure ulcer prevalence in an ICU setting . JWOCN 2007; 34:163–175.
4. ConvaTec. Flexi-SealTM fecal management system. www.convaTec.com, December 12, 2008. [retrieved].
5. Doughty, DB. Prevention and early detection of pressure ulcers in hospitalized patients. JWOCN. 2008; 35:76–78.
6. Echols, J, Friedman, BC, Mullins, RF, et al. Clinical utility and economic impact of introducing a bowel
management system. JWOCN. 2007; 34:664–670.
7. Faria, DT, Shwayder, T, Krull, EA, Perineal skin injury . extrinsic environmental risk factors. Ostomy Wound
Manage . 1996; 42:28–37.
8. Gray, M, Incontinence-related skin damage. essential knowledge. Ostomy Wound Manage 2007; 53:28–31.
9. Gray, M, Bliss, DZ, Doughty, DB, et al, Incontinence-associated dermatitis. a consensus. JWOCN 2007; 34:45–54.
10. Gray, M, Bohacek, L, Weir, D, et al, Moisture vs pressure. making sense out of perineal wounds. JWOCN 2007;
43 :134–142.
11. Grogan, T, Kramer, D, The rectal trumpet. use of a nasopharyngeal airway to contain fecal incontinence in
critically ill patients. JWOCN. 2002; 29(1):193–201.
12. Hollister, Incorporated, ZassiTM bowel management system. www.holister.com, December 12, 2008 [retrieved].
13. Junkin, J, Selekof, JL, Prevalence of incontinence and associated skin injury in the acute care inpatient . JWOCN
2007; 34:260–269.
14. Keshava, A, Renwick, A, Stewart, P, et al, A nonsurgical means of fecal diversion. the Zassi Bowel Management
System. Dis Colon Rectum 2007; 50:1017–1022.
15. Newman, DK, Double taboos. urinary and fecal incontinencethe state of the science. Ostomy Wound Manage
2007; 53:6–7.
16. Nix, D. Prevedntion and treatment of perineal skin breakdown due to incontinence. Ostomy Wound Manage.
2006; 52:26–28.
17. Padula, CA, Osborne, E, Williams, J, Prevention and early detection of pressure ulcers in hospitalized patients .
JWOCN 2008; 35:65–75.
18. Palmieri, B, Benuzzi, Bellini, N, The anal bag. a modern approach to fecal incontinence management. Ostomy
Wound Manage 2005; 51:44–52.
19. Roach, M, Christie, JA, Fecal incontinence in the elderly . Geriatrics . 2008; 63:13–22.
20. Vollman, KM. Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement
in the ICU. Crit Care Nurs Clin North Am. 2006; 18:453–467.
21. Watterworth, B, Ryzeuski, J, Managing fecal incontinence . JWOCN 2005; 32:217–218.
22. Wishin, J, Gallagher, TJ, McCann, E. Emerging options for the management of fecal incontinence in hospitalized
patients. JWOCN. 2008; 35:104–110.
23. Zulkowski, K, Perineal dermatitis versus pressure ulcer. distinguishing characteristics. Adv Skin Wound Care
2008; 21:382–388.
Additional Readings
Bliss, DZ, S tuart, J, S avik, K, et al. Fec al inc ontinenc e in hospitalized patients who are ac utely ill. Nurs Res. 2000; 49:101–108.
Gray, M, Ratliff, C, Donovan, A. Perineal skin c are for the inc ontinent patient. Adv Skin Wound Ca re. 2002; 15:170–177.
Leandefel, CS , Bowers, BJ, Feld, AD, et al, National Institutes of Health S tate-of-S c ienc e Conferenc e S tatement . prevention of fec al and urinary inc ontinenc e in
adults. Ann Intern Med 2008; 148:449–460.
P R OC E D UR E 1 3 1
PURPOSE:
The purpose of negative-pressure wound therapy is to apply controlled subatmospheric (negative) pressure to
the wound bed for stimulation of granulation tissue and edema reduction, and thus, enhancement of wound
healing.
FIGURE 131-1 Components of the Vacuum-Assisted Closure System: ActiV.A.C.® and InfoV.A.C.® Therapy Systems. (Courtesy of KCI Licensing, Inc. 2009.)
FIGURE 131-2 Components of RENASYS EZ® NPWT therapy. (Courtesy of Smith & Nephew, Inc.)
• Most randomized controlled studies and case studies on NPWT have been conducted with the V.A.C. therapy. No
randomized controlled trials are found that compare the effectiveness of various NPWT techniques or systems.11
Further clinical research to evaluate wound closure outcomes with the different NPWT units is needed.5,8,10,11
• NPWT assists with wound closure by applying a controlled subatmospheric (negative) pressure evenly over a wound
bed. This mechanical stress creates a noncompressive force on the wound bed that dilates the arterioles, increasing the
effectiveness of local circulation and enhancing the proliferation of granulation tissue.1,4,5 NPWT enhances lymphatic
flow and removal of excessive fluid, decreasing wound edema and bacterial load at the wound site, further aiding
wound healing (Fig. 131-3).1,2,4,5,9,10
FIGURE 131-3 ActiV.A.C.® and InfoV.A.C.® Therapy Systems. Fluid, exudate, and debris removed from w ound bed. (Courtesy of KCI Lincensing, Inc. 2009)
• Wound healing is best achieved through adequate cleansing, débridement, and dressing of the wound bed on the
basis of patient and wound characteristics.
• Wounds heal by either primary or secondary intention (see Fig. 126-1). Most clean surgical wounds heal by primary
intention. Suturing each layer of tissue approximates the wound edges. These wounds typically heal quickly and
require minimal wound care. Contaminated surgical or traumatic wounds (open wounds) heal by secondary
intention. Wounds that heal by secondary intention granulate from the base of the wound to the skin surfaces; care
must be taken to allow for uniform granulation and prevention of open pockets or tunneling.
• Openly granulating wounds heal more slowly and must remain moist to enhance tissue granulation. Wound care for
these wounds focuses on maintaining a moist environment free of necrotic tissue, and decreasing pain.
• Open wounds may have excessive wound drainage that necessitates application of absorptive dressings, protection of
periwound skin, and more frequent dressing changes to facilitate healing. NPWT provides wound drainage
management and decreased frequency of dressing changes (most NPWT dressing changes are three times per week)
with improved pain management.
• NPWT has been approved by the U.S. FDA for the following wounds:
Acute wounds (orthopedic trauma wounds, partial-thickness burns, abdominal wounds, surgical dehisced wounds,
flaps, and grafts)
Chronic wounds (diabetic wounds, pressure ulcers, leg ulcers)
• Goals of NPWT in the management of wounds may include wound bed preparation for skin grafts, full wound
closure, decrease in wound size, removal of wound edema for delayed primary closure, and increased perfusion to
marginally viable flaps.
• The effectiveness of NPWT should be evaluated with each dressing change to include a comprehensive wound
assessment and weekly wound measurements. If wound measurements have not improved at least 15% after 2 weeks
of therapy, reevaluate the continuation of NPWT with reassessment of wound healing variables.13
• Wounds with infections should have systemic antibiotic treatment before initiation of NPWT. If continued
deterioration of the wound or infection persists, consider discontinuation of NPWT with possible evaluation for
surgical drainage of infection per healthcare provider.
• Wounds treated with NPWT develop a characteristic, beefy red granulation bed. Pale, friable granulation tissue is a
secondary sign of infection and may be more reliable than the traditional indicators of infection.3
• Dehisced infected sternal wounds with use of NPWT require effective débridement of infected bone and a specific
nonadherent wound contact layer before a NPWT dressing is placed.
• Successful management of enteric fistulae with NPWT with use of special application techniques has been reported in
case studies but no clinical trials at this time. See NPWT device manuals for specific techniques in the management of
fistulae.
• Rapid formation of granulation tissue with NPWT can lead to development of abscesses. The surgically dehisced
wound with NPWT should be monitored closely for abscess formation, particularly in patients with large irregular
wounds with undermining present.
• Transcutaneous oxygen pressure (TcpO2 ) evaluation should be considered before initiation of NPWT to lower
extremity or toe wounds because of vascular flow requirements that are needed for optimal wound healing with
NPWT.
• Contraindications to use of NPWT include malignancy disease in the wound, untreated osteomyelitis, nonenteric and
unexplored fistulae, and necrotic tissue with eschar present.10 See manufacturer NPWT manual for special
precautions required with exposed blood vessels, organs, tendons, and nerves. Precautions should be used for
wounds with active bleeding, for difficult wound hemostasis, and for patients undergoing anticoagulation therapy.
• For optimal NPWT with the V.A.C. device, at least 22 of 24 hours of daily uninterrupted therapy should be delivered.
The newer vacuum units do not have research evidence at this time for required time duration of uninterrupted
therapy for optimal wound healing. NPWT dressings are usually changed every 48 hours.5,7-10 However, infected
wound beds may require more frequent dressing changes (every 12 hours), and dressings over grafts may be changed
less frequently (every 3 to 5 days).5,8 The wound bed should be free of necrotic tissue and debris before application of
the NPWT dressing.
• In highly exudative wounds, drainage from the wound bed may be significant in the first 24 to 48 hours of therapy.
Studies have not suggested direct fluid replacements as necessary for ensuring homeostasis in highly exudative
wounds.1,3,4 Excessive bleeding should be noted for discontinuation of therapy.
• Nutritional requirements for wound healing are great. These needs must be assessed, met, and monitored frequently
because poor nutrition can impede successful NPWT wound healing.
• The NPWT units discussed previously (ActiV.A.C.® and InfoV.A.C.® Therapy Systems and RENASYS EZ®) have
home units with increased portability. Smaller size and increased battery life allow for continuation of therapy outside
of the acute hospital setting.
EQUIPMENT
The following is generic equipment used for most NPWT units. Device- and wound-specific variations may need to be
considered by the healthcare provider.
• Standard Precautions equipment: gloves, gown, as indicated per institution policy
• Normal Precautions or wound cleanser with appropriate psi delivery device (see Procedure 126)
• Protective barrier film/wipe for periwound protection
• NPWT dressing with tubing/transparent drape kit (device-specific)
• NPWT vacuum unit/collection chamber (device-specific)
• Sterile scissors
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure patient and family understanding of procedure. Reinforce teaching points as needed. Rationale:
Understanding of previously taught information is evaluated, and a conduit for questions is provided.
• Validate presence of patent intravenous access. Rationale: Access may be needed for administration of intravenous
analgesic medications.
• Position the patient in a manner that will ensure patient comfort and privacy and facilitate dressing application.
Rationale: Patient is prepared to undergo procedure.
• Administer prescribed analgesics if needed. Rationale: Analgesics improve comfort level and tolerance of the
procedure and decrease patient anxiety and discomfort.
Procedure for Negative-Pressure Wound Therapy
Table 131-1
Recommended Therapy Setting for KCI V.A.C. Therapy
Flap x
Highly exuding x
Grafts x
Painful wounds x
Tunnels or undermining x
Unstable structures x
Minimally exuding x x
Large wounds x x
Small wounds x x
Stalled wound healing progress x x
V.A.C. white foam dressing x x
Responsible physician or advanced practice nurse should be consulted for individual patient conditions. Consult device user manual and manufacturer’s recommended
guidelines before use.
(Adapted from Smith APS: V.A.C.® therapy clinical guidelines: a reference source for clinicians, San Antonio, TX, 2006, KCI Licensing, Inc.)
References
1. Argenta, LC, Morykwas, MJ, Vacuum-assisted closure. a new method for wound control and
treatmentclinical experience. Ann Plastic Surg 1997; 38:563–576.
2. Armstrong, D, et al. Proceedings from the 2003 National V. A. C. ® Education Conference. Ostomy Wound
Manage. 2004; 50(4A Suppl):3S–27S.
3. Bergstrom, N, et al, Treatment of pressure ulcers. clinical practice guideline, no. 15. US Department of Health
and -Human Services, Public Health Service, Agency for -Healthcare Policy and Research, Rockville, MD, 1994.
[AHCPR publication no. 95-0652].
4. Broughton, G, et al, Wound healing. an overview. Plast Reconstruct Surg. 2006; 117(7S Suppl):1e-s–32e-s.
5. Bovill, E, et al, Topical negative pressure wound therapy. a review of its role and guidelines for its use in the
management of acute wounds. Int Wound J. 2008; 65(3):722–731.
6. Campbell P, Smith J, Smith G, eds. Negative pressure wound therapy (NPWT) clinical case reports. St
Petersburg, FL: Smith & Nephew, 2007.
7. Chariker, ME, Gerstle, TL, Morrison, CS. An algorithmic approach to the use of gauze-based negative-pressure
wound therapy as a bridge to closure in pediatric extremity trauma. Plast Reconstruct Surg. 2009; 123(5):1510–
1520.
8. Gupta, S, Differentiating negative pressure wound therapy devices. an illustrative case series. Wounds J. 2007;
19(1 Suppl):26S–28S.
9. Koehler, C, et al, Wound therapy using the vacuum-assisted closure device. clinical experience with novel
indications. J Trauma. 2008; 65(3):722–732.
10. Long, MA, Blevins, A, Options in negative pressure wound therapy. five case studies. J Wound Ostomy
Continence Nurs. 2009; 36(2):202–211.
11. Sullivan, N, Snyder, DL, Tipton, K, et al, Negative pressure wound therapy devices. technology assessment report,
project ID WNDT1108. US Department of Health and Human Services, Agency for Healthcare Research Quality,
Rockville, MD, 2009.. www.ahrq.gov/clinic/ta/negpresswtd [available at].
12. Smith, APS, V. A. C. ® therapy clinical guidelines. a reference source for clinicians. KCI Licensing, Inc, San
Antonio, TX, 2006.
13. World Union of Wound Healing Societies (WUWHS). Principles of best practice: vacuum assisted closure.
recommendation for use: a consensus document. MEP Ltd, London, 2008.
UNIT VIII
Nutrition
P R OC E D UR E 1 3 2
PURPOSE:
The CORTRAK® system uses electromagnetic technology to enhance the safety of bedside placement of small-
bore nasoenteric feeding tubes. The guidance system directs feeding tube placement by tracking the relative
location of the tube as it proceeds down the alimentary tract. This visual guidance aids in avoiding intubation of
the pulmonary system and facilitates postpyloric placement of feeding tubes.1,5,8,12,15
EQUIPMENT
• CORTRAK® feeding tube placement device (Fig 132-1)
FIGURE 132-1 Electromagnetic Guidance System (CORTRAK®). (Courtesy of Corpak MedSystems, 2009.)
References
1. Ackerman, M, Mick, DJ. Technologic approaches to -determining proper placement of enteral feeding tubes.
AACN Adv Crit Care. 2006; 17:246–249.
2. Aguilar-Nescimento JE, Kudsk, KA, Use of small bore feeding tubes. success and failures. Curr Opin Clin Nutr
Metab Care 2007; 10:226–291.
3. Bankhead, RR, Fang, JC, Enteral access devices Gottschlich MM, ed.. The A. S. P. E. N. Nutrition Support Core
Curriculum. American Society for Parenteral and Enteral Nutrition: Silver Spring, MD, 2007:233–245.
4. CORPAK MedSystems, CORTRAK® contraindication statement . CORPACK MedSystems, Wheeling, IL, 2008.
5. CORPAK Medsystems, CORTRAK® enteral access system operator’s guide . CORPAK Medsystems, Wheeling,
IL, 2008.
6. Cresci, G. Trauma, surgery, burns. In: Gottschlich MM, et al, eds. The A. S. P. E. N. Nutrition Support Core
Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2007:455–476.
7. Ellett, ML, et al. Predicting the insertion distance for placing gastric tubes. Clin Nurs Res. 2005; 14:11–27.
8. Gray, R, et al, Bedside electromagnetic-guided feeding tube placement. an improvement over traditional
placement technique. Nutr Clin Pract 2007; 22:436–444.
9. Metheny, NA, et al. Indicators of tube site during feedings. J Neurosci Nurs. 2005; 37(6):320–325.
10. Metheny, NA, Preventing respiratory complications of tube feedings. evidence based practice. Am J Crit Care.
2006; 15(4):360–369.
11. Metheny, NA, Meert, KL, Clouse, RE, Complications related to feeding tube placement. Curr Opin Gastroenterol .
2007; 23:178–182.
12. Phang, J, Marsh, W, Prager, R. Feeding tube placement with the aid of a new electromagnetic transmitter. JPEN J
Parenter Enteral Nutr. 2006; 30:S48. [[abstract SO82]].
13. Roberts, S, Echeverria, P, Gabriel, SA. Devices and techniques for bedside enteral feeding tube placement. Nutr
Clin Pract. 2007; 22:412–420.
14. Sorokin, R, Gottlieb, JE, Enhancing patient safety during feeding-tube insertion. a review of more than 2000
insertions. JPEN J Parenter Enteral Nutr 2006; 30:440–445.
15. Stockdale, W, et al. Nasoenteric feeding tube insertion utilizing an electromagnetic tube placement system. Nutr
Clin Pract. 2007; 22:118. [[abstract NP24]].
Additional Readings
Baskin, WN. Ac ute c omplic ations assoc iated with bedside plac ement of feeding tubes. Nutr Clin Pra ct. 2006; 21:40–55,105.
Metheny, NA, et al, Trac heal aspiration of gastric c ontents in c ritic ally ill tube-fed patients. frequenc y outc omes, and risk fac tors. Crit Care Med 2006; 34:1007–
1015.
P R OC E D UR E 1 3 3
PURPOSE:
Gastrostomy, percutaneous endoscopic gastrostomy, and jejunostomy tubes provide long-term access to the
gastrointestinal tract for nutrition.
• A jejunostomy tube, which does not have a balloon, is indicated in those patients at risk for aspiration or who are
unable to tolerate enteral feedings into the stomach. These tubes are routinely sutured in place for stability (Fig. 133-
3). They are usually smaller bore, less than 14 Fr, and therefore are more prone to occlusion.
FIGURE 133-3 Jejunostomy tube placement.
• If the tubes are inadvertently removed, reinsertion of the tubes is a routine procedure after the tunnel and stoma are
healed (approximately 2 to 6 weeks after insertion).
• Because these tubes all enter through the abdominal wall, skin care at the site of insertion is important for skin
integrity and prevention of infection.
• Consult with the multidisciplinary team to individualize nutrition goals. The nutrition plan is developed on the basis
of the collaborative assessment of the nurse, dietitian, and physician or advance practice nurse.
EQUIPMENT
• Nonsterile gloves
• 4 × 4 gauze pads
• Cotton-tipped swabs
• 4 × 4 gauze pads, drain cut
• Protective skin barrier (e.g., vitamin A and D ointment)
• Silk tape (or paper tape if patient has a sensitivity to silk tape)
Additional equipment to have available, as needed includes the following:
• Hydrogen peroxide
• Abdominal binder
Patient Preparation
• Ensure that patient understands preprocedural teachings. Answer questions as they arise, and reinforce information as
needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Assist patient to position of comfort. Rationale: Stoma of tube is easily accessible.
Procedure for Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, or Jejunostomy Tube Care
References
1. Baskin, WN. Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract. 2006;
21:40–55.
2. Loser, C, Aschl, G, Hebuterne, et al. ESPEN guidelines on artificial enteral nutrition-percutaneous endoscopic
gastrostomy (PEG). Clin Nutr. 2005; 24:845–861.
3. McClave, SA, Neff, RL. Care and long term maintenance of percutaneous endoscopic gastrostomy tubes.
JPEN. 2006; 30:S27–S38.
4. Metheny, NA, Schallom, ME, Edwards, SJ, Effect of gastrointestinal motility and feeding tube site on
aspiration risk in critically ill patients. a review. Heart Lung 2004; 33:131–145.
5. Metheny, NA, Preventing respiratory complications of -tube feedings. evidence-based practice. Am J Crit Care
2006; 15:360–369.
Additional Readings
Guenter, P, S ilkroski, M, Tube feeding. prac tic al guidelines and nursing protoc ols. Aspen Publishing, S ilver S pring, MD, 2001.
Heiser, M, Malaty, H, Balloon type versus nonballoon type replac ement perc utaneous endosc opic gastrostomy. whic h is better. Gastroenterol Nurs 2001; 24:58–
63.
Lord, LM. Enteral ac c ess devic es. Nurs Clin North Am. 1997; 32:685–702.
P R OC E D UR E 1 3 4
PURPOSE:
A small-bore feeding tube is inserted to provide access to the gastrointestinal tract for the patient who is unable
to orally consume adequate calories. The tube can be used for administration of nutrients, fluid, and medications.
EQUIPMENT
• Small-bore feeding tube
• Small glass of water (bottle or tap, depending on institutional practice)
• 60-mL Luer-Lok tip, or catheter-tip syringe, appropriate for feeding tube (be sure size does not exceed recommended
pressure limit for particular tube)
• Skin preparation agent
• Plastic adhesive or clear tape, or commercial fixation device
• Nonsterile gloves
• Water-soluble lubricant (if tube is not prelubricated)
PATIENT AND FAMILY EDUCATION
• Explain reason for insertion of tube and need for support of enteral nutrition. Rationale: Knowledge may decrease
anxiety and fear of the unknown.
• Explain how patient can assist with passage of the tube by positioning (e.g., sitting upright, head tipped forward and
swallowing) when cued. Rationale: Tube may pass more easily with patient cooperation.
• Explain the risk for gag reflex stimulation during insertion. Rationale: Knowledge may decrease anxiety and fear of
the unknown.
• Explain the reason for the radiograph after insertion. Rationale: Knowledge may decrease anxiety and fear of the
unknown.
• Discuss reasons for not pulling at the tube once it has been placed and secured. Rationale: Leaving the tube in place
avoids the need for reinsertion and another radiograph for verification. Reinsertion increases risk for trauma to
nasopharyngeal passages. Dislodgment of the tube can increase the risk of aspiration.
Patient Preparation
• Ensure that the patient understands preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• If the patient has a large-bore nasogastric tube, it needs to be removed before placement of the small-bore nasogastric
tube. Rationale: Passing a small-bore tube is extremely difficult with an oral or nasal tube already in place. Removal
of the large-bore tube after placement of the small-bore tube will likely cause displacement of the newly placed small
tube.
• Perform oral care to moisten mucosa. Suction oropharyngeal area of excess secretions.1 Rationale: A moist, cleared
oropharyngeal area facilitates patient comfort and passage of the tube.
Procedure for Small-Bore Feeding Tube Insertion and Care
References
1. AACN Practice Alert. Oral care in the critically ill,. www.aacn.org, 2007. [accessed 01/03/10].
2. AACN Practice Alert. Verification of feeding tube placement,. www.aacn.org, 2006. [accessed 01/03/10].
3. Baskin, WN. Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract. 2006;
21:40–55.
4. Burns, SM, et al. Comparison of nasogastric tube securing methods and tube types in medical intensive care
patients. AJCC. 1995; 4:198–203.
Metheny, NA, S c hallom, ME, Edwards, S J, Effec t of gastrointestional motility and feeding tube site on aspiration risk in c ritic ally ill patients. a review. Heart Lung
2004; 33:131–145.
6. Metheny, NA, Preventing respiratory complications of tube feedings. evidence-based practice. Am J Crit Care
2006; 15:360–369.
7. Sorokin, R, Gottleib, JE, Enhancing patient safety during feeding tube insertion. a review of more than 2000
insertions. JPEN 2006; 30:440–445.
Additional Readings
Guenter, P, S ilkroski, M, Tube feeding. prac tic al guidelines and nursing protoc ols,. Aspen Publishers, S ilver S pring, MD, 2001.
Lord, LM, et al. Comparison of weighted vs unweighted enteral feeding tubes for effic ac y of transpyloric intubation. JPEN. 1993; 17:271–273.
Metheny, N. Assessing plac ement of feeding tubes. AJN. 2002; 101:36–45.
UNIT IX
End of Life
P R OC E D UR E 1 3 5
PURPOSE:
This procedure describes how death is determined. Institution policies and legislation governing declaration of
death may vary across practice settings and states. However, standardized evidence-based criteria provide
guidelines for practice involving the determination of cardiopulmonary and brain death.
EQUIPMENT
• For cardiopulmonary death determination:
Stethoscope
Electrocardiogram (ECG) monitor
ECG leads
ECG electrodes
Nonsterile gloves
• For brain death determination:
Flashlight
Laboratory testing supplies
Iced saline or water solution
60-mL Luer-Lok syringe and 18- or 20-gauge angiocatheter with needle removed (or 60-mL Toomey syringe)
Small basin
Towels and protective bedding
Nonsterile gloves
Oxygen delivery via an endotracheal airway with a nasal cannula or straight tubing for oxygen delivery
Arterial blood gas kit supplies
Pulse oximeter
Blood pressure monitoring system
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the family understands preprocedural teaching. Answer questions as they arise, and reinforce information
as needed. Rationale: This communication evaluates and reinforces understanding of previously taught
information.
• Facilitate the discussion of organ donation by notifying the organ procurement organization (OPO). Rationale:
Centers for Medicare and Medicaid Services (CMS) require that all deaths be reported to the local OPO regardless of
age or circumstances. Many OPOs have instituted the use of clinical triggers to initiate the referral. The triggers are
based on OPO and hospital agreed-on physical examination findings. Patients who are brain dead are potential
candidates for organ donation. Request for organ donation is the responsibility of representatives from the OPO or a
specially trained designated hospital requester after consultation with the OPO (see Procedure 136).2
• Place the patient in a supine position. Rationale: Positioning facilitates patient assessment, oculovestibular testing,
and arterial puncture.
Procedure for Determination of Death
Table 135-1
Apnea Test Results
Table 135-2
Confirmatory Brain Death Test Results
Cerebral angiography No intracerebral filling at the level of the carotid bifurcation or circle of Willis
External carotid circulation patent
Electroencephalogram (EEG) No electrical activity during a period of at least 30 minutes of recording
Transcranial Doppler ultrasound scan Absent diastolic or reverberating flow
Flow only through systole or retrograde diastolic flow
Small systolic peaks in early systole
Technetium 99m brain scan (cerebral blood flow scan) No uptake of isotope in brain parenchyma (“hollow skull phenomenon”)
FIGURE 135-1 The trapezius pinch.
FIGURE 135-2 Oculocephalic reflex (doll’s eyes). A, Normal. B, Abnormal. C, Absent. (From Urden LD, Stacy KM, Lough ME, editors: Critical care nursing, ed 6, St
Louis, 2010, Elsevier.)
FIGURE 135-3 Oculovestibular reflex (cold caloric test). A, Normal. B, Abnormal. C, Absent. (From Urden LD, Stacy KM, Lough ME, editors: Critical care nursing, ed
6, St Louis, 2010, Elsevier.)
References
1. A definition of irreversible coma. report of the Ad Hoc Committee of the Harvard Medical School to Examine
the Definition of Brain Death. JAMA. 1968; 205(6):337–340.
2. Center for Medicare and Medicaid Services. Hospital conditions of participation about organ/tissue donation,.
www.cms.gov/manuals/downloads/som107ap_a_hospitals.pdf, November 6, 2008. [retrieved].
3. Guidelines for the determination of death, report of the medical consultants on the diagnosis of death to the
President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research .
JAMA. 1981; 246(19):2184–2186.
4. Heran, MK, Heran, NS, Shemie, SD. A review of ancillary tests in evaluating brain death. Can J Neurol Sci. 2008;
35(4):409–419.
5. Practice parameters for determining brain death in adults (summary statement), the Quality Standards
Subcommittee of the American Academy of Neurology . Neurology. 1995; 45(5):1012–1014.
6. Wijdicks, EF, Determining brain death in adults . Neurology. 1995; 45(5):1003–1011.
7. Wijdicks, EF, Rabinstein, AA, Manno, EM, et al, Pronouncing brain death. contemporary practice and safety of
the apnea test . Neurology. 2008; 71(16):1240–1244.
8. Young, GB, Shemie, SD, Doig, CJ, et al, Brief review. the role of ancillary tests in the neurological determination
of death. Can J Anaesth. 2006; 53(6):620–627.
Additional Reading
Medina, J, Puntillo, K AACN protoc ols for prac tic e. palliative c are and end-of-life issues in c ritic al c are,. Jones and Bartlett Publishers, S udbury, MA, 2006.
This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)
with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.
P R OC E D UR E 1 3 6
PURPOSE:
The purpose of this procedure is to outline the process of solid organ donation, with recognition for the care of
donors and their families, the role of healthcare providers, the role of the regional organ procurement
organization, and the importance of early referral.
EQUIPMENT
• Thermometer
• Ventilator
• Central venous access (e.g., pulmonary artery or triple-lumen catheter)
• Blood pressure monitoring system (invasive or noninvasive)
• Intravenous (IV) infusion pumps
• Prescribed IV fluids
• Cardiac monitoring system
• Pulse oximetry
• Arterial blood gas kits
• Blood sampling tubes
• Consent forms
• Death certificates
• Request for anatomic gift certificates
Additional equipment, to have available as needed, includes the following:
• Medications as prescribed
• Pen light
• Tongue blade
• Cotton-tipped applicator
• Ice lavage
• 60-mL Toomey syringe
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the family understands preprocedural teaching. Answer questions as they arise, and reinforce information
as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• When neurologic testing to determine clinical brain death begins, ensure that the patient is normothermic and that no
sedating or paralyzing medications have been given. Rationale: Hypothermia and sedating or paralyzing
medications interfere with brain death testing.
• Facilitate the discussion of organ donation by notification of the OPO. Rationale: The Centers for Medicare and
Medicaid Services (CMS) require that all deaths be reported to the OPO regardless of age or circumstances. Many
OPOs have instituted the use of clinical triggers to initiate the referral. The triggers are based on OPO and hospital
agreed-upon physical examination findings.
• Patients who are brain dead are potential candidates for organ donation. Follow hospital policy regarding first
mention. Rationale: Request for organ donation is the responsibility of representatives from the OPO or a specially
trained designated hospital requester after consultation with the OPO.7
• If a decision is made to donate organs, follow the plan of care determined by the OPO. Rationale: The plan of care
provides important care to promote organ survivability to transplant.
• An arterial catheter may be inserted, if not already in place. Rationale: Assessment of blood pressure and ease of
blood sampling are facilitated.
• Involve additional hospital resources (e.g., clergy, grief counselors, palliative care specialists). Rationale: Additional
family support is provided throughout the end-of-life process. Pastoral care may offer additional insights into faith,
hope, and encouragement to those who may be experiencing despondency, remorse, guilt, or anger at this time.
Procedure for Organ Donation: Identification of Potential Organ Donors, Request for Organ Donation, and Care of
the Organ Donor
References
1. Brook, NR, Nicholson, ML, Kidney transplant from non heart-beating donors. Surg J Royal Coll Surg Edinb
Ireland . 2003; 1:311–322.
2. Doig, CJ, Rocker, G, Retrieving organs from non-heart-beating organ donors. a review of medical and ethical
issues. Can J Anesth 2003; 50:1069–1076.
3. Ehrle, R. Timely referral of potential organ donors. Crit Care Nurse. 2006; 26:88–93.
4. Intensive Care Society. Guidelines for adult organ and tissue donation. www.ics.ac.uk, 2004. [retrieved
November 3, 2008, from].
5. Joint Commission, JCAHO standards related to organ donation. www.jointcommission.org, 2008 [retrieved
November 3, 2008, from].
6. Joint, Commission. Revisions to standard LD. 3. 110. Joint Commission Perspect. 2006; 26:7.
7. Metzger, RA, et al, Research to practice. a national consent conference. Prog Transplant 2005; 15:1–6.
8. New York Organ Donor Network. History of organ transplantation. www.donatelifeny.org, 2008. [retrieved
October 21, 2008, from].
9. OrganDonor, Gov. Access to U. S. government information on organ & tissue donation and transplantation.
www.organdonor.gov, 2010. [retrieved May 4, 2010 from].
10. Siminoff, LA, et al, Factors influencing families’ consent for donation of solid organs for transplantation .
JAMA 2001; 286:71–77.
Additional Reading
Bernat, JL, et al. Report of a national c onferenc e on donation after c ardiac death. Am J Tra nspla nt. 2006; 6:281–291.
P R OC E D UR E 1 3 7
PURPOSE:
The purpose of this procedure is to outline the process of donation of select organs after withdrawal of life-
sustaining therapy and cardiopulmonary death.
EQUIPMENT
• Consent forms
• Prepared operating room
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the family understands preprocedural teaching. Answer questions as they arise, and reinforce information
as needed. Families need special emotional consideration during all counseling and teaching. Rationale:
Understanding of previously taught information is evaluated and reinforced.
• Refer patients with a potentially life-threatening illness or injury to the OPO as early as possible for evaluation as a
potential organ donor. Specific criteria do not exist for referral, unlike the case with the brain-dead organ donor.
Rationale: The OPO coordinator can evaluate the patient, and the critical care nurse is provided with information
about the patient’s potential as an organ donor.
• Involve additional hospital resources (e.g., clergy, grief counselors, palliative care specialists). Rationale: Additional
family support is provided throughout the end of the life process. Pastoral care may offer additional insights into faith,
hope, and encouragement to those who may be experiencing despondency, remorse, guilt, or anger at this time.
Procedure Donation After Cardiac Death
References
1. Campbell, ML, Bizek, KS, Thill, MC, Patient responses during rapid terminal weaning from mechanical
ventilation. a prospective study. Crit Care Med 1999; 27:73–77.
2. Center for Medicare and Medicaid Services. Hospital conditions of participation about organ/tissue donation.
www.cms.gov/manuals/downloads/som107ap_a_hospitals.pdf, November 6, 2008. [retrieved].
3. Fidler, SA. Implementing donation after cardiac death protocols. J Health Life Sci Law. 2008; 2(1):123–125-149.
4. Kelso, CM, Lyckholm, LJ, Coyne, PJ, et al. Palliative care consultation in the process of organ donation after
cardiac death. J Palliat Med. 2007; 10(1):118–126.
5. Medina, J, Puntillo, K, AACN protocols for practice. palliative care and end-of-life issues in critical care,. Jones
and Bartlett Publishers, Sudbury, MA, 2006.
Additional Readings
Americ an College of Critic al Care Medic ine, S oc iety of Critic al Care Medic ine, Rec ommendations for non-heart-beating organ donation. a position paper by the
ethic s c ommittee. Crit Care Med 2001; 29:1826–1831.
Arnold, RM, Youngner, S J, Time is of the essenc e. the pressing need for c omprehensive non-heart-beating c adaveric donation polic ies. Transplant Proc 1995;
27:2913–2921.
D’Alessandro, AM, Hoffman, RM, Belzer, FO, Non-heart-beating donors. one response to the organ shortage. Transplantation Rev 1995; 9:168–176.
Edwards, JM, Hasz, RD, Robertson, AM, Non-heart-beating organ donation. proc ess and review. AACN Clin Issues Crit Care 1999; 10:293–300.
Frader, J, Non-heart-beating organ donation. personal and institutional c onflic ts of interest. Kennedy Inst Ethic s J 1993; 3:189–198.
Institute of Medic ine, Potts, J, princ ipal, investigator, Non-heart-beating organ transplantation. medic al and ethic s issues in proc urement. National Ac ademy Press,
Washington, DC, 1997.
Institute of Medic ine, Non-heart-beating organ transplantation. prac tic e and protoc ols. National Ac ademy Press, Washington, DC, 2000.
Younger, S J, Arnold, RM. Ethic al, psyc hosoc ial, and public polic y implic ations of proc uring organs from non-heart-beating c adaver donors. JAMA. 1993;
269:2769–2774.
Van Norman GA, Another matter of life and death. what every anesthesiologist should know about the ethic al, legal, and polic y implic ations of the non-heart-
beating c adaver organ donor. Anesthesiology 2003; 98:763–773.
P R OC E D UR E 1 3 8
PURPOSE:
This procedure is performed to assist patients and family members with the process of withholding or
withdrawing life-sustaining therapy. Life-sustaining therapy may include nutrition, hydration, antibiotics, dialysis,
ventilatory therapy, vasoactive therapy, implantable cardioverter-defibrillator therapy, intraaortic balloon pump
therapy, ventricular assist device, and additional therapies.
Patient Preparation
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Collaborate with the patient and family to plan the day and time that LST will be withheld or withdrawn.
Rationale: Family and friends have time to spend with the patient and to arrive from out of town. The healthcare
team has time to plan availability to be present during therapy changes.
• Identify family or friends whom the patient and family would like present during the withholding or withdrawal
process. Rationale: The patient and family are involved in planning of the withholding or withdrawal of therapy,
and patient preferences are respected.
