CCN Lab (Feu)

CRITICAL CARE NURSING (MSN 3)
SKILLS (ECG) | REVIEWER | BATCH 2023
References: SA NODE • Primary pacemaker

(60-100bpm) • Generates an electrical
• Nursing PowerPoint (FEU Version)
signal that causes the
• Lecture Notes atria to contract
OUTLINE INTERMODAL PATHWAY • Connecting pathways
that form a direct
I. ECG connection between the
II. Conduction System sinoatrial node and the
III. Types of ECG Recordings atrioventricular node in
IV. Skin Preparation the right atrium
V. Chest Lead Placement & Augmented AV NODE • Located in the Koch
Limb Leads (40-60bpm) Triangle, near the
A. Standard Placements coronary sinus.
B. AVL • Electrically connects
C. AVF the heart’s atria and
ventricles to coordinate
D. AVR beating in the top of the
VI. Troubleshooting heart.
VII. 6-step Method EKG Interpretation BUNDLE OF HIS • Receives the electrical
VIII. ECG Waveforms (40-60bpm) signal from the AV node
A. QRST duration and carries it to the
B. P-wave Purkinje Fibers
C. P-R interval RIGHT& LEFT BUNDLE • Pathway where
D. QRS Complex BRANCH electrical impulses are
E. T-wave (20-40bpm) sent through
F. Q-T Interval PURKINJE FIBERS • Specialized myocardial
(20-40bpm) fibers that conduct an
G. S-T segment
electrical stimulus or
IX. Heart Rate Segment using ECG impulse that enables
X. Different Arrhythmias the heart to contract in a
A. Sinus Rhythm coordinated fashion
B. Sinus Tachycardia BACHMANN’S BUNDLE • Main pathway of
C. Sinus Bradycardia interatrial conduction
D. Premature Ventricular Contraction
E. Ventricular Tachycardia III. TYPES OF ECG RECORDINGS
F. Ventricular Fibrillation • 12 Leads (standard) ECG
G. Ventricular Asystole • Electrodes are placed on the patient’s limb to
I. ECG (ELECTROCARDIOGRAPHY) create Limb Leads at specific points on his
chest to create the Precordial Leads
• Diagnostic tool used in assessing the
• 6 LIMB LEADS- reflects electrical activity in the
Cardiovascular System. It is the graphic
heart’s frontal plane & this consists of: Leads I,
recording of the electrical activity of the heart;
II, III, AVR (Augmented Vector Right), AVL
an ECG can be recorded with 12, 15, or 18
(Augmented Vector Left), & AVF (Augmented
leads, showing the activity from those reference
Vector Foot)
points
• 6 PRECORDIAL LEADS- provide information
• A series of waves and deflections recording the
on the heart’s horizontal plane & consists of:
heart’s electrical activity from a certain view
V1, V2, V3, V4, V5, V6
• Many views, each called a lead, monitor voltage
• Single Lead ECG commonly referred to as the
changes between electrodes placed in different
Rhythm Strip, commonly monitors lead in
positions on the body
Rhythm Strip Leads I, II, III
II. CONDUCTION SYSTEM • Electrodes are applied in patient’s chest to pick
up heart’s electrical activity
• This strip attached to monito display
measurements such as heart rate & provides
print outs of cardiac rhythm
IV. SKIN PREPARATION
1. Shave hair away from electrode placement
site (Ask permission)
2. Rub site briskly with alcohol pad
3. Rub site with 2x2 gauze
ALVAERA, M.E., MEDALLO, A.M. 1