• In addition to nursing, medicine, and possibly respiratory therapy, identify additional members of the healthcare team
who the patient or family would like present during the withholding or withdrawal process (e.g., clergy, social
worker, palliative care specialist, grief counselor). Rationale: The patient and family are provided control as they
determine essential members of the healthcare team who should be involved with the withholding or withdrawing of
therapy process.
• Encourage the patient and family to personalize the environment by bringing in music or other items that will make
the room as the patient would want it to be. Rationale: An individualized, peaceful, caring environment is
promoted.
• Establish or maintain a patent intravenous access. Rationale: Intravenous access is necessary for administration of
analgesia and anxiolytics.
Procedure for Withholding and Withdrawing Life-Sustaining Therapy
References
1. American Nurses Association, American Nurses Association position statement on pain management and
control of distressing symptoms in dying patients . ANA, Washington, DC, 2003.
2. Beauchamp, TL, Childress, JF. Principles of biomedical ethics, ed 5. New York: Oxford University Press; 2001.
3. Campbell, ML, Treating distress at the end of life. the principle of double effect. AACN Adv Crit Care. 2008;
19(3):340–344.
4. Campbell, ML, Bizek, KS, Thill, MC, Patient responses during rapid terminal weaning from mechanical
ventilation. a prospective study. Crit Care Med 1999; 27:73–77.
5. Clark, K, Butler, M. Noisy respiratory secretions at the end of life. Curr Opin Support Palliat Care. 2009; 3(2):120–
124.
6. Hospice and Palliative Nurses Association, HPNA position statement. pain management . HPNA, Pittsburgh,
2008.
7. Hospice and Palliative Nurses Association, HPNA position statement. the ethics of opiate use within palliative
care . HPNA, Pittsburgh, 2008.
8. Medina, J, Puntillo, K, AACN protocols for practice . palliative care and end-of-life issues in critical care . Jones
and Bartlett Publishers, Sudbury, MA, 2006.
9. National Consensus Project for Quality Palliative Care. ed 2. Clinical practice guidelines for quality palliative care,
Pittsburgh, 2009.
10. Prendergast, TJ, Claessens, MT, Luce, JM. A national survey of end-of-life care for critically ill patients. Am J
Resp Crit Care Med. 1998; 158:1163–1167.
11. Tolle, SW, et al. Families reports of barriers to optimal care of the dying. Nurs Res. 2000; 49(6):310–317.
12. Truog, RD, Campbell, ML, Curtis, JR, et al, Recommendations for end-of-life care in the intensive care unit. a
consensus statement by the American College of Critical Care Medicine. Crit Care Med. 2008; 36(3):953–963.
13. Truog, RD, Burns, JP, Mitchell, C, et al. Pharmacologic paralysis and withdrawal of mechanical ventilation at
the end of life. N Engl J Med. 2000; 342(7):508–511.
14. Wiegand DL, Petri L : Is a good death possible after withdrawal of life-sustaining therapy ? Crit Care Clin North
Am. In press
15. Wiegand, DL, Williams, LD. End-of-life care. In: Carlson K, ed. AACN advanced critical care nursing. Philadelphia:
Elsevier; 2009:1507–1525.
16. Wiegand, DL, Withdrawal of life-sustaining therapy after sudden, unexpected life-threatening illness or injury .
interactions between patients’ families, healthcare providers, and the healthcare system. Am J Crit Care. 2006;
15(2):178–187.
Additional Readings
Ballentine, JM, Pac emaker and defibrillator deac tivation in c ompetent hospic e patients. an ethic al c onsideration. Am J Hosp Palliat Med 2005; 22:14–19.
Braun, TC, Hagen, NA, Hatfield, RE, et al. Cardiac defibrillators in terminal c are. J Pa in Symptom Ma na ge. 1999; 18:126–131.
Campbell, ML. Terminal dyspnea and respiratory distress. Crit Ca re Clin North Am. 2004; 20:403–417.
Campbell, ML, Forgoing life-sustaining therapy . AACN, Laguna Niguel, CA, 1998.
Daly, BJ, Thomas, D, Dyer, MA. Proc edures used in withdrawal of mec hanic al ventilation. Am J Crit Ca re. 1996; 5(5):331–338.
Dudzinski, DM. Ethic s guidelines for destination therapy. Ann Thora c Surg. 2006; 81:1185–1188.
Goldstein, NE, Lampert, R, Bradley, E, et al. Management of implantable c ardioverter defibrillators in end-of-life c are. Ann Intern Med. 2004; 141:835.
Grassman, D. EOL c onsiderations in defibrillator deac tivation. Am J Hospice Pa llia t Med. 2005; 22:179–180.
The Hastings Center, Guidelines on the termination of life sustaining treatment and the c are of the dying . University Press, Bloomington, IN, 1987.
Hospic e and Palliative Nurses Assoc iation, HPNA position statement. withholding and/or withdrawing life sustaining therapies,. HPNA, Pittsburgh, 2008.
Lampert R, et al : HRS expert c onsensus statement on the management of Cardiovasc ular Implantable Elec tronic Devic es (CIEDs) in patients nearing end of life or
requesting withdrawal of therapy. ( In Press ). Heart Rhythm.
Lewis, WR, Luebke, DL, Johnson, NJ, et al. Withdrawing implantable defibrillator shoc k therapy in terminally ill patients. Am J Med. 2006; 119:892.
Mayer, S A, Kossoff, S B. Withdrawal of life support in the neurologic al intensive c are unit. Neurology. 1999; 52(8):1602–1609.
Nambisan, V, Chao, D, Dying and defibrillation. a shoc king experienc e. Palliat Med 2004; 18:482–483.
President’s Commission for the S tudy of Ethic al Problems in Medic ine and Biomedic al and Behavioral Researc h, Dec iding to forego life-sustaining treatment. a
report on the ethic al medic al, and legal issues in treatment dec isions. US Government Printing Offic e, Washington DC, 1983.
Mac Iver, J, Ross, HJ. Withdrawal of ventric ular assist devic e support. J Pa llia t Ca re. 2006; 21:151–156.
Morreim, EH, S urgic ally implanted devic es. ethic al c hallenges in a very different kind of researc h. Thorac S urg Clin 2005; 15:555–563.
Pellegrino, ED, Dec isions to withdraw life-sustaining treatment. a moral algorithm. JAMA 2000; 283:1065–1067.
Tilden, VP, Tolle, S W, Nelson, CA, et al. Family dec ision making in foregoing life-extending treatments. J Fa mily Nurs. 1999; 5:426–442.
Tilden, VP, Tolle, S W, Garland, MJ, et al, Dec isions about life sustaining treatment. impac t of physic ians’ behavior on the family. Arc h Intern Med. 1995;
155(6):633–638.
Wiegand, DL, In their own time. the family experienc e during the proc ess of withdrawal of life-sustaining therapy. J Palliat Med. 2008; 11(8):1115–1121.
Wiegand, DL, Deatric k, JA, Knafl, K. Family management styles related to withdrawal of life-sustaining therapy from adults who are ac utely ill or injured. J Fa mily
Nurs. 2008; 14(1):16–32.
Wiegand, DL, Kalowes, PG. Withdrawal of c ardiac medic ations and devic es. AACN Adv Crit Ca re. 2007; 18(4):415–425.
Wiegand, DL, Families and withdrawal of life-sustaining therapy. state of the sc ienc e. J Family Nurs. 2006; 12(2):165–184.
UNIT X
Calculating Medication Doses
P R OC E D UR E 1 3 9
PURPOSE:
Calculation of doses and flow rates and administration of continuous intravenous infusions are performed to
ensure accurate delivery of medications administered via the intravenous route. Many of the medications
delivered via continuous intravenous infusion have potent effects and narrow margins of safety; therefore,
accuracy in calculation and administration of these agents is imperative.
Table 139-1
Basic Formula*
*Because there are units on the top of the equation and units on the bottom of the equation, to ensure that the final units are correct, the units on the bottom of the
equation must be inverted and multiplied by the units of the top of the equation.
Table 139-2
Variation for Medication Doses Measured per Minute (mg/min or mcg/min)*
*The time factor of 60 min/hr must be added to the basic formula.
Table 139-3
Variation for Weight-Based Medication Doses Measured per Minute (mcg/kg/min)*
*The patient’s w eight in kilograms and the time factor of 60 min/hr must be added to the basic formula.
• Calculations for weight-based medications include the patient’s weight in the formula. The choice of which weight to
use can be challenging. Much disagreement and inconsistency are found in the literature as to which weight to use,
ideal body weight, actual body weight, or dry body weight.2,7 Distribution of specific medications across fat and fluid
body compartments varies, thus affecting the therapeutic level. Because most medications are titrated to patient
response and a desired clinical end point, a consistent approach is to use the patient’s admission weight for initial dose
calculations. The clinical pharmacist then should be consulted for obese patients and for medications that have
potentially dangerous toxicities.
• Central IV access should be used for vasoconstrictive medications and medications that can cause tissue damage when
extravasated.3 Mechanisms and agents that may cause tissue damage include osmotic damage from hyperosmolar
solutions, ischemic necrosis caused by vasoconstrictors and certain cation solutions, direct cellular toxicity caused by
antineoplastic agents, direct tissue damage from pH strong acids and bases, and direct irritation.9
• The Joint Commission goal for medication safety includes standardization and limiting the number of drug
concentrations available in organizations.11 Standardized dosing methods for the same medications reduce IV infusion
errors.7
• The Institute of Healthcare Improvement (IHI) recommendations for IV medication safety include conducting
independent double checks, dose calculation aids on IV solution bag labels, use of IV smart infusion pumps with
safety features, and use of premade dose and flow-rate charts.1
• Another recommendation identified the positive impact of regular drug administration updates and formal arithmetic
testing on the frequency and cause of medication errors that are the result of lack of ability to calculate drug dosage
correctly.8
EQUIPMENT
• Prepared IV solution with medication to be administered
• IV tubing
• IV infusion device
• Nonsterile gloves
• Alcohol pads
• Calculator (optional)
Patient Preparation
• Ensure that the patient and family understand preprocedural teachings. Answer questions as they arise, and reinforce
information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Weigh the patient, if the medication is weight-based. Rationale: Calculation of the correct dose based on patient
weight is permitted. If the patient’s weight has changed during hospitalization because of edema or other causes, use
of the baseline admission weight is preferable.
• Verify patency or obtain patent, appropriate IV access. Rationale: Delivery of the medication into the IV space is
ensured. Some continuous infusion medications require central line access to prevent irritation or damage to smaller
peripheral veins and to reduce the risk for extravasation.
Procedure for Calculating Doses and Flow Rates and Administering Continuous Intravenous Infusions
References
1. Crimlisk, J, Johnstone, D, Sanchez, G, Evidence-based practice, clinical simulations workshop, and intravenous
medications. moving toward safer practice. Med Surg Nurs. 2009; 18(3):153–160.
2. Deglin, JH, Vallerand, AH. Davis’s drug guide for nurses, ed 11. Philadelphia: F. A. Davis Co; 2009.
3. Ekle E. &, Sibley A, eds. Nurses handbook of IV drugs, ed 3, Sudbury, MA: Jones & Bartlett -Publishers, 2009.
4. Institute for Safe Medication Practices (ISMP), Medication safety alert. smart infusion pumps join CPOE and
bar coding as important ways to prevent medications errors. Institute for Safe Medication Practices, Huntington
Valley, PA, 2002.
5. Institute for Safe Medication Practices (ISMP), Medication safety alert nurse advise. ERRdouble key bounce and
double keying errors. Institute for Safe Medication Practices, Huntington Valley, PA, 2006.
6. Institute for Safe Medication Practices (ISMP). Smart pumps are not smart on their own. ISMP Medication Safety
Alert. 2007; 12(8):1–2.
7. Institute for Safe Medication Practices (ISMP), Medication safety alert nurse advise. ERRlack of standard dosing
methods contributes to IV infusion errors,. Institute for Safe Medication Practices, Huntington Valley, PA, 2008.
8. Pentin, J, Smith, J, Drug calculations. are they safer with or without a calculator. Br J Nurs. 2006; 15(14):778–781.
9. Polovich M, Whitford JM, Olsen M, eds. Chemotherapy and biotherapy guidelines and recommendations for
practice, ed 3, Pittsburgh: ONS Publishing, 2009.
10. Reves, JG. “Smart pump” technology reduces errors, 2003.
http://www.apsf.org/resource_center/newsletter/2003/spring/smartpump.htm, July 28, 2009. [retrieved].
11. Spratto G, Woods A, eds.. 2008 PDR nurse’s drug handbook. patient safety goals [appendix 12]. Thompson
Healthcare Inc and Delmar Learning: Clifton Park, NY, 2008.
Additional Readings
Guiliano, K, et al. A new strategy for c alc ulating medic ation infusion rates. Crit Ca re Nurs. 1993; 13:77–82.
Hadaway, LC. How to safeguard delivery of high-alert IV drugs. Nursing. 2001; 31:36–42.
Keohane, C, Hayes, J, S aniuk, C, et al. Intravenous medic ation safety and smart infusion systems. J Infusion Nurs. 2005; 28(5):321–328.
Mc Millen, P. Calc ulating medic ation dosages. Crit Ca re Nurs. 2000; 20:17–19.
S hilling, Mc Cann, JA. executive publisherSpringhouse’s dosa ge ca lcula tions ma de incredibly ea sy, ed 2. S pringhouse, PA: S pringhouse; 2000.
Index
Page numbers followed by f, t, and b indic ate figures, tables, and boxes, respec tively.
A
Abdominal c ompartment syndrome (ACS )
definition, 967
development, risk, 968t
oc c urrenc e, 967
physiologic c hanges, 970t
Abdominal girth, c hanges (evaluation), 991
Abdominal perfusion pressure (APP), derivation, 967
Abdominal radiographs, obtaining, 1208
ABIOMED AB 5000, 465
c onsole alarm, troubleshooting, 472
c onsole failure, 472
high pressure/low flow, 472
low battery, 472
low flow, 472
low pressure/low flow, 472
patient monitoring/c are, 485
Ventric le, 471
ventric le, 466f
ABIOMED BVS 5000, 465
c onsole alarm, troubleshooting, 472
c onsole failure, 472
high pressure/low flow, 472
low battery, 472
low flow, 472
low pressure/low flow, 472
patient monitoring/c are, 485
system, 465f
VAD, 470
Ablative therapies, 1010
Absent waveform, troubleshooting, 658
Absorbable sutures, 1134
Absorption, 1020, 1033
Abviser Bladder Pressure S ystem, setup diagram, 975f
Ac idosis, usage, 1057
Ac tiFlow Indwelling Bowel Catheter, 1176f
Ac tiV.A.C., 1182
usage, 1183f
Ac tivated c harc oal (AC) administration, 958-959
Ac tivated c lotting time (ACT)
mac hine, usage, 681
usage, 1075
Ac tivated partial thromboplastin time (aPTT), 558
Ac tive range-of-motion exerc ises, enc ouragement, 156, 169, 187
Ac ute brain injury, management, 837
Ac ute c ompartment syndrome, 1119
Ac ute c oronary syndrome (ACS ), 511-513
c omplic ation, 618
Ac ute hypoxemic respiratory failure (treatment), NPPV (usage), 226
Ac ute inferior MI, 504f
Ac ute inferior wall MI, VF indic ation, 506f
Ac ute isc hemia, signs/symptoms (assessment), 517
Ac ute lung injury (ALI), 129
c linic al indic ations, 1125
impac t, 244
Ac ute respiratory distress, signs/symptoms (monitoring), 233, 281
Ac ute respiratory distress syndrome (ARDS ), 129, 626
ABG indic ation, 713
ARDS Network, RCT, 244-245, 263-266
impac t, 244
quantific ation, 255
volume-pressure trauma, signs (assessment), 268-269
Ac ute respiratory failure (treatment), NPPV (usage), 226
Ac ute ventilatory failure
definition, 262
signs/symptoms, assessment, 228, 268
Adaptive support ventilation (AS V), 277
Adenosine triphosphate (ATP), storage, 313
Adhesive skin strips, usage, 1134
Adhesive tape
sec uring, methods, 18f
usage, 18, 27
Adsorption, 1020, 1033
Adult patient death determination
apnea test, performing, 1218
brain death
c onfirmation, absenc e, 1221
determination, 1213
grief resourc es, usage, 1221
c ardiopulmonary func tion c essation, irreversibility (c onfirmation), 1213
c erebral motor pain responses, assessment, 1214
c oma/unresponsiveness, evidenc e (establishment), 1214
c onfirmatory brain death test results, 1220t
c orneal/jaw reflexes, assessment, 1215
doc umentation, 1221
ECG, performing, 1213
equipment, 1212
expec ted outc omes, 1220
family educ ation, 1212
gag/c ough reflexes, assessment, 1215
neuromusc ular bloc kade use, presenc e, 1214
nursing knowledge, 1211-1212
oc uloc ephalic (doll’s eye) reflexes, 1217f
assessment, 1215
oc ulovestibular (c aloric ) reflexes, assessment, 1216
patient assessment, 1212
patient educ ation, 1212
patient monitoring/c are, 1220
patient preparation, 1212
proc edure, 1213-1221t
pupillary size/bilateral response, assessment, 1215
purpose, 1211
unexpec ted outc omes, 1220
Adult respiratory distress syndrome (ARDS ), 1125
Advanc ed c ardiac life support (ACLS )
c ontinuation, 334
initiation, 338, 1224
therapies, 313
Afterload, 578
Agenc y for Health Care Polic y and Researc h (AHCPR), patient self report ac c eptanc e, 915-916
Agenc y for Healthc are Researc h and Quality (AHRQ), patient self report ac c eptanc e, 928
Air embolism, oc c urrenc e, 595
Air-fluid interfac e, level, 666
Air fluid interfac e, stopc oc k (zeroing), 677f
Air-leak c hamber assessment, 199
Air leak detec tor, bubble, 171
Air leaks, resolution, 178
Airway
c ompromise, potential, 59
direc t visualization, Combitube requirement, 1
parts, 69f
patenc y
assessment, 59, 65
maintenanc e, 667
resistanc e, determination, 249
respiration rate, c alc ulation, 105
Airway pressure release ventilation (APRV), 273
selec tion, 275
Airway protec tive reflexes (inadequac y), NPPV (nonusage), 226
Alligator c lips, 425f
Allografts (homografts), 1111
Alveolar-arterial (A-a) gradient, trends (evaluation), 255
Alveolar-arterial oxygen differenc e (A-aDO 2), 255
c alc ulation, 256
table, 256t
Alveolar overdistention, 240
Alveolar oxygen, diffusion, 255
Americ an Assoc iation of Blood Banks (AABB), therapeutic apheresis indic ation c ategories, 1071
Americ an Pain S oc iety (APS ), unrelieved pain, 915
Americ an S oc iety for Apheresis (AFS A), therapeutic apheresis indic ation c ategories, 1071
Amylase testing, 215
Andioseal, 681
Aneroid pressure manometer, usage, 286
Angiolink, 682
Angiotensin-c onverting enzyme (ACE) inhibitors, usage, 1020, 1071-1074
Angle of Louis, identific ation, 495
Ankle/arm index, assessment, 445
Antec ubital spac e, vasc ulature assessment, 766
Anterior c erebral artery (ACA), insonation, 849
Anterior c ommunic ating artery (AComA), insonation, 849
Anterior (front) pac ing elec trode, 416f
Anterior-lateral pac ing elec trodes, loc ation, 417f
Antibradyc ardia pac ing, revised NAS PE/BPEG generic c ode, 404t
Antic oagulation therapy, 209
assessment, 528
monitoring, 1031
thorac entesis c ontraindic ation, 219
Antiseptic oral rinses, usage, 34
Antitac hyc ardia pac ing (ATP)
delivery, 393
programming, 409
Anuria, dec rease, 970
Apheresis
assistanc e, proc edure, 1075-1078t
CBC, nec essity, 1075
c entrifugal apheresis mac hine, 1071
doc umentation, 1078
equipment, 1074
expec ted outc omes, 1076
family educ ation, 1074-1075
filtration, 1071
medic ation administration, holding, 1077
nurse, review, 1075
nursing knowledge, 1070-1074
patient assessment, 1075
patient c are, 1077
patient educ ation, 1074-1075
patient monitoring, 1077
patient preparation, 1075
purpose, 1070
therapeutic apheresis, indic ation c ategories, 1072-1074t
treatment length/frequenc y, variation, 1071
unexpec ted outc omes, 1076
Apic es
ausc ultation, 26
FRC, 130
Apnea, 262
Apnea test
abortion, 1219
performanc e, preparation, 1217
performing, 1218
prec autions, c onditions (ac hievement), 1218
results, 1219t
interpretation, 1219
Aqueduc t of S ylvius, 837
Arac hnoid villi, CS F absorption, 837
Argyle system, 184-185
Arms
c overing, meshed split-thic kness skin graft, 1111f
partial-thic kness burn wound, blisters, 1098f
veins, anatomy, 734f
Arrhythmogenic right ventric ular dysplasia (ARVD), 391
Arterial ac c ess port, c lamping, 1028
Arterial:alveolar ratio, c alc ulation (equation), 256t
Arterial blood
gas/saturation, 236
oxygen c ontent (CaO 2), c alc ulation, 235
sample, drawing, 260
Arterial blood gas (ABG), 256
analysis, 713
assessment, 296
obtaining, 960
patient indic ations, 713
sample, obtaining, 556, 559
serial dec rement, 262
Arterial c annulation
c onsideration, 713
need, determination, 714
Arterial c atheter alarm, usage, 683
Arterial c atheter insertion (assist)
arterial air-fluid interfac e, leveling, 538
arterial c atheter plac ement, loc ation, 535
arterial tree, arterial pressure, 535f
doc umentation, 546
dressing c hange, proc edure, 542-543t
dynamic response test (square wave test), fast flush system (usage), 539f
equipment, 535-536
expec ted outc omes, 544
family educ ation, 536
flush solution, preparation, 537
hemodynamic monitoring system, c hange, 545
insertion, assistanc e, 537
neurovasc ular status, assessment, 536
oc c lusive dressing, applic ation, 538
overdamped arterial waveform, 540f
overdamped waveform, troubleshooting (proc edure), 540-542t
patient assessment, 536
patient educ ation, 536
patient monitoring/c are, 544
patient preparation, 536
peripheral vasc ular status, assessment, 536
proc edure, 537-540t
pulsatile waveform, generation, 534f
purpose, 534
radial artery, pressure monitoring, 535
removal, proc edure, 543-546t
supraventric ular tac hyc ardia (S VT), development, 541f
underdamped waveform, troubleshooting (proc edure), 542t
unexpec ted outc omes, 544
vasodilators/vasoc onstric tors, appearanc e (c hange), 535
Arterial c atheter insertion (perform)
air-fluid interfac e, level, 531
antic oagulation therapy, assessment, 528
arterial c atheter insertion site, assessment, 532
arterial waveform inspec tion, 527
artery preferenc e, 527
blood return, absenc e, 531
brac hial artery, usage, 528
c ollateral flow, presenc e, 529
doc umentation, 532
equipment, 528
expec ted outc omes, 531
family educ ation, 528
femoral artery, usage, 528
noninvasive indirec t blood pressure, 527
nursing knowledge, 527-528
patient assessment, 528-529
patient educ ation, 528
patient monitoring/c are, 532
patient preparation, 528-529
perc utaneous punc ture, performing, 530
proc edure, 529-532t
punc ture site, loc al anesthesia, 530
purpose, 527
radial artery
pressure, maintenanc e, 530
usage, 529
site selec tion, 528
unexpec ted outc omes, 532
Arterial lines, investigation, 678
Arterial partial pressure of oxygen (PaO 2)
determination, 255
inc rease, observation, 261
PaO2:FiO 2 (P:F) ratio, c alc ulation, 257t
reduc tion, 262
Arterial pH, determination, 268
Arterial pressure-based c ardiac output (APCO) monitoring
APCO sensor kit, usage, 551
arterial pressure, determination, 548
c annulated extremity, neurovasc ular/peripheral vasc ular status (assessment), 553
doc umentation, 554
equipment, 549
expec ted outc omes, 553
FloTrac sensor, 552f
flush solution, preparation, 550
mean arterial pressure (MAP), 549
neurovasc ular status, assessment, 549
nursing knowledge, 548-549
patient assessment, 549-550
patient monitoring/c are, 553
patient preparation, 549-550
peripheral vasc ular disease, medic al history (obtaining), 549
peripheral vasc ular status, assessment, 549
pressure, representation, 548
priming/flushing, 551
proc edure, 550-554t
initiation, 550-554t
purpose, 548
unexpec ted outc omes, 553
Vigileo monitor, 552f
Arterial pressure-based c ardiac output (APCO) system, setup, 551
Arterial pressure monitoring, usage, 534
Arterial pressure waveform, balloon pressure waveform (superimposition), 454f
Arterial punc ture
allergy history, assessment, 714
arterial c annulation, c onsideration, 713
c omplic ations, 713
doc umentation, 720
equipment, 714
expec ted outc omes, 719
failure, 717
family educ ation, 714
femoral artery, anatomic landmarks, 714f
laboratory form, c ompletion, 719
nursing knowledge, 713-714
pain assessment, 719
patient assessment, 714-715
patient educ ation, 714
patient monitoring/c are, 719
patient preparation, 714-715
perc utaneous punc ture, performing, 717
preheparinized syringe, unavailability, 716
proc edure, 715-720t
purpose, 713
radial/brac hial arteries, anatomic landmarks, 713f
site assessment, 719
site preparation, 716
site selec tion, 714
unexpec ted outc omes, 719
Arterial sheath removal
assoc iation, 682
doc umentation, 688
equipment, 682
expec ted outc omes, 686
family educ ation, 682
nursing knowledge, 681-682
patient assessment, 682-683
patient educ ation, 682
patient monitoring/c are, 687
patient preparation, 682-683
proc edure, 683-688t
purpose, 681
unexpec ted outc omes, 686
Arterial-venous oxygen c ontent differenc e (a-vDO 2)
c alc ulation, 236-238t
c onsumption c alc ulations, 235
doc umentation, 238
equipment, 236
expec ted outc omes, 237
family educ ation, 236
nursing knowledge, 235-236
oxygen transport, delivery, 235
patient assessment, 236
patient educ ation, 236
patient preparation, 236
proc edure, 236-238t
purpose, 235
trend, observation, 238
unexpec ted outc omes, 237
Arterial-venous sample measurements, obtaining/analysis, 237
Arteriovenous jugular oxygen c ontent differenc e (AVjDO 2), 817
Artific ial airways, suc tioning (c omplic ations), 80
Artific ial skin, usage, 1111
Asc ending edema, 908
Asc itic fluid
analysis, 988
produc tion, 988
Aseptic tec hnique, 838
princ iples
knowledge, 655
understanding, 836
understanding, 738, 936
As low as reasonably ac hievable (ALARA), princ iples, 850
Assist/c ontrol (A/C), 264t
breath, initiation, 263
Assisted mandatory ventilation (AMV), 264t
Asystole, IABP troubleshooting, 455
Atelec tasis, impac t, 244
Atrial ac tivity, identific ation, 407
Atrial elec trogram (AEG)
atrial epic ardial pac ing wire
attac hment, 375
plac ement, 376
atrial epic ardial wire, 372
tip c ontac t, 373f
atrial pac ing wires, usage, 376
atrial wires
disc onnec tion, 378
exit, 373f
bipolar AEG
multic hannel telemetry/bedside ECG monitor, usage, 376
strip, lead I, 376f
12-lead ECG mac hine, 377
c ardiac rhythm, assessment, 372
c onduc tive gel, attac hment, 373
doc umentation, 379
dual-c hannel strip, rec ording, 373-374, 376
dysrhythmias
assessment, 372, 378
treatment, 378
ECG rhythm, monitoring, 378
elec trode, wrapping, 373f
equipment, 371-372
evaluation, 378
expec ted outc omes, 378
family educ ation, 372
hemodynamic status, assessment, 372
indic ations, 371
lead I, analysis, 377
multic hannel ECG monitor/rec order, usage, 372
nursing knowledge, 371
obtaining, 378
patient assessment, 372
patient educ ation, 372
patient monitoring/c are, 378
patient preparation, 372
performing, 371
proc edure, 372-379t
purpose, 371
rec ording, AHA Prac tic e S tandards for Elec troc ardiographic Monitoring in Hospital S ettings rec ommendation, 371
right arm (RA) lead wire, detac hment, 374
site, c are, 378
strip, analysis, 374
12-lead ECG, 375f
atrial pac ing wires, usage, 377f
usage, 375, 377
types, 371
unexpec ted outc omes, 378
unipolar AEG
multic hannel telemetry/bedside ECG, usage, 372, 374
strip, lead I, 375f
strip, lead V, 374f
12-lead ECG mac hine, usage, 375
vital signs, monitoring, 378
Atrial epic ardial lead
loc ation, 431f
wires, loc ation, 431f
Atrial fibrillation
IABP troubleshooting, 455
Atrial fibrillation, termination, 380
Atrial overdrive pac ing (perform)
ac c essory pathway, presenc e, 381
approac h, 380
atrial fibrillation termination, 380
atrial pac ing
c ompletion, 384
wire, identific ation, 381
atrial tac hydysrhythmia, c onversion, 381
blood pressure c uff, plac ement, 382
bursts, performing, 380
c ardiac rhythm, monitoring, 385
c linic al/tec hnic al c ompetenc e, 380
doc umentation, 385
dual-c hamber pulse generator, overdrive atrial pac ing c apability, 381f
ECG lead II, 383f
ECG rhythm/intervals, assessment, 381
epic ardial atrial pac ing, 382
epic ardial pac ing wires
c onnec tor pins, insulating material, 381
site c are materials, 381
epic ardial wires, c oiling, 384
equipment, 381
expec ted outc omes, 384
external pulse generator, c onnec ting c able (attac hment), 382
family educ ation, 381
hemodynamic parameters, assessment, 381
initiation, 383
intravenous ac c ess, patenc y (assessment), 381
nursing knowledge, 380-381
overdrive suppression, 381
paroxysmal atrial tac hyc ardia, episode, 383f
patient assessment, 381-382
patient educ ation, 381
patient monitoring/c are, 385
patient preparation, 381-382
pre-proc edure verific ation, performing, 382
proc edure, 382-385t
purpose, 380
rapid atrial pac ing, 381
rhythm strip, 383f
signs/symptoms, assessment, 381
supraventric ular dysrhythmias, 380
transvenous atrial pac ing, 382
unexpec ted outc omes, 384
vital signs
assessment, 381
monitoring, 385
Wolff-Parkinson-White (WPW) syndrome, 380
Atrial pac ing lumens, usage, 430f
Atrial pac ing wires, usage, 376
Atrial tac hydysrhythmia, c onversion, 381
Atrioventric ular (AV) demand pac ing, 436
Atrioventric ular (AV) fistula/graft, c annulation, 1036
Atrioventric ular (AV) nodal reentry tac hyc ardia, 380
Atrium system, 184-185
Autograft, 1109
treatment, 1101
Autolytic debridement, 1163
equipment, 1160
usage, 1160
Automated external defibrillation (AED)
attac hment, 313
barrier devic e, 313
devic e, 312f
doc umentation, 317
ECG paper, usage, 314
elec trodes, attac hment, 314
emergenc y situation usage, 314
equipment, 313-314
expec ted outc omes, 317
family educ ation, 314
nursing knowledge, 312-313
patient assessment, 314
patient educ ation, 314
patient monitoring/c are, 317
patient preparation, 314
patient rhythm analysis, 316
prehospital setting usage, 313
proc edure, 314-317t
purpose, 312
shoc k, 312
c hanc e, 313
sudden c ardiac event, 314
time, fac tor, 312
unexpec ted outc omes, 317
usage, 313
rec ommendation, 313
vital signs, monitoring, 317
Automated pronation therapy
proc edure, 140
tubes/invasive lines, position, 140
Automated Prone Positioning RotoProne, usage
absolute c ontraindic ations, 131
relative c ontraindic ations, 131
Automatic tube c ompensation (ATC), 277
Autonomic nervous system dysfunc tion, 908
Auto-positive end-expiratory pressure (auto-PEEP)
amount, identific ation, 245
baseline pressure level, observation, 241
breathing work, inc rease, 239
c alc ulation, proc edure, 240-242t
c ause, 266
c omplic ation risks, 240
detec tion, absenc e, 240
doc umentation, 242
end-expiratory hold button, identific ation, 240
equipment, 240
expec ted outc omes, 241
family educ ation, 240
identific ation/monitoring/elimination, 241
impac t, 239
mec hanic al ventilation c omplic ation, 266
nursing knowledge, 239-240
oc c ult, term (usage), 239
offsetting, interventions, 239-240
patient assessment, 240
patient educ ation, 240
patient preparation, 240
presenc e, 240
assessment, 240
evaluation, 242
purpose, 239
set-PEEP, relationship, 239f
status asthmatic us risk, 240
therapy, titration, 241
unexpec ted outc omes, 241
ventilation requirements, assoc iation, 239
Autotransfusion
blood transfusion reac tion, monitoring, 153
c ardiopulmonary status, assessment, 152
c ontraindic ations, 150
devic es, availability, 150
disposable systems, availability, 150
doc umentation, 153
drainage level, marking, 153
drainage tube patenc y, evaluation/maintenanc e, 152
drainage type/amount, monitoring, 153
equipment, 150-151
expec ted outc omes, 152
family educ ation, 151
nursing knowledge, 150
patient assessment, 151
patient educ ation, 151
patient monitoring/c are, 152
patient preparation, 151
proc edure, 151-153t
reservoir, disposable systems, 150
unexpec ted outc omes, 152
AutoValve
opening, c onfirmation, 976
usage, 974
Average tidal volume, analysis, 253
A wave, 629f, 804f
elevation, 655-656
plateau, 837
understanding, 739
Axillary bloc k, needle insertion loc ation, 937f
B
B. Braun Diapac t CRRT system, 1071f
Bac krest elevation (BRE), maintenanc e, 280
Bac teria infec tion (Sta phylococcus), , 1175
Bagging, indic ation, 248-249
Bag-valve-mask devic e
c onnec tion, 4, 25
requirement, 2
usage, 3
Balanc ed suspension trac tion, tamponade tube/plac ement, 948f
Balloon
lumen, blood aspiration, 665
overwedging, 657f
perforation, 456
suspic ion, 456
rupture, 666
Balloon-inflation valve, 626
Balloon pressure waveform
illustration, 453f
pressure plateau, 454
proc edure, 453-454t
superimposition, 454f
Balloon-tipped bipolar lead wire, usage, 430f
Bariatric pressure reduc tion surfac es, 1125
Barotrauma
result, 239
risk, 240
signs/symptoms, assessment, 242
Basal rate, 930
Baseline c ardiopulmonary status, assessment, 156, 187
Baseline S T-segment deviation, 504f
Basilar artery (BA), insonation, 849
Basilic veins, PICC c annulation, 763
Bed rest
explanation, importanc e, 682
maintenanc e, 687
time, reduc tion, 687
Bedside ECG
monitor, 376
usage, 372
Bedside elec trophysiologic monitoring, usage, 492
Bedside monitoring system, 491f
Berman airway
c harac teristic s, 74
parts, 75f
Bias flow, 278
Bilateral breath sounds, ausc ultation, 26
Bilevel positive airway pressure (BiPAP)
c ontrol mode, 230
level, selec tion, 230
nursing knowledge, 225-227
options, 230
positive pressure ventilation, addition, 225
proc edure, 229-233t
purpose, 225
spontaneous mode, 230
spontaneous-timed option, 230
Biobrane, usage, 1092, 1102
Biosynthetic dressings, usage, 1102
Biphasic defibrillation, 323f
Biphasic defibrillators, transthorac ic impedanc e measurement/c ompensation, 329-330
Biphasic ventilation, 275
Biphasic waveforms, energy delivery, 320, 329
Bipolar AEG
multic hannel telemetry/bedside ECG monitor, usage, 376
strip, lead I, 376f
Bipolar elec trogram, 371
Bipolar lead wire, 422f
Bipolar pac ing, usage, 404
BIS A2000 system, 781
Bispec tral (BIS ) index monitoring
ac c essories, usage, 778f
advanc ed setup menu, 784f
analgesia, 779
analgesic agents, 778
anesthetic agents, 778
data, obtaining, 779
digital signal c onverter (DS C)
sec uring, 783
usage, 776
doc umentation, 787
EEG c hannel, observation, 787
EEG single c hannel, 777
elec tromyographic (EMG) ac tivity, 779
equipment, 780
monitoring/setup, 780
usage, 778f
expec ted outc omes, 785
family educ ation, 780
hypothermia, 779
indic ations, 778
initiation, 776
monitor
display, observation, 784
settings, setup menu, 784f
neurologic injury, 779
neurologic status, assessment, 781
neuromusc ular bloc kade/monitoring issues, 780
neuromusc ular bloc king agents, 779
nursing knowledge, 775-780
patient assessment, 780-781
patient educ ation, 780
patient monitoring/c are, 786
patient preparation, 780-781
proc edure, 781-787t
purpose, 775
sedation, 778-779
sensor
c hange, 786
c hec k, 782f
monitoring/setup, 780
plac ement, 776f
settings, adjustment, 784
skin c ondition, assessment, 781
tec hnology, 775
terminology, 775t
unexpec ted outc omes, 785
value, 777
elevation, 779
interpretation, 779
medic ation effec ts, 779-780
monitor, 786
sedation level/EEG state, 778t
VIEW monitoring system, 776f
VIS TA monitoring system, 777f
BIS VIS TA system, 781
Bite-bloc k/airway tube, taping, 54f
Bite-bloc k insertion, 27
Bite-bloc k plac ement, 280
Biventric ular assist devic es (BiVADs), 466-467, 467f
Biventric ular pac emaker (c ardiac resync hronization therapy), 405f
Biventric ular pac ing, 410f
Bladder dec ompression, 989
Bladder drainage system, c lamping, 971
Bladder pressure
measurement, 967-968
c ontraindic ation, 968
position, 969f
system, 974f
monitoring
setup, 969f
system, 978f
rec ording, 976
serial monitoring, 968
Blakemore tube, 947
Blood bac kup (troubleshooting), PA c atheter/pressure transduc er system (usage), 666
Blood-borne infec tion, transmission risk, 565
Blood c irc uit, c omponents, 1034
Blood pressure (BP), 691
dec rease, 970
measurement, avoidanc e, 774
Blood pump, 1021
Blood sample, obtaining, 558, 562
Blood sampling, arterial c atheter (usage)
blood sampling port, usage, 560
blood spec imens, obtaining, 562
c losed arterial sampling system, 560
c losed blood sampling system, 561f
blood sampling port, needleless c annula (attac hment), 561f
needleless c annula, 561f
stopc oc k, 561f
doc umentation, 563
equipment, 555
expec ted outc omes, 563
family educ ation, 555
needleless blood sampling ac c ess devic e, 556f
needleless c annula, 561f
nursing knowledge, 555
patient assessment, 555-556
patient educ ation, 555
patient monitoring/c are, 563
patient preparation, 555-556
proc edure, 556-563t
purpose, 555
three-way stopc oc k port, syringe attac hment, 559f
unexpec ted outc omes, 563
Blood sampling, c entral venous c atheter (usage)
CVC port, needleless blood sampling devic e attac hment, 569f
doc umentation, 571
equipment, 565
addition, 565
expec ted outc omes, 570
family educ ation, 565
hemodynamic monitoring system, 566
needleless blood sampling devic e, attac hment, 567f
nursing knowledge, 565
patient assessment, 566
patient educ ation, 565
patient monitoring/c are, 571
patient preparation, 566
patient verific ation, identifier usage, 566
proc edure, 566-571t
purpose, 565
single CVC port, monitoring (avoidanc e), 568
three-way stopc oc k, syringe attac hment, 568f, 569f
unexpec ted outc omes, 570
Blood sampling, pulmonary artery c atheter (usage)
ABG syringe, insertion, 574
blood, fast flush, 575
doc umentation, 576
equipment, 572
expec ted outc omes, 575
family educ ation, 572
nursing knowledge, 572
patient assessment, 572-573
patient educ ation, 572
patient monitoring/c are, 576
patient preparation, 572-573
proc edure, 573-576t
purpose, 572
three-way stopc oc k, syringe attac hment, 574f
unexpec ted outc omes, 575
Blood sampling devic e, detac hment, 566
Blood shunting, 259
Blood transfusion reac tion, monitoring, 153
Blood urea nitrogen (BUN), removal, 1033
Body surfac e area (BS A), 469-470
Body temperature
dec rease, 578
measurement, 861-862
thermometers, usage, 862
variations, rec tal temperature basis, 862t
Bone injec tion gun (BIG), 756
insertion, 758
photo, 756f
Bone marrow biopsy/aspiration (assist)
aspirate proc essing, nonheparinized (EDTA) syringe (usage), 1089
c omponents, 1087
c ontraindic ations, 1086-1087
doc umentation, 1090
equipment, 1087
expec ted outc omes, 1089
family educ ation, 1087
indic ations, 1086
nursing knowledge, 1086-1087
patient assessment, 1087-1088
patient c are, 1089
patient educ ation, 1087
patient monitoring, 1089
patient preparation, 1087-1088
proc edure, 1088-1090t
purpose, 1086
unexpec ted outc omes, 1089
usage, 1086
Bone marrow biopsy/aspiration (perform)
aspirate needle, advanc ement, 1082
aspiration, 1081
biopsy, 1083
c ontraindic ations, 1080
doc umentation, 1085
equipment, 1080
expec ted outc omes, 1084
family educ ation, 1080
indic ations, 1079
nursing knowledge, 1079-1080
oxygenation status, assessment, 1081
patient assessment, 1080-1081
patient c are, 1084
patient educ ation, 1080
patient monitoring, 1084
patient preparation, 1080-1081
proc edure, 1081-1085t
purpose, 1079
unexpec ted outc omes, 1084
vital signs, assessment, 1081
Bowel management program, disc ussion, 1177
Bowel management system (BMS ), 1175
balloon, inflation, 1179
insertion, 1176
manufac turer-spec ific c ontraindic ations, 1176
plac ement, 1180f
proc edure, 1177-1181t, 1178
Bowel sounds, assessment, 865
Brac hial artery
anatomic landmarks, 713f
punc ture, 715
syringe, usage, 718f
Braden S c ale, usage, 1124
Bradypnea, 286
Braided sutures, 1134
Brain death
c ardinal findings, 1212
c onc ept, 1211
c onfirmation, absenc e, 1221
c onfirmatory test results, 1220t
determination, 1213
c omplianc e, fac ilitation, 1219
c onfirmatory tests, obtaining (assistanc e), 1220
func tion c essation, determination, 1211
grief resourc es, usage, 1221
irreversibility, determination, 1211
Brain tissue oxygenation (Pbto 2), 853
Brain tissue oxygen monitoring: insertion (assist)/c are/troubleshooting
c alibration c ard, insertion, 796
c erebral perfusion pressure (CPP), 792
c oagulation laboratory parameters, obtaining/reviewing, 795
doc umentation, 800
equipment, 794
expec ted outc omes, 799
family educ ation, 794
Glasgow Coma S c ale sc ore, 794
IM3 triple lumen introduc er, 794f
sec uring, demonstration, 797f
intrac ranial pressure (ICP), 792
loc al infec tion, signs/symptoms (assessment), 795
neurologic status, assessment, 795
nursing knowledge, 792-794
oxygen c hallenge test, 798, 800
parameters, measurement, 792
patient assessment, 795
patient educ ation, 794
patient monitoring/c are, 800
patient preparation, 795
Pbto 2 monitor c ables, sec uring, 796
Pbto 2 monitoring system, troubleshooting, 798
Pbto 2 probe plac ement, 793-794
Pbto 2 system, expec ted outc omes (explanation), 794
Pbto 2 values
dec rease, 793
inc rease, 793
inc rease/dec rease, management, 793t
monitoring, 792
pressure module, selec tion, 798
proc edure, 795-800t
purpose, 792
removal, 799
sedation/analgesia, administration, 795
setup, bedside monitor (usage), 797
systemic jugular venous oxygen (S jVO 2), 792
temperature c hanges, avoidanc e, 799
unexpec ted outc omes, 799
Brain Trauma Foundation Guides, 836
Brain tumor, 836
Break-through dose, 930
Breath-hold maneuver, Cstat measurement, 244
Breathing, work, 240
inc rease, 239
Breath sounds, absenc e, 17, 27
Breath-to-breath basis, 263
Burn c are fac ility, patient transfer c riteria, 1100t
Burn injury zones, 1098-1099
Burn patient c ondition, hypermetabolic c ondition, 1102
Burns
anatomic areas, 1100
debridement, purpose, 1159
presenc e, assessment, 304
Burns Weaning Assessment Program (BWAP), 292t
weaning fac tor, 294-295
Burn wound c are
autograft, treatment, 1101
baseline vital signs, obtaining, 1106
Biobrane, usage, 1102
biosynthetic dressings, usage, 1102
c hemic al burns, initial treatment, 1100
c reams, usage, 1105
debrided full-thic kness wound, protec tion, 1102
dermis, 1097
doc umentation, 1107
epidermis, 1097
equipment, 1102-1103
esc harotomy, performing, 1099
expec ted outc omes, 1106
family educ ation, 1103
healing signs, evaluation, 1103
infec tion signs/symptoms, evaluation, 1103-1104
instruc tions, 1103
Integra, usage, 1102
Lund and Browder c hart, usage, 1099f
management, 1102
negative-pressure wound therapy, usage, 1102
nothing by mouth (NPO) status, 1100
nursing knowledge, 1097-1102
opioids/sedatives/drugs, synergistic effec ts, 1104
pain assessment, 1106
pain management, determination, 1104
partial-thic kness burn, 1098f
patient assessment, 1103-1104
patient educ ation, 1103
patient monitoring/c are, 1106
patient preparation, 1103-1104
peripheral pulses/c irc ulation, monitoring, 1107
proc edure, 1104-1107t
purpose, 1097
respiratory exc ursion, adequac y, 1099
sc issors/forc eps, usage, 1104
soaks, usage, 1105
spec ialized burn c are fac ility, patient transfer c riteria, 1100t
splints, applic ation, 1105
survival rates, 1101
temperature, assessment, 1106
thermal injuries, emergenc y treatment, 1100
topic al antimic robial agents, usage, 1101-1102
unexpec ted outc omes, 1106
vital signs, assessment, 1103
Burn wounds
assessment, 1105
c olor, assessment, 1107
c ontrac tion, 1102
depth
c harac teristic s, 1098t
temperature intensity, relationship, 1098
perfusion, dec rease, 1098-1099
size/depth, Lund and Browder c hart (usage), 1099f
B waves, 804f
C
Calf, musc le c ompartments, 1119f
Cannulated extremity, neurovasc ular/peripheral vasc ular status (assessment), 553
Capnogram, 106
Capnograph, c onnec tion, 107
Capnographic waveform, essentials, 106f
Capnography, 105
monitoring, 944
Capture
evidenc e, 431-432
failure, pac emaker definition, 404t
pac emaker c onduc tion, 422
pac emaker definition, 404t
term, usage, 431-432
Carbon dioxide (CO 2) detec tion, 17
indic ation, 27
Carbon dioxide (CO 2) tension
determination, 268
inc rease, 286
Cardiac arrest, 422
esophageal detec tion devic e, usage, 16
Cardiac c hambers, PA c atheter insertion (waveform progression), 628f
Cardiac c yc le, events, 443
Cardiac death, organ donation, 1223-1224
analgesia, initiation, 1232
anxiolytic s, initiation, 1232
doc umentation, 1233
equipment, 1229
expec ted outc omes, 1233
family educ ation, 1229
height/weight, determination, 1230
ICU/OR teams, preparedness, 1231
life-sustaining therapy proc ess, withdrawal, 1231
medic al/soc ial history, review, 1230
nursing knowledge, 1229
patient assessment, 1229-1230
patient data, monitoring, 1230
patient educ ation, 1229
patient monitoring/c are, 1233
patient preparation, 1229-1230
patient prognosis, disc ussion, 1230
personnel, roles (determination), 1231
physic al assessment, 1230
prepping/draping, oc c urrenc e, 1232
proc edure, 1230-1233t
purpose, 1229
unexpec ted outc omes, 1233
Cardiac diagnostic proc edures, 430
Cardiac diseases, medic al history (assessment), 504
Cardiac energy depletion, ventric ular fibrillation (impac t), 313
Cardiac failure, signs/symptoms (assessment), 445
Cardiac index (CI), 617
c alc ulation, 591
obtaining, 644
Cardiac index (CI), assessment, 1059
Cardiac irritability (inc rease), elec trolyte abnormalities (impac t), 388
Cardiac isc hemic c omplic ations, absenc e, 226
Cardiac monitor, purpose (explanation), 959
Cardiac monitoring
c entral station, 492f
doc umentation, 501
equipment, 492
addition, 492
expec ted outc omes, 499
family educ ation, 492
monitor strip
baseline problem, 499f
interferenc e, 500f
60-c yc le interferenc e, 499f
nursing knowledge, 490-492
patient assessment, 492-493
patient educ ation, 492
patient monitoring/c are, 500
patient preparation, 492-493
proc edure, 493-501t
purpose, 490
telemetry
monitoring system, 492f
usefulness, 490
unexpec ted outc omes, 499
Cardiac output (CO)
c alc ulation, 579-580
c omputer, ac tivation, 586
c urves
assessment, 587
examination, 580f
variations, 581f
dec rease, 970
definition, 577
determination, 585-587t, 587-589t
systematic assessment, 578f
heart rate, impac t, 578
information, 617
measurement, determination, 589
obtaining, 644
produc tion, 235
values, CCO (relationship), 583
Cardiac output measurement tec hniques (invasive)
afterload, 578
c ardiac output, definition, 577
CCO values, 590
c losed injec table delivery system, 582f
c losed/open thermodilution method, usage, 584-585t
c old injec tate, 588
c omputation, selec tion, 584
c ontrac tility, 578
doc umentation, 592
equipment, 583
expec ted outc omes, 591
family educ ation, 583
hemodynamic parameters, 579t
nursing knowledge, 577-583
patient assessment, 583
patient educ ation, 583
patient monitoring/c are, 591
patient preparation, 583
patient vital signs, assessment, 583
proc edure, 584-585t
proximal lumens, infusions, 582-583
purpose, 577
respiratory pattern, observation, 586
stopc oc k, turning, 586
syringe preparation
c losed method, 585-587t
open method, 587-589t
TDCO method, 579
unexpec ted outc omes, 591
Cardiac pac ing, princ iples, 404, 422
Cardiac resync hronization therapy (CRT), 392-393
biventric ular pac emaker usage, 405f
Cardiac rhythm, assessment, 372
Cardiac surgery, anesthesia, 618
Cardiac tamponade
effusion/drainage, 364
indic ation, 343
mediastinal exploration, goal, 343, 350
signs/symptoms, assessment, 344, 351
symptoms, 364
Cardiogenic shoc k, c hronotropic inc ompetenc e (impac t), 430
Cardiographic pulmonary edema (treatment), NPPV (usage), 226
Cardiopulmonary c ollapse, 262
Cardiopulmonary func tion c essation, irreversibility (c onfirmation), 1213
Cardiopulmonary resusc itation (CPR)
performing, 314
restarting, 316
Cardiopulmonary status, assessment, 98, 572
Cardiovasc ular depression, signs (assessment), 269
Cardiovasc ular status
assessment, 656
monitoring, 327, 858
Cardiovasc ular system, anatomy/physiology, 329, 371
Cardioversion
all c lear statement, 325
anterior-posterior plac ement, usage, 324
arterial blood gas results, obtaining, 320
biphasic defibrillation, 323f
biphasic waveforms, energy delivery, 320
c ardiovasc ular status, monitoring, 327
c onduc tive gel/paste, usage, 320
c urrent flow, 323f
defibrillator
c harging, 324
sync hronization mode verific ation, 325
depolarizing elec tric al c urrent, 319
digitalis levels, obtaining, 320
doc umentation, 327
dysrhythmia etiology, patient/family understanding (assessment), 320
elec tive c ardioversion, usage, 319
elec troc ardiogram (ECG) rec order, usage, 323
equipment, 320
expec ted outc omes, 326
family educ ation, 320
implementation, 319
monitor lead, selec tion, 321
monophasic defibrillation, 323f
monophasic waveforms, energy delivery, 319
neurologic status, evaluation, 326
nursing knowledge, 319-320
oxygen sourc e, disc onnec tion, 325
paddle plac ement, 323f
paddle pressure, applic ation, 325
patent airway, maintenanc e, 321
patient assessment, 320-321
patient educ ation, 320
patient monitoring/c are, 326
patient preparation, 320-321
peripheral pulses, presenc e/absenc e (assessment), 320
preoxygenation, 321
proc edure, 321-327t
pulmonary status, monitoring, 326
purpose, 319
R wave sync hronization, 322f
self-adhesive defibrillation pads, anterior-posterior plac ement, 324f
serum potassium/magnesium levels, obtaining, 320
tac hydysthythmia
ECG results, assessment, 320
treatment, AHA energy level rec ommendations, 325t
transdermal medic ation patc hes, removal, 321
unexpec ted outc omes, 326
vital signs, assessment, 320
Catec holamine release, 578
Catheter size, guidelines, 32t
CCO method, 580-581
Cec um, fixation, 994
Centers for Medic are and Medic aid S ervic es (CMS ) deaths (reporting), 1212, 1225
Central nervous system (CNS ) evaluation, EEG waveforms (impac t), 775
Central venous ac c ess
obtaining, 617
presenc e/position, assessment, 423
Central venous c atheter (CVC) insertion (assist)
aseptic tec hnique, understanding, 738
c ardiac monitor, observation, 741
doc umentation, 744
ECG monitoring, 739
equipment, 739
expec ted outc omes, 742
family educ ation, 739
femoral vein insertion, 740
indic ations, 738
jugular vein insertion, 740
nursing knowledge, 738-739
pac emaker, presenc e, 739
patient assessment, 739-740
patient educ ation, 739
patient monitoring/c are, 743
patient preparation, 739-740
plac ement, 742
proc edure, 740-744t
purpose, 738
relative c ontraindic ations, 738
sedation/analgesic s, administration, 740
skin preparation, 741f
subc lavian insertion, 740
unexpec ted outc omes, 742
vasc ulature, anatomy/physiology (knowledge), 738
Central venous c atheter (CVC) insertion (perform)
advanc ement, 732
anesthetic , administration, 728
anomalous veins, medic al history (determination), 726
arms, veins (anatomy), 734f
assessments, performing, 736
c ardiac /pulmonary status, assessment, 726
c lavic le
middle/median thirds junc tion, identific ation, 731
needle insertion, 731
c oagulopathic state, assessment, 726
c omplic ations, 723-725t
doc umentation, 737
elec trolyte levels, assessment, 726
equipment, 722
expec ted outc omes, 736
family educ ation, 722
femoral vein, 733
anatomy, identific ation, 733
loc ation, 733
heparin sensitivity, assessment, 726
indic ations, 721
insertion site, assessment, 726
internal jugular vein, 727
identific ation, 727
jugular vein, identific ation, 727
median basilic vein, 734
identific ation, 734
nursing knowledge, 721-722
pac emaker, presenc e, 722
patient assessment, 722-726
patient educ ation, 722
patient monitoring/c are, 736
patient preparation, 722-726
plac ement, 721
proc edure, 726-737t
purpose, 721
relative c ontraindic ations, 722
S eldinger’s tec hnique, usage, 728, 733, 735
subc lavian vein, 731
loc ation, 731
punc ture, 732f
unexpec ted outc omes, 736
venous tourniquet, applic ation, 735
Central venous c atheter (CVC) removal
doc umentation, 599
equipment, 595
expec ted outc omes, 598
family educ ation, 595-596
gauze pad pressure, 597
need, assessment, 598
nursing knowledge, 595
patient assessment, 596
patient educ ation, 595-596
patient monitoring/c are, 598
patient preparation, 596
patient supine position, 596
proc edure, 596-599t
purpose, 595
Trendelenburg position, 596
unexpec ted outc omes, 598
Central venous c atheter (CVC) site c are, 600
c hlorhexidine impregnated sponge, applic ation, 601
doc umentation, 602
equipment, 600
expec ted outc omes, 602
family educ ation, 600
gauze dressings, replac ement, 602
nursing knowledge, 600
patient assessment, 600-601
patient educ ation, 600
patient monitoring/c are, 602
patient preparation, 600-601
proc edure, 601-602t
unexpec ted outc omes, 602
Central venous c atheters (CVCs)
blood withdrawal, 565
c atheter-related infec tions, assoc iation, 600
knowledge, 565
port, needleless c ap (needleless blood sampling devic e attac hment), 570
illustration, 569f
Central venous pressure (CVP), 577-578
assessment, 1059
dec rease, 603t
elevation, 721
impac t, 722
inc rease, 603t
value, ECG monitoring (impac t), 722
waveform, 605f
Central venous pressure/right atrial pressure (CVP/RAP) measurement, 605
Central venous pressure/right atrial pressure (CVP/RAP) trac ing, 606
Central venous pressure/right atrial pressure (CVP/RAP) waveform strip, obtaining, 607
Central venous/right atrial pressure (CVP/RAP) monitoring
doc umentation, 607
dual-c hannel rec orded strips, usage, 605
dynamic response test (square wave test), performing, 607
equipment, 604
expec ted outc omes, 606
family educ ation, 604
hemodynamic monitoring system, c hange, 607
nursing knowledge, 603
patient assessment, 604
patient educ ation, 604
patient monitoring/c are, 606
patient preparation, 604
patient supine position, 604
PR interval, alignment, 605
proc edure, 604-607t
purpose, 603
transduc er, zeroing, 607
unexpec ted outc omes, 606
waveforms, freeze framing, 605
Centrifugal apheresis mac hine, 1071
Cephalic antec ubital fossa veins, PICC c annulation, 763
Cerebral autoregulation, definition, 803, 810
Cerebral blood flow (CBF), CMRO 2, relationship, 817
Cerebral c irc ulatory arrest, 849
Cerebral extrac tion of oxygen (CEO 2), 817
Cerebral hypoxia, management, 793
Cerebral injury, 778
Cerebral metabolic rate of oxygen c onsumption (CMRO 2), 817
energy requirement, 817
Cerebral motor pain responses, assessment, 1214
Cerebral motor responses, assessment, 1214
Cerebral perfusion pressure (CPP), 792
c alc ulation derivation, 836
definition, 802-803, 810
determination, 853
monitoring, 842
Cerebrospinal fluid (CS F), 809
c harac teristic , 837
c ontinuous drainage, 812
drainage, 843
system, fluid-filled transduc er (attac hment), 828
formation, 837
overdrainage, 837
c onsequenc es, 810
sampling port, 844f
spec imens, c ollec tion assistanc e, 883
underdrainage, 837
c onsequenc es, 810
waveform, dampening, 831
Cerebrospinal fluid (CS F) drainage, intraventric ular c atheter/external transduc er (usage)
allergy assessment, 838
c linic al c onditions, 836
CS F drainage, 843
CS F sampling, 844
port, 844f
distal stopc oc k, c essation, 841f, 843f
external ventric ular drainage (EVD)
CS F drainage, 843
transduc er (c onnec tion), bedside monitor (usage), 839
external ventric ular drainage (EVD) system
assembly, 838
flushless transduc er, usage, 840f
intrac ranial pressure, monitoring, 842
intraventric ular c atheter, insertion (assistanc e), 839
medic al/surgic al history, obtaining, 838
parameters, monitoring, 845
pressure monitor tubing, flushing, 839
proc edure, 838
purpose, 826
sampling, supplies (obtaining), 844
transduc er
leveling, 841
zeroing, 841
waveforms, explanation, 838
Cervic al tongs, insertion, 908
Cervic al trac tion (assist) usage, c ervic al tongs/halo ring applic ation
allergies, assessment, 890
c ervic al spine trac tion, 888
c ervic al tongs, types, 889f
c ervic al trac tion applic ation, 889
c ontinuous trac tion, 889f
doc umentation, 894
equipment, 889-890
expec ted outc omes, 892
family educ ation, 890
Gardner-Wells tongs, insertion, 889
halo pins/ring, plac ement, 889f
halo ring insertion, 891
loss, 893
MRI-c ompatible graphite body, 889
neuroanatomy/physiology, knowledge, 888
neurologic assessment, 890, 892
nursing knowledge, 888-889
orthopedic trac tion frame, usage, 890
patient assessment, 890
patient educ ation, 890
patient monitoring/c are, 892
patient preparation, 890
pin sites
hemostasis monitoring, 892
preparation, 891
proc edure, 890-894t
purpose, 888
respiratory func tion, assessment, 892
spinal c ord injury, signs/symptoms, 888
tong insertion, 891
unexpec ted outc omes, 892
Cervic al trac tion maintenanc e
c omfort, assessment, 909
doc umentation, 914
equipment, 908
expec ted outc omes, 910
family educ ation, 908
high-risk foc us area skin assessment guide, 913t
immobility, ac ute physiologic responses, 912t
neurologic assessment, 909, 911
nursing knowledge, 908
patient assessment, 909
patient educ ation, 908
patient monitoring/c are, 911
patient preparation, 909
peripheral vasc ular assessment, 911
proc edure, 909-914t
purpose, 908
respiratory management, 913
Rotating Kinetic Treatment Table, 909f
spinal c ord injury, ac ute physiologic responses, 912t
straight line, maintenanc e, 910
unexpec ted outc omes, 910
Cetylpyridinium c hloride (CPC), usage, 34
Chemic al burns, initial treatment, 1100
Chemic al debridement, 1162
equipment, 1160
usage, 1160
Chest-abdominal dyssync hrony, 286
Chest expansion (improvement), c hest esc harotomy (usage), 1099f
Chest lead plac ement, 522f
Chest pain, symptom relief, 219
Chest radiographs
assessment, 210, 220-221
obtaining, 440
requirement, 219
usage, 172
Chest tube plac ement (assist)
ac tive/passive range-of-motion exerc ises, enc ouragement, 169
applic ations, 167
c hest drainage system, evaluation, 166
c hest tube
c onnec tion, 164
usage, 167
c losed pneumothorax, 167
c onnec tion points, sec uring, 165f
doc umentation, 166
equipment, 165
preparation, assistanc e, 164
expec ted outc omes, 165
family educ ation, 165-166
indic ations, 166
mediastinal tubes, plac ement, 167
medic al history/injury, assessment, 169
nursing knowledge, 164-165
oc c lusive c hest tube dressing, 165f
oc c lusive dressing, applic ation, 164
open pneumothorax, 167
Parham-Martin bands, 165f
patient assessment, 166-167
patient c ough/deep breath, 169
patient educ ation, 165-166
patient monitoring/c are, 165
patient position, c hange, 169
patient preparation, 166-167
physic ian assistanc e, 164
proc edure, 167-169t
semi-Fowler’s position, 169
tension pneumothorax, 167
unexpec ted outc omes, 165
water-seal c hamber, bubble, 167
Chest tube plac ement (perform)
ac tive/passive range-of-motion arm exerc ises, 156
applic ations, 155
baseline c ardiopulmonary status, signs/symptoms (assessment), 156
blunt dissec tion, 159f
buffered 1% lidoc aine, usage, 158f
c ardiopulmonary/vital signs, assessment, 161
c onnec tion, 160
points, taping, 161
c urved c lamp, 160f
introduc tion, 159
diagnostic test results, evaluation, 156
doc umentation, 162
equipment, 155
preparation, 157
expec ted outc omes, 161
family educ ation, 155-156
hand hygiene, 156
insertion, 160
insertion site
determination, 156
identific ation, 157
medic al history/injury, assessment, 156
nursing knowledge, 154-155
oc c lusive dressing, applic ation, 160
output, monitoring, 161
patient assessment, 156-157
patient c ough/deep breath, 156
patient educ ation, 155-156
patient monitoring/c are, 161
patient position, c hange, 156
patient preparation, 156-157
pleura infiltration, 158f
pleura pressure, 159f
preproc edure verific ation/time-out, 157
proc edure, 157-162t
rib, c lamp c losure, 159f
semi-Fowler’s position, 156
skin, surgic al preparation, 157
skin anesthetization, 158
skin infiltration, 158f
stay suture, 160f
thorac ic c avity, c losed airspac e, 154
transverse skin inc ision, 158f
unexpec ted outc omes, 161
Chest tube removal (assist)
air leak detec tor
bubble, 178
zone, observation, 180t
air leaks, assessment, 179
air leaks, resolution, 178
antiseptic swab, usage, 181
c hest radiographic results, c ollec tion, 179
doc umentation, 183
end expiration, 181
end inspiration, 181
equipment, 179
expec ted outc omes, 182
family educ ation, 179
indic ations, 178
insertion site, monitoring, 182
mediastinal c hest tubes, removal, 178
nursing knowledge, 178
patient assessment, 179
patient educ ation, 179
patient monitoring/c are, 182
patient preparation, 179-180
pleural tubes, plac ement, 178
preproc edural teac hings, patient understanding, 180
pre-proc edure verific ation/time out, performing, 180
proc edure, 180t
respiratory status, assessment, 179
S ilastic drains, usage, 178
subc utaneous emphysema, development, 182
sutures, usage, 179
unexpec ted outc omes, 182
Chest tube removal (perform)
air leak detec tor
bubble, 171
observation, 173
air leaks, resolution, 171
c hest radiographs
c ollec tion, 175
usage, 172
doc umentation, 177
equipment, 172
expec ted outc omes, 176
family educ ation, 172
goal, 172
indic ations, 171
insertion area, monitoring, 176
mediastinal c hest tubes, removal, 171
nursing knowledge, 171-172
patient assessment, 172-173
patient educ ation, 172
patient monitoring/c are, 176
patient preparation, 172-173
pleural tubes, plac ement, 171
premedic ation, administration, 173
preproc edural teac hing, 173
pre-proc edure verific ation, performing, 173
proc edure, 173-177t
purse-string suture, 172f
presenc e, 175
respiratory status, assessment, 172-173
S ilastic drains, usage, 171-172
suc tion, disc ontinuanc e, 173
sutures, usage, 172
tape, removal, 174
unexpec ted outc omes, 176
Valsalva maneuver, performing, 174
Chest tubes
c lamping, 185
drainage, exc ess (assessment), 344
Children, patient-c ontrolled intravenous opioid administration (guidelines), 929t
Chin strap, usage, 229
Chlorhexidine, usage, 34
Chronic obstruc tive lung disease, 626
Chronic obstruc tive pulmonary disease (COPD)
ABG indic ation, 713
treatment, NPPV (usage), 226
Chronic respiratory distress syndrome (ARDS ), 226
Chronotropic inc ompetenc e, 422
impac t, 430
Circ le of Willis
anatomic variations, 851
arteries, depth/direc tion/mean flow veloc ities, 851t
variants, 853f
Citrate phosphate dextrose (CPD), usage, 151
Claustrophobia, 226
Clearanc e, term (usage), 1020, 1034
Clinic al brain death, initiation (neurologic testing), 1225
Closed arterial blood sampling system, 560
Closed blood sampling system, 561f
blood sampling port, needleless c annula
attac hment, 561f
removal, 562f
needleless c annula, 561f
stopc oc k, 561f
Closed c hest drainage system (CDS )
ac tive/passive range-of-motion exerc ises, enc ouragement, 187
air-leak c hamber assessment, 199
all bottle systems, 186
assessment, 198
baseline c ardiopulmonary status, assessment, 187
c ardiopulmonary system, assessment, 198
c hest drain system, 201
c hest tube maintenanc e/c hec king, 200
c ollec tion c hamber, monitoring, 201
disposable dry suc tion c hest drainage system, 188
disposable dry suc tion system, 188
disposable setup (wet/dry systems), 186
disposable wet suc tion c hest drainage system, 189
disposable wet suc tion system, 188
doc umentation, 202
drainage bottle, stabilization, 191, 194
drainage c ollec tion bottle, 193f
drainage spec imen, c ollec tion, 202
drainage tubing, maintenanc e, 200
dry suc tion, 188
one-way valve, usage, 188
usage, 185
Emerson disposable suc tion system setup, 190
Emerson pump
disposable suc tion, 188
illustration, 186f
usage, 185
equipment, 186
expec ted outc omes, 198
family educ ation, 187
float valve, usage, 201
flow rates, differenc es, 184
four-bottle c hest drainage system, 196f
four-bottle setup, 195
four-bottle system, 186, 188
gravity drainage, 188-189, 190, 192
inc lusion, 184
insertion site, assessment, 201
intrapleural pressures, measurement, 184
long straw, insertion, 191, 193, 195
nursing knowledge, 184-185
one-bottle c hest drainage system, 191f
one-bottle setup, 190
one-bottle system, 186, 188
one-way mec hanism, 184
patenc y, assessment, 200
patient assessment, 187, 198
patient drainage tubing, c onnec tion, 191
patient educ ation, 187
patient monitoring/c are, 198
patient preparation, 187
patient verific ation, identifiers (usage), 187
positive-pressure relief valve, usage, 185
presc ribed analgesic s/sedatives, administration, 187
pressure c onversion c hart, 185t
proc edure, 188-202t
short straw, insertion, 191, 193, 195
sterile tubing, usage, 193
suc tion c ontrol bottle, 193
suc tion drainage, 189
suc tion initiation, 189
suc tion sourc e, addition, 184
three-bottle c hest drainage system, 194f
three-bottle setup, 194
vented water-seal bottle, usage, 195
three-bottle system, 186, 188
disposable system, c orrelation, 185f
two-bottle c hest drainage system, 193f
two-bottle setup
drainage c ollec tion bottle, usage, 191
water-seal/drainage c ollec tion bottle, usage, 193
two-bottle system, 186, 188
unexpec ted outc omes, 198
usage, 184
vented water-seal bottle, filling, 196
waterless c harac teristic , 185
water-seal bottle
filling, 194, 196
usage, 190-191, 192
Closed injec tate delivery system
c old temperature injec tate, 582f
room temperature injec tate, 582f
Closed pneumothorax, 154, 167
Closed-suc tion tec hnique, 80f
Closed thermodilution method, usage, 584-585t
Closed wound, c leaning, 1153
Clo-S ur P.A.D., 681
Coagulation disorder, thorac entesis c ontraindic ation, 219
Coagulation study results, obtaining, 989
Coagulopathic state, assessment, 620
COBE S pec tra Apheresis S ystem, 1071f
Collagen plug devic es, 681
bed rest time, reduc tion, 687
deployment, 682
Collateral flow, presenc e, 529
Coma, NPPV (nonusage), 226
Combination intraventric ular/fiberoptic c atheter insertion (assist), monitoring/nursing c are/troubleshooting/removal
advantages/disadvantages, 809
allergies, assessment, 811
c atheter removal, 813
doc umentation, 815
equipment, 810
expec ted outc omes, 813
external ventric ular drainage system, priming, 811
family educ ation, 811
fiberoptic system, 812
ICP monitoring, 809
ICP waveform, peaks, 810
informed c onsent, obtaining, 811