4. Place electrode. Be sure that the electrode 3. Could external electrical equipment
has adequate gel and is not dry interference be a problem?
4. Was skin preparation adequate?
V. CHEST LEAD PLACEMENT 5. Could the electrodes suffer from:
a. Gel dry out?
b. Poor Adhesion?
VII. 6-STEP METHOD EKG
INTERPRETATION
1. Identify and examine the P waves- Present &
upright
2. Measure the PR Interval- PR: 0.12-0.20 sec
3. Measure the QRS Complex- QRS: 0.06-0.12
4. Identify the Rhythm- Regular or Irregular
5. Determine the heart rate
6. Interpret strip
VIII. ECG WAVEFORMS
P-WAVE
• First component of a normal ECG
• Represents that Atrial Depolarization has
occurred & the impulse originated in the SA
node at the atria
• Time duration: between 0.6 to 11 seconds
• Configuration: usually rounded & upright
VARIANCE OF A P-WAVE
• PEAKED- signifies right atrial hypertrophy
V1 th
4 Intercostal space to right • BROAD OR NOTHCED- associated with
sternum left atrial hypertrophy
V2 4th intercostal space to left of • INVERTED- indicates impulse not coming
sternum from SA node meaning not from the
V3 Directly between V2 and V4 pacemaker but from AV or junctional areas
V4 5th Intercostal space at left • VARYING- if the shapes & sizes of P wave
midclavicular line vary, the impulse may be originating at
V5 Level with V4 at left anterior various sites, at times caused by irritability
axillary line in the atrial tissue or damage near the SA
V6 Level with V5 at left midaxillary node
line • MISSING- if a P wave doesn’t precede
each QRS complex, a third-degree AV
INHERENT RATES block is suspected
SA NODE 60-100 bpm P-R INTERVAL
AV NODE 40-60 bpm • Represents the activity from the beginning
BUNDLE OF HIS 40-60 bpm of atrial depolarization to the beginning of
RIGHT AND LEFT 20-40 bpm ventricular depolarization
BUNDLE BRANCHES • It is the time it takes an impulse to travel
PURKINJE FIBERS 20-40 bpm from the SA node through the atria & to AV
node down to the bundle branches
VI. TROUBLESHOOTING • Time duration: 0.12 to 0.20 seconds (3-5
When no signal or a poor signal is observed the small squares)
following should be considered: SIGNIFICANCE
1. Have the cables been correctly • Provide some evidence of an impulse
connected? formation or conduction delay disturbance
2. Is the equipment functioning correctly? such as AV blocks

• Varies with the HR shortens with • PEAKED- indicative of Hyperkalemia

Tachycardia & lengthen with Bradycardia (Tented-wave)
VARIANCE • NOTCHED- indicative of Pericarditis in
• SHORT- indicates that the impulse adult but is normal for children
originated in other areas like the AV • VARIED- indicative of electrolyte
function but not the SA Node imbalance (may be large & small)
• PROLONGED- indicates impulse is
Q-T INTERVAL
delayed as it passes through the AV node
but there are blocks such as 1st degree • Represent ventricular depolarization &
repolarization; this extends from the end
heart block or cardiac toxicity
of T-wave
QRS COMPLEX • Time duration: between 0.36 to 0.44
• Represents ventricular depolarization that seconds
follows the PR Interval • RULE OF THUMB: QT interval should not
• Configuration differs in all 12 leads be greater than ½ the distance between
• Time duration: 0.06 to 0.10 seconds adult consecutive R wave (called the R-R
• Q: having negative deflection interval) within a regular rhythm
• R: positive deflection VARIANCE
• S: negative deflection 1. SHORTENED- indicative of Hypercalcemia
Question: Why QRS has a larger deflection 2. PROLONGED- indicative of:
than P waves? a. Congenital Anomaly
Because the ventricles are larger than b. Due to some medication (anti-
the atria, so it requires a stronger electrical arrhythmias)
impulse to depolarize the whole ventricular c. Normal for some trained
mass athletes
VARIANCE d. Leads to other life-threatening
• QRS is longer than 0.10 sec & P-wave conditions
not apparent- signifies that the impulse S-T SEGMENT
probably originated in the ventricle 1. ELEVATION- indicative of myocardial
indicating a Ventricular Arrhythmia injury
• QRS longer than 0.10 sec & P-wave is 2. DEPRESSION- indicative of Ischemia
apparent- signifies that impulse is of 3. CHANGES- indicative of inflammatory
supra-ventricular in origin and is delayed heart conditions, LVH, PE, Electrolyte
in the ventricle due to a conduction defect Imbalance.
such as BBB and with BBB- QRS
configuration show an extra notch in RS IX. HEART RATE COMPUTATION
wave USING ECG
• QRS complex does not appear or is • FORMULA 1: HR= 300/no. of big square
missing after each P wave- suspected between R-R
condition in which the impulse conduction • FORMULA 2: HR= 1,500/no. of small
to the ventricle is being interrupted such as squares between R-R
AVB or Ventricular Standstill
X. DIFFERENT ARRHYTHMIAS
T-WAVE
• Represents ventricular repolarization;
where the heart can regain (-) charge; here, SINUS RHYTHM
the cells are readying to be depolarized • Applied when all the following criteria
again; cells here are vulnerable to another are met.
strong stimuli • This rhythm is consistent with an intact
conduction pathway from the sinus
• Configuration: Round & symmetrical node to the ventricular conduction
VARIANCE system
• INVERTED- to some lead is normal • P-wave: present, identical before each
however, for L1, L2, L3 & V6- indicative of QRS
myocardial ischemia • Rhythm: Regular