intraventric ular/fiberoptic c atheter plac ement, 812
laboratory profile, assessment, 811
neurologic status, assessment, 811
nursing knowledge, 809-810
patient assessment, 811
patient educ ation, 811
patient monitoring/c are, 814
patient preparation, 811
preproc edural analgesia/sedation, administration, 811
proc edure, 811-815t
purpose, 809
safe environment, provision, 814
troubleshooting, 813
unexpec ted outc omes, 813
Combitube
airway, rigidity, 1
c omponents, 1f
c uffs
integrity, testing, 3
usage, 1-2
design, 1-2
devic e plac ement, assessment, 5
direc t airway visualization, requirement, 1
distal c uff, 1
inflation, 4
doc umentation, 7
equipment, 2
esophageal insertion, 2f
esophageal position, 2f
expec ted outc omes, 6
family educ ation, 3
fluid deflec tor, attac hment, 4
head/jaw position, maintenanc e, 4
insertion
nursing knowledge, 1-2
proc edure, 3-7t
ventilation, requirement, 2
kit/pac kaging, 2
latex, allergic reac tion, 2
lubric ation, 4
oxygenation, adequac y, 3
patient
assessment, 3
educ ation, 3
height, assessment, 3
history, assessment, 3
monitoring/c are, 7
preparation, 3
personal protec tive equipment, removal, 6
proximal c uff, 1
inflation, 4
removal, 6
nursing knowledge, 1-2
size, availability, 1
suc tion equipment, assembly/func tion, 3
tip, insertion, 4
trac heal position, 2f
tube plac ement, assessment, 5
unexpec ted outc omes, 6
usage, 9
c ontraindic ation, 2
ventilation
adequac y, 3
c ontinuation, 5
Compartment syndrome
c harac teristic , 1118-1119
pathophysiology, 1118
Complete blood c ount (CBC), 802
nec essity, 1075
Complianc e, definition, 244
Complianc e/resistanc e measurement
c omplianc e, definition, 244
c onditions, impac t, 244
doc umentation, 247
equipment, 245
expec ted outc ome, 246
family educ ation, 245
nursing knowledge, 244-245
patient assessment, 245
patient educ ation, 245
patient monitoring/c are, 246
patient preparation, 245
proc edure, 245-247t
purpose, 244
resistanc e, definition, 244
unexpec ted outc omes, 246
CompressAR, 681
Computed tomography-pulmonary angiography (CT-PA), 250
Confirmatory brain death test results, 1220t
Congestive heart failure (CHF), NPPV (effic ac y), 226
Connec ting c ables, example, 431f
Consc iousness level, assessment, 11, 24, 865
Continual lateral rotation therapy (CLRT)
pressure reduc tion ac hievement, explanation, 1127
purpose, 1124
support surfac es, 1125
information, 1126
usage, 1125
Continuous c ardiac output (CCO)
display, 581
fluid boluses elimination, 580-581
measurements, 581
method, 581
TDCO, c omparison, 581
values, 590
c omparison, 590
doc umentation, 590
Continuous end-tidal CO 2 monitoring
c apnographic waveform, essentials, 106f
c apnography, 105
doc umentation, 111
equipment, 106
expec ted outc omes, 108
family educ ation, 107
indic ations, 106
nursing knowledge, 105-106
oxygenation measurement, inability, 106
patient assessment, 107
patient educ ation, 107
patient monitoring/c are, 108
patient preparation, 107
PetCO 2, inc rease, 109f
proc edure, 107-111t
unexpec ted outc omes, 108
Continuous end-tidal CO 2 monitors
attac hment, 16, 26
usage, 10, 23
Continuous intravenous infusions, dose/flow rates c alc ulations/administration
c entral IV ac c ess, usage, 1243
c ontinuous IV infusions, c alc ulations, 1243
doc umentation, 1247
equipment, 1244
expec ted outc omes, 1246
family educ ation, 1244
flow rate, determination, 1245
formulae, 1243t
IV medic ation, IHI rec ommendations, 1243
mathematic al formula, 1243
medic ation administration, rights (verific ation), 1245
medic ation doses, variation, 1243t
nursing knowledge, 1242-1243
patient assessment, 1244-1245
patient educ ation, 1244
patient monitoring/c are, 1246
patient preparation, 1244-1245
proc edure, 1245-1247t
purpose, 1242
unexpec ted outc omes, 1246
weight-based medic ations
c alc ulations, 1243
variation, 1244t
Continuously wedged waveform, troubleshooting, 663
Continuous peripheral nerve bloc ks, 939t
Continuous positive airway pressure (CPAP), 264t
absenc e/presenc e, 630
level, selec tion, 230
mode, selec tion, 229
nursing knowledge, 225-227
OS A treatment, 225
proc edure, 229-233t
protoc ol, example, 293t
purpose, 225
referenc e, 273
Continuous renal replac ement therapy (CRRT)
ACE inhibitors, usage, 1020
antic oagulant, usage, 1020
artific ial kidney, usage, 1020
baseline/ongoing assessments, 1029
baseline vital signs, assessment, 1022
blood pump
flow rate, observation, 1026
usage, 1021
c atheter c lamps, c losure, 1025, 1028
c atheter insertion site, assessment, 1022-1023
c learanc e, 1020
dialysate, c omponents, 1020
dialyzers, 1020
doc umentation, 1031
elec trolytes/gluc ose, albumin, monitoring, 1030
emergenc y termination, 1028
expec ted outc omes, 1029
extrac orporeal blood purific ation therapy, 1018
family educ ation, 1022
flushing, 1026
hemofilter, flushing, 1027
heparin/c itrate, usage, 1020
informed c onsent, 1023
initiation
equipment, 1022
proc edure, 1023-1031t
integrated pump systems, 1021
list, 1019t
medic ations, administration, 1030
methods, 1018
nursing knowledge, 1018-1022
patient assessment, 1022-1023
patient educ ation, 1022
patient monitoring/c are, 1029
patient preparation, 1022-1023
proc edure, explanation, 1022
protec tive c ap, disc onnec tion, 1025
purpose, 1018
explanation, 1022
systems, 1023
initiation, 1024
termination, 1026
equipment, 1022
proc edure, 1023-1031t
unexpec ted outc omes, 1029
vasc ular ac c ess site, assessment, 1022-1023
venous line, flushing, 1027
venous monitor pressure, observation, 1026
Continuous S T-segment monitoring
ac ute c oronary syndrome (ACS ), isc hemia, 511-513
demand-related isc hemia, S T-segment pattern, 513f
doc umentation, 517
ECG c omplex, 516f
ECG c ontinuous monitoring, 511
elec trode plac ement, identific ation, 514
equipment, 513
expec ted outc omes, 516
family educ ation, 513-514
limb elec trodes, loc ation, 514f
measurement points, 516f
monitoring leads, selec tion, 515
multiliead S T-segment monitoring, indic ation, 513
myoc ardial isc hemia, diagnosis, 513
nursing knowledge, 511-513
patient assessment, 514
patient educ ation, 513-514
patient monitoring/c are, 516
patient preparation, 514
proc edure, 514-517t
purpose, 511
S T segments, trend assessment (importanc e), 512f
supply-related isc hemia, S T-segment pattern, 512f
three-dimensional image, 512f
12-lead S T-segment monitoring, lead plac ement, 514f
unexpec ted outc omes, 516
Continuous venous oxygen saturation monitoring
c atheter pac kage, outer wrap (removal), 116
c onsideration, 113
doc umentation, 120
equipment, 115
expec ted outc omes, 118
family educ ation, 115
LEDs, optic module, 114
monitor, c alibration, 114-115
nursing knowledge, 113-115
oximetry c atheters, 115f
oximetry system, reflec tanc e spec trophotometry, 114f
patient assessment, 116
patient educ ation, 115
patient height/weight data, input, 117
patient monitoring/c are, 119
patient preparation, 116
PA waveforms, monitoring, 119
performing, 114-115
pre-proc edure verific ation, performing, 117
proc edure, 116-120t
S VO 2 value/trends, observation, 119
unexpec ted outc omes, 118
venous blood sampling skill, 118
venous oxygen saturation, measurement, 113
in vivo c alibration, 118
Continuous venovenous hemodiafiltration (CV-VHDF), 1018
fluid replac ement, 1021f
fluid/solute removal, 1022
Continuous venovenous hemodialysis (CVVHD), 1018
fluid/solute removal, 1021f
usage, 1022
Continuous venovenous hemofiltration (CVVH), 1018
fluid removal/replac ement, 1020f
fluid/solute removal, 1022
Continuous venovenous renal replac ement therapy, ac hievement, 1020
Contrac tility, 578
Controlled mandatory ventilation (CMV), 264t
Control ventilation (CV), 264t
Convec tive transport, 1018, 1033
Cooling devic e, usage, 864
CORTRAK
Anterior View S c reen, 1196
Monitor Unit, usage, 1196
plac ement, 1197f
power button, 1195f
printed trac ing/radiograph, 1198f
sc reen, 1195f
system, c ontraindic ation, 1193
usage, 1192
CO-S et, usage, 592
Costophrenic angle, blunting, 210
Cough
development, 209
medic al history, assessment, 221
reflexes, assessment, 1215
symptom relief, 219
Coughing, enc ouragement, 46
Counterpulsation, 444f
Cranial bone thic kness, c omparison, 849
Cric oid pressure
applic ation, 9, 22, 26
downward pressure, 10f
Cric othyroid membrane
identific ation, 60-61
loc ation, 60f
Critic ally ill, single-shot/c ontinuous peripheral nerve bloc ks, 939t
Cuff c are, assistanc e, 31
Cuff inflation, ensuring, 35
Cuff leakage, signs/symptoms (assessment), 90
Cuff pressure measurement, 91
devic es, 88
pressure monitor, usage, 92f
Cultured epidermal autografts, usage, 1110-1111
Cumulative dose limit, 930
Curved laryngosc ope blade (Mac intosh blade), usage, 9, 22
C wave, 629f, 804f
understanding, 739
Cyanosis, 204
development, 364
Cytapheresis, 1070
Cytotoxic c leaning agents, usage, 1150
Cytotoxic disposal rec eptac le, 691
D
DDD pac ing, 408f
DDD system, c apture/sense failure, 408f
Debrided full-thic kness wound, protec tion, 1102
Débridement
ac hievement, 1160
autolytic débridement, 1163
equipment, 1160
usage, 1160
c hemic al débridement, 1162
equipment, 1160
usage, 1160
c lean/sterile tec hnique, usage (c linic al judgment), 1160
c oagulation parameters, limits, 1161
doc umentation, 1164
dressing, monitoring, 1164
enzymatic agent, applic ation, 1162
enzymatic débridement, usage, 1160
equipment, 1160
expec ted outc omes, 1163
family educ ation, 1160
loc al/systemic infec tion, assessment, 1161
mec hanic al débridement, 1162
equipment, 1160
usage, 1160
moisture-retentive dressing, usage, 1162
nursing knowledge, 1159-1160
patient assessment, 1161, 1164
patient educ ation, 1160
patient monitoring/c are, 1164
patient position, 1161
patient premedic ation, 1161
patient preparation, 1161
patient verific ation, identifiers (usage), 1161
proc edure, 1161-1164t
purpose, 1159
S harp debridement, 1161
equipment, 1160
performing, 1160
usage, 1160
surgic al debridement, usage, 1160
tissue assessment, 1161
unexpec ted outc omes, 1163
Universal Protoc ol requirements, c omplianc e, 1161
vasc ular assessment, 1161
wet-to-dry-gauze dressing, usage, 1162
wound assessment, 1164
Deep breathing
enc ouragement, 46
importanc e, 40
Deep tissue injury, suspic ion, 1159
Deep vein thrombosis (DVT)
c omplic ation, 266-267
prophylaxis, c onsideration, 911
weaning proc ess c omplic ation, 291
Defibrillation (external)
airway/pulmonary status, monitoring, 335
all c lear statement, 333
anterior-posterior plac ement, usage, 332
biphasic defibrillators, transthorac ic impedanc e measurement/c ompensation, 329-330
biphasic dose, AHA rec ommendation, 329
biphasic waveforms, energy delivery, 329
burns, assessment, 335
depolarization, 329
doc umentation, 336
dysrhythmia c onversion, 334
ECG rec order, usage, 332
ECG results, assessment, 330
elec trolyte levels, monitoring, 335
equipment, 330
expec ted outc omes, 335
family educ ation, 330
implantable c ardioverter-defibrillator, pad/paddle plac ement, 333
internal paddle c able, c onnec tion, 339
intravenous antidysrhythmic pharmac ologic therapy, initiation, 335
metallic objec ts, removal, 330
mode, plac ement, 331
monophasic waveforms, energy delivery, 329
neurologic status, evaluation, 335
nursing knowledge, 329-330
oxygen sourc e, disc onnec tion, 333
pad/paddle plac ement, 332
patient assessment, 330-331
patient educ ation, 330
patient monitoring/c are, 335
patient oxygenation, 331
patient preparation, 330-331
proc edure, 331-336t
pulseless ventric ular tac hyc ardia, assessment, 338
purpose, 329
transdermal medic ation patc hes, removal, 330
unexpec ted outc omes, 335
ventric ular defibrillation, ECG results (assessment), 330
vital signs
assessment, 330
monitoring, 335
wearable c ardioverter defibrillator (WCD) development, 330
Defibrillation (internal)
ACLS , initiation, 338
assist, proc edure, 338-341t
doc umentation, 341
dysrhythmias, assessment, 338
ECG osc illosc ope, usage, 337
ECG rec order
c ontinuous printout, 339
usage, 337
elec trophysiologic studies (EPS ), usage, 337
equipment, 337
expec ted outc omes, 341
family educ ation, 337-338
mode, setting, 338
neurologic status, assessment, 341
nursing knowledge, 337
paddle plac ement, 339f
patient assessment, 338
patient educ ation, 337-338
patient monitoring/c are, 341
patient preparation, 338
patient response, assessment, 340
proc edure, 338-341t
pulmonary status, monitoring, 341
purpose, 337
sterile internal paddles, usage, 337
unexpec ted outc omes, 341
ventric ular defibrillation, assessment, 338
vital signs
assessment, 338
monitoring, 341
Defibrillator c ode, development, 393
Defibrillators
c ables, position, 332
c harging, 324
c leaning, 340
energy/c urrent delivery, 319-320, 329
Delta c ompartment pressure, 1119
Demand dose, 930
Demand-related isc hemia, S T-segment pattern, 513f
Dentures, presenc e, 24
Dermatomes, 920f
Dermis, 1097
Desc ending thorac ic aorta, intra-aortic balloon (positioning), 444f
Diagnostic peritoneal lavage (DPL), 1002
avoidanc e, 1002
c ontraindic ations, 995
preferenc e, 995, 1002-1003
relative c ontraindic ations, 1003
sensitivity, 994
tool, sensitivity, 994
usage, 994, 1002
Diagnostic thorac entesis, 209
affec ted side, perc ussion, 211
antiseptic site preparation, 212
assistanc e, proc edure, 221-224t
baseline diagnostic study results, 220
c ompletion, 214
equipment, 209, 220
assembly, 211
indic ation, 208, 219
lidoc aine, usage, 212
patient positioning, 211
periosteum, anesthesia, 212
personal protec tive equipment, applic ation, 211
pleural fluid, obtaining, 213
preproc edural medic ations, 212
pre-proc edure verific ation/time out, 211
proc edure, 211-217t
Dialysate, c omponents, 1020, 1033-1034
Dialysis, adequac y, 1034
Dialyzers
ports, 1020, 1034
UF c oeffic ients, 1020, 1034
Diarrhea
c ommonness, 1177
identific ation/treatment, 1175
personal protec tive equipment, usage, 1175
Differential diagnosis, 852t
Diffusion, 1018-1020, 1033, 1048
Digital signal c onverter (DS C), usage, 776
Dilated c ardiomyopathy (DCM), presenc e, 391
Disposable CDS s, 184-185
Disposable dry suc tion c hest drainage system, 188
Disposable end-tidal CO 2 detec tors
attac hment, 16, 26
c hemic al treatment, 10, 23
Distal c uff, inflation, 4
Distal lumen port, usage, 618
Distal tibia, palpation, 758
Donation after c ardiac death (DCD), 1229
Donor site c are
antimic robial c reams/ointments, usage, 1092
appearanc e, assessment, 1095
baseline vital signs, obtaining, 1095
Biobrane, usage, 1092
donor site, photograph, 1091f
epithelium, reopening/melting, 1092
equipment, 1092
family educ ation, 1093
healing/c omplic ation signs, assessment, 1094
healing stage, photograph, 1092f
instruc tions, 1093
mesh gauze, applic ation, 1092
multilayer oc c lusive dressings, usage, 1092
nursing knowledge, 1091-1092
pain/anxiety, premedic ation, 1093
pain assessment, 1095
pain c ontrol, adequac y (evaluation), 1093
partial-thic kness wound, surgic al c reation, 1091
patient assessment, 1093
patient educ ation, 1093
patient preparation, 1093
preproc edural teac hings, understanding, 1093
purpose, 1091
range of motion (ROM), evaluation, 1093
site assessment, 1092
slow-release silver dressings, usage, 1092
wounds, epithelialization, 1092
Donor site treatment goals, 1091
Doppler ec hoc ardiography, 705
Double-lumen endotrac heal tubes, usage, 11, 23
Double-lumen vasc ular ac c ess c atheter, usage, 1020-1021, 1071
Double-pressure transduc er system
illustration, 671f
usage, 670
Drain removal
doc umentation, 1174
drainage, presenc e (assessment), 1173
dressing, applic ation, 1172
equipment, 1172
expec ted outc omes, 1173
family educ ation, 1172
infec tion signs, monitoring, 1174
nursing knowledge, 1172
patient assessment, 1172-1173
patient educ ation, 1172
patient monitoring/c are, 1173
patient preparation, 1172-1173
proc edure, 1173-1174t
purpose, 1172
unexpec ted outc omes, 1173
Drain type, 1172
Dry disposable system, 186
D-shaped trac hea, c ross-sec tional view, 89f
D-S tat Dry, 681
Dual-c hamber DDD pac ing, 408f
Dual-c hamber pac emaker, requirements, 422
Dual-c hamber pac ing
initiation, 430
requirements, 422
Dual-c hamber pulse generator, overdrive atrial pac ing c apability, 381f
Dual-c hamber rec orded strip, usage, 611
Dual-c hamber temporary pulse generator, 431f
example, 431f
Dual-drive hospital driver (DDC), 466
Dual Driver (Thoratec ), 478
Dynamic c omplianc e (Cdyn), 244
exhaled tidal volume, identific ation, 245
Level B, 245
measurement, 244
trends, observation, 246
Dynamic hyperinflation, enc ouragement, 240
Dynamic response test (square wave test)
fast flush system, usage, 539f
performing, 545, 607, 644, 663
Dyspnea, 204, 286
medic al history, assessment, 221
pleural effusion sign/symptom, 219
Dysrhythmias, 204
assessment, 338
c omplic ation, 421
c onversion, 334
etiology, patient/family understanding (assessment), 320
hemodynamic response, determination, 414-415
interpretation, 690
treatment, 361, 368
Dyssync hrony, observation, 250
E
Early inflation, 451f
Ec hoc ardiography tec hniques, 705
Elastomeric infusion pumps, 939f
Elastomeric pumps, 937-938
Elec tive c ardioversion, usage, 319
Elec tive replac ement indic ated (ERI), 394
Elec tric al burn, entry site, 1100f
Elec tric al c apture, oc c urrenc e, 413-414
Elec tric al flow, rule, 490-491
Elec tric al therapy, delivery, 393
Elec troc ardiogram (ECG)
assessment, 649
lead plac ement, 690
pattern, monitor stripo, 498f
rec order, usage, 323
rec ording, line/spike (representation), 431
Elec troc ardiographic (ECG) c hannels, number (identific ation), 508
Elec troc ardiographic (ECG) leads
c entral station, 492f
doc umentation, 501
equipment, 492
addition, 492
expec ted outc omes, 499
family educ ation, 492
monitor strip
baseline, problems, 499f
60-c yc le interferenc e, 499f
nursing knowledge, 490-492
patient assessment, 492-493
patient educ ation, 492
patient monitoring/c are, 500
patient preparation, 492-493
plac ement, 519
proc edure, 493-501t
purpose, 490
telemetry, 490
monitoring system, 492f
unexpec ted outc omes, 499
Elec troc ardiographic (ECG) pac ed rhythm, 427
Elec troc ardiographic (ECG) rec ordings, evaluation, 509
Elec troc ardiographic (ECG) rhythm, rec ording, 426f
Elec troc ardiography, elec tric al flow (rule), 490-491
Elec troc autery c able, usage, 346
Elec troc autery devic e, preparation (assistanc e), 352
Elec troenc ephalogram (EEG)
ac tivity, requirements, 775
trac ings, obtaining, 775
waveforms, examination, 775
Elec troenc ephalographic (EEG) monitoring, usage, 837
Elec trolyte abnormalities, impac t, 388
Elec trolyte levels, monitoring, 335, 428
Elec tromagnetic guidanc e system (CORTRAK), 1193f
usage, purpose, 1192
Elec tromagnetic interferenc e (EMI)
c ause, 393
impac t, 405-406
sourc es, 395
Elec trophysiologic monitoring
ECG trac ing, examination, 498
elec trodes, plac ement, 496
five-lead applic ation, 498f
five-lead system, 494
five-lead wire system, 494f
hardwire/telemetry, proc edure, 493-501t
lead wires/c ables, tension (reduc tion), 497
three-lead applic ation, 496f
three-lead system, 493
Lewis lead, addition, 497f
three-lead wire system, 494f
Elec trophysiologic studies (EPS ), usage, 337
Emergenc y c uff inflation, attac hments, 93f
Emergenc y medic al servic es (EMS ), ac tivation, 394
Emergenc y response system (EMS ), AED usage, 313
Emergent open sternotomy (assist)
c ardiac tamponade, signs/symptoms (assessment), 351
c ardiovasc ular assessment, 354
elec troc autery devic e, preparation (assistanc e), 352
equipment, 350-351
family educ ation, 351
hemodynamic assessment, 354
hemodynamic status, assessment, 351
indic ation, 350
intra-aortic balloon pump, usage, 351
laboratory blood study results, 354
laboratory data, assessment, 351
mediastinal exploration, goal, 350
medic al history, assessment, 351
neurologic status, assessment, 351
nursing knowledge, 350
open-c hest set/sternotomy tray, usage, 350
patient educ ation, 351
patient transport, assistanc e, 353
peripheral vasc ular assessment, 354
polypropylene (Prolene) suture, usage, 350
pre-proc edure verific ation/time out, performing, 351
proc edure, 351-354t
pulseless ventric ular tac hyc ardia, oc c urrenc e, 352
purpose, 350
sternal dressing, assistanc e, 352
ventric ular fibrillation, oc c urrenc e, 352
Emergent open sternotomy (perform)
bleeding, presenc e, 344
c ardiac tamponade, signs/symptoms (assessment), 344
c ardiovasc ular assessment, 348
doc umentation, 348
elec troc autery devic e, preparation, 345
emergenc y medic ation/resusc itation equipment, usage, 344
equipment, 343-344
exc essive c hest tube drainage, assessment, 344
expec ted outc omes, 348
family educ ation, 344
hemodynamic assessment, 348
hemodynamic status, assessment, 344
indic ation, 343
laboratory data, assessment, 344
mediastinal exploration, goal, 343
medic al history, assessment, 344
neurologic status, assessment, 344
nursing knowledge, 343
oozing/bleeding, c auterization, 346
paralytic agents, usage, 343
patient assessment, 344
patient educ ation, 344
patient monitoring/c are, 348
patient preparation, 344
peripheral vasc ular assessment, 348
persistent hemorrhage, mediastinal exploration (goal), 343
personal protec tive equipment, usage, 345
pre-proc edure verific ation, performing, 344
proc edure, 345-348t
pulseless ventric ular tac hyc ardia, oc c urrenc e, 346
purpose, 343
sternal dressing, removal, 345
sternal retrac tor, plac ement, 346
sternal wires, c utting, 346
sternotomy tray, usage, 345
unexpec ted outc omes, 348
ventric ular fibrillation, oc c urrenc e, 346
Emerson disposable suc tion system setup, 190
Emerson pump
disposable setup, 186
illustration, 186f
usage, 185
Enc ephalopathy, NPPV (nonusage), 226
End expiration
determination, 640
c hest rise/fall, observation, 640
hemodynamic pressure measurement, 640
End-expiratory hold button, identific ation, 240
End of life (EOL), indic ation, 394
Endosc opic sc lerotherapy (ES T), 1010
Endosc opic therapy
ablative therapies, 1010
assistanc e, proc edure, 1012-1017t
baseline c ardiac rhythm, obtaining, 1011
baseline c oagulation study results, 1011
baseline vital signs, obtaining, 1011
c ardiovasc ular/respiratory/neurologic status, 1015
endosc ope, insertion (assistanc e), 1013
equipment, 1011
expec ted outc omes, 1015
family educ ation, 1011
informed c onsent, 1012
nursing knowledge, 1010-1011
patient assessment, 1011-1012
patient educ ation, 1011
patient/family educ ation, c ontinuation, 1016
patient monitoring/c are, 1015
patient preparation, 1011-1012
preferenc e, 1010
preproc edural teac hings, understanding, 1012
purpose, 1010
sc lerosing agents, ac tion, 1010
sedation sc ore, 1011
unexpec ted outc omes, 1015
upper GI bleeding, history, 1011
venous ac c ess, 1012
Endosc opic transgastric ultrasound sc an, usage, 989
Endosc opic varic eal ligation (EVL), 1010
illustration, 1014f
Endotrac heal (ET) intubation (assist)
adhesive tape, usage, 27
attempts, duration, 22
c onsc iousness level, assessment, 24
c ric oid pressure (S ellic k maneuver), applic ation, 22, 26
doc umentation, 29
double-lumen endotrac heal tubes, usage, 23
equipment, 23
c hec king, 25
expec ted outc omes, 28
family educ ation, 24
indic ations, 22
intravenous/intraosseous ac c ess, initiation, 24
laryngosc ope blades, types, 22
nasal/oral routes, 23
nothing-by-mouth (NPO) status, assessment, 24
nursing knowledge, 22-23
oxygen saturation (S pO 2), evaluation, 26
patient
assessment, 24
educ ation, 24
monitoring/c are, 28
position assistanc e, 25
positioning, 24
preparation, 24
premedic ation, 24
need, assessment, 24
preoxygenation, 25
primary c onfirmation, 23
proc edure, 25-29t
pulse oximetry, usage, 22
sec ondary c onfirmation, 23
setup, 25
trauma history, assessment, 24
twill tape, usage, 27
unexpec ted outc omes, 28
vital signs, assessment, 24
Endotrac heal (ET) intubation (perform)
adhesive tape
sec uring, methods, 18f
usage, 18
attempts, 9
c ric oid pressure, applic ation, 9
disposable end-tidal CO 2 detec tors, c hemic al treatment, 10
doc umentation, 20
end-tidal CO 2 (PetCO 2) monitoring devic es, usage, 10
equipment, 11
c hec king, 12
expec ted outc omes, 19
family educ ation, 11
indic ations, 9
laryngosc ope blades, usage, 9
nasal/oral routes, 10
nursing knowledge, 9-11
patient
assessment, 11-12
educ ation, 11
monitoring/c are, 19
positioning, 12
preparation, 11-12
preoxygenation, 13
pre-proc edure verific ation, 12
primary c onfirmation, performing, 10
proc edure, 12-20t
sec ondary c onfirmation, 10
suc tion apparatus, setup, 12
twill tape, usage, 17
unexpec ted outc omes, 19
Endotrac heal (ET) tube, hemoptysis/bloody sec retions (development), 667
Endotrac heal (ET) tube/oral c are
c uff inflation, ensuring, 35
doc umentation, 37
equipment, 32
expec ted outc omes, 35
family educ ation, 32
nursing knowledge, 31
oral hygiene
c ompletion, 35
initiation, 33
patient
assessment, 32
educ ation, 32
intubation, 33
monitoring/c are, 36
preparation, 32
verific ation, identifiers (usage), 32
proc edure, 33-37t
signs/symptoms, assessment, 32
tube plac ement, rec onfirmation, 36
unexpec ted outc omes, 35
Endotrac heal (ET) tube suc tioning
c ardiopulmonary status, monitoring, 82
c atheter size, guidelines, 32t, 81t
c losed-suc tion tec hnique, 83, 85
illustration, 80f
doc umentation, 86
equipment, 80-81
expec ted outc omes, 86
family educ ation, 81
hyperoxygenation, 83
indic ations, 79
nursing knowledge, 79-80
open-suc tion tec hnique, 82, 85
patient assessment, 81
patient educ ation, 81
patient monitoring/c are, 86
patient preparation, 81
PEEP valve, 81
proc edure, 82-86t
self-inflating manual resusc itation bag-valve devic e, removal, 83
suc tion c atheter c ontrol vent, thumb plac ement, 84
unexpec ted outc omes, 86
ventilator c irc uit, removal, 83
Endotrac heal tube (ETT)
advanc ement, 16f
c onnec tion, 17
depth, c hanges, 269
holder, usage, 17, 27
hyperoxygenation/suc tion, 40, 44
malpositioning, signs/symptoms (assessment), 269
oxygen sourc e c onnec tion, 27
parts, 10f
plac ement, 26
positioning, 16f
sec uring, 27
apparatus, 23
size, 10, 23
usage, 79
voc al c ord passage, 15f
End-tidal CO 2 (PetCO 2)
alveolar plateau, 111f
assessment, 296
c ombination, 105
c onc entration, 106
dec rease, 110f
detec tors, 10
devic e, usage, 5
exponential fall, 110f
inc rease, 109f
monitoring, princ iples, 106
monitors, usage, 10, 23
sudden dec rease, 111f
values, sudden dec rease, 110f
waveform, 106
Enzymatic debridement, usage, 1160
Epic ardial atrial pac ing, 382
Epic ardial pac ing wire removal
antic oagulation therapy, avoidanc e, 388
aseptic tec hnique knowledge, 387
bed rest, maintenanc e, 389
c ardiac tamponade, signs/symptoms, 390
c ardiovasc ular anatomy/physiology knowledge, 387
doc umentation, 390
elec tric al safety princ iples, knowledge, 387
elec troc ardiographic (ECG) monitoring, 388
c ontinuation, 389
elec trolyte abnormalities, impac t, 388
equipment, 387
exit sites, c leansing, 388
expec ted outc omes, 389
family educ ation, 387
intravenous (IV) c atheter patenc y, determination, 388
nursing knowledge, 387
pain assessment, 390
partic ipation, 387
patient assessment, 388
patient educ ation, 387
patient monitoring/c are, 389
patient preparation, 388
postremoval assessment data, 388
proc edure, 388-390t
purpose, 387
timing, 388
unexpec ted outc omes, 389
vital signs, obtaining, 390
wire inspec tion, 389
Epic ardial pac ing wires
c onnec tor pins, insulating material, 381
site c are, materials, 381
Epic ardial wires, 430f
attac hment, 430
Epidermis, 1097
Epidural analgesia
advantages, 916
pharmac ology, 915
Epidural c atheters, insertion/pain management assistanc e
antic oagulation therapy, assessment, 917
aspirin/NS AIDs, usage, 917
blood pressure, 924
bolus dose, preparation, 921
dermatomes, 920f
doc umentation, 926
ears, ringing, 925
epidural bolus, administration, 921
epidural tubing, c onnec tion, 918
equipment, 916
expec ted outc omes, 923
family educ ation, 917
heart rate, 924
infusion rate, monitoring, 924
insertion site, 922
insertion/therapy, 917
IV ac c ess, 917
loc al infec tion/sepsis assessment, 917
motor/sensory bloc kade, 915
nausea/vomiting, presenc e, 925
neurologic status, 922
NPO c onsideration, 917
nursing knowledge, 915-916
pain level, 923
patient assessment, 917
patient educ ation, 917
patient monitoring/c are, 923
patient positioning, 918f
patient preparation, 917
plac ement, 915
pre-proc edure verific ation, 917
proc edure, 918-920t
pump/tubing, labeling, 925
purpose, 915
removal assistanc e, proc edure, 922-926t
respiratory rate, 924
sac rum/heels, skin integrity, 925
surgery trauma, pain response, 916
therapy, initiation, 919
unexpec ted outc omes, 923
Epidural spac e, 915
Epigastrum, ausc ultation, 16, 26
Epithelium, reopening/melting, 1092
Erythema, presenc e, 1152
Erythroc ytapheresis, 1070
Esc har, definition, 1101
Esc harotomy, performing, 1099
Esophageal balloon
deflation, assistanc e, 956
inflation, 950f
pressure
dec rease, 956
monitoring, 956
Esophageal detec tion devic es, usage (c onsideration), 26
Esophageal detec tor devic es, func tion, 10-11, 23
Esophageal output, monitoring, 957
Esophageal temperature probe, insertion (proc edure), 869-871t
Esophageal varic es history, evaluation, 960
Esophagogastric tamponade tube
airway protec tion, 949
balanc ed suspension trac tion, tamponade tube/plac ement, 948f
baseline c ardiac rhythm, 949
baseline respiratory status, 949
bleeding c ontrol, 953
blood loss, signs/symptoms (assessment), 949
c ontraindic ations, 947
equipment, 947-948
family educ ation, 948
gastric balloon
inflation, 952, 954
port, attac hment, 950
inflation/deflation, c hange, 954
introduc tion, 947
Lopez valve, 949f
mental status, assessment, 949
Minnesota four-lumen tube, 948f
nasal esophageal plac ement, antic ipation, 949
nursing knowledge, 947
patient educ ation, 948
plac ement
c onfirmation, 952
radiographic c onfirmation, 952
posterior oropharynx, topic al anesthetic agent (applic ation), 951
purpose, 947
sedation, c onsideration, 947
S engstaken-Blakemore tube, usage, 953
tamponade (sec uring), helmet (usage), 949f
tamponade tube balloon integrity, testing, 950
therapy
disc ontinuation, 954
maintenanc e, 955
Esophagogastroduodenosc opy (EGD), 1010
Esophagus
Combitube insertion, 1f
Combitube position, 2f
oc c lusion, distal c uff (usage), 1
Exc essive sec retions, NPPV (nonusage), 227
Exsanguinating hemorrhage, indic ation, 343
Extended daily dialysis (EDD), 1022
usage, 1035
External arteriovenous (AV) hemodialysis, 1020-1021
External auditory meatus, level, 836-837
External c ardiac pac ing, 413
External defibrillation, purpose, 329
External defibrillator, c linic al/tec hnic al c ompetenc e, 391
External fec al c ontainment devic e, usage, 1176
External/intravasc ular waming/c ooling devic es
ac tive external rewarming, termination, 864
body temperature, variations (rec tal temperature basis), 862t
bowel sounds, assessment, 865
c ardiac rhythm, monitoring, 865
c onsc iousness level, assessment, 865
doc umentation, 871
equipment, 864
esophageal temperature probe, proc edure, 869-871t
expec ted outc omes, 870
external warming/c ooling devic es, proc edure, 866-868t
family educ ation, 865
heat flows, 861
heat gain, inc rease (tec hniques), 862t
heat loss, inc rease, 863
heat produc tion, dec rease, 863
hemodynamic values, obtaining, 865
hypothalamus, thermoregulation, 861
hypothermia, c auses, 863
hypothermia, physiologic responses, 863t
intravasc ular warming/c ooling devic es, proc edure, 866-868t
malignant hyperthermia
oc c urrenc e, 864
treatment, c ooling devic e (usage), 864
medic al history, assessment, 865
medic ation therapy, assessment, 865
neurologic func tion, assessment, 865
nursing knowledge, 861-864
patient assessment, 865-866
patient educ ation, 865
patient monitoring/c are, 870
patient preparation, 865-866
proc edure, 865-871t
purpose, 861
rewarming shoc k, oc c urrenc e, 864
risk fac tors, assessment, 865
shivering, 862
skin integrity, assessment, 865
temperature, terms, 862t
thermoregulation, 861
unexpec ted outc omes, 870
ventilatory func tion, assessment, 865
vital signs, obtaining, 865
warm air devic e, usage, 868
warming/c ooling fluid devic e, usage, 866
External pac emaker settings, c ontrols, 417f
External pac ing, ECG trac ing, 414f
External strain gauge transduc er, usage, 809
External ventric ular drainage system
assembly, 838
flushless transduc er, usage, 840f
illustration, 840f
priming, 811
provision, 837
tubing, flushing, 839
External ventric ular drain (EVD)
drainage system tubing, c onnec tion, 839
infec tion risk, 836
External warming/c ooling devic es, proc edure, 866-868t
Extrac orporeal blood purific ation therapy, 1018
Extra elec troc ardiographic leads
apic al involvement, 504f
doc umentation, 510
ECG rec ording, 509f
equipment, 503
expec ted outc omes, 508
family educ ation, 503
initial ECG, 504f
left posterior leads, 507
rec ording, elec trode loc ations, 507f
limb leads, 505
nursing knowledge, 502-503
patient educ ation, 503
patient monitoring/c are, 509
patient supine position, 505
proc edure, 505-510t
purpose, 502
right prec ordial leads, 505
RV infarc tion, 506f
S T-segment elevation, 506f
12-lead ECG, 506f
interpretation, 504
unexpec ted outc omes, 508
Extremity (digit), assessment, 123
Extubation, signs/symptoms (assessment), 269
Extubation/dec annulation (assist)
c oughing/breathing, enc ouragement, 46
definitions, 43
doc umentation, 46
equipment, 43
expec ted outc ome, 45
family educ ation, 44
hyperoxygenation/suc tion, 44
indic ations, 43
nursing knowledge, 43
oc c urrenc e, 43
oral pharynx, suc tion, 45
oxygenation, 45
patient
assessment, 44
educ ation, 44
monitoring/c are, 45
preparation, 44
proc edure, 44-46t
tube c uff, deflation, 44
twill tape, c utting, 44
unexpec ted outc omes, 45
vital signs, monitoring, 45
Extubation/dec annulation (perform)
aspiration, monitoring, 42
c oughing/breathing, importanc e, 40
doc umentation, 42
equipment, 39
expec ted outc omes, 41
family educ ation, 40
indic ations, 39
nursing knowledge, 39
oc c urrenc e, 39
oxygenation, promotion, 41
oxygen/humidific ation support, 40
patient
assessment, 40
educ ation, 40
monitoring/c are, 41
preparation, 40
proc edure, 40-42t
suc tioning proc ess, disc ussion, 40
supplemental oxygen/aerosol, applic ation, 41
tube c uff, deflation, 40
twill tape, c utting, 40
unexpec ted outc omes, 41
used supplies, disc arding, 41
vital signs, monitoring, 41
Extubation failure, 226
Exudative effusions, indic ation, 208, 219
Exudative pleural effusions, c riteria, 208, 219
EZ-IO, 756
insertion, 759
needle sets, 759f
power driver, 756f
F
Fac ial deformities, impac t, 226
Fac ial nerve
elec trode plac ement, 306f
testing, 306
Failure of pulse generation, pac emaker definition, 404t
Failure to wean (treatment), NPPV (usage), 226
FAS T1 adult intraosseous infusion system, 756
insertion, 758
FAS T1 adult intraosseous infusion systems, 756f
Fast flush system, usage, 539f
Fatigue, signs/symptoms
assessment, 228, 281
monitoring, 233
Fec al c ontainment devic es
absorbent underpads, usage, 1176
bowel management system, 1175-1181
c hange, 1178
doc umentation, 1181
equipment, 1177
expec ted outc omes, 1179
family educ ation, 1177
inc ontinenc e-assoc iated dermatitis (IAD), 1175
moisturizer, applic ation, 1176
nursing knowledge, 1175-1177
patient assessment, 1177
patient c are, 1179
patient educ ation, 1177
patient monitoring, 1179
patient preparation, 1177
proc edure, 1177, 1177-1181t
purpose, 1175
unexpec ted outc omes, 1179
Fec al c ontents, evaluation, 1177
Fec al drainage, amount/c onsistenc y (evaluation), 1180
Fec al inc ontinenc e, management, 1175-1176
Fec al material, c onsistenc y (evaluation), 1179
Fec al matter, volume/c onsistenc y/c olor (monitoring), 1178
Femoral artery
anatomic landmarks, 714f
anatomy, identific ation, 733
punc ture, 715
syringe, usage, 718f
Femoral veins
ac c ess, 722
CVC insertion, 733
loc ation, 733
FemoS top, 681
position, 681f
Fever, oc c urrenc e, 864
Fiberoptic c atheter
assessment, 811
insertion proc edure, 804
plac ement, 836-837
removal, 806
Fiberoptic endosc ope, usage, 1010
Fiberoptic light delivery systems, inc lusion, 9, 22-23
Fibrous parietal membrane, distention, 364
Filtration, 1071
Finger c ot, usage, 205f
First-degree burns (superfic ial burns), 1097
First intention (primary union), 1150f
Flexi-S eal FMS , 1176f
FloTrac sensor, 552f
Fluid-filled pressure monitoring systems, usage, 670
Foley Manometer
bladder pressure monitoring system, 978f
pouc h, opening, 977
priming, 977
urine filling, 978f
Foramen of Magendie, 837
Foramen of Monro
anatomic referenc e point, 809
level, 836-837
Forc e meter, usage, 286
Forearm, musc le c ompartments, 1119f
Four-bottle c hest drainage system, 196f
Frac tion of inspired oxygen (FiO 2), 129
adjustment, 272
delivery, 231
level, selec tion, 230
Frank-S tarling law, 578
Frenc h size oximetry c atheters, pediatric patient applic ations, 114
Fresh frozen plasma (FFP), usage, 1057
Full fac e mask
noninvasive interfac e, 229
usage, 228f
Full-thic kness burn, 1099f
Full-thic kness esc har, assessment, 1099
Func tional intravenous ac c ess, 220
Func tional residual c apac ity (FRC), 130
Fungal c ultures, sterile tubes (usage), 220
G
Gag reflex
adequac y, assessment, 960
assessment, 1215
Gambro Prismaflex CRRT mac hine, 1021f
Gardner-Wells tongs, insertion, 889
Gastric balloon, inflation, 952, 954
Gastric lavage, hemorrhage/overdose
ac tivated c harc oal (AC), administration, 958-959
aspiration, 961
baseline c ardiovasc ular/neurologic assessments, 959
baseline respiratory assessment/pulse oximetry, 959
bleeding/c olor, rec urrenc e (monitoring), 964
blood loss, signs/symptoms, 959-960
blood volume loss, measurement, 964
c ardiac monitor, purpose (explanation), 959
c rystralloid IV fluids, administration, 964
doc umentation, 965
equipment, 959
esophageal varic es history, evaluation, 960
expec ted outc omes, 963
family educ ation, 959
gag reflex, adequac y (assessment), 960
GI hemorrhage, 962
hemodynamic status, assessment, 959
indic ations/proc edure, explanation, 959
intermittent lavage, 962
intravenous (IV) ac c ess, establishment/maintenanc e, 960
left lateral dec ubitus position, 960
nec essity, 959
neurologic status, monitoring, 963
nursing knowledge, 958-959
odors, presenc e, 960
OG/NG tube, removal, 962
oral airway, insertion, 961
orogastric (OG) tube, opening, 958-959
patient assessment, 959-960
patient educ ation, 959
patient monitoring/c are, 963
patient preparation, 959-960
pharyngeal func tion, assessment, 964
proc edure, 960-965t
proton pump inhibitors (PPIs), administration, 965
purpose, 958
rec ommendation, avoidanc e, 958
respiratory status, monitoring, 963
risks/benefits, understanding, 959
serum toxic ology sc reen, 960
skin assessment, 960
suic ide prec autions, institution, 965
unexpec ted outc omes, 963
usage, indic ations, 958
vasoac tive medic ations, administration, 965
Gastric lavage, performing/assistanc e, 1012
Gastric varic eal oc c lusion (GVO), 1010
Gastrointestinal (GI) bleeding
c omplic ation, 266-267
weaning c omplic ation, 291
Gastrointestinal (GI) hemorrhage, 958
Gastrostomy, 1201
doc umentation, 1205
equipment, 1202-1203
expec ted outc omes, 1204
family educ ation, 1202
nursing knowledge, 1201-1202
patient assessment, 1202-1203
patient c are, 1204
patient educ ation, 1202
patient monitoring, 1204
patient preparation, 1202-1203
proc edure, 1203-1205t
tube, 1202f
unexpec ted outc omes, 1204
Glasgow Coma S c ale sc ore, 794
Graft plac ement goals, 1110
Granulating wounds, healing, 1149
slowness, 1183
Granulation, 1150f
Group A S treptoc oc c i, 1151
Guedel airway
c harac teristic s, 74
illustration, 75f
H
Half-buried mattress suture, 1135
Half-step tec hnique, usage, 136
Halo ring
devic e, 895
purpose, 888
Halo ring/vest c are
c hest ac c ess, manufac turer rec ommendations, 903
devic e, explanation, 896
doc umentation, 903
dysphagia, monitoring, 902
dyspnea, monitoring, 902
equipment, 896
expec ted outc omes, 901
family educ ation, 896
flow sheet doc umentation form, sample, 897f
hypoxia, monitoring, 902
musc le strength, assessment, 898t
neuroanatomy/physiology, knowledge, 895
neurologic func tion, dec line, 896
nursing knowledge, 895-896
patient assessment, 898
patient educ ation, 896
patient monitoring/c are, 902
patient preparation, 898
posterior sheepskin liner, c hange, 900
proc edure, 899-903t
purpose, 895
ring/pins, plac ement, 895
sensory testing, guidelines, 898f
tidal volumes, dec rease, 902
treatment options, 895
unexpec ted outc omes, 901
vest c are, manufac turer rec ommendations, 899-900
vest tightness/looseness, 898
Halo vest, information referenc e, 896
Halo-vest apparatus, 896f
Halo-vest side panels, opening, 896
Head, in-line c ervic al immobilization (maintenanc e), 10, 23
Head of bed (HOB)
angle, 947
degree, 971
Healing trajec tories, c omorbidities (impac t), 1151
Heart, PA c atheter loc ation, 627f
Heart failure, medic al history assessment, 221
HeartMate II LVAS , 467, 472
alarms, 477-478
alarms, troubleshooting, 477
power base, 478
HeartMate IP c onsole, operation, 466
HeartMate XVE (extended lead vented elec tric ), 472
hand pumping, 475
LVAD, c omponents, 466
LVAS , 466
troubleshooting, 476
Heart rate (HR)
c ardiac output, relationship, 577
inc rease, 578
Hearttouc h c omputer, 480
Heat flows, 861
Heat gain, inc rease (tec hniques), 862t
Heat loss, inc rease, 863
Heat produc tion, dec rease, 863
Hemidiaphragm, obliteration, 210, 220-221
Hemispheric index (HI), 851
Hemodialysis
antic oagulation, monitoring, 1045
artific ial kidney, usage, 1034
AV fistula, usage, 1036
AV fistula/AV graft, 1043
baseline vital signs, assessment, 1035
dialysis c irc uit, monitoring, 1044
doc umentation, 1046
equipment, 1035
expec ted outc omes, 1043
extremity, c irc ulation monitoring, 1044
family educ ation, 1035
flush syringe, removal, 1039
initiation, 1040
mac hine, venous drip c hamber loc ation, 1039
nursing knowledge, 1033-1035
ongoing assessments, 1044
patient assessment, 1035-1036
patient c are, 1044
patient educ ation, 1035
patient monitoring, 1044
patient preparation, 1035-1036
proc edure, 1036-1046t
purpose, 1033
system, c omponents, 1034f
termination, 1040, 1042
unexpec ted outc omes, 1043
VAC disc onnec tion, 1039
VAC patenc y, assessment, 1036
vasc ular ac c ess, patenc y (monitoring), 1045
Hemodynamic c hanges
extent, 266
observation, 232, 281
Hemodynamic c ompromise
oc c urrenc e, 240
result, 239
signs/symptoms, assessment, 242
Hemodynamic instability, NPPV (nonusage), 226
Hemodynamic monitoring, patient/family understanding (assessment), 672
Hemodynamic monitoring system
c hange, 545, 644
needleless c apped stopc oc k, needleless blood sampling devic e attac hment, 567f
referenc e points, 676f
zeroing, 660, 666, 679
Hemodynamic parameters, 579t
Hemodynamic pressure measurement, 640
Hemodynamic profile, 236
Hemodynamic stability, 326
Hemodynamic status, assessment, 572, 656
Hemodynamic values, knowledge, 655
Hemodynamic waveforms/values
c linic al applic ation, 577
monitoring, 644
Hemoglobin level, measurement, 236
Hemoptysis, development, 667
Hemorrhage
death, c ause, 1057
gastric lavage, purpose, 958
Hemorrhagic c omplic ations, 209
Hemostasis
ac hievement, 685-686, 687
option, position, 684
valve, c over, 650
Hemostat, usage, 220
Heparin, usage, 1034-1035
Heparinized arterial blood samples
analysis, 259
drawing, 260
Heparinized arterial line, 558
High FiO 2 requirements, NPPV (nonusage), 227
High-frequenc y elec tric al artifac t, 779
High-frequenc y osc illation (HFO), 278
parameters, 278
High-pressure low-volume work, 294
High-risk foc us area skin assessment guide, 913t
Hollow-fiber dialyzers, 1020
usage, 1034
Holtec h Foley Manometer S ystem, usage, 977-980t
Hospital LOS , 293
Humerus, palpation, 758
Humidific ation support, 40
Hydrostatic pressure, 1020, 1033
Hyperc apnia, impac t, 851
Hyperc arbia
inc rease, 970
signs/symptoms, monitoring, 233, 281
Hyperemia zone, 1098-1099
Hyperinflation, assessment, 240
Hyperventilation, impac t, 851
Hypodynamic c onditions, 235
Hypoperfusion, 778
Hypopharynx oc c lusion, proximal c uff (usage), 1
Hypotension, 204
development, 364
oc c urrenc e, 209
presenc e, 414-415
Hypothalamus
temperature regulation, 861
thermoregulation, 861
Hypothermia
c auses, 863
c orrec tion, 1057
fluid resusc itation, c onsequenc e, 1058
physiologic responses, 863t
Hypoxemia
c onfirmation, 260
observation, 229
pleural effusion sign/symptom, 220
severity, 262
signs/symptoms, monitoring, 233, 281
symptom relief, 219
Hypoxia, inc rease, 970
I
IM3 triple lumen introduc er, 794f
sec uring, demonstration, 797f
Immobility, ac ute physiologic responses, 912t
Immunoadsorption, 1070
Impella LP 2.5/LP 5.0, 467
Impending ventilatory failure, definition, 262
Implantable c ardioverter-defibrillator (ICD)
anterior-posterior defibrillation elec trodes/paddles, applic ation, 398
ATP delivery, 393
battery longevity, 392
c ardiac rate/rhythm, assessment, 395
Class I, 391
Class IIa, 391-392
Class IIb, 392
c linic al/tec hnic al c ompetenc e, 391
deac tivation, 398
defibrillation, monitoring, 400
defibrillation elec trodes, applic ation, 398
defibrillator c ode, development, 393
detec tion, 393
doc umentation, 401
elec troc ardiography (ECG)
leads, attac hment, 397
monitoring, 400
pac ing artifac t, 392
elec tromagnetic interferenc e (EMI), c ause, 393
elec trophysiology study (EPS ), 391
EMI sourc es, 395
emotional adjustments, 393
epic ardial leads, 392
equipment, 393-394
expec ted outc omes, 400
family educ ation, 394-395
ICD/lead system, 392f
integration, printout, 396-397f
interrogation, questions (c onsideration), 396-397f
intravenous ac c ess, patenc y assessment, 395
leads, insulation/attac hment, 392
magnet, applic ation, 393
manufac turer, identific ation, 395
NAS PE/BPEG defibrillator c ode, 393t
nursing knowledge, 391-393
pad/paddle plac ement, 333
patc h, 392f
patient assessment, 395
patient educ ation, 394-395
patient feelings, exploration, 395
patient monitoring/c are, 400
patient preparation, 395
physic ian presc ription, 399
pre-proc edure verific ation, performing, 395
presurgic al instruc tions, 395
proc edure, 397-401t
programmer, unavailability, 399
purpose, 391
reac tivation, 399
skin, c leansing, 397
therapies
information, providing, 394
patient/family understanding, assessment, 394
program, 393
unexpec ted outc omes, 400
VT/VF c onversion, 398
Implantable venous ac c ess devic e (ac c ess/deac c ess/c are)
ac c ess, 747
aseptic /sterile tec hnique, princ iples (understanding), 745
blood spec imen, obtaining, 751
c hemotherapeutic /c ytotoxic agents, properties, 745
c leansing, 748
deac c essing, 751
doc umentation, 753
equipment, 746
expec ted outc omes, 753
family educ ation, 746
information, 746
nonc oring needle, usage, 745-746
non-c oring PowerLoc Needle, insertion, 750f
nursing knowledge, 745-746
patient assessment, 746
patient educ ation, 746
patient monitoring/c are, 753
patient preparation, 746
perc utaneous ac c ess, 745
port
plac ement, 745f
triangulation, 749f
PowerPort devic e, needle ac c ess, 749f
proc edure, 747-753t
purpose, 745
subc utaneous tissue, palpation, 747
supplies, preparation, 748
surgic al plac ement, 745
unexpec ted outc omes, 753
venous ac c ess devic e
flushing, 751
triangulation, 748
Impulse generation, sourc e (reestablishment), 326
Inc ontinenc e-assoc iated dermatitis (IAD), 1175
risk, inc rease, 1175
Indwelling c atheter
plac ement, 360
removal, 362
Indwelling peric ardial c atheter
removal, 691
system, 690f
Inflation valve, fault, 92-93
InfoV.A.C., 1182
usage, 1183f
Injec tion therapy, usage, 1010
In-line c ervic al immobilization, maintenanc e, 10, 23
In-line thermometer, monitoring, 231
Inner c annulas, fenestrations (inc lusion), 43
Insonation depths, c riteria, 850
Inspiratory flow, triggering, 239
Inspiratory pressure level (IPL), selec tion, 274
Inspiratory respiratory musc le strength (measurement), NIF (usage), 285-286
Inspiratory-to-expiratory (I:E) ratio, optimization, 266
Inspired gases, humidific ation, 31
Institute of Healthc are Improvement (IHI), IV medic ation rec ommendations, 1243
Integra, ac ellular matrix c omposite graft, 1102
Integra Dermal Regeneration Template, usage, 1111
Integrated pump systems, 1021
Intensive c are unit (ICU) patients, c ognitive dysfunc tion, 293
Interc ostal spac e (ICS ), 522
Intermittent mandatory mec hanic al ventilation, end expiration determination, 641
Intermittent mandatory ventilation (IMV), ventilation mode, 642f
Intermittent positive-pressure breathing (IPPB), 154, 167
Internal c ardioverter defibrillator (ICD)
pad/paddle plac ement, 324
presenc e, 315
Internal defibrillation
paddle plac ement, 339f
purpose, 337
Internal jugular vein, CVC insertion, 727
International normalized ratio (INR), 615, 804-805
assessment, 714
Interrupted dermal suture, 1135
appearanc e, 1135f
Interrupted mattress suture, removal, 1146f
Intersc alene brac hial plexus bloc k, landmarks, 938f
Intoleranc e c riteria, 293t
Intraabdominal hypertension (IAH)
definition, 967
development risk, 968t
oc c urrenc e, 967
physiologic c hanges, 970t
progression, signs (assessment), 970
signs, assessment, 970
Intraabdominal pressure (IAP) monitoring
AutoValve, usage, 974
bladder pressure monitoring setup, 969f
doc umentation, 980
end expiration reading, 973f
equipment, 969
expec ted outc omes, 979
expression, 968
family educ ation, 969-970
frequenc y, 979
health history, obtaining, 970
Holtec h Foley Manometer S ystem, usage, 977-980t
measurement, 972
end expiration, 968
patient supine position, 968
nursing knowledge, 967-968
pathologic elevation, 967
patient assessment, 970-971
patient educ ation, 969-970
patient monitoring/c are, 979
patient preparation, 970-971
patient verific ation, identifiers (usage), 971
pre-proc edure verific ation/time out, 971
proc edure, 971-973t
purpose, 967
readings, reporting, 973
sampling port, c leansing, 972
system, zeroing, 971
unexpec ted outc omes, 979
waveform, 973f
WolfeTory Medic al Abviser, usage, 973-976t
Intraaortic balloon (IAB) c atheter
fast fluc h/blood sampling, avoidanc e, 447
inner lumen, flushing, 447
insertion, assistanc e, 446-448t
plac ement, 444
extremity assessment, 445
removal, proc edure, 457-461t
Intraaortic balloon positioning, usage, 444f
Intraaortic balloon pump (IABP)
ankle/arm index, assessment, 445
asystole, 455
atrial fibrillation, 455
balloon perforation, suspic ion, 456
balloon pressure waveform, proc edure, 453-454t
c hest radiograph, obtaining, 448
c onsole
balloon pressure waveform, presenc e (determination), 453
initiation, 446
deflation, 449
oc c urrenc e, 444
doc umentation, 461
early deflation, 452f
early inflation, 451f
ECG input, establishment, 446
equipment, 444-445
expec ted outc omes, 458
failure, 456
family educ ation, 445
frequenc y, 449f
setting, 450
IAB c atheter removal, proc edure, 457-461t
inflation
adjustment, 449
illustration, 450f
oc c urrenc e, 443
insertion/plac ement verific ation, 444
laboratory profile, assessment, 445
late deflation, 453f
late inflation, 452f
management, purpose, 443
nursing knowledge, 443-444
patient assessment, 445-446
patient educ ation, 445
patient identific ation, verifiers (usage), 445
patient monitoring/c are, 458
patient preparation, 445-446
personnel, impac t, 446
proc edure, 446-448t
tac hyc ardia, 455
timing
c orrec tion, 451f
maintenanc e, 459
proc edure, 448-452t
troubleshooting, proc edure, 455-457t
unexpec ted outc omes, 458
VT/VF, 456
weaning, proc edure, 457-461t
Intraaortic balloon pump (IABP) therapy, 443
c ardiac failure, signs/symptoms (assessment), 445
c ontraindic ations, 443
indic ations, 443
relative value, 443
timing methods, variation, 444
Intrac ardiac pressures
assessment, 583
equalization, 344
Intrac ardiac (right atrial/pulmonary artery) pressure, invasive measurement, 670
Intrac ardiac shunt evaluation, 706
Intrac ompartmental pressure monitoring (IPM)
ac ute c ompartment syndrome, 1119
c alf/forearm/thigh, musc le c ompartments, 1119f
c ompartment syndrome, development (risk), 1118
delta c ompartment pressure, 1119
doc umentation, 1123
equipment, 1119
expec ted outc omes, 1122
family educ ation, 1120
intrac ompartmental measurement, initiation, 1120
neurovasc ular assessment, c ompletion, 1122
nursing knowledge, 1118-1119
pain, 1120
parasthesia, 1120
paresis/paralysis, 1120
patient assessment, 1120
patient educ ation, 1120
patient monitoring/c are, 1122
patient preparation, 1120
pressure, 1120
proc edure, 1120-1123t
pulselessness, 1120
purpose, 1118
S tryker intrac ompartmental pressure monitor, 1121f
unexpec ted outc omes, 1122
Intrac ranial bolt/fiberoptic c atheter insertion (assist)/ICP monitoring/c are/troubleshooting/removal
allergies, assessment, 805
CBC, 804-805
c erebral autoregulation, definition, 803
c ontraindic ations, 803
CPP definition, 802-803
doc umentation, 808
equipment, 804
expec ted outc omes, 807
family educ ation, 804
fiberoptic c atheter insertion proc edure, 804
fiberoptic c atheter plac ement, 805
fiberoptic c atheter removal, 806
fiberoptic system preparation, 805
ICP definition, 802
ICP elevations, 803, 804f
ICP monitoring, indic ation, 803
ICP waveform, example, 803f
INR, 804-805
insertion, 803f
intrac ranial pressure waveform c omponents, 803f
laboratory profile, 804-805
Lundberg waves, 804f
neurologic al status/vital signs, assessment, 804
nursing knowledge, 802-803
patient assessment, 804-805
patient educ ation, 804
patient monitoring/c are, 807
patient preparation, 804-805
plateau waves, 804f
platelet c ount, 804-805
proc edure, 805-808t
PTT, 804-805
purpose, 802
troubleshooting, 806
unexpec ted outc omes, 807
Intrac ranial pressure (ICP), 792
definition, 802, 809
elevations, 810
result, 836
inc rease, 795, 970
management, 837
oc c urrenc e, 809
measurement, 853
monitoring, 842
range, 802, 836
signs/symptoms, assessment, 881
values, review, 802
Intrac ranial pressure (ICP) monitoring
c ontraindic ations, 810
fiberoptic c atheters, plac ement, 836-837
indic ation, 803, 810
mic rosensors, plac ement, 836-837
purpose, 836
Intrac ranial pressure (ICP) monitoring, intraventric ular c atheter/external transduc er (usage)
aseptic tec hnique, 838
c linic al c onditions, 836
CPP monitoring, 842
CS F sampling, 844
port, 844f
distal stopc oc k, c essation, 841f, 843f
equipment, 837
external ventric ular drainage (EVD)
CS F drainage, 843
transduc er c onnec tion, bedside monitor (usage), 839
external ventric ular drainage (EVD) system
assembly, 838
illustration, 840f
family educ ation, 838
ICP, monitoring, 842
intermittent drainage, order, 843
intraventric ular c atheter, insertion (assistanc e), 839
nursing knowledge, 836-837
patient assessment, 838
patient educ ation, 838
patient preparation, 838
patient supine position, 841
pressure monitoring/drainage, proc edure, 838-847t
purpose, 826
referenc e level, position, 839
sampling supplies, obtaining, 844
transduc er
leveling, 841
zeroing, 841
waveforms, explanation, 838
Intrac ranial pressure (ICP) waveform, 802
morphology, 837
peaks, 810
trends, 802, 810
inc lusion, 837
Intrac ranial vasc ulature, noninvasive assessment, 849
Intraosseous (IO) ac c ess
BIG insertion, 758
blood, usage, 756
bone injec tion gun (BIG), 756f
c irc ulation, 755f
c omplic ations, 756
doc umentation, 762
equipment, 757
expec ted outc omes, 761
EZ-IO insertion, 759
family educ ation, 757
FAS T1 insertion, 758
frac tures/infec tions, assessment, 757
insertion site
observation, 761
palpation, 757
marrow toxic medic ations, 756
medic ations
ac tion, onset, 756
administration, 760
nursing knowledge, 755-757
patient assessment, 757
patient educ ation, 757
patient monitoring/c are, 761
patient preparation, 757
pre-proc edure verific ation, performing, 757
proc edure, 757-762t
purpose, 755
relative c ontraindic ations, 756-757
removal, proc edure, 760
resusc itation medic ations, 756
sites, availability, 756
unexpec ted outc omes, 761
Volkmann’s c anals, loc ation, 755
Intraparenc hymal hemorrhage, 836
Intraparenc hymal spac es, 836-837
Intrapleural pressures, measurement, 184
Intrathorac ic pressures, c hanges, 266
Intravasc ular (arterial) pressure, invasive measurement, 670
Intravasc ular warming/c ooling devic es
doc umentation, 871
equipment, 864
expec ted outc omes, 869
family educ ation, 864
nursing knowledge, 861-864
patient assessment, 864
patient educ ation, 864
patient monitoring/c are, 870
patient preparation, 865-866
proc edure, 866-868t
purpose, 861
unexpec ted outc omes, 869
Intravenous antidysrhythmic pharmac ologic therapy, initiation, 335
Intravenous patient-c ontrolled analgesia
design, 930
initiation, proc edure, 931-934t
medic ation errors, 929
usage, 928
Intraventric ular c atheter, external transduc er (attac hment), purpose, 836
Intraventric ular c atheters, assessment, 811
Intrinsic ventric ular ac tivation (left bundle branc h bloc k), 410f
Introduc er
stabilization, 651f
withdrawal, 651
Intubation
attempts, 9
tec hnique, impac t, 10
Invasive mec hanic al ventilation, artific ial airway usage (volume/pressure modes)
A/C, 270
ac ute ventilatory failure, 262
signs/symptoms, assessment, 268
adaptive support ventilation (AS V), 277
alarms, ac tivation, 279
apnea, 262
APRV, 275
settings, 276
assist/c ontrol (A/C) breath, initiation, 263
automatic tube c ompensation (ATC), 277
bac krest elevation (BRE), maintenanc e, 280
bias flow, 278
biphasic mode, 276
Bi-Phasic settings, 276
biphasic ventilation, 275
c ardiovasc ular depression, signs (assessment), 269
CPAP, 273
selec tion, 276
doc umentation, 281
elec troc ardiogram, usage, 267
endotrac heal tube (ETT)
depth, c hanges, 269
usage, 267
end-tidal c arbon dioxide detec tor, usage, 267
equipment, 267
expec ted outc omes, 279
family educ ation, 267
FiO 2, adjustment, 272
hemodynamic c hanges, observation, 281
high-frequenc y osc illation (HFO), 278
parameters, 278
HMEs, plac ement, 279
humidity, 278
hypoxemia, severity, 262
impending ventilatory failure, 262
inadvertent extubation, signs/symptoms (assessment), 269
in-line thermometer, monitoring, 280
IPL, selec tion, 274
malpositioned endotrac heal tube, signs/symptoms (assessment), 269
mean airway pressure, 278
mec hanic al ventilation, indic ations, 262
modes, selec tion, 270, 273
modifiable risk fac tors, 267
nursing knowledge, 262-267
osc illatory frequenc y (fx), 278
oxygenation (inadequac y), signs/symptoms (assessment), 268
patient assessment, 268-269
patient educ ation, 267
patient monitoring/c are, 279
patient preparation, 268-269
patient-ventilator dyssync hrony, evaluation, 281
peak inspiratory pressure (PIP), c hanges (exploration), 280
PEEP
level, selec tion, 272, 274
setting, 274
perc ent inspiratory time, 278
pneumothorax, early detec tion, 268
positive pressure ventilation, 263
preproc edural teac hing, patient understanding, 269
pressure c ontrol inverse ration ventilation (PC/IRV), 274
pressure modes, 273
pressure-sensing sensitivity mec hanisms, 271
pressure ventilation, usage, 263
proc edure, 270-281t
proportional assist ventilation (PAV), 277
PS V level, selec tion, 274
pulse oximetry, usage, 267
purpose, 262
respiratory frequenc y, selec tion, 271
respiratory musc le fatigue, 262
self-inflating manual resusc itation bag-valve devic e, availability (ensuring), 280
trac heostomy tube, usage, 267
unexpec ted outc omes, 279
VAP, oc c urrenc e, 267
ventilation, c ontrol, 270
ventilator tec hnology, sophistic ation (inc rease), 263
volume-guaranteed pressure, options, 275
volume modes, 270
volume-pressure trauma, assumption, 269
volume ventilation, 263
wet lung, nonc ardiac etiology, 269
Invasive mec hanic al ventilation, endotrac heal tube/trac heostomy (usage), 225
Invasive ventilation (treatment), NPPV (usage), 226
Inverted subc utaneous suture, appearanc e, 1135f
In vivo c alibration, 118
Isc hemia, types, 511-513
Isc hemic stroke, 849
Isc hemic S T-segment c hanges, ECG c ontinuous monitoring, 511
J
Jejunostomy tube c are, 1201
doc umentation, 1205
equipment, 1202
expec ted outc omes, 1204
nursing knowledge, 1201-1202
patient assessment, 1202-1203
patient c are, 1204
patient educ ation, 1202
patient monitoring, 1204
patient preparation, 1202-1203
proc edure, 1203-1205t
unexpec ted outc omes, 1204
Jejunostomy tube plac ement, 1202f
Joint Theater Trauma Registry, foc us, 1057
Jugular bulb venous c atheter, plac ement, 817f
Jugular vein
anatomy, 728f
identific ation, 727
Jugular venous oxygen saturation (S jVO 2), 853
Jugular venous oxygen saturation (S jVO 2) monitoring: insertion (assist)/patient c are/troubleshooting/removal
blood sample, obtaining, 823
derived S jVO 2 parameters, 817
doc umentation, 823
equipment, 817-818
expec ted outc omes, 822
family educ ation, 818
jugular venous sample, obtaining, 822
nursing knowledge, 816-817
patient assessment, 818
patient educ ation, 818
patient monitoring/c are, 822
patient preparation, 818
preproc edural analgesia/sedation, administration, 818
proc edure, 819-820t
purpose, 816
sampling/c alibration errors, 821
signal quality intensity (S QI), 820
identific ation, 820
S jVO 2 c atheter
c oiling, 821
insertion, assistanc e, 819-820t
tip, positioning, 816-817
troubleshooting, proc edure, 820-823t
S jVO 2 data
c alc ulations, formulas (usage), 817t
c linic al interventions, 818t
c onfirmation, 821
S jVO 2 data/c alc ulations, ranges, 817t
S jVO 2 dec rease/inc rease, 817
S jVO 2 desaturation, 821
identific ation, 821
S jVO 2 monitoring
c ontraindic ations, 816
rec ommendation, 816
S jVO 2 trends, rhythmic fluc tuations (identific ation), 821
S jVO 2 values, oc c lusion (relationship), 820
unexpec ted outc omes, 822
in vivo c alibration errors, avoidanc e, 821
Jugular venous pressure/jugular distension, inc rease, 691
K
KCI RotoRest Delta kinetic therapy bed, 1126f
illustration, 1126f
KCI V.A.C. therapy, therapy setting, 1186t
Kelly c lamp, usage, 220
Keloids, formation, 1102
Kinetic therapy
surfac e, patient positioning, 1128
usage, 1125
King Airway, usage, 9
Kyphosc oliosis, impac t, 244
L
Lac tate dehydroxygenase (LDH)-to-serum LDH ratio, 208
Lac tic ac id, measurement, 235
Large-volume parac entesis, performing, 989
Laryngeal mask airway (LMA)
bite-bloc k/airway tube, taping, 54f
c omponents, 47f
c onsc iousness/responsiveness level, assessment, 48
c uff deflation, 50f
method, 49f
c uff inflation volumes
maximum, 54t
test, 50t
design, 47
doc umentation, 56
dorsal view, 48f
equipment, 48
expec ted outc omes, 55
family educ ation, 48
history, assessment, 48
inflation, mask seating, 54f
insertion
holding method, 51-52f
proc edure, 49-56t
thumb method (usage), 52
limitations, 47-48
LMA-Unique devic es, 48
weight ranges, 48
LMA-Unique insertion, 49-56t
mask, seating, 54f
nursing knowledge, 47-48
patient assessment, 48-49
patient educ ation, 48
patient monitoring/c are, 55
patient preparation, 48-49
plac ement/inflation, 53
pre-proc edure verific ation, 49
removal, 54
sec uring, 54
suc tion equipment, assembly, 47
thumb insertion
holding method, 53f
usage, 52
unexpec ted outc omes, 55
usage, 48
Laryngosc ope blades
availability, fiberoptic light delivery systems (inc lusion), 9, 22-23
types, 9, 22
Laryngosc ope lift, glottis exposure, 14f
Late deflation, 453f
Late inflation, 452f
Lateral c hest radiographs, performing, 210
Lateral dec ubitus radiographs, assistanc e, 210
Lateral rotation therapy, proc edure, 1128-1131t
Lavage fluid, drainage, 999
Lead impedanc e, pac emaker definition, 404t
Left anterior desc ending (LAD) c oronary artery, oc c lusion, 511-513
Left atrial c atheter (LAC), removal c are/assist
doc umentation, 615
dual-c hannel strip, running, 611
equipment, 610
expec ted outc omes, 614
family educ ation, 610
gauze dressings, replac ement, 615
hemodynamic monitoring system, c hec king, 610
intravenous (IV) pole, 611
LAP c atheter, slippage, 613f
LAP waveform, 609f
LA waveform strips, obtaining, 615
nursing knowledge, 609-610
patient assessment, 610
patient educ ation, 610
patient monitoring/c are, 614
patient preparation, 610
proc edure, 610-615t
purpose, 609
QRS c omplex, alignment, 611
transduc er, zeroing, 614
unexpec ted outc omes, 614
Left atrial pressure (LAP)
hemodynamic monitoring, 614
measurement, 611
polyvinyl c atheter, usage, 609
monitoring, 609-610
obtaining, 612
slippage, 613f
waveform, 609
c omponents, 609f
Left c irc umflex (LCX) c oronary artery, 511-513
balloon inflation, 504f
Left hemidiaphragm, elevation, 209
thorac entesis c ontraindic ation, 219
Left posterior leads, 507
purpose, 502
rec ording, elec trode loc ations, 507f
Left prec ordium, anterior pad plac ement, 324f
Left-sided pleural effusion, 209
thorac entesis c ontraindic ation, 219
Left ventric le (LV), blood amount, 578
Left ventric ular assist devic es, c ardiac evaluation, 706
Left ventric ular assist system (LVAS ), 466
Left ventric ular ejec tion frac tion (LVEF), 391
Left ventric ular end-diastolic pressure (LVEDP), 617, 626
Left ventric ular end-diastolic volume (LVEDV), 617
Left ventric ular (LV) dysfunc tion, 391
Left ventric ular pac ing, 410f
Leg esc harotomy, c irc ulation improvement, 1099f
Length of stay (LOS ), dec rease, 1111
Leukoc ytapheresis, 1070
Lewis lead, 496
inc lusion, 497f
LIFEPAK 20, 414f
Life-sustaining therapy (LS T) proc ess, withdrawal, 1231
nursing knowledge, 1235-1236
Life-sustaining therapy (LS T) withholding/withdrawal