• HR: 60-100 bpm • A symptomatic px may be given drugs

• PR Interval: 0.12 to 0.20 sec such as Propranolol to regulate the HR.
• QRS width: 0.06 to 0.10 sec • Treatment would focus on finding the
• QT Interval: 0.35 to 0.44 sec cause of Sinus Tachycardia
• ST Segment: Normal SINUS BRADYCHARDIA (SB)
SINUS TACHYCARDIA (ST)
• Sinus node creates an impulse at a slower

than normal rate below 60/min
• Occurs when sinus node creates an • ECG tracing shows the PQRST complexes
impulse at a faster than normal rate to be normal in size & configuration except
around 100-160 bpm for lowered rate
• Rate above 160 bpm indicate ectopic SIGNIFICANCE
focus • Many athletes develop sinus bradycardia
• QRS shape/configuration: normal because their heart are well-conditioned &
• ST is almost same as NSR except for the thus maintain stroke volume with reduce
rate effort
• P Wave: Identical before each QRS ETIOLOGY
• PR Interval: 0.12 to 0.20 seconds • SB may be seen when patient may be in a
ETIOLOGY slower metabolic need
• Occurs sometimes in a healthy person o Sleep
without seriousness; but when ST persist or o Hypothermia
is prolonged — needs medical attention o Hypothyroidism
• If ST persists too long: o Vagal stimulation activities such as
o Acute Blood loss vomiting, suctioning, severe pain,
o Anemia extreme emotion
o Shock • In MI patient involving the inferior wall, has
o Hypovolemia a tendency to increase vagal tone & may
o Congestive Heart Failure eventually cause SB
o Extreme Pain • Certain drugs such as Anti-cholinesterase,
o Hypermetabolic states Beta blockers, Digitalis, Morphine
o High fever, too strenuous exercise, too CLINICAL MANIFESTATION
much anxiety • The patient will have a peripheral rate of
CLINICAL MANIFESTATION 60/min and below but have regular rhythm.
• Patient will have a peripheral pulse rate • If patient unable to compensate for the
greater than 100 bpm, but with a regular decrease in cardiac output – Sign and
rhythm symptoms: hypotension, syncope, blurring
• Usually, px will be asymptomatic of vision, palpitation
• If px’s cardiac output falls & compensatory INTERVENTION
mechanisms fall, px may experience • If patient asymptomatic, treatment isn’t
hypotension, syncope, & blurring of vision. necessary, but if symptomatic, treatment
INTERVENTION should be aimed to identify & correct the
• Unless px shows s/sx of decreased underlying cause
cardiac output or hemodynamic instability, • Atropine may be given by IV push to
treatment isn’t required regulate the HR

• If medical management not effective may • When 3 or more PVC’s occurs in a row &
have to start Temporary Pacemaker the rate exceeds 100.min this is called VT
• It may be Paroxysmal (lasting for a few
PREMATURE VENTRICULAR CONTRACTION
beats) or sustained (longer time)
(PVC)
PATHOLOGY
• There is no association between the atrial
rhythm & ventricular rhythm; hence, VT
develops & ends suddenly.
• It is a major Arrhythmia, which can reduce
cardiac output & lower BP
• Here the patient may not be able to
withstand the increase Myocardial
• Ventricles are stimulated by an ectopic irritability & consequently, V. Fib will
focus in their walls. They contract too early develop
giving an extra heart beat & because the ETIOLOGY
focus of stimulation is outside the normal • Ventricular Dysrhythmia can cause a
pathway, the impulse will travel around the decrease in cardiac output which in turn will
ventricle at a slower rate, resulting in wide make the heart work harder to eject the
&. bizarre QRS complex additional blood on the next sinus beat
CLINICAL MANIFESTATIONS • Exercise, ingestion of caffeine, tobacco &
• PR may be normal 60-100/min but it is the alcohol can trigger PVC’s
rhythm that may be irregular. When • A PVC may be caused by certain drugs
palpating the peripheral pulse, one may feel • Cardiac glycosides
a longer than normal pause immediately
• Sympathomimetic drugs (Epinephrine)
after the PVC
• Conditions (Electrolyte imbalance,
• Palpitation
Hypokalemia, Hypocalcemia)
• Sighs of decrease cardiac output
• VT usually results from Myocardial
o Hypotension
irritability
o Syncope
• Some cardiac conditions an bring about VT
o Blurring of vision
INTERVENTION such as: AMI, CAD, RHD, Mitral Valve
o Treatment will depend on the cause of the prolapse, Heart Failure & Cardiomyopathy.
problem • Non-cardiac conditions
o If PVC results from a cardiac problem – o Pulmonary Embolism
DOC is Lidocaine (Xylocaine) 50-100mg o Electrolyte imbalance
given by IV Bolus followed by a constant o Drug toxicity – Digitalis
infusion of 1-4 mg/min IV drip o Quinidine
o If PVC is caused by SB where myocardial o Epinephrine
irritation triggers its manifestation – DOC is INTERVENTION
Atropine to increase the HR -treating the • When you detect VT, immediately check
SB you eliminate the PVC your PT for responsiveness & LOC. Give
immediate treatment. If patient alert – give
VENTRICULAR TACHCARDIA (V-TACH) lidocaine bolus; if after medication still not
effective may recommend to proceed to
synchronized cardioversion
• If patient suffers CV collapse – loss of
consciousness prepare instead to
defibrillate. If you are at patient bedside
immediately deliver a single precordial
thump, while CPR team are preparing the
paddles & awaiting for electrical charge.

VENTRICULAR FIBRILLATION (V-FIB) • Drug induced – digitalis, quinidine, toxicity

• Irritation from pacemaker electrode
• Acidosis and electrolyte imbalance
• During cardiac cath/cardiac surgery
• Immediately following electrocution
CLINICAL MANIFESTATION
• The patient will be in cardiopulmonary
arrest, so patient will be unresponsive &
have no palpable pulse
• To verify the absence of a pulse, try to
palpate the carotid or femoral pulse
• If patient is responsive & pulse is palpable,
• Rapid disorganized & quivering of the check to see if patient is shivering. Because
ventricles developed because of rapid in some cases, excessive muscle
impulse formation & irregular impulse movement can create ECG pattern like that
transmission. The focus of impulse is in the of ventricular fibrillation
ventricles but all fire together so there is no • Sometimes also, electrical interference
organized conduction & no organized such as one coming from the most common
contraction electric razor – so nurses always evaluates
• The ventricles displays those quivering the patient first when you see this ECG
motion & are unable to fill or expel blood pattern
with any rhythmic patient INTERVENTION
SIGNIFICANCE • The only effective treatment for ventricular
• With ventricular fibrillation, the ventricle fibrillation is Defibrillation
quiver rather than contract. As a result, they • To increase its effectiveness at the same
fail to pump blood & cardiac output falls to time give epinephrine & anti-arrhythmic
zero drug such as lidocaine or procainamide
• If fibrillation continues, it eventually leads to give IV push because time is critical
ventricular asystole to standstill. • CPR & other life-support measure should
CLINICAL MANIFESTATION be started while you are waiting for the
• There is no audible heart sounds, no defibrillator
palpable pulses, no response – this is a
MAJORITY ARRYTHMIA may be fatal VENTRICULAR ASYSTOLE
• This is a MEDICAL EMERGENCY - (CARDIAC STANDSTILL)
immediate intervention is necessary or
death could occur within minutes
TYPES OF VENTRICULAR FIBRILLATION
1. COARSE FIBRILLATION - indicates more
electrical activity in the ventricles than the
fine fibrillation
2. FINE FIBRILLATION – fibrillatory waves
become finer as acidosis & hypoxemia
develop
ECG INTERPRETATION
• Atrial rate & rhythm cannot be determined
• Ventricular rate & rhythm cannot be
determined
• With VS, electrical activity in the ventricles
• P wave is indiscernible; PR interval is also
stops. What will be seen on an ECG strip
indiscernible
almost flat line
• QRS complex duration is indiscernible
• Some activity may be evident in the atria,
• T-wave is indiscernible but the atrial impulse isn’t conducted to the
ETIOLOGY ventricles
• AMI • P waves may continue for a time but the
• Cardiomyopathy QRS complexes have disappeared