analgesia, initiation, 1239
anxiolytic s, initiation, 1239
dec ision-making c apac ity/healthc are proxy, absenc e, 1237
doc umentation, 1240
dying proc ess, family expec tations, 1237
expec ted outc omes, 1240
family educ ation, 1236
family involvement, 1236
patient assessment, 1236-1237
patient c are, 1239
patient educ ation, 1236
patient monitoring/c are, 1240
patient preparation, 1236-1237
proc edure, 1237-1240t
purpose, 1235
unexpec ted outc omes, 1240
vital signs, assessment, 1240
Limb leads, 505
plac ement, 521f
reversal, 525f
Lindegaard ratio, 851
Linton-Nac hlas tube, 947
Loading dose, 930
Loc kout interval, 930
Long QT syndrome, 422
Long-term artific ial airway, patient need (assessment), 286-287
Long-term mec hanic al ventilation, short-term mec hanic al ventilation (c ontrast), 291
Long-term pressure redistribution strategies, nec essity, 1127
Lopez valve, 949f
Low-intensity laser, usage, 677
Low-pressure high-volume work, 294
Low-shear GORE medic al fabric , 1126
Lumbar punc ture (LP) (assist)
anatomic site, assistanc e, 882
aseptic tec hnique, 883
baseline neurologic func tion, establishment, 881
c ontraindic ations, 880
CS F spec imens, c ollec tion assistanc e, 883
disc omfort, explanation, 881
doc umentation, 886
equipment, 880-881
expec ted outc omes, 884
family educ ation, 881
ICP, signs/symptoms (assessment), 881
indic ations, 880
laboratory profile, assessment, 881
loc al anesthesia, preparation (assistanc e), 883
meningeal irritation, signs/symptoms (assessment), 881
neurologic assessment, 881
nursing knowledge, 880
patient assessment, 881
patient educ ation, 881
patient monitoring/c are, 885
patient preparation, 881
positioning, 882f
preferenc e, 880
proc edure, 882-886t
punc ture site, observation, 884
purpose, 880
Quec kenstedt test, 883
unexpec ted outc omes, 884
vital signs, 881
assessment, 885
Lumbar punc ture (LP) (perform)
baseline neurologic assessment, 873
c ontraindic ations, 872
CS F tests, 872-873
doc umentation, 879
equipment, 873
expec ted outc omes, 878
family educ ation, 873
indic ations, 872
laboratory samples, obtaining, 877
loc al anesthetic , administration, 876
meningeal irritation, signs/symptoms (assessment), 873-874
neurologic status, monitoring, 878
nursing knowledge, 872-873
patient assessment, 873-874
patient educ ation, 873
patient monitoring/c are, 878
patient preparation, 873-874
proc edure, 874-879t
purpose, explanation, 873
purpose, 872
Quec kenstedt test, 876
spinal c ord, 875f
unexpec ted outc omes, 878
Lumbar subarac hnoid c atheter insertion (assist) for c erebrospinal fluid drainage/pressure monitoring
allergies, assessment, 827
bed position, 830
c omplic ations, 826-827
CS F drainage system, fluid-filled transduc er (attac hment), 828
CS F waveform, dampening, 831
dislodgment, prevention, 833
doc umentation, 834
drainage, c ontraindic ation, 827
drip c hamber, referenc e line, 829f
equipment, 827
expec ted outc omes, 832
external auditory meatus, drip c hamber, 829f
family educ ation, 827
informed c onsent, obtaining, 827
insertion site, assessment, 833
intraspinal pressure, 826
laboratory profile, assessment, 827
medic ation profile, assessment, 827
neurologic status
assessment, 827
monitoring, 832
observation, 831
nursing knowledge, 826-827
overdrainage, suspic ion, 833
patient assessment, 827
patient educ ation, 827
patient monitoring/c are, 832
patient preparation, 827
patient verific ation, identifiers (usage), 827
preproc edural analgesia/sedation, administration, 827
preproc edural antibiotic , administration, 827
pressure waveform, absenc e (assessment), 831
proc edure, 828-830t
purpose, 826
transduc er level, drip c hamber, 829f
troubleshooting, proc edure, 831t
unexpec ted outc omes, 832
usage, 826-827
Lund and Browder c hart
illustration, 1099f
usage, 1099
Lundberg a/b/c waves, 837
Lundberg waves, 837
Lungs
bases, ausc ultation, 16, 26
disease, 209
pulmonary vasc ular pressures, 130
zone model, 131f
Lymphoplasmapheresis, 1070
M
Mac intosh laryngosc ope blade, usage, 9, 22
Malignanc y disease, medic al history assessment, 221
Malignant hyperthermia
indic ation, 864
oc c urrenc e, 864
treatment, c ooling devic e (usage), 864
Malpositioned endotrac heal tube, signs/symptoms (assessment), 269
Manual defibrillators, purc hase, 313
Manual pronation therapy
c ontraindic ations/prec autions, 131
doc umentation, 148
expec ted outc omes, 144
patient monitoring/c are, 145
proc edure, 134-148t
prone (lying), 138f
prone (turning)
half-step tec hnique, usage, 136
Vollman Prone Positioner, usage, 137f
supine position, return, 139
illustration, 140f
supine position (turning), RotoProne Therapy S urfac e (usage), 143
unexpec ted outc omes, 144
ventilator tubing, positioning, 135f
Manual self-inflating resusc itation bag-valve devic e
airway resistanc e, determination, 249
average tidal volume, analysis, 253
bagging
diffic ulty, 249
indic ation, 248-249
bag-valve assembly, 249f
breathing pattern/rate, observation, 250
distress, elimination, 251
doc umentation, 254
dyssync hrony, observation, 250
equipment, 249
expec ted outc omes, 253
family educ ation, 249
FiO 2 delivery, analysis, 253
maintenanc e ventilation, 252
manual breaths, rate (dec eleration), 251
nursing knowledge, 248-249
oxygen analyzer, removal, 253
oxygenation status, determination, 249
oxygen sourc e, 249
patient assessment, 249-250
patient c omfort, 251
patient educ ation, 249
patient identific ation, verific ation, 249
patient monitoring/c are, 254
patient preparation, 249-250
patient status, ac ute c hange, 249
patient/ventilator, interac tion (evaluation), 250
PEEP valve/attac hment, 249
personal protec tive equipment, 249
proc edure, 250-254t
purpose, 248
respirometer, removal, 253
self-inflating bags, 249f
unexpec ted outc omes, 253
usage, 267
ventilation
status, determination, 249
tec hnique, 248f
Marrow toxic medic ations, 756
Mask fit/intoleranc e, NPPV (nonusage), 226
Massive infusion devic e/pressure infusor bag
air eliminator, replac ement, 1063
alarms, troubleshooting, 1064
automatic blood pressure monitor, plac ement, 1060
bags, c hange, 1063
doc umentation, 1068
equipment, 1059
expec ted outc omes, 1066
family educ ation, 1059
filter, replac ement, 1063
hemodynamic parameters, assessment, 1059, 1067
IV sites, integrity (assessment), 1067
laboratory values, assessment, 1059
large-bore IV sites, patenc y (assessment), 1059
Level 1 rapid infuser, 1058f
tubing, plac ement, 1059f
Luer-Lok, disc onnec tion, 1063
male Luer-Lok c ap, replac ement, 1062
nursing knowledge, 1057-1059
patient assessment, 1059-1060
patient c are, 1066
patient educ ation, 1059
patient history, assessment, 1059
patient monitoring, 1066
patient preparation, 1059-1060
patient transportation, rapid infuser (usage), 1064
peripheral IV sites, plac ement, 1060
proc edure, 1061-1064t
rapid infuser filter, 1060f
rapid infusion devic e, usage, 1058
temperature, assessment, 1059
unexpec ted outc omes, 1066
urine output, assessment, 1067
usage, purpose, 1057
Massive transfusion (MT)
prac tic es, 1057
protoc ol, 1057
Mattress sutures, 1135
removal, 1146
Maximal inspiratory pressure (MIP), 285-286
Mean airway pressure, 278
Mean arterial pressure (MAP), 445, 802-803
c alc ulation, 535
ICP subtrac tion, 836
representation, 535
Mec hanic al debridement, 1162
equipment, 1160
usage, 1160
Mec hanic al ventilation
c omplic ation, 266
end expiration determination, 640
indic ations, 262
modes, 264t
nec essity, 295-296
pressure support-type ventilator, 642f
Mec hanic al ventilatory assistanc e, patient need (assessment), 286-287
Mec hanic al ventilatory support, need, 39
Median basilic vein, CVC insertion, 734
Mediastinal c hest tubes, removal, 171
Medic al history, assessment, 221
Medtronic Kappa Pac emaker advertisement, 403f
Meningeal irritation, signs/symptoms (assessment), 873-874, 881
Meninges, 915
Meningitis, 836
Meshed split-thic kness skin graft, 1109f
Methic illin-resistant Sta phylococcus a ureus (MRS A), 1151
Mic rosensors, plac ement, 836-837
Middle c erebral artery (MCA)
insonation, 849
waveforms, 850f
Miller laryngosc ope blade, usage, 9, 22
Minimal leak tec hnique (MLT), 88
tec hnique, 91
Minimal oc c lusion volume (MOV), 88
tec hnique, 90
Minnesota four-lumen tube, 948f
Minute ventilation (MV), ensuring, 263
Mixed venous blood samples, analysis, 259
Mixed venous oxygenation (S VO 2), 617
Mixed venous oxygen saturation (S VO 2), assessment, 1059
Mixed venous oxygen (S VO 2)
c orrelation, 576
drawing, 573
saturation, analysis, 572
Mixed venous sample measurements, obtaining/analysis, 237
Modifiable VAP prevention interventions, 264t
Modified Allen’s test
illustration, 716f
performing, 715
Modified S eldinger tec hnique, 770f
performing, 769
Modified S tewart Hamilton equation, 580
Monitor strip
baseline, problems, 499f
c lear ECG pattern, 498f
interferenc e, 500f
60-c yc le interferenc e, 499f
Monofilament sutures, 1134
Monomorphic ventric ular tac hyc ardia, 325t
Monophasic defibrillation, 323f
Monophasic waveforms, energy delivery, 319, 329
Montgomery straps
illustration, 1156f
usage, 1156
Motion-mode (M-mode) ec hoc ardiography, 705
Mouth, opening (c rossed-finger tec hnique), 77f
Mouth-to-mask devic e
requirement, 2
usage, 3
Multic hannel telemetry, usage, 372, 376
Multillumen irrigation urinary c atheters, usage, 970
Multiple-c hannel ECG mac hine, 523f
Multiple-pressure transduc er system
c arpenter level, 677
equipment, 672
expec ted outc omes, 678
family educ ation, 672
monitor setup, 675
nursing knowledge, 670-672
patient assessment, 672
patient educ ation, 672
patient monitoring/c are, 677
patient preparation, 672
phlebostatic axis, supine position, 676f
proc edure, 672-679t
purpose, 670
stopc oc k position, 674f
transduc er
leveling, 675
zeroing, 678
unexpec ted outc omes, 678
Musc le twitc h response, 303
Myoc ardial infarc tion (MI), c omplic ation, 618
Myoc ardial isc hemia, diagnosis, 513
Myoc ardium
depolarization, pac emaker ability, 432
stimulation, 421
temporary pac ing, usage, 429
N
Nail bed, disc oloration, 122
Nares, patenc y (assessment), 24
Narrow-c omplex supraventric ular tac hyc ardias, differentiation, 371
Nasal esophageal tube plac ement, antic ipation, 949
Nasal intubation, c ontraindic ation, 10
Nasal mask
noninvasive interfac e, 229
usage, 228f
Nasal pillow
noninvasive interfac e, 229
usage, 228f
Nasal spec ulum, insertion, 61
Nasogastric tube
measurement, 951f
presenc e, 47
Nasopharyngeal airway, 69f
advantages, 69
external diameter, 69
parts, 69
passage, 69
preparation, 71
size, estimation, 70f
sizing, 70t
usefulness, 70
Nasopharyngeal airway insertion
doc umentation, 72
equipment, 70
expec ted outc omes, 72
family educ ation, 70
mouth, opening, 71
nursing knowledge, 69-70
patient assessment, 70-71
patient educ ation, 70
patient monitoring/c are, 72
patient preparation, 70-71
proc edure, 71-72t
unexpec ted outc omes, 72
Nasotrac heal intubation, 18
National Conferenc e of Commissioners on Uniform S tate Laws, Uniform Anatomic al Gift Ac t c reation, 1223
National Organ Transplant Ac t, establishment, 1223
National Pressure Ulc er Advisory Panel (NPUAP) staging system, usage, 1159
Near-normal ventric ular func tion, 391
Nec k
anatomy, 60f
hyperextension, sniffing position, 12f
Nec k vein distention, 204
development, 364
Nec rotic tissue, 1159
removal, debridement (usage), 1159
Needle aspiration, 1155
Needleless blood sampling ac c ess devic e, 556f
attac hment, 557f, 558f
needleless c annula, 561f
removal, 660
usage, 557
Needleless blood sampling devic e, attac hment, 569
illustration, 567f, 569f
Needleless c ap, needleless blood sampling devic e attac hment, 569f
Needleless c apped stopc oc k, needleless blood sampling devic e attac hment, 567f
Needle thorac ostomy (perform)
doc umentation, 207
equipment, 204-205
expec ted outc omes, 206
family educ ation, 205
nursing knowledge, 204
patient assessment, 205
patient educ ation, 205
patient monitoring/c are, 207
patient preparation, 205
patient role, explanation, 205
patient verific ation, 205
performing, proc edure, 206-207t
pre-proc edure verific ation, 205
proc edure, 206-207t
proc edure, explanation, 205
unexpec ted outc omes, 206
Negative inspiratory forc e (NIF), 285-286
measurement, 288
purpose, 285
Negative inspiratory pressure (NIP), 285-286
measurement, 288f
purpose, 285
Negative-pressure wound therapy (NPWT)
airtight seal, maintenanc e, 1190
doc umentation, 1190
effec tiveness, 1183
equipment, 1184
expec ted outc omes, 1188
family educ ation, 1184
FDA approval, 1183
goals, 1183
mec hanic al wound, 1109
nursing knowledge, 1182-1184
optimum, V.A.C. devic e (usage), 1184
patient assessment, 1184-1185
patient educ ation, 1184
patient monitoring/c are, 1189
patient preparation, 1184-1185
periwound, preparation, 1186
proc edure, 1185-1190t
purpose, 1182
randomized c ontrolled studies/c ase studies, 1182
transc utaneous oxygen pressure evaluation, 1184
unexpec ted outc omes, 1188
usage, 1102
c ontraindic ations, 1184
V.A.C. dressing removal proc edure, 1188
V.A.C. transparent drape, plac ement, 1187
vac uum units, 1182
Networked patient monitor, 491f
Neuromusc ular bloc kade
monitoring level, 780
rec eiving, 785
use, presenc e (assessment), 1214
Neuromusc ular bloc king agent, usage, 642f
Neuromusc ular bloc king drugs (NMBDs)
administration, 303-304
ICU usage, 303
impac t, 303
medic ations, potentiation, 303
therapy, 310
train-of-four (TOF) stimulation method, usage, 303
Neuromusc ular c ollapse, 262
Neurovasc ular assessment, importanc e, 681
Neurovasc ular status, assessment, 687
Nighttime hypoventilation, 225-226
Nonabsorbable sutures, 1134
Nonabsorbable synthetic monofilament sutures, 1134
Non-ARDS , 263
Nonc oring needle, usage, 745-746
Non-c oring PowerLoc needle
insertion, 750f
usage, 749f
Nondependent zone, FRC result, 130
Non-heart-beating donation, 1223-1224
Non-heparin-c oated c atheter, usage, 620
Noninvasive blood pressure measurements, 527
Noninvasive hemostasis pad
manual c ompression, c ombination, 685
usage, 683
Noninvasive positive pressure ventilation (NPPV)
ac ute ventilatory failures, signs/symptoms (assessment), 228
applic ations, 225-226
attrac tion, 225
c omplic ations, 227
development, 227
doc umentation, 233
equipment, 227
expec ted outc omes, 231
failure, c auses, 227
family educ ation, 227-228
fatigue, signs/symptoms (assessment), 228
hemodynamic c hanges, observation, 232
interfac es, 227
selec tion, 229
stabilization/maintenanc e, 231
mask intoleranc e/leaks, 227
modes, randomized c ontrolled trial (RCT), 226
oxygenation inadequac y, signs/symptoms (assessment), 228
patient assessment, 228-229
patient body position, c hange, 232
patient educ ation, 227-228
patient interfac es, 228f
patient monitoring/c are, 231
patient preparation, 228-229
patient relaxation, enc ouragement, 227
patient selec tion, problem, 227
patient ventilator dyssync hrony, 227
proc edure, 229-233t
purpose, 225
signs/symptoms, 228
monitoring, 233
unexpec ted outc omes, 231
usage
exc lusions, 226-227
intensiveness, 225
suc c ess, 225
ventilator limitation, 227
Noninvasive pulse oximetry, usage, 26
Nonisc hemic dilated c ardiomyopathy (DCM), presenc e, 391
Nonmeshed grafts (sheet grafts), 1109
Nontherapeutic laparotomy rates, dec rease, 995
Nonurgent unc omplic ated PCI, 513
Normal saline solution (NS ), usage, 745
North Americ an S oc iety of Pac ing and Elec trophysiology/British Pac ing and Elec trophysiology Group (NAS PE/BPEG)
antibradyc ardia pac ing, revised generic c ode, 404t
defibrillator c ode, 393t
Nothing-by-mouth (NPO)
c onsideration, 940
status
assessment, 11, 24
ensuring, 1012
O
Obesity, impac t, 244
Obstruc tive sleep apnea (OS A), 273
CPAP, usage, 225-226
treatment, 225
Oc c lusion, c uffs (usage), 1-2
Oc c lusive c hest tube dressing, 165f
Oc c lusive dressing, applic ation, 164
Oc uloc ephalic (doll’s eye) reflexes, 1216f
assessment, 1215
Oliguria, dec rease, 970
Onc otic pressure, 1018-1020, 1033
One-bottle c hest drainage system, 191f
One-way flutter, usage, 205f
Onset atrial/ventric ular dysrhythmias, 286
Open pneumothorax, 154, 167
Open stopc oc k valve, usage, 213
Open thermodilution method, usage, 584-585t
Open wound c leaning/irrigating/c ulturing dressing
analgesia, administration, 1157
c leaning, 1152
illustration, 1154f
c losed wound, c leaning, 1153
c olonization, 1150
c ritic al c are, 1151
doc umentation, 1157
dressing, 1155
dressings, c ategorization, 1149
equipment, 1151-1152
expec ted outc omes, 1157
family educ ation, 1152
healing, 1149
medic ations/treatment, impac t, 1151
irrigation, 1152
illustration, 1151f
nec essity, 1153
Montgomery straps
illustration, 1156f
usage, 1156
needle aspiration, 1155
nursing knowledge, 1149-1151
nutritional status, 1151
pain assessment, 1157
patient assessment, 1152
patient educ ation, 1152
patient monitoring/c are, 1157
patient preparation, 1152
proc edure, 1152-1157t
purpose, 1149
spec imen, labeling, 1155
tubular mesh dressings, usage, 1156
unexpec ted outc omes, 1157
waterproof barrier, position, 1152
Open wounds, wound drainage (exc ess), 1183
Ophthalmic artery (OA), insonation, 849
Opioid-naive adults/c hildren, patient-c ontrolled intravenous opioid administration (guidelines), 929t
Opioid selec tion, c onsiderations, 930t
Oral airway
manufac ture, 74
parts, 74
position, rec hec king, 76
sizes, 75t
rec hec king, 76
suc tioning fac ilitation, 74
Oral c avity
assessment, 36
denture presenc e, assessment, 11, 24
Oral hygiene
c ompletion, 35
initiation, 33
Oral pharynx, suc tion, 45
Organ donation
proc edure, 1225-1228t
request, 1226
Organ donors
c are, 1223, 1226
identific ation, 1223, 1225
Organ identific ation
blood samples, obtaining, 1227
doc umentation, 1228
equipment, 1224
expec ted outc omes, 1227
family identific ation, 1224
hemodynamic status, assessment, 1228
hospital resourc es, involvement, 1225
laboratory results, assessment, 1224
laboratory samples, obtaining, 1225
neurologic testing, 1225
nursing knowledge, 1223-1224
oxygenation, assessment, 1224
patient assessment, 1224-1225
patient educ ation, 1224
patient monitoring/c are, 1227
patient preparation, 1224-1225
proc edure, 1225-1228t
pulse oximetry, monitoring, 1228
purpose, 1223
unexpec ted outc omes, 1227
vital signs, assessment, 1224
Organ proc urement organization (OPO), 1212, 1224
c oordinator, 1231
c ollaboration, 1226
rec overy proc ess explanation, 1226
polic ies, 1229
referral, doc umentation, 1230
transplant c oordinator, assistanc e, 1224-1225
Orogastric (OG) tube, opening, 958-959
Oropharyngeal airway
insertion, 77f
nonreplac ement, 77
parts, 75f
size selec tion, 75f
Oropharyngeal airway insertion, 27
doc umentation, 78
equipment, 74
expec ted outc omes, 76
family educ ation, 75
mouth opening, c rossed-finger tec hnique, 77f
nec k, hyperextension, 75
nursing knowledge, 74
patient assessment, 75
patient educ ation, 75
patient monitoring/c are, 77
patient preparation, 75
pharyngeal suc tion tip (Yankauer) c atheter, 76
proc edure, 76-78t
semi-Fowler’s/supine position, 75
unexpec ted outc omes, 76
Oropharyngeal sec retions, suc tioning, 33
Oropharyngeal tube, insertion, 75f
Oropharynx, blade advanc ement, 14f
Orotrac heal intubation, 13
tec hnique, 14f
Osc illatory frequenc y (fx), 278
O-silk suture, usage, 445
Osmosis, 1018-1020, 1033, 1048
Ostomy pouc h, 1169f
Overdamped arterial waveform, 540f
Overdamped waveform
monitoring, 545
troubleshooting, 659
proc edure, 540-542t
Overdose, 958-959
gastric lavage, 958
Overdrive atrial pac ing
performing, 380
rapid pac ing stimuli, delivery, 380
Overwedged balloon
prevention, 657
troubleshooting, 656
Oximetric proc essor, initiation, 819
Oximetry c atheters, 115f
pediatric patient applic ations, 114
Oximetry system, reflec tanc e spec trophotometry, 114f
Oxygen
analyzer, removal, 253
c hallenge test, 798, 800
c ontent, c alc ulation, 235
delivery/c onsumption
c alc ulations, 237
values, 236
delivery devic es, usage, 262
support, 40
transport, delivery (purpose), 235
usage, c ardiac output (impac t), 235
Oxygenation
assessment, 309
c linic al indic es, 255
dec rease, signs/symptoms, 123
failure, signs/symptoms (assessment), 228
inadequac y, signs/symptoms, 260
assessment, 256, 268
measurement, absenc e, 106
promotion, 41
status, 259
Oxygenation indic es
assessment, 296
c alc ulation, 256
doc umentation, 258
equipment, 256
expec ted outc omes, 257
family educ ation, 256
nursing knowledge, 255-256
patient assessment, 256
patient educ ation, 256
patient monitoring/c are, 257
patient preparation, 256
patient rec ord doc umentation, 257
patient verific ation, identifiers (usage), 256
proc edure, 256-258t
purpose, 255
unexpec ted outc omes, 257
Oxygen-c arrying c apac ity, usage, 237
Oxygen saturation, 121
evaluation (S pO 2), evaluation, 26
monitoring, 944
patient ventilation, ability, 122
values, 121
variation, 122
Oxygen saturation monitoring (pulse oximetry usage)
doc umentation, 128
equipment, 123
expec ted outc omes, 127
extremity (digit), assessment, 123
family educ ation, 123
nursing knowledge, 121-123
oxygenation, dec rease (signs/symptoms), 123
patient assessment, 123
patient educ ation, 123
patient monitoring/c are, 127
patient preparation, 123
proc edure, 124-128t
pulse oximeters, usage, 122
pulse oximetry monitoring, sensor types/sites, 125f
sensor devic e, 122f
sensor site, selec tion, 124
unexpec ted outc omes, 127
P
Pac emakers
c hec king, performing, 410
definitions, 404t
depolarization ability, 423
dials/touc h pads, usage, 432
firing, 418
func tion
evaluation, 419
knowledge, 403
history, determination, 406
intrinsic rhythm detec tion ability, 432
leads, c onnec tion, 427
presenc e, 315
determination, 649
programmed mode, identific ation, 406
programming, 405
stability, provision, 426
Pac ing
c ontraindic ation, 413
elec trodes, adherenc e (c hec king), 419
modes, programming, 405t
oc c urrenc e, 413, 422, 431
PA c atheter, 430
rate, determination, 422
Pac ked red blood c ells (PRBCs), 1057
Pallor, development, 364
Palm, rule, 1099
Parac entesis (assist)
abdomen, anatomy/physiology, 988
abdominal girth
assessment, 989
c hanges, evaluation, 991
abdominal pain, monitoring, 992
asc itic fluid, floating, 988
baseline fluid/elec trolyte status, 989
baseline pain assessment, 989
baseline vital signs, 989
bowel/bladder distention, assessment, 989
c atheter removal, 991
c ec um, fixation, 988
c oagulation study results, obtaining, 989
c omplic ations, monitoring, 992
c ontraindic ation, 988
doc umentation, 992
endosc opic transgastric ultrasound sc an, usage, 989
equipment, 989
preparation, assistanc e, 990
expec ted outc omes, 991
family educ ation, 989
fluid removal, 991
intake/output, monitoring, 992
medic al history, 989
nursing knowledge, 988-989
patient assessment, 989-990
patient educ ation, 989
patient monitoring/c are, 991
patient preparation, 989-990
preproc edural teac hings, understanding, 989
pre-proc edure verific ation/time out, 990
proc edure, 990-992t
purpose, 988
respiratory status, assessment, 989
ultrasound sc an, usage, 988
unexpec ted outc omes, 991
vital signs, monitoring, 992
Parac entesis (perform)
c omplic ations, monitoring, 986
equipment, 982
family educ ation, 982
fluid removal, 985
laboratory data, evaluation, 986
nursing knowledge, 981-982
patient assessment, 982-983
patient educ ation, 982
patient preparation, 982-983
proc edure, 983-986t
purpose, 981
Z-trac k method, 985f
Parac oporeal Ventric ular Assist Devic e (PVAD) (Thoratec ), 466
Parallel-plate dialyzers, usage, 1034
Paralysis, 1120
Parasthesia, 1120
Parasympathetic neural stimulation, inc rease, 578
Parenc hyma, intrac ranial bolt insertion, 803f
Paresis, 1120
Parham-Martin bands, 161, 165f
Paroxysmal atrial tac hyc ardia, episode, 383f
Partial pressure of arterial oxygen/frac tion of inspired oxygen (PaO 2/FiO 2), 226
Partial pressure of arterial oxygen (PaO 2), 129
Partial pressure of mixed venous oxygen pressure (PO 2), 235
Partial pressure of mixed venous oxygen saturation (S O 2), 235
Partial pressure of oxygen (PaO 2), measurement, 713
Partial-thic kness burn, 1098f
wound, blisters, 1098f
Partial-thic kness wound
healing time, 1091
surgic al c reation, 1091
Partial thromboplastin time (PTT), 615, 804-805
assessment, 714
Passive range-of-motion exerc ises, enc ouragement, 156, 169, 187
Patient anatomy, hindranc e, 219
Patient anxiety level, assessment, 296
Patient c ontrolled analgesia (PCA)
assessment, frequenc y, 928
availability, 929
c andidates, 929
c omplic ation risk, inc rease, 929
doc umentation, 934
dose, 930
equipment, 929-930
expec ted outc omes, 933
family educ ation, 930
intravenous c atheter c ap, c leansing, 932
intravenous initiation, proc edure, 931-934t
intravenous solution, programming, 932
medic ation allergies, review, 931
nursing knowledge, 928-929
opioid selec tion, c onsiderations, 930t
pain rating sc ale, review, 930
patient assessment, 930-931
patient-c ontrolled intravenous opioid administration guidelines, 929t
patient educ ation, 930
patient monitoring/c are, 933
patient preparation, 930-931
postoperative pain, result, 928
presc ription review, 931
princ iples, review, 930
pump
programming, 932
settings, 928
usage, 940
purpose, 928
self report ac c eptanc e, AHRQ rec ommendation, 928
support, absenc e (The Joint Commission), 929
terms, 930b
unexpec ted outc omes, 933
vital signs, monitoring, 933
Patient-c ontrolled epidural analgesia (PCEA) pump system, 915
Patient-c ontrolled intravenous opioid administration, guidelines, 929t
Patient/stopc oc k, air (presenc e), 661f
Patient ventilator dyssync hrony, 227
Patient-ventilator dyssync hrony, evaluation, 232, 281
Peak inspiratory pressure (PIP)
c hange, 244
exploration, 280
inc rease, 970
monitoring, 245
rec ording, 245
volume, division, 244
Perc ent inspiratory time, 278
Perc lose, 682
Perc utaneous endosc opic gastrostomy (PEG)
equipment, 1202
expec ted outc omes, 1204
family educ ation, 1202
illustration, 1201f
monitoring, 1205
nursing knowledge, 1201-1202
patient assessment, 1202-1203
patient c are, 1204
patient educ ation, 1202
patient monitoring, 1204
patient preparation, 1202-1203
plac ement, relative c ontraindic ations, 1201-1202
proc edure, 1203-1205t
purpose, 1201
unexpec ted outc omes, 1204
Perc utaneous punc ture, performing, 717
Perc utaneous staple-mediated c losure devic es, 682
bed rest time, reduc tion, 687
deployment, 682
Perc utaneous suture-mediated c losure devic es, 682
bed rest time, reduc tion, 687
deployment, 682
Perfusion, distribution, 130
Perianal skin, external fec al c ontainment system (adherenc e), 1176
Peric ardial c atheter bloc kage
external mec hanic al c ause, assessment, 694, 699
relief, 694
Peric ardial c atheter management
c ardiovasc ular assessment, 702
c atheter drainage, assoc iation, 691
c atheter site c are, performing, 692
c hlorhexidine-based solution, usage, 692
c onnec tion, 690
doc umentation, 703
drainage system, absenc e, 692
dysrhythmia interpretation, 690
ECG lead plac ement, 690
equipment, 691
expec ted outc omes, 702
family educ ation, 691
hemodynamic assessment, 702
infusion port, stopc oc k (usage), 699
intermittent drainage, 698
intermittent fluid drainage, c ompletion, 698
IV medic ation solution, c onnec tion, 700
medic ation syringe, c onnec tion, 700
nursing knowledge, 690-691
oc c lusive dressing, applic ation, 693
patient assessment, 691
patient educ ation, 691
patient monitoring/c are, 702
patient preparation, 691
peric ardial c atheter, patenc y (assessment), 702
peric ardial c losed drainage system management, 696
plac ement, 690
proc edure, 692-703t
purpose, 690
removal, 691
stopc oc k, usage, 693, 696
unexpec ted outc omes, 702
Peric ardial drainage bag, emptying, 698
Peric ardial effusion
ac c umulation, 364
c auses, 690
treatment, peric ardioc entesis (usage), 690
Peric ardial spac e, medic ation dwelling, 701
Peric ardioc entesis (assist), 690
ac ute fluid ac c umulation, presentation, 364
c ardiac tamponade
effusion/drainage, verific ation, 364
symptoms, 364
c hest exploration, preparation, 369
c hronic fluid ac c umulation, presentation, 364
c ontinuous drainage, 367
doc umentation, 369
dysrhythmias, treatment, 368
ECG, monitoring, 368
ec hoc ardiogram, assistanc e, 365
emergenc y c art, usage, 365
equipment, 364-365
expec ted outc omes, 368
family educ ation, 365
healthc are provider, assistanc e, 367
illness, history (determination), 365
injury, mec hanism (determination), 365
needle tip position, c onfirmation, 367
nursing knowledge, 364
patient assessment, 365
patient c are, 368
patient educ ation, 365
patient monitoring, 366, 368
patient preparation, 365
peric ardial effusion, 364
personnel, assistanc e, 366
pre-proc edure verific ation, performing, 365
proc edure, 366-369t
purpose, 364
site
c are, 369
monitoring, 368
two-dimensional ec hoc ardiogram
ensuring, 368
usage, 366-367
unexpec ted outc omes, 368
Peric ardioc entesis (perform)
c ontinuous drainage, 360
dysthythmias, treatment, 361
ECG, monitoring, 361
effusion size, evaluation, 362
equipment, 356
family educ ation, 356
hemoglobin/hematoc rit/c oagulation, monitoring, 361
indwelling c atheter
plac ement, 360
removal, 362
needle tip position, c onfirmation, 360
nursing knowledge, 355
patient assessment, 356
patient educ ation, 356
patient preparation, 356
pigtail/soft c atheters, usage, 360
proc edure, 357-362t
purpose, 355
site
c are, 362
monitoring, 361
two-dimensional ec hoc ardiogram, usage, 359
Peric ardioc entesis treatment, 690
Perineal area (c leaning), no-rinse c leansing solution (usage), 1178
Perineal skin
assessment, 1177
c are, 1175-1176
damage, 1175
Periosteum, anesthesia, 212
Peripherally inserted c entral c atheter (PICC)
allergy history, determination, 766
antec ubital spac e, vasc ulature assessment, 766
arm position, 766-767
availability, 764
baseline vital signs/c ardiac rhythm, obtaining, 766
blood pressure measurement, avoidanc e, 774
c annulation, 763
c hest radiographic report, assessment, 772
c ontraindic ation, 763
doc umentation, 774
equipment, 765
expec ted outc omes, 771
family educ ation, 765
head positioning, 767
insertion, 764
c annula, usage, 764
indic ations, 763
site, assessment, 773
mid upper arm c irc umferenc e, measurement, 767
modified S eldinger tec hnique, 770f
performing, 769
nursing knowledge, 763-764
patient assessment, 766-767
patient educ ation, 765
patient monitoring/c are, 772
patient preparation, 766-767
patient refusal, 765
preferenc e, 763
primed extension tubing, attac hment, 771
proc edure, 767-774t
purpose, 763
S tatloc k Devic e, 772f
superior vena c ava plac ement, c atheter length measurement, 766f
tourniquet, positioning/applic ation, 767-768
ultrasound sc an tec hnology, usage, 764
unexpec ted outc omes, 771
veins, loc ation, 764f
ultrasound sc an tec hnology, usage, 765f
venipunc ture, performing, 768
Peripheral nerve bloc ks, insertion/pain management assistanc e
advantages, 937
analgesia, 937-938
quality, assessment, 942
anatomic position, 937
antiseptic preparation, assistanc e, 941
axillary bloc k, needle insertion loc ation, 937f
c apnography, monitoring, 944
c atheter plac ement, assistanc e, 941
c ontraindic ations, 939
doc umentation, 945
effic ac y/utility, basis, 936-937
elastomeric pumps, usage, 937-938
equipment, 939-940
expec ted outc omes, 943
family educ ation, 940
guidelines, 936
infusion rate, monitoring, 944
intersc alene brac hial plexus bloc k, landmarks, 938f
loc al anesthetic s
pharmac okinetic s/pharmac odynamic s, 938-939
usage, 937
loc al infec tion/generalized sepsis, observation, 940
motor/sensory bloc kade, levels (assessment), 943
nothing by mouth (NPO), c onsideration, 940
nursing knowledge, 936-939
outpatient setting, 937
oxygen saturation, monitoring, 944
pain
assessment, 943
impac t, 936
patient assessment, 940
patient educ ation, 940
patient monitoring/c are, 943
patient preparation, 940
patient verific ation, identifiers (usage), 940
PCA pump, usage, 940
proc edure, 941-945t
purpose, 936
sensory/motor bloc kade, ac c eptanc e, 939
single-shot/c ontinuous peripheral nerve bloc ks, 939t
skin integrity, monitoring, 945
systemic toxic ity, assessment, 944
therapy, c onnec tion, 942
three-in-one peripheral nerve bloc k, usage, 937
tissue trauma, 936
unexpec ted outc omes, 943
vasoc onstric tor, addition, 938-939
vital signs, assessment, 943
Peripheral nerve stimulators (PNS s)
doc umentation, 310
drugs titration, 304
elec trodes
c hange, 308
plac ement, 307
equipment, 304
expec ted outc omes, 309
fac ial nerve
elec trodes, plac ement, 306f
testing, 306
family educ ation, 304
initiation, 305, 308
lead wires, usage, 306
monitoring, 304
purpose, 304
musc le twitc h response, 303