SIGNIFICANCE
• Asystole is life threatening. Without
ventricular activity, ventricular contraction
does not occur. Consequently, there is no
cardiac output or perfusion
ECG INTERPRETATION
• Atrial rate & rhythm is indiscernible
• Ventricular rate & rhythm doesn’t even exist
• P wave is absent
• PR interval not measurable; QRS complex
is absent; T wave is absent
• Because of these findings, one would
interpret the ECG as showing Asystole
ETIOLOGY
• Any condition that cause inadequate blood
flow can lead to Asystole
• Non-cardiac causes include
o Pulmonary embolism
o Air embolism
o Hemorrhage
• Cardiac causes include ineffective cardiac
contractility stemming from
o Heart failure
o Heart rupture
o MI
o Cardiac tamponade
o Insufficient conduction
o AVB
o Cocaine overdose
CLINICAL MANIFESTATION
• the patient will be in CP arrest; so patient
will be unresponsiveness & will not able to
palpate a pulse
• Nurse, please verify the absence of the
pulse, try to palpate the carotid or femoral
pulse
• Same ECG pattern may appear if the
patient’s electrodes fall off or the monitor
probably is not turned ON
• Nurses evaluate the patient before you try
to perform any emergency measures
INTERVENTION
• a patient with Asystole needs immediate
treatment including CPT & other life-
supporting measures
• if patient has a temporary demand
peacemaker, turn it on & check the
electrodes as well