nursing knowledge, 303-304
oxygenation/ventilation, assessment, 309
patient assessment, 304-305
patient educ ation, 304
patient monitoring/c are, 309
patient preparation, 304-305
posterior tibial nerve
elec trodes, plac ement, 307f
testing, 307
pre-gelled elec trode pads, usage, 304-305
proc edures, 305-310t
purpose, 303
stimulating c urrent, measurement, 303
supramaximal stimulation (S MS ), determination, 308
train-of-four (TOF)
key, initiation, 306-307
response determination, NMBD infusion, 308
response testing, 304
retesting, 308
stimulation c orrelation, 304t
stimulation method, usage, 303
testing, performing, 310
ulnar nerve
elec trode plac ement, 306f
testing, 305
unexpec ted outc omes, 309
zero twitc hes, troubleshooting, 308
Peripheral pulses, 691
presenc e/absenc e, assessment, 320
Peripheral resistanc e, impac t, 578
Peripheral vasc ular assessment, importanc e, 681
Peripheral vasc ular disease, medic al history (obtaining), 549
Peripheral vasc ular status, assessment, 687
Peritoneal dialysis (PD)
abdominal exit site, assessment, 1050
blood urea nitrogen (BUN), removal, 1048
c atheters
assessment, 1050
c logs, 1049
exit site c are, 1052
dialysate
c omponents, 1048
warming, 1049
diffusion, 1048
disc ontinuation, 1036, 1052
doc umentation, 1055
drain c yc le, 1052
dwell c yc le, 1051
equipment, 1049
expec ted outc omes, 1053
family educ ation, 1049
fluid exc hanges/c yc les, repetition, 1048
func tion, 1048
initiation, 1050
instillation c yc le, 1051
nursing knowledge, 1048-1049
orders, verific ation, 1050
osmosis, 1048
patient assessment, 1049-1050
patient c are, 1054
patient educ ation, 1049
patient monitoring, 1054
patient preparation, 1049-1050
performing, 1048
proc edure, 1050-1055t
purpose, 1048
Tenc khoff c atheter, usage, 1049f
unexpec ted outc omes, 1053
volume status, assessment, 1050
Peritoneal lavage (assist)
allergies, presenc e, 1003
baseline vital signs, 1003
bowel/bladder distension, assessment, 1003
c oagulation study results, 1003
c omplementary CT/DPL, impac t, 1003
c omplic ations, monitoring, 1008
c omputed tomographic (CT) sc an, usage, 1002
c ontraindic ation, 1003
doc umentation, 1008
18-gauge needle, insertion, 1005
equipment, 1003
expec ted outc omes, 1007
family educ ation, 1003
fluid removal, 1007
lavage equipment, setup (assistanc e), 1004
lavage fluid, drainage, 1006
medic al history, 1003
No. 11 blade sc alpel, usage, 1005
nursing knowledge, 1002-1003
patient assessment, 1003-1004
patient educ ation, 1003
patient monitoring/c are, 1008
patient preparation, 1003-1004
preproc edural teac hings, understanding, 1004
proc edure, 1004-1008t
purpose, 1002
unexpec ted outc omes, 1007
Universal Protoc ol requirements, c omplianc e, 1004
written informed c onsent, 1004
Peritoneal lavage (perform)
abdominal pain, presenc e/level (assessment), 1000
allergies, presenc e (identific ation), 995
c oagulation studies, 995
c omplementary CT sc an, 995
c omplic ations, monitoring, 1000
c omputer tomography (CT) sc an, usage, 994
doc umentation, 1000
DPL, impac t, 995
equipment, 995
expec ted outc omes, 999
family educ ation, 995
guidewire, introduc tion, 997
insertion site, c leansing, 996
lavage fluid
drainage, 999
instilling, 998
medic al history, obtaining, 995
nursing knowledge, 994-995
patient assessment, 995-996
patient educ ation, 995
patient monitoring/c are, 1000
patient preparation, 995-996
peritoneal fluid, c harac teristic , 994
plain radiographs, obtaining, 995
plastic c atheter, plac ement, 998f
preproc edural teac hings, understanding, 996
proc edure, 996-1000t
purpose, 994
red blood c ell (RBC) c ount, 994
respiratory status, c hanges (monitoring), 1000
unexpec ted outc omes, 999
Peritoneum, penetration, 985f
Periwound skin
assessment, 1152
c ondition, assessment, 1153
Permanent pac emaker, presenc e, 324, 332
Permanent pac emaker (assessing func tion)
antibradyc ardia pac ing, revised NAS PE/BPEG generic c ode, 404t
antitac hyc ardia pac ing, programming, 409
atrial ac tivity, identific ation, 407
bipolar pac ing, usage, 404
biventric ular pac emaker (c ardiac resync hronization therapy), 405f
leads, usage, 405
biventric ular pac ing, 410f
c ardiac pac ing, princ iples, 404
c ontraindic ations, 403
DDD pac emakers, c omponents, 404-405
DDD pac ing, 408f
DDD system, c apture/sense failure, 408f
doc umentation, 412
dual-c hamber DDD pac ing, 408f
dual-c hamber pac emakers, c omponents, 404-405
elec troc ardiographic (ECG) assessment, 406
elec troc ardiographic (ECG) rhythm, assessment, 407
elec tromagnetic interferenc e (EMI), impac t, 405-406
equipment, 406
expec ted outc omes, 411
family educ ation, 406
hemodynamic response, assessment, 406
information, provision, 406
intrinsic atrial ac tivity, absenc e, 409
intrinsic ventric ular ac tivation (left bundle branc h bloc k), 410f
intrinsic ventric ular ac tivity, absenc e, 409
learning needs, assessment, 406
left ventric ular dysfunc tion, 403
left ventric ular pac ing, 410f
Medtronic Kappa Pac emaker advertisement, 403f
nursing knowledge, 403-406
pac emakers
definitions, 404t
func tion, knowledge, 403
history, determination, 406
programmed mode, identific ation, 406
programmer, appropriateness, 406
systems, c omponents, 405
patient assessment, 406-407
patient educ ation, 406
patient monitoring/c are, 411
patient preparation, 406-407
permanent pac ing, indic ation, 403
proc edure, 407-412t
programmed pac ing modes, 405t
purpose, 403
rate-responsive pac emakers, inc lusion, 405
right ventric ular pac ing, 410f
support, identific ation, 406
unexpec ted outc omes, 411
unipolar pac ing, 404
ventric ular ac tivity, identific ation, 409
ventric ular oversensing, 408f
ventric ular undersensing, 408f
Permissive hypotension, c orrec tion, 1057
Persistent hemorrhage, mediastinal exploration (goal), 343, 350
Personal protec tive equipment (PPE), 1126
PetCO 2 monitoring devic es, 10, 23
pH, measurement, 713
Pharynx
hyperoxygenation/suc tion, 40, 44
suc tioning, oral airway (fac ilitation), 74
Phlebostatic axis, supine position, 676f
Photopheresis, 1070
Pin site c are (c ervic al tong/halo pins)
c leansing, 905
doc umentation, 906
equipment, 904
expec ted outc omes, 906
family educ ation, 905
nursing knowledge, 904
patient assessment, 905
patient educ ation, 905
patient monitoring/c are, 906
patient preparation, 905
preproc edural teac hings, understanding, 905
proc edure, 905-906t
purpose, 904
spinal c olumn, anatomy/physiology, 904
treatment options, 904
unexpec ted outc omes, 906
Pin sites, inspec tion, 904
Plain interrupted sutures, removal, 1146f
Plasma adsorption/perfusion, 1070
B. Braun Diapac t CRRT system, usage, 1071f
Plasma exc hange, 1070
proc edures, 1070
Plasmapheresis, proc edure, 1075-1078t
Plasma volume, estimate, 1070
Plateau pressure, c hange, 244
Platelet c ount, 804-805
Platelet levels, 615
assessment, 714
Plethysmography, requirement, 244
Pleural c ytology results, 215
Pleural effusion
c hest radiograph, assessment, 220-221
c lassific ation, 208
definition, 219
diagnosis, 219
measurement, 220-221
physic al findings, 210
suggestion, 220
presenc e, 210
verific ation, thorac entesis (nonusage), 208
signs/symptoms, 220
signs/symptoms, assessment, 210
Pleural fluid
LDH
amount, 208
c omparison, 219
LDH-to-serum LDH ratio, 208
c omparison, 219
protein-to-serum protein ratio, 208
c omparison, 219
samples, analysis, 208
Pleural pressure, influenc es, 130
Pleural tubes, plac ement, 171
Pleur-Evac , 184-185
Pleuritic c hest pain, 220
medic al history, assessment, 221
Pneumatic splint, usage, 225-226
Pneumomediastinum, barotrauma manifestation, 266
Pneumonia
ABG indic ation, 713
impac t, 244
Pneumoperic ardium, barotrauma manifestation, 266
Pneumothorax
barotrauma manifestation, 266
early detec tion, 268
postthorac entesis c omplic ation, 209
risk, 722, 739
Pneumothorax, c lassific ation, 154-155, 166-167, 204
Polytetrafluoroethylene-c oated (PTFE-c oated) unipolar/bipolar stainless steel wires, usage, 430
PORT-A-CATH reservoir, 746f
Positive end-expiratory pressure (PEEP), 264t
amount, identific ation, 245
c linic al goal, 235
level, selec tion, 272
mec hanic al ventilation, 154, 167
patient rec eipt, 209
presenc e/absenc e, 630
rec ording, 241
therapies, 260
thorac entesis c ontraindic ation, 219
Positive expiratory pressure (PEP), 285
effort dependenc y, 286
measurement, 289
illustration, 288f
purpose, 285
Positive-pressure relief valve, usage, 185
Positive-pressure ventilation (PPV), 263
c linic al goal, 235
c omplic ations, 263-266
assoc iation, 266-267
dominanc e, 262-263
hemodynamic c hanges, extent (assoc iation), 266
inadequate ventilation, symptoms (presenc e), 286
Postac ute MI, 513
Posterior-anterior c hest radiographs, performing, 210
Posterior (bac k) pac ing elec trode, loc ation, 416f
Posterior c erebral artery (PCA), insonation, 849
Posterior oropharynx, topic al anesthetic agent (applic ation), 951
Posterior sheepskin liner, c hange, 900
Posterior tibial nerve
elec trodes, plac ement, 307f
testing, 307
Postinsertion hemodynamic values, assessment, 623
Postoperative c ardiac surgery, 422
Postthorac entesis c omplic ation, 209
Power motion Doppler (M-mode), 855f
usage, 852
PowerPort devic e
needle ac c ess, 749f
triangulating, non-dominant hand (usage), 749f
Prec ordial dullness, 691
Pressure c ontrol inverse ratio ventilation (PC/IRV), 274
Pressure-c ontrolled/inverse ratio ventilation (PC/IRV), 264t
Pressure c onversion c hart, 185t
Pressure-induc ed injury, prevention princ iples, 1124
Pressure infusor bag, usage (purpose), 1057
Pressure modes, 264t
ventilator parameters, relationship, 264-265t
Pressure redistribution surfac es, c ontinual lateral rotation therapy/RotoRest lateral surfac e
bariatric pressure reduc tion surfac es, 1125
bladder assessment, 1127
Braden S c ale, usage, 1124
CPR, initiation, 1130
doc umentation, 1131
equipment, 1126
expec ted outc omes, 1130
family educ ation, 1126-1127
goals, disc ussion, 1127
KCI RotoRest Delta kinetic therapy bed, 1126f
kinetic therapy surfac e, patient positioning, 1128
lateral rotation therapy, proc edure, 1128-1131t
nursing knowledge, 1124-1126
patient assessment, 1127
patient educ ation, 1126-1127
patient monitoring/c are, 1130
patient preparation, 1127
pressure redistribution support surfac e, definition, 1124
pressure ulc er risk assessment, usage, 1124
preventative interventions, 1124
pulmonary status, assessment, 1127
purpose, 1124
skin assessment, 1127, 1130
unexpec ted outc omes, 1130
vasc ular system, assessment, 1127
wounds
assessment, 1127
healing, princ iples, 1125
Pressure support maximum (PS Vmax), initiation, 299
Pressure support-type ventilator, 642f
Pressure support ventilation (PS V), 225, 264t
c linic al goal, 299
level, selec tion, 274
weaning mode, 294
Pressure support weaning method, 299
Pressure transduc ers
attac hment, 975
pressure waveform detec tion, 670
system, 619
usage, 666
zeroing, 975
Pressure ulc ers
desc ription, NPUAP staging system (usage), 1159
wound debridement, 1159
Pressure ventilation
augmented inspiration, 263
usage, 263
Pressure waveform (detec tion), pressure transduc ers (usage), 670
Primary intention, 1149
Primary union, 1150f
Primary wound c losure, princ iples, 1134
Pronation therapy
analyses, variability, 129
doc umentation, 148
equipment, 132
expec ted outc omes, 144
family educ ation, 132
FRC, 130
lungs, zone model, 131f
mec hanic al ventilation, 129
meta-analyses, 129
nursing knowledge, 129-132
patient assessment, 132-133
patient educ ation, 132
patient monitoring/c are, 145
patient positioning, 133
patient preparation, 132-133
perfusion, distribution, 130
pleural pressure, influenc es, 130
proc edure, 134-148t
prone, lying, 138f
prone, turning
ventilator tubing, positioning, 135f
Vollman Prone Positioner, usage, 137f
size/weight load, assessment, 132
supine position, return, 139
illustration, 140f
supine position (turning), RotoProne Therapy S urfac e (usage), 143
tube feeding, c essation, 133
unexpec ted outc omes, 144
ventilation, distribution, 130
ventilator tubing, positioning, 135f
Proportional assist ventilation (PAV), 277
Protein-to-serum protein ratio, 208
Prothrombin time (PT), 615
assessment, 714
Proton pump inhibitors (PPIs), administration, 965
Proximal c uff, inflation, 4
Proximal left c irc umflex (LCX) c oronary artery, balloon inflation, 504f
Proximal lumens
infusions, 582-583
port, 617
Proximal tibia, palpation, 757
Pulmonary artery diastolic pressure (PADP), 623
c atheter insertion, 636
LVEDP measure, 626
PAOP
c omparison, 640
c orrelation, 610
Pulmonary artery distal lumen port, 626
Pulmonary artery oc c lusion (PAO) waveform, a wave elevation (oc c urrenc e), 656
Pulmonary artery oc c lusion pressure (PAOP)
c atheter insertion, 637
LVEDP measure, 626
measurement, 430, 578
obtaining, 639f
PADP
c omparison, 640
c orrelation, 610
referenc e, 655
waveform, 629f
Pulmonary artery (PA) balloon inflation syringe, removal, 663
Pulmonary artery (PA) c atheter
anatomy, 627f
understanding, 655
atrial/ventric ular pac ing lumens, usage, 430f
CCO c apability, 580-581
defec ts, examination, 632
external c entimeter marking, observation, 665
gate valve, 633f
insertion, waveform progression (sc hematic ), 628f
integrity, assessment, 649
loc ation, 627f
understanding, 655
monitoring, hemoptysis/bloody sec retions (development), 667
need, assessment, 652
plac ement, c onfirmation/verific ation, 236, 630
position (verific ation), waveform analysis (usage), 649
therapy, indic ations, 628
waveform c onfiguration, assessment, 656
wedge inability, troubleshooting, 665
wedging, air removal, 655
Pulmonary artery (PA) c atheter insertion (assist), pressure monitoring
alarms, setting, 634
assistanc e, 631
diastolic pressure, 636
doc umentation, 646
dual-c hannel rec orded strip, usage, 635
dual-c hannel strip, usage, 634
end expiration, hemodynamic pressure measurement, 640
equipment, 630
expec ted outc omes, 643
family educ ation, 630
gauze dressings, replac ement, 645
intermittent mandatory mec hanic al ventilation, end expiration determination, 641
mec hanic al ventilation, end expiration determination, 640
nursing knowledge, 626-630
PAOP, 637
measurement, obtaining, 639f
PA pressure measurements, obtaining, 634, 636f
PAP waveform, c hange, 638f
PA syringe, c onnec tion, 637
patient assessment, 630
patient educ ation, 630
patient monitoring/c are, 643
patient preparation, 630
pressure c ables, c onnec tion, 631
pressure transduc er system, c onnec tion, 631
proc edure, 631-646t
proximal injec tate lumen port, 626
purpose, 626
P wave, vertic al lines, 634f
QT interval identific ation, 637
RA/CVP, 634
measurements, obtaining, 635f
RA leveling, 632
sheath introduc er, plac ement, 631
spontaneous breathing, end expiration determination, 640
systolic pressure, 636
thermistor c onnec tor, c onnec tion, 631
unexpec ted outc omes, 643
Pulmonary artery (PA) c atheter insertion (perform)
advanc ement, 622f
bedside hemodynamic monitoring system, 619
c ardiac disorders, 618-619
c ardiac surgery, anesthesia, 618
c atheters, types, 617
c entral venous ac c ess, 618
obtaining, 620
c oagulopathic state, assessment, 620
c ontraindic ations, 619
distal lumen port, usage, 618
doc umentation, 623
elec trolyte imbalanc es, 619
equipment, 619
expec ted outc omes, 622
family educ ation, 619
general surgery, 618
hemodynamic assessments, 623
heparin sensitivity/allergy, assessment, 620
indic ations, 618-619
latex sensitivity/allergy, 620
markings, 621
mixed venous oxygenation monitoring ability, 621
nursing knowledge, 617-619
patient assessment, 619-620
patient educ ation, 619
patient monitoring/c are, 623
patient preparation, 619-620
peripheral vasc ular assessment, 623
postinsertion hemodynamic values, assessment, 623
pressure transduc er system, 619
proc edure, 620-623t
pulmonary disorders, 619
purpose, 617
right subc lavian vein, 618
systematic c ardiovasc ular assessment, 623
Trendelenburg position, 619
unexpec ted outc omes, 622
Pulmonary artery (PA) c atheter/pressure lines, troubleshooting
absent waveform, troubleshooting, 658
balloon inflation, 657f
blood bac kup troubleshooting, PA c atheter/pressure transduc er system (usage), 666
bloody sec retions, development, 667
c ontinuously wedged waveform, troubleshooting, 663
doc umentation, 668
endotrac heal tube, hemoptysis/bloody sec retions (development), 667
equipment, 656
expec ted outc omes, 667
family educ ation, 656
hemoptysis, development, 667
nursing knowledge, 655-656
overdamped waveform, troubleshooting, 659
overwedged balloon
prevention, 657
troubleshooting, 656
PA c atheter
monitoring, hemoptysis/bloody sec retions (development), 667
wedge inability, troubleshooting, 665
PAP c hange, troubleshooting, 666
PAP waveform, overdamping effec t, 659f
patient assessment, 656
patient educ ation, 656
patient monitoring/c are, 667
patient preparation, 656
patient/stopc oc k, air (presenc e), 661f
proc edure, 656-668t
purpose, 655
RAP waveform, overdamping effec t, 659f
right ventric le, c atheter troubleshooting, 664
stopc oc k, open position, 658f
unexpec ted outc omes, 667
waveforms, oc c urrenc e, 655
Pulmonary artery (PA) c atheter removal
c ardiac rate/rhythm, monitoring, 653
doc umentation, 653
equipment, 648-649
expec ted outc omes, 652
family educ ation, 649
hemostasis valve, c over, 650
introduc er
stabilization, 651f
withdrawal, 651
nursing knowledge, 648
patient assessment, 649
patient educ ation, 649
patient monitoring/c are, 652
patient preparation, 649
proc edure, 649-653t
purpose, 648
syringe removal, 650
Trendelenburg position, 649
unexpec ted outc omes, 652
vital signs, monitoring, 653
Pulmonary artery (PA) patenc y, maintenanc e, 591
Pulmonary artery (PA) waveforms, c ontinuous monitoring, 656, 667
Pulmonary artery pressure (PAP), 691
assessment, 1059
c hange
ac c urac y, 666
troubleshooting, 666
elevation, 655
measurements, obtaining, 634, 636f
respiratory fluc tuations, 641f
waveform
c hange, 638f
overdamping effec t, 659f
Pulmonary artery wedge pressure (PAWP), 629f
Pulmonary barotrauma
impac t, 266
signs/symptoms, assessment, 233
Pulmonary c apillary wedge pressure (PCWP), assessment, 1059
Pulmonary disorders, 619
Pulmonary edema, impac t, 244
Pulmonary embolus, 626
Pulmonary fibrosis, impac t, 244
Pulmonary hypertension, 626
Pulmonary status, monitoring, 326
Pulmonary vasc ular resistanc e (PVR), 578, 617
Pulsatile waveform, generation, 534f
Pulsatility index (PI), 851
Pulse generation
failure
illustration, 408f
pac emarker definition, 404t
pac emaker definition, 404t
Pulse generator
attac hment, 430
epic ardial wires, c onnec tion, 437
settings, 438
terminals, c able c onnec tions, 432f
Pulseless elec tric al ac tivity (PEA), 204
Pulselessness, 1120
Pulseless ventric ular tac hyc ardia, 333
assessment, 338
oc c urrenc e, 346, 352
Pulse oximetry
monitoring, sensor types/sites, 125f
usage, 9, 22, 959
Pulsus paradoxus, development, 364
Purse-string suture, 172f
P wave, vertic al lines, 634f
Q
QRS c omplexes
alignment, 611
appearanc e, 321
real-time method, 444
rec ognition, 443
T wave peak, defibrillator distinc tion, 322
QRS duration, prolongation, 392-393
QT interval, identific ation/alignment, 637
QT syndrome, 391
Quec kenstedt test, 876, 883
R
Radial artery
anatomic landmarks, 713f
pressure, maintenanc e, 530
punc ture, 715
syringe, usage, 717f
usage, 715
Randomized c ontrolled trial (RCT)
ARDS Network, 244-245, 263-266
standard weaning c riteria, 286
usage, 226
weaning proc ess, 291
Rapid infusion devic e, usage, 1058
Rapid shallow breathing index (fx/Vt), 286
c omparison, 292t
purpose, 285
Rate-responsive pac emakers, inc lusion, 405
Rec tum, BMS plac ement, 1180f
Red blood c ells (RBCs) c ount, 994
Reentrant tac hyc ardia, 380
Reexpansion pulmonary edema, oc c urrenc e, 209
Reintubation (prevention), NPPV (usage), 226
Renal replac ement therapy tec hniques, 1035
RENAS YS EZ, 1182
c omponents, 1183f
Resistanc e
definition, 244
measurement, purpose, 244
Resistanc e index (RI), 850f
Respiratory distress
indic ation, 268
signs/symptoms, 248-249
Respiratory effort, assessment, 59, 65
Respiratory exc ursion, adequac y (assessment), 1099
Respiratory frequenc y, selec tion, 271
Respiratory func tion, impairment, 908
Respiratory musc le enduranc e, measurement
spontaneous tidal volume, usage, 286
vital c apac ity, usage, 286
Respiratory musc le fatigue, 262, 294
Respiratory musc le rest, ensuring, 263
Respiratory rate (RR), 273
c alc ulation, 105
Respiratory status
assessment, 40
information, 286
monitoring, 858
Respirometer
attac hment, 287
removal, 253
usage, 286
Reverse Trendelenberg, 971
Rewarming shoc k, oc c urrenc e, 864
Right atrial pressure/c entral venous pressure (RAP/CVP)
measurement, obtaining, 635f
monitoring alarm, 566
waveform, wave identific ation, 629f
Right atrial pressure (RAP), 577-578, 617, 691
paper printout, reading, 606f
waveform, overdamping effec t, 659f
Right atrium, straight shot, 618
Right c oronary artery (RCA), oc c lusion, 511-513
Right heart preload, 577-578
Right heart pressure, 617
Right prec ordial ECG, elec trode loc ations, 506f
Right prec ordial leads, 505
purpose, 502
Right sc apula, posterior pad plac ement, 324f
Right shoulder, veins (loc ation), 764f
Right subc lavian vein, 618
Right-to-left intrapulmonary shunting, 259
expression, 259
hallmark, 259
Right ventric le (RV)
c atheter, troubleshooting, 664
waveform, identific ation, 664
Right ventric ular assist devic e (RVAD), 466-467
Right ventric ular ejec tion frac tion (RVEF), 617
Right ventric ular end-diastolic volume (RVEDV), 617
Right ventric ular pac ing, 410f
Right ventric ular pressure (RVP) waveform, 664f
Rotating Kinetic Treatment Table, 909f
RotoProne Therapy S urfac e
piec es, removal, 132
prone, turning, 141
supine, turning, 143
RotoProne Therapy S urfac e, usage, 140
RotoProne Therapy S ystem, 133f
RotoRest Delta kinetic therapy bed, 1126
RotoRest lateral rotation surfac e
kinetic therapy, 1125
purpose, 1124
Rule of nines, 1099
Rule of the palm, 1099
Running suture, removal, 1145
R wave
optimization, 448
rec ognition, 443
sync hronization, 322f
S
S c lerosing agents
ac tion, 1010
availability, 1010
injec tion, 1014f
list, 1011t
S ec ondary intention, 1149
S ec ondary suture, 1150f
S ec ond-degree burns, 1097-1098
S ec ond intention (granulation), 1150f
S edation sc ore, assessment, 1011
S eldinger’s tec hnique, 728
proc edure, 729f
usage, 733, 735
S elf-adhesive defibrillation pads
anterior-posterior plac ement, 324f
usage, 324
usage, 334
S elf-inflating manual resusc itation bag-valve-mask devic e
availability, ensuring, 280
c onnec tion, 4, 25
usage, 3, 286
S ellic k maneuver, applic ation, 9, 22
S emi-Fowler patient position, maintenanc e, 32
S engstaken-Blakemore tube, 947
plac ement, 948f
usage, 953
S ense failure, pac emaker definition, 404t
S ensing
pac emaker ability, 422
pac emaker definition, 404t
term, usage, 431
S ensitivity, pac emaker ability, 413
S ensitivity threshold
c hec king/doc umentation, 441
determination, 438
S ensory dermatomes, 898f
S erum ionized c alc ium, monitoring, 1077
S erum-to-asc ites albumin gradient, c alc ulation, 988
S et-positive end-expiratory pressure (set-PEEP), 239
auto-PEEP, relationship, 239f
splint purpose, 239-240
S evere agitation, NPPV (nonusage), 227
S harp debridement, 1161
equipment, 1160
performing, 1160
suc c ess, 1160
usage, 1160
S heath removal, assoc iation, 682
S heet graft, 1109-1110
S hivering, 862
body shaking, 862
early detec tion, 862
S hoc k resusc itation, goal, 1057-1058
S hort-term mec hanic al ventilation, long-term mec hanic al ventilation (c ontrast), 291
S hunt
c onc epts, 255
evaluation, 259
S hunt c alc ulation
doc umentation, 261
equipment, 259
expec ted outc omes, 260
family educ ation, 259
nursing knowledge, 259
oxygenation
inadequac y, signs/symptoms, 260
status, 259
patient assessment, 260
patient educ ation, 259
patient monitoring/c are, 261
patient preparation, 260
personal protec tive equipment, removal, 260
proc edure, 260-261t
pulmonary artery c atheter, usage, 259
purpose, 259
Qs/Qt equation, 259
right-to-left intrapulmonary shunting, 259
unexpec ted outc omes, 260
S hunted blood flow-to-total blood flow ratio (Qs:Qt)
c alc ulation, 255-256
table, 261t
expression, 259
trends
determination, 260
observation, 261
S hunted c ardiac output, inc rease, 259
S ignal quality intensity (S QI), 820
identific ation, 820
S ilastic drains, usage, 171-172
S ilic one nonthrombogenic c atheters, 154
S imple interrupted dermal suture, 1135
S ingle-c hamber temporary pulse generator, 431f
example, 431f
S ingle-c hamber ventric ular pac ing, 422
method, c ommonness, 430
S ingle CVC port, monitoring (avoidanc e), 568
S ingle-lumen urinary c atheter, c onnec tion, 970
S ingle-pressure transduc er system
c arpenter level, 677
doc umentation, 679
equipment, 672
expec ted outc omes, 678
family educ ation, 672
illustration, 670f
monitor setup, 675
nursing knowledge, 670-672
patient assessment, 672
patient educ ation, 672
patient monitoring/c are, 678
patient preparation, 672
phlebostatic axis, supine position, 676f
pressure transduc er system setup, disposal, 672
proc edure, 672-679t
purpose, 670
stopc oc k position, 674f
transduc er
leveling, 675
zeroing, 678
unexpec ted outc omes, 678
usage, 670
S ingle-shot peripheral nerve bloc ks, 939t
S inusitis, weaning c omplic ation, 291
S inus node
dysfunc tion, 421
overdrive suppression, 381
S keletal trac tion, princ iples, 908
S kin
c ross sec tion, 1097f
eversion, promotion, 1135
integrity, assessment, 865
S kin graft c are
baseline vital signs, 1115
blebs, rec urrenc e, 1110f
c omplic ations, signs (monitoring), 1112
c ultured epidermal autografts, usage, 1110-1111
doc umentation, 1116
equipment, 1112
expec ted outc omes, 1115
family educ ation, 1112
fluid evac uation, c aution, 1110
graft, stapling/suturing, 1111
graft plac ement goals, 1110
length of stay (LOS ), usage, 1111
meshed split-thic kness skin graft, 1109f
arm c overing, 1111f
nonadherent dressing, applic ation, 1114
nonviable tissue, surgic al exc ision, 1110
nursing knowledge, 1109-1112
pain assessment, 1115
pain c ontrol regimen, adequac y (determination), 1113
patient assessment, 1112-1113
patient educ ation, 1112
patient mobilization, 1111
patient monitoring/c are, 1115
patient preparation, 1112-1113
positioning, importanc e, 1112
proc edure, 1113-1116t
explanation, 1112
purpose, 1109
sc issors/forc eps, usage, 1114
splints, applic ation, 1114
split-thic kness skin graft (S TS G), 1109
suc c ess, evaluation, 1112
surgic al blade/c otton-tipped applic ator, usage, 1110f
unexpec ted outc omes, 1115
vital signs, assessment, 1112
wound c are, pain (relationship), 1111
S kin grafts (autografts), 1109
c ontrac tion, 1111
treatment, impac t, 1109
S low c ontinuous ultrafiltration (S CUF), 1020f
usage, 1021
S low-release silver dressings, usage, 1092
S mall-bore feeding tube insertion, elec tromagnetic guidanc e system (CORTRAK)
doc umentation, 1199
equipment, 1192
expec ted outc omes, 1199
family educ ation, 1192-1193
feeding tube
length, determination, 1194
water flushing, 1195
gastrointestinal func tion, assessment, 1193
nursing knowledge, 1192
patient assessment, 1193-1194
patient educ ation, 1192-1193
patient monitoring/c are, 1199
patient preparation, 1193-1194
proc edure, 1194-1199t
purpose, 1192
unexpec ted outc omes, 1199
S mall-bore feeding tube insertion/c are
abdominal radiograph, obtaining, 1208
doc umentation, 1209
equipment, 1206
expec ted outc omes, 1209
family educ ation, 1207
nursing knowledge, 1206
patient assessment, 1207
patient educ ation, 1207
patient monitoring/c are, 1209
patient preparation, 1207
postpyloric plac ement, 1208
proc edure, 1207-1209t
purpose, 1206
small-bore tubes, preferenc e, 1206
unexpec ted outc omes, 1209
S pinal anatomy, 916f
S pinal c olumn, anatomy/physiology, 904
S pinal c ord, struc ture, 916f
S pinal c ord injuries
ac ute physiologic responses, 912t
in-line c ervic al immobilization maintenanc e, 10, 23
S pinal shoc k, 908
S pirometry, requirement, 244
S plenomegaly, 209
thorac entesis c ontraindic ation, 219
S plit-thic kness skin graft (S TS G), 1109
S pontaneous breathing
end expiration determination, 640
PAP waveform, respiratory fluc tuations, 641f
S pontaneous breathing trials (S BTs), 293
S pontaneous respiratory rate (fx), 273
ratio, 286
S pontaneous tidal volume (S Vt), 285
measurement, 286-287
purpose, 285
S tandard weaning c riteria (S WC), 285-286
doc umentation, 290
equipment, 286
expec ted outc ome, 289
family educ ation, 286
inadequate ventilation, signs/symptoms (assessment), 286
inspiratory one-way valve, c losure/c apping, 287
Level B, 287
measurements, c omparison, 289
nursing knowledge, 285-286
patient assessment, 286-287
patient educ ation, 286
patient inhalation, instruc tion, 288
patient monitoring/c are, 289
patient preparation, 286-287
patient verific ation, identifiers (usage), 287
proc edure, 287-290t
purpose, 285
randomized c ontrolled trials (RCTs), 286
respirometer, attac hment, 287
unexpec ted outc omes, 289
usage, 286
S taple removal
allergies, assessment, 1145
doc umentation, 1148
equipment, 1144
expec ted outc omes, 1148
family educ ation, 1144
illustration, 1147f
injury/medic al history, obtaining, 1145
nursing knowledge, 1144
patient assessment, 1145
patient educ ation, 1144
patient monitoring/c are, 1148
patient preparation, 1145
proc edure, 1147-1148t
purpose, 1144
staple line, c leaning, 1147
suture line, c leaning, 1145
timing, 1144
unexpec ted outc omes, 1148
S taples, usage, 1134
S tapling, usage, 1134
S tarc lose, 682
S tatic c omplianc e (Cstat), 244
measurement, 244
breath-hold maneuver, 244
trends, observation, 246
ventilatory respiratory c yc les, observation, 246
S tatic pressure
elevation, auto-PEEP (impac t), 239
helpfulness, 244-245
S tatloc k Devic e, 772f
S tatus asthmatic us
auto-PEEP risk, 240
NPPV, nonusage, 226
S tay suture, 160f
S teri-S trips, usage, 1134
S ternal notc h, identific ation, 495
S ternal retrac tor, plac ement, 346
S ternum, palpation, 758
S timulation threshold
c hec king/doc umentation, 441
determination, 438
S toma drainage, skin integrity/quality (assessment), 1204
S traight laryngosc ope blade (Miller blade), usage, 9, 22
S treptoc oc c us pyogenes, , 1151
S troke evaluation, 706
S troke volume/stroke index (S V/S I), 617
S troke volume (S V), c ardiac output (relationship), 577
S tryker intrac ompartmental pressure monitor, 1121f
S ubarac hnoid hemorrhage, 836
S ubc lavian vein
ac c ess, avoidanc e, 1033
anatomic loc ation, 730f
c entral c atheter plac ement, 722
CVC insertion, 731
loc ation, 731
punc ture, 732f
S ubc utaneous emphysema
barotrauma manifestation, 266
development, 182
S ubc utaneous sutures, inverted knot/buried stitc h, 1135
S ubc utic ular running suture, 1135
appearanc e, 1136f
S ubglottic sec retion drainage ET tube, plac ement, 36
S ubglottic suc tioning, 34
S ubmandibular insonation, 858
S udden c ardiac death (S CD), risk fac tors, 391
S uic ide prec autions, institution, 965
S uperior vena c ava plac ement, c atheter length measurement, 766f
S upplemental oxygen/aerosol, applic ation, 41
S upply-related isc hemia, S T-segment pattern, 512f
S upramaximal stimulation (S MS )
determination, 308
level, determination, 305
S upraventric ular dysrhythmias, 380
S upraventric ular tac hyc ardia (S VT), development, 541f
S urgic al c ric othyrotomy (assist)
absolute c ontraindic ations, 64
airway patenc y, assessment, 65
assistants, availability, 66
c ontraindic ations, 64
doc umentation, 67
equipment, 65
expec ted outc omes, 67
family educ ation, 65
nec essity, 64
nursing knowledge, 64
patient assessment, 65
patient educ ation, 65
patient monitoring/c are, 67
patient preparation, 65
patient unresponsiveness, 65
proc edure, 66-67t
relative c ontraindic ations, 64
respiratory effort, assessment, 65
unexpec ted outc omes, 67
usage, 64
S urgic al c ric othyrotomy (perform)
airway c ompromise, potential, 59
airway patenc y, assessment, 59
c ontraindic ations, 58-59
doc umentation, 63
equipment, 59
expec ted outc omes, 62
nec essity, 58
nursing knowledge, 58-59
patient assessment, 59
patient educ ation, 59
patient monitoring/c are, 62
patient preparation, 59
proc edure, 60-63t
respiratory effort, assessment, 59
sc alpel
direc tion, 61
usage, 61f
self-inflating manual resusc itation bag-valve devic e, attac hment, 62
unexpec ted outc omes, 62
usage, 58
S urgic al debridement, usage, 1160
S urgic al site infec tions, risk fac tors, 1134
S urgic al/trauma stress response, 916
S ustained low effic ienc y dialysis (S LED), 1022
usage, 1035
S uture removal, 1135