SKILLS (TPN) | REVIEWER | BATCH 2023
References: ROUTES FOR ADMINISTRATION OF

• Nursing PowerPoint (FEU Version) PARENTERAL ADMINISTRATION
• Lecture Notes - Superior Vena Cava
- Subclavian Vena
OUTLINE - Peripheral Vein
I. Parenteral Feeding
II. Indications III. COMPONENTS OF INGREDIENTS
III. Components • Usual fluid volume us 1.5-2.5L over a 24 hour
IV. Ordering & Mixing PN Solution period for most people
V. PN Routes • Actual infusion depends on:
VI. Equipment • Site of infusion
VII. Initial Considerations • Patient’s fluid and nutrition requirements
VIII. Types of Parenteral Nutrition TPN usually runs for 72 hours
A. Peripheral Parenteral Nutrition (PPN) CARBOHYDRATE
B. Total Parenteral Nutrition (TPN)
• Dextrose provides the carbohydrate content of
IX. Choice of Nutrition Regimen
PN, up to 75% of the total energy of the solution.
X. PN Infusion Rate
It provides 3.4 kcal/g
XI. Monitoring
• Glucose is the body’s main source of energy
XII. Parenteral Nutrition Infusion Utilizing the
Peripheral Access • Concentration is 12.5% (max for peripheral
XIII. Parenteral Nutrition Infusion Utilizing the introduction) to 25% (total parenteral nutrition)
Central Vascular Access • Restricted in ventilator patients because oxidation
XIV. Discontinuing Parenteral Infusion Solution of glucose produces more carbon dioxide than
does oxidation of fat
I. PARENTERAL FEEDING PROTEIN
a way of supplying all the nutritional needs directly into • Mixture of essential; and non-essential amino
blood stream bypassing gastrointestinal tract. acids
• Concentration is 3.5-15%
Other term: Hyperalimentation
• Quantity of amino acids depends on patient’s
ENTERAL NUTRITION FORM
estimated requirements and hepatic renal function
1. NGT ( Nose)
FAT
2. Gastrotomy Tube (stomach)
• Lipid emulsion is a soluble form of fat that allows it
- PEG Insertion= Percutaneous Endoscopic
to be infused safely into the blood.
Gastrotomy
3. Jejunostomy (Intestine) • Safflower and soybean oil with egg lecithin used
- PEJ Insertion= Percutaneous Endoscopic as an emulsifier.
Gastronomy • Isotonic.
• Significant source of calories.
II. INDICATIONS • Usual dose is 0.5 to 1 g/kg/day to supply 20-30%
1. When individuals cannot or should not get nutrition of total kcal requirement.
through eating • IV fat contraindicated for severe hepatic
2. When the intestines are obstructed, when the pathology, hyperlipidemia or severe egg allergies.
small intestine is not absorbing nutrients properly • Used cautiously with atherosclerosis, blood.
or a gastrointestinal fistula (abnormal connection) coagulation disorders
is present. MICRONUTRIENTS
3. When the bowels need to rest and not have any • Standard multi-vitamin and trace mineral
food passing through them. Bowel rest may be preparations added to parenteral solutions to meet
necessary in Crohn's disease, pancreatitis, micronutrient needs
ulcerative colitis, and with prolonged bouts of ELECTROLYTE
diarrhea in young children. • Dictated by patient’s blood chemistry values and
4. Individuals with severe burns, multiple fractures, physical assessment findings
and in malnourished individuals to prepare them
for major surgery, chemotherapy. or radiation IV. ORDERING & MIXING PN SOLUTIONS
treatment. • The physician writes the order for the TP
5. Individuals with aids or widespread infection prescription.
(sepsis) • The pharmacist mixes the TPN solution using
aseptic
ALVAERA, M.E. 1
• technique. INTRA-DIALYTIC
• Prescriptions are compounded by mixing the Administered during hemodialysis
solutions at a 1:1 dextrose-to-amino acid ratio and • Access:
placing in 1-L bags. o Venous port of hemodialysis tubing (into
AV shunt)
Nursing Resp: Assessment & Lab Values
• Indication:
V. PARENTERAL NUTRITION ROUTES o Malnourished hemodialysis patients who
THE ROUTES DEPENDS ON: are unable to maintain weight and oral/
• Intended duration of nutrition support enteral nutrition is not possible or has
• Patient’s condition failed
• Osmolality of available solution VI. EQUIPMENT USED
• Any limitations to access (such as trauma or • Intravenous Access Device
obstruction) • Intravenous Giving Set
TWO WAYS OF ACCESS: • Administration Reservoir Containing PN Solution
• Light Protective Covering
CENTRAL VENOUS ACCESS • Infusion Pump
• It means that the fluids are delivered to the • Syringes for Additives
superior vena cava or right atrium, or less
commonly the inferior vena cava (from a femoral- VII. INITIAL CONSIDERATIONS
inserted line) • TPN should start slowly so that the body has time
• Central position of the line tip as always to adapt to both glucose load and the
PERIPHERAL VENOUS ACCESS hyperosmolarity of the solution
• Tip of the line is usually in the axillary or subclavian • A pump controls the infusion rate of the TPN
access Solution
• Intradialytic PN is another form of peripheral GENERAL PN INITIATION PROCEDURE
access 1. Start with 1 liter of TPN solution during the first 24
SITES OF DELIVERY hours (or use cc/hr as a typical start rate).
2. Increase volume by 1 liter each day until the
CENTRAL
desired volume reached.
Superior vena cava, right atrium or inferior vena cava
3. Monitor blood glucose and electrolytes closely
• Access:
4. Pump administer TPN at a steady rate
o Percutaneous central catheter
5. Don t attempt to catch up it administration gets
o Hickman Line
behind
o Broviac
o Grosshong Line VIII. TYPES OF PARENTERAL NUTRITION
o PICC Line (Peripherally Insertion Central
Catheter) PERIPHERAL PARENTERAL NUTRITION (PPN)
o Portacath - Peripheral vein is used
• Indications - Must be isotonic and therefore low in dextrose and
o Longer Term use amino acids to prevent phlebitis and increased risk
o Short term use when peripheral solution of thrombus formation
cannot meet full nutritional needs or if - The need to maintain isotonic solutions of dextrose
peripheral route not available and amino acids while avoiding fluid overload
When giving medications, you need to stop first the limits the caloric and nutritional value of PPN.
TPN before giving medication ADVANTAGES
PERIPHERAL 1. Delivers complete but limited nutrition
Any other veins 2. The final concentration cannot exceed 12.5%
• Access: dextrose-lower concentrations of amino acids
o Peripheral Cannula 3. Vitamins and minerals are added.
o Midline Catheter 4. Lipid emulsion may be added to supplement
o Midclavicular Catheter calories depending on the patients' tolerance.
• Indication: 5. Provides temporary nutritional support.
o Short-term use (<10-14 days) 6. Short-term: 7-10 days and do not require more
than 2000 to 2500 kcal per day.
7. May be used for a post-surgical ileus or
anastomotic leak or for patients who require
ALVAERA, M.E. 2
nutritional support but are unable to use TPN • It helps prevent hepatotoxicity that can develop
because of limited accessibility to a central vein. with long-term TPN and the fasting period allows
8. Sometimes used to supplement an oral diet or essential fatty acids to be released from fat stores.
tube feeding transition from TPN to enteral intake. • Used for home patients.
ADVANTAGES
TOTAL PARENTERAL NUTRITION (TPN)
- Superior vena cava is used. • Allows greater patient mobility (may improve
- Hypertonic solutions provide more dextrose and/or quality of life).
protein but they must be delivered centrally in a • Mimics physiological feeding/fasting pattern,
large diameter vein so that they can be quickly which may help to prevent