allergies, assessment, 1145
doc umentation, 1148
equipment, 1144
expec ted outc omes, 1148
family educ ation, 1144
injury/medic al history, obtaining, 1145
mattress sutures, removal, 1146
nursing knowledge, 1144
patient assessment, 1145
patient educ ation, 1144
patient monitoring/c are, 1148
patient preparation, 1145
proc edure, 1145-1146t
purpose, 1144
sterile forc eps/sc issors, usage, 1146f
suture line, c leaning, 1145
timing, 1144, 1144t
unexpec ted outc omes, 1148
S utures
c harac teristic s, 1134
number, requirement, 1135
usage, 172
S wab c ulture, 1154
S ymmetric al c hest wall movement, observation, 16, 26
S ympathetic neural stimulation, dec rease, 578
S ync hronization mode, verific ation, 325
S ync hronized c ardioversion, rec ommendation, 319
S ync hronized intermittent mandatory ventilation (S IMV), 264t
usage, 270
weaning method, 298
S ync ope, presenc e, 391
S yringe preparation, c losed method, 585-587t
S ystemic hydration, adequac y, 31
S ystemic inflammatory response syndrome (S IRS ), 863
S ystemic jugular venous oxygen (S jVO 2), 792
S ystemic toxic ity, assessment, 944
S ystemic TPA therapy, monitoring, 851
S ystemic vasc ular resistanc e (S VR), 691
assessment, 1059
S ystolic blood pressure, dec rease, 226
S yvek Patc h, 681
T
Tac hyc ardia, 204, 626
development, 364
IABP troubleshooting, 455
Tac hydysrhythmia
c onversion, 326
ECG results, assessment, 320, 330
treatment, AHA energy level rec ommendation, 325t
Tac hypnea, 286
development, 364
pleural effusion sign/symptom, 204
Tac tile fremitus, pleural effusion sign/symptom, 220
Tamponade (sec uring), helmet (usage), 949f
TandemHeart (Cardiac Assist), 467
Teeth, absenc e (impac t), 226
Telemetry monitoring system, 492f
Temperature, terms (usage), 862t
Temporary atrial pac ing, 430
Temporary epic ardial pac ing, 430-431
Temporary invasive pac ing
indic ation, 429-430
methods, 430
Temporary pac ing, usage (impac t), 429
Temporary pulse generator, 432
features, 422
Temporary transc utaneous (external) pac ing
analgesic , administration, 415
anterior (front) pac ing elec trode, loc ation, 416f
anterior-lateral pac ing elec trodes, loc ation, 417f
async hronous mode, oc c urrenc e, 413
bac k pac ing elec trodes, applic ation, 416
bedside ECG monitoring, maintenanc e, 415
c ardiac output, 418
c ardiac rate/rhythm
assessment, 414
monitoring, 419
c omfort level, monitoring, 419
doc umentation, 420
elec tric al c apture, oc c urrenc e, 413-414
elec troc ardiographic (ECG) elec trodes, applic ation, 415-416
elec troc ardiographic (ECG) lead, adjustment, 416
elec troc ardiographic (ECG) rec ording strip, obtaining, 419
equipment, 414
expec ted outc omes, 418
external c ardiac pac ing, 413
external pac emaker settings, c ontrols, 417f
external pac ing, ECG trac ing, 414f
family educ ation, 414
front pac ing elec trodes, applic ation, 416
hemodynamic response, determination, 414-415
indic ations, 413
LIFEPAK 20, 414f
nondemand mode, oc c urrenc e, 413
nursing knowledge, 413-414
pac emaker
firing, 418
func tion, evaluation, 419
pac ing elec trodes
adherenc e, c hec king, 419
c onnec tion, 417
patient assessment, 414-415
patient educ ation, 414
patient monitoring/c are, 418
patient preparation, 414-415
patient verific ation, identifiers (usage), 415
posterior (bac k) pac ing elec trode, loc ation, 416f
proc edure, 415-420t
pulse generator, usage, 415
purpose, 413
sedation
administration, 415
level, monitoring, 419
sedative/analgesic medic ation, administration, 415
sensitivity, 413
systemic tissue perfusion, 418
temporary pac emaker func tion, knowledge, 413
transvenous pac ing, indic ation, 413
unexpec ted outc omes, 418
vital signs, monitoring, 418
Temporary transvenous/epic ardial pac ing
advanc ed c ardiac life support, knowledge/skills, 429
atrial epic ardial lead, loc ation, 431f
AV demand pac ing, 436
battery plac ement, 433f
bedside monitoring system, usage, 435
c apture, term (usage), 431-432
c ardiac rate/rhythm, assessment, 439
c hest radiograph, obtaining, 440
c onnec ting c ables, 431f
attac hment, 433
dual-c hamber temporary pulse generator, 431f
ECG, evaluation, 441
elec tric al safety princ iples, knowledge, 429
elec trodes, positioning, 436
elec trolyte levels, monitoring, 441
epic ardial pac ing wires, exposure, 437
epic ardial wires, pulse generator c onnec tion, 437
equipment, 432
family educ ation, 432
hemodynamic monitoring, princ iples (importanc e), 429
hemodynamic response, monitoring, 441
institutional polic y, c hec king, 436
invasive temporary pac ing, methods, 430
nursing knowledge, 429-432
oc c urrenc e, 431
PA c atheter, usage, 430
pac emaker
mode, setting, 437
stability, provision, 440
patient assessment, 432-433
patient c onnec tion, 433
patient educ ation, 432
patient preparation, 432-433
personal protec tive/sterile equipment, usage, 434
positive/negative elec trode c onnec tor pins, c onnec tion, 435
proc edure, 433-442t
pulmonary artery oc c lusion pressure (PAOP), measurement, 430
pulse generator terminals, 432f
purpose, 429
sensing, term (usage), 431
sensitivity threshold
c hec king/doc umentation, 441
determination, 438
single-c hamber temporary pulse generator, 431f
stimulation threshold
c hec king/doc umentation, 441
determination, 438
temporary invasive pac ing
indic ation, 429-430
methods, 430
temporary pac emakers, usage
c linic al/tec hnic al c ompetenc e, 429
insertion, 429
understanding, 429
transvenous pac ing lead wire, position verific ation, 434
12-lead ECG mac hine, usage, 435
ventric ular epic ardial lead, loc ation, 431f
vital signs, monitoring, 441
Temporary transvenous pac emaker insertion (perform)
alligator c lips, 425f
AV interval dial, 422
balloon-tipped pac ing c atheter insertion, 424
bipolar lead wire, 422f
c apture, referenc e, 422
c ardiac rhythm, assessment, 423
c entral line insertion, c linic al/tec hnic al c ompetenc e, 421
c entral venous ac c ess, presenc e/position (assessment), 423
c omplic ations, monitoring, 428
c onduc tion system fac ts, 423
c onnec ting c able, attac hment, 424
doc umentation, 428
dressing, c hange, 428
dual-c hamber pac ing, requirements, 422
elec tric al safety princ iples, applic ation, 421
elec troc ardiographic (ECG) observation, 426
elec troc ardiographic (ECG) rhythm, rec ording, 426f
elec trodes, positioning, 426
elec trolyte levels, monitoring, 428
equipment, 423
expec ted outc omes, 427
family educ ation, 423
guidewire, 423
hemodynamic response, assessment, 423
indic ation, 421-422
informed c onsent, obtaining, 424
laboratory study results, review, 423
learning needs, assessment, 423
medic ations, review, 423
nursing knowledge, 421-423
pac emaker
c onnec tions, ensuring, 428
depolarization ability, 423
func tion, assessment, 424
stability, provision, 426
pac ing lead
advanc ement, 425
type, 422
pac ing oc c urrenc e, 422
pain medic ation, presc ription, 424
patient assessment, 423-424
patient educ ation, 423
patient monitoring/c are, 427
patient preparation, 423-424
performing, 421
prec autions/restric tions, desc ription, 423
pre-proc edure verific ation, performing, 424
proc edure, 424-428t
desc ription, 423
purpose, 421
sedation, administration, 424
sensing, referenc e, 422
sensitivity/threshold, c hec king/doc umentation, 427
single-c hamber ventric ular pac ing, 422
temporary pac emakers, usage (c linic al/tec hnic al c ompetenc e), 421
temporary pulse generator, features, 422
transc utaneous ultrasound, avoidanc e, 425
unexpec ted outc omes, 427
usage, 421
veins, usage, 422
Temporary transvenous pac ing, pulse generator attac hment, 430
Tenc khoff c atheter, usage, 1049f
Tension pneumothorax, 154, 167
emergenc y evac uation, one-way flutter (usage), 205f
medic al emergenc y, 204
signs/symptoms, c onsistenc y, 205
Tertiary intention, 1149
Therapeutic apheresis, 1070
indic ation c ategories, 1071
list, 1072-1074t
Therapeutic lavage, 1002
usage, 994
Therapeutic plasma exc hange (assist)
B. Braun Diapac t CRRT system, usage, 1071f
doc umentation, 1078
equipment, 1074
expec ted outc omes, 1076
family educ ation, 1074-1075
medic ation administration, holding, 1077
nursing knowledge, 1070-1074
patient assessment, 1075
patient c are, 1077
patient educ ation, 1074-1075
patient monitoring, 1077
patient preparation, 1075
plasma exc hange treatment, 1071
proc edure, 1075-1078t
purpose, 1070
unexpec ted outc omes, 1076
Therapeutic thorac entesis, 209
amylase testing, 215
anaerobic /aerobic media bottles, usage, 220
assistanc e, proc edure, 221-224t
c atheter advanc ement, 215
c atheter insertion, 214
c omplete blood c ount (CBC) tubes, usage, 220
equipment, requirement, 220
evac uated bottles, attac hment, 215
indic ation, 208, 219
needle attac hment, 214
needle insertion, 213
patient response, evaluation, 214
pH testse, 215
pleural fluid
filling, 215
obtaining, 214
pleural fluid-filled syringe, spec imen tubes (filling), 213
proc edure, 211-217t
three-way stopc oc k, attac hment, 213
Vac utainer attac hment, 215
Thermal injuries, emergenc y treatment, 1100
Thermistor c onnec tor, 626
Thermodilution c ardiac output (TDCO)
ac c urac y, 580
method, 579
Thermodilution PA c atheter, 627f
Thermoregulation, alteration, 861
Thigh, musc le c ompartments, 1119f
Third-degree burn (full-thic kness burn), 1098
Third intention (sec ondary suture), 1150f
Thorac entesis (assist)
assistanc e, proc edure, 221-224t
atropine, availability, 221
baseline vital signs, assessment, 221
c ompletion, 222
c ontraindic ations, 219
diagnostic thorac entesis
baseline diagnostic study results, 220
equipment, 220
indic ation, 219
doc umentation, 224
equipment, 220
assembly, 221
expec ted outc omes, 223
family educ ation, 220
hemidiaphragm, obliteration, 220-221
laboratory results, assessment, 221
nonusage, 219
nursing knowledge, 219-220
patient assessment, 220-221
patient educ ation, 220
patient monitoring/c ase, 223
patient positioning, 221
assistanc e, 222
patient preparation, 220-221
patient repositioning, 223
patient role, explanation, 220
patient vital signs, monitoring, 222
performing, 219
personal protec tive equipment, removal, 223
pre-proc edure verific ation/time-out, performing, 221
proc edure, 221-224t
explanation, 220
pulse oximetry
monitoring, initiation, 221
usage, 221
punc ture site, pressure (applic ation, 222
purpose, 219
explanation, 220
sedation/paralysis, c onsideration, 221
soiled equipment/supplies, disposal, 223
therapeutic thorac entesis, 220
anaerobic /aerobic media bottles, usage, 220
c omplete blood c ount (CBC) tubes, usage, 220
equipment, requirement, 220
indic ation, 219
ultrasound sc an-guided thorac entesis, impac t, 220
unexpec ted outc omes, 223
Thorac entesis (perform), 208-218
analgesia, 217
baseline diagnostic study results, 209
c atheter insertion, 208
c hest radiograph, assessment, 210
c ompletion, 216
c omplic ations, 209
c omputed tomography (CT), usage, 208
c ontraindic ations, 208-209
diagnostic thorac entesis, 209
doc umentation, 217
equipment, 209
example, 212-214f
expec ted outc omes, 216
family educ ation, 209
hemorrhagic c omplic ations, 209
lateral c hest radiographs, performing, 210
magnetic resonanc e imaging (MRI), usage, 208
needle insertion, 208
plac ement, 212-214f
nursing knowledge, 208-209
patient assessment, 210
patient educ ation, 209
patient monitoring/c are, 216
patient position, 212-214f
patient preparation, 210
posterior-anterior c hest radiographs, performing, 210
proc edure, 211-217t
therapeutic thorac entesis, 209
three-way stopc oc k syringe, c atheter attac hment, 212-214f
ultrasound sc an
guidanc e, c onsideration, 210
usage, 208
unexpec ted outc omes, 216
Thorac ic c avity, c losed airspac e, 154, 166, 204
Thora-Klex, 184-185
Thoratec alarms, troubleshooting, 481
Thoratec biventric ular assist devic e (BiVAD), 467f
Thoratec dual driver, 478
Thoratec IVAD, 466-467
patient monitoring/c are, 486
Thoratec Parac oporeal Ventric ular Assist Devic e (PVAD), 466
patient monitoring/c are, 486
Thoratec TLC-II, 478
alarms, troubleshooting, 482
full signal, loss, 482
high pressure, 482
high temperature, 482
high vac uum, 482
internal alarm, 483
low temperature, 483
low vac uum, 482
mec hanic al failure, 483
oc c lusion alarms, 482
servic e interval, 483
startup proc edure, 480
Three-bottle c hest drainage system, 194f
Three-bottle system, disposable system (c orrelation), 185f
Three-in-one peripheral nerve bloc k, usage, 937
Three-point mattress suture, 1135
Three-way stopc oc k
syringe attac hment, 568f, 569f, 574f
syringe/vac utainer, c atheter attac hment, 212-214f
usage, 220
Threshold, c hec king, 427
Thromboc ytapheresis, 1070
Thrombolysis in brain infarc tion (TIBI)
flow grade definitions, 854t
grading sc ale, 853f
usage, 851
Tidal volume (Vt)
division, 246
ensuring, 263
rec ording, 245
Tissue hypoxia, assessment, 235
Tissue oxygenation (inadequac y), signs/symptoms (assessment), 236
Tissue plasminogen ac tivator (TPA) therapy, monitoring, 851
TLC-II (Thoratec ), 478
alarms, troubleshooting, 482
full signal, loss, 482
high pressure, 482
high temperature, 482
high vac uum, 482
internal alarm, 483
low temperature, 483
low vac uum, 482
mec hanic al failure, 483
oc c lusion alarms, 482
servic e interval, 483
startup proc edure, 480
TOF response determination, NMBD infusion, 308
Topic al antimic robial agents, usage, 1101t
Total PEEP
rec ording, 241, 245
subtrac tion, 245-246
Trac hea
Combitube insertion, 2f
deviation, 220
oc c lusion, distal c uff (usage), 1
Trac heal deviation, 204
Trac heal dilator, insertion, 61
Trac heal muc osal damage, 80
Trac heal tube c uff c are
air-filled syringe, attac hment, 92
c uff leakage, signs/symptoms (assessment), 90
c uff pressure measurement, 91
pressure monitor, usage, 92f
doc umentation, 95
D-shaped trac hea, c ross-sec tional view, 89f
emergenc y c uff inflation, attac hments, 93f
equipment, 89
expec ted outc omes, 94
family educ ation, 89-90
hyperoxygenation, 90
inadequate ventilation, signs/symptoms (assessment), 90
inflation valve, fault, 92-93
MLT, 88
tec hnique, 91
MOV, 88
tec hnique, 90
nursing knowledge, 88-89
patient assessment, 90
patient educ ation, 89-90
patient monitoring/c are, 94
patient preparation, 90
proc edure, 90-95t
explanation, 89
trac heal c uff problems, troubleshooting, 92
unexpec ted outc omes, 94
Trac heostomy
c apping, 43
c are, 103
c ollar, plac ement, 99
indic ations, 97t
insertion, sites, 96f
surgic al c reation, 96f
twill tape, plac ement, 101f
Trac heostomy tube c are
c ardiopulmonary status, assessment, 98
c uffed tube, appropriateness, 97
doc umentation, 103
equipment, 98
expec ted outc omes, 101
family educ ation, 98
hyperoxygenation, 99
nondisposable inner c annula, 99
nursing knowledge, 96-98
patient assessment, 98
patient educ ation, 98
patient monitoring/c are, 102
patient preparation, 98
proc edure, 99-103t
trac heostomy dressing, removal, 99
twill tape, usage, 100
unexpec ted outc omes, 101
Trac heostomy tubes
holder, attac hment, 100
parts, 96-97
illustration, 97f
plac ement, timing, 291
view, 98
Trac heostomy tube suc tioning
c ardiopulmonary status, monitoring, 82
c atheter size, guidelines, 32t, 81t
c losed-suc tion tec hnique, 83, 85
illustration, 80f
doc umentation, 86
equipment, 80-81
expec ted outc omes, 86
family educ ation, 81
hyperoxygenation, 83
indic ations, 79
nursing knowledge, 79-80
open-suc tion tec hnique, 82, 85
patient assessment, 81
patient educ ation, 81
patient monitoring/c are, 81
patient preparation, 81
PEEP valve, 81
proc edure, 82-86t
self-inflating manual resusc itation bag-valve devic e, removal, 83
suc tion c atheter c ontrol vent, thumb plac ement, 84
unexpec ted outc omes, 86
ventilator c irc uit, removal, 83
Trac heostomy tube usage, 79
Trac heotomy, 96f
c ollar, setup, 295
dec ision, 97
performing, 97
surgic al proc edure, 96
Trac tion maintenanc e, proc edure, 909-914t
Train-of-four (TOF) key, depression, 306
Train-of-four (TOF) response testing, 304
Train-of-four (TOF) retesting, 308
Train-of-four (TOF) stimulation
c orrelation, 304t
method, usage, 303
Train-of-four (TOF) testing, performing, 310
Transc ranial Doppler (TCD) insonation, windows, 849f
Transc ranial Doppler (TCD) monitoring
blood pressure, obtaining, 853
c irc le of Willis, variants, 853f
c linic al c onditions, 851
CPP, determination, 853
c riteria, 850
differential diagnosis, 852t
distal c irc ulatory c onditions, 851
doc umentation, 859
equipment, 852
expec ted outc omes, 858
family educ ation, 852-853
foc al intrac ranial c onditions, 851
ICP, measurement, 853
low-resistanc e flow, 858
neurologic findings, 851
nursing knowledge, 849-852
patient assessment, 853-855
patient educ ation, 852-853
patient history, 853
patient monitoring/c are, 858
patient positioning, assessment, 853-855
patient preparation, 853-855
PMD (M-mode), usage, 852
power motion Doppler (M-mode), 855f
proc edure, 856-859t
proximal extrac ranial c onditions, 851
purpose, 849
respiratory/c ardiovasc ular status, monitoring, 858
submandibular insonation, 858
TIBI grading sc ale, 853f
transforaminal insonation, 857
transorbital insonation, 857
transtemporal insonation, 856
unexpec ted outc omes, 858
Transc ranial Doppler (TCD) sc an findings, c riteria, 851t
Transc ranial Doppler (TCD) sc an monitoring, proc edure, 856-859t
Transc utaneous oxygen pressure (Tc pO 2) evaluation, 1184
Transc utaneous pac ing
c ontraindic ations, 413
indic ations, 413
Transc utaneous ultrasound, avoidanc e, 425
Transdermal medic ation patc hes, removal, 330
Transduc ers
air, fast flush, 660
blood, presenc e, 663
pole mount, 675f
stopc oc k opening, 658f
Transesophageal atrial pac ing stress ec hoc ardiography (TAPS E), 706
Transesophageal ec hoc ardiography (assist) (TEE)
abdominal esophageal perforation, 711
absolute c ontraindic ations, 707
baseline assessments, 708
baseline c ardiac rhythm, assessment, 708
c ardiac assessment, 706
c ardioversion, 706
c ervic al area, esophageal perforation, 710
c ontraindic ations, 707
doc umentation, 711
ECG monitoring, 708
ec hoc ardiography tec hniques, 705
equipment, 707
expec ted outc omes, 710
family educ ation, 707
fiberoptic probe, usage, 705
hemothorax/pneumothorax, perforation, 711
imaging, risk, 705
indic ations, 705-707
informed c onsent, 708
IV c onsc ious sedation, administration, 709
medic ations, c onfirmation, 707-708
nursing knowledge, 705-707
patient assessment, 707-708
patient educ ation, 707
patient monitoring/c are, 710
patient preparation, 707-708
preproc edure verific ation, 708
probe, insertion, 706f
proc edure, 708-711t
purpose, 705
relative c ontraindic ations, 707
saline c ontrast, administration, 709
sedation sc ore, assessment/monitoring, 710
sensitivity/spec ific ity, 706
thorac ic perforation, 711
ultrasound beams, penetration, 706
ultrasound transduc er, insertion, 705
unexpec ted outc omes, 710
usage, 706
vital signs, assessment, 708
Transesophageal ec hoc ardiography-dobutamine stress ec hoc ardiography (TEE-DS E), 706
Transforaminal insonation, 857
Transient fec al inc ontinenc e, c ommonness, 1177
Transient isc hemic attac k, 706
Transjugular intrahepatic portosystemic shunt (TIPS ), 1010
Transnasal hypophysec tomy, 10
Transorbital insonation, 857
Transtemporal insonation, 856
Transthorac ic imaging, risk, 705
Transthorac ic impedanc e, measurement/c ompensation, 329-330
Transudative effusions
systemic etiologies, assoc iation, 219
Transudative effusions, assoc iation, 219
Transudative pleural effusion
c onsideration, 208
option, 219
Transvenous atrial pac ing, 382
Transvenous pac ing, 430
balloon-tipped bipolar lead wire, usage, 430f
elec trode c onnec tor pins, usage, 381
lead
insulation, 422
wire, position verific ation, 434
Trapezius pinc h, 1214f
Trauma
history, assessment, 11, 24
patient, positioning, 12
Trauma-assoc iated wounds, c onsiderations, 1151
Trauma-induc ed c oagulopathy, c orrec tion, 1057
Traumatic brain injury, 836
Trendelenburg position, 596, 619
Triple-pressure transduc er system
illustration, 671f
usage, 670
Tube c uff, deflation, 40, 44
Tuberc ulosis c ultures, sterile tubes (usage), 220
Tube thorac ostomy, sites, 155f
Tube thorac otomy insertion tray, 155
T wave peak, QRS c omplex peak (defibrillator distinc tion), 322
12-lead elec troc ardiogram, 375f
atrial pac ing wires, c onnec tion, 377f
c hest leads, 522
doc umentation, 526
equipment, 520
expec ted outc omes, 524
family educ ation, 520
horizontal plane leads, 520f
lead sites, identific ation, 521
limb lead
plac ement, 521f
reversal, 525f
mac hine, usage, 375, 377
multiple-c hannel ECG mac hine, 523f
nursing knowledge, 519-520
patient assessment, 520
patient educ ation, 520
patient monitoring/c are, 526
patient preparation, 520
prec ordial/c hest lead plac ement, 522f
pregelled elec trodes, usage, 523
proc edure, 521-526t
purpose, 519
rec ording
illustration, 525f
interpretation, 524
obtaining, 524
unexpec ted outc omes, 524
vertic al plane leads, 69f
wireless ECG devic e, example, 520f
12-lead S T-segment monitoring, lead plac ement, 514f
2-oc tyl c yanoac rylate, usage, 1134
Twill tape, usage, 17, 27
Two-dimensional (2-D) ec hoc ardiography, 705
Two-dimensional ec hoc ardiogram
ensuring, 368
usage, 359, 366-367
U
Ulnar nerve
elec trodes, plac ement, 306f
pre-gelled elec trodes, applic ation, 305
rec ommendation, 304
testing, 305
Ultrafiltration (UF), 1018-1020, 1033
c oeffic ients, 1020
monitoring, 1030
Ultrasound sc an-guided thorac entesis, 220
Underdamped waveform
monitoring, 545
troubleshooting, proc edure, 542t
Uniform Anatomic al Gift Ac t, c reation, 1223
Uniform Determination of Death Ac t (UDDA)
passage, 1223
publishing, 1211
Unipolar AEG
multic hannel telemetry/bedside ECG, usage, 372
strip, lead I, 375f
Unipolar elec trogram, 371
Unipolar pac ing, involvement, 404
Upper airway, anatomy/physiology (understanding), 1
Upper arm, veins (loc ation), 764f
Upper endosc opic interventions, fiberoptic endosc ope (usage), 1010
Upper gastrointestinal (GI) bleeding, history, 1011
Upper gastrointestinal (GI) hemorrhage, 1010
Urine c ollec tion devic e, Foley Manometer (usage), 978f
V
V.A.C. ac c ess, 1037
V.A.C. disc onnec tion, 1039
V.A.C. dressing removal proc edure, 1188
Vac uum-Assisted Closure S ystem, 1182f
Validated pressure ulc er risk assessment, usage, 1124
Vallec ula, blade tip plac ement, 14f
Valsalva maneuver, performing, 174
Varix, sc lerosing agent (injec tion), 1014f
Vasc ular ac c ess
patenc y, maintenanc e, 1020
requirement, 1033
Vasc ular ac c ess c atheter (VAC)
flushing, 1028
patenc y, assessment, 1023
usage, 1020-1021
Vasc ular evaluation, importanc e, 1159
Vasoc onstric tive medic ations/medic ations, c entral IV ac c ess, 1243
Vasoc onstric tor, addition, 938-939
Vasomotor reac tivity, impairment, 849
Vasomotor tone, dec rease, 908
VasoS eal, 681
Vasovagal reac tion, 209
Vec uronium, usage, 642f
Veins
loc ation, 764f
ultrasound sc an tec hnology, usage, 765f
pac ing insertion, 430
Venipunc ture, performing, 768
Venous ac c ess devic e, triangulation, 748
Venous air embolus, signs/symptoms (presenc e), 598
Venous blood sampling skill, 118
Venous oxygen saturation
measurement, 113
perc ent, measurement, 114
values, c onditions/ac tivities, 114t
Venous sheath removal
assoc iation, 682
doc umentation, 688
equipment, 682
expec ted outc omes, 686
family educ ation, 682
nursing knowledge, 681-682
patient assessment, 682-683
patient educ ation, 682
patient monitoring/c are, 687
patient preparation, 682-683
proc edure, 683-688t
purpose, 681
unexpec ted outc omes, 686
Venous vasc ular ac c ess port, c lamping, 1028
Venovenous slow c ontinuous ultrafiltration (S CUF), 1018
Ventilation
assessment, 309
c ontrol, 270
distribution, 130
gases, bulk movement, 105-106
inadequac y, signs/symptoms (assessment), 90, 286
modes, promotion, 263
tec hnique, 248f
vital sign, 105
Ventilation-perfusion (V/Q)
mismatc h, 255
sc ans, 250
Ventilator-assoc iated pneumonia (VAP)
c omplic ation, 266-267
inc idenc e, inc rease, 31
oc c urrenc e, 267
prevention interventions, 267t
risk, 1125
fac tor, 31
weaning c omplic ation, 291
Ventilators
alarms, 266t
c ategorization, 262-263
inspiratory c yc le, initiation (identific ation), 246
measurements, 245
parameters, volume/pressure modes (relationship), 264-265t
pressure-sensing sensitivity mec hanisms, 271
respiratory c yc les, observation, 246
sophistic ation, inc rease, 263
tubing, positioning, 135f
Ventilatory failure, indic ation, 268
Ventric ular ac tivity, identific ation, 409
Ventric ular assist devic e (VAD)
alarm, 476
antic oagulation therapy, 465
assessment, 470
blac k triangles, lineup, 474
blood pump, level (adjustment), 470
c annulas/drivelines exit sites, assessment, 485
c ardiac assistanc e, 464
c oagulation studies, assessment, 485
c ontroller, c hange, 474
doc umentation, 488
dressing supplies, 469
drive c onsole systole c ontrol, 465
ejec tion, assessment, 479
emptying, inc ompletion, 480
equipment, 467-469
addition, 469
list, 468-469t
expec ted outc omes, 483
family educ ation, 469
filling, assessment, 479
hand pumping, 475
Impella LP 2.5/LP 5.0, 467
laboratory profile, assessment, 470
modes, c hanging, 473
nursing knowledge, 464-467
patient assessment, 469-470
patient educ ation, 469
patient monitoring/c are, 484
patient preparation, 469-470
power base, 477
proc edure, 470-488t
psyc hosoc ial/c ognitive c onditions, impac t, 464
pulsatile/nonpulsatile c harac teristic s, 465
purpose, 464
self-test, 474
TandemHeart (Cardiac Assist), 467
therapy
c omplic ations, 464
c ontraindic ations, 464
indic ations, 464
unexpec ted outc omes, 483
Ventric ular c atheter, external strain gauge transduc er (inc lusion), 809
Ventric ular depolarization, 408f
Ventric ular dysrhythmias, possibility (reduc tion), 421
Ventric ular epic ardial lead
loc ation, 431f
wires, loc ation, 431f
Ventric ular fibrillation (VF), 333
assessment, 338
c ardiac energy depletion, 313
CPR c ontinuation, 334
defibrillation treatment, 312-313
ECG results, assessment, 330
elec trophysiology study, 391
IABP troubleshooting, 456
oc c urrenc e, 346, 352
stages, 313
Ventric ular oversensing, 408f
Ventric ular pac ing lumens, usage, 430f
Ventric ular standstill, 422
Ventric ular tac hyc ardia (VT), 312
elec trophysiology study, 391
IABP troubleshooting, 456
treatment, defibrillation (usage), 312-313
Ventric ular undersensing, 408f
Vertebral artery (VA), insonation, 849
Vertic al mattress sutures
appearanc e, 1135f
skin eversion promotion, 1135
Vessels, tortuosity, 209
Vigileo monitor, 552f
VIS TA monitoring system, 777f
Vital c apac ity (VC), 285
helpfulness, 286
measurement, 286-287
purpose, 285
Voc al c ords, endotrac heal tube
advanc ement, 16f
passage, 15f
Volkmann’s c anals, loc ation, 755
Vollman Prone Positioner (VPP)
attac hment, 136
c hest/pelvic support, plac ement, 135
diagram, 132f
patient, prone
lying, 138f
turning, 137f
Volume-guaranteed pressure, options, 275
Volume modes, 264t
ventilator parameters, relationship, 264-265t
Volume-pressure trauma
assumption, 269
signs, assessment, 268-269
Volume-responsive shoc k, risk (determination), 503
Volume ventilation, 263
V wave, 629f
elevation, 655-656
understanding, 739
W
Warm air devic e, usage, 868
Weaning assessment, 291-293
Weaning c riteria, 292t
Weaning indic es, indic ator problems, 291-293
Weaning modes, 294
pressure support ventilation (PS V), 294
Weaning proc ess
arterial blood gases, assessment, 296
breathing pattern, observation, 296
Burns Weaning Assessment Program (BWAP), 292t, 294-295
c onditioning, 294
types, 294
c onsc iousness level, c hange, 296
c ontinuous positive airway pressure (CPAP)
addition, 294
protoc ol, example, 293t
trials, 298
doc umentation, 301
elements, 293-294
end-tidal c arbon dioxide (PetCO 2) levels, assessment, 296
equipment, 295
expec ted outc omes, 300
fac tors, evaluation, 295
family educ ation, 295
high-pressure low-volume work, 294
intoleranc e signs
absenc e, 300
emergenc e, 297
length of stay (LOS ), 293
low-pressure high-volume work, 294
mec hanic al ventilation, nec essity, 295-296
modes, 294
multidisc iplinary approac hes, 294-295
nonverbal behavior level, c hanges, 296
nursing knowledge, 291-295
oxygenation indic es, assessment, 296
patient anxiety level, assessment, 296
patient assessment, 295-296
patient educ ation, 295
patient monitoring/c are, 300
patient preparation, 295-296
patient stability, evaluation, 300
pressure support maximum (PS Vmax), initiation, 299
pressure support ventilation (PS V), c linic al goal, 299
pressure support weaning method, 299
proc edure, 297-301t
progress, assessment, 295
protoc ols
adherenc e, 294
effec ts, 294t
pulmonary-spec ific fac tors, foc us, 291-293
purpose, 291
randomized c ontrolled trial (RCT), 291
public ation, 293
respiratory musc le fatigue, 294
resting settings, c hanges, 298
sedation, effec ts, 294t
short-term mec hanic al ventilation, long-term mec hanic al ventilation (c ontrast), 291
spontaneous breathing trials (S BTs), 293
sync hronized intermittent mandatory ventilation (S IMV)
breaths, dec rease, 298
weaning method, 298
system initiatives
effec ts, 295t
outc omes, 295
T-piec e
setup, 295
trials, 297
trac heostomy tube plac ement, timing, 291
trac heotomy c ollar
setup, 295
trials, 297
trial protoc ols, 293
unexpec ted outc omes, 300
ventilator, usage, 295
weaning trial protoc ols, 293
Weaning readiness, assessment, 291
Wean sc reen, 293t
Wearable c ardioverter defibrillator (WCD), development, 330
Wedged waveform, identific ation, 663
Weight-based medic ations, c alc ulations, 1243
West’s lung zones, 618
illustration, 618f
Wet disposable system, 186
Wet lung, nonc ardiac etiology, 269
Wet-to-dry-gauze dressing, usage, 1162
White blood c ells (WBCs)
c ount, 994
level, 837
Wide-c omplex rhythms, differentiation, 371
Willis arteries, c irc le (depth/direc tion/mean flow veloc ities), 851t
Wireless ECG devic e, example, 520f
WolfeTory Medic al Abviser, usage, 973-976t
Wolff-Parkson-White (WPW) syndrome, 380
Wound beds
assessment, 1157
c harac teristic s, assessment, 1152
wound healing, impac t, 1149
Wound c are
goals, 1149
produc ts, matc hing, 1149
Wound-c leaning materials, position, 1153
Wound c losure
adhesive skin strips, usage, 1134, 1140
anesthetization, 1137
c leaning, 1138
doc umentation, 1142
epithelialization, 1133
equipment, 1135-1136
examination, 1137
expec ted outc omes, 1141
family educ ation, 1136
goals, 1134
inflammation, 1133
kinins/prostaglandins, impac t, 1133
knotting tec hnique, 1135
laser-drilled hole, 1139f
needle holder, thumb-ring finger grip, 1139f
nursing knowledge, 1133-1135
patient assessment, 1136-1137
patient educ ation, 1136
patient monitoring/c are, 1141
patient preparation, 1136-1137
preproc edural teac hings, 1137
primary intention, usage, 1133
proc edure, 1137-1142t
proliferation, 1133
prophylac tic antibiotic s, 1141
purpose, 1133
sec ondary intention, usage, 1134
skin adhesives, usage, 1134, 1140
staples, usage, 1134, 1140
stapling, usage, 1134
surgic al site infec tions, risk fac tors, 1134
suture knot, tying, 1139
suture site, hair removal, 1134
suturing
c onsideration, 1134-1135
tec hniques, 1135
tec hniques, 1134
unexpec ted outc omes, 1141
Wound debridement
purpose, 1159
Wound exudate
absorption, dressings (impac t), 1149
assessment, 1166
management, proc edure, 1167-1171t
produc tion, 1166
Wound healing
delay, wound infec tions (impac t), 1150-1151
goals, jeopardy, 1151
injury response, 1144
oc c urrenc e, 1133
primary/sec ondary intention, 1183
primary/sec ondary/tertiary intention, 1149
princ iples, 1125
Wound management, exc essive drainage
doc umentation, 1171
equipment, 1166
expec ted outc omes, 1170
family educ ation, 1167
nursing knowledge, 1166
patient assessment, 1167
patient educ ation, 1167
patient monitoring/c are, 1170
patient preparation, 1167
pouc hing, 1166
proc edure, 1167-1171t
purpose, 1166
unexpec ted outc omes, 1170
wound dressing, drains
illustration, 1168f
usage, 1167
wound pouc hing, 1169f
exudate, presenc e, 1168
Wounds
assessment, 1164
bac terial invasion, management, 1151
c are, goals, 1166
c leaning/c leansing
illustration, 1154f
c leansing, 1150
c losure, NPWT assistanc e, 1182
c ontamination, 1150
c ulturing, 1154
debridement, purpose, 1159
drainage
exc ess, 1166
drainage, assessment, 1152
drains, plac ement, 1172
dressing, drain (usage), 1168f
fluid, exc ess, 1166
infec tion, presenc e, 1150-1151
irrigation, 1151f
management, tetanus prophylaxis guide, 1137t
margins, c ondition, 1152
measurement/assessment, 1152f
pouc hing, 1169f
exudate, presenc e, 1168
treatment
goals, 1149
NPWT usage, 1184
Wrist, ulnar nerve testing rec ommendation, 304
X
X-S ite, 682
Y
Yeast (Ca ndida a lbica ns) infec tion, 1175
Z
Zero twitc hes, troubleshooting, 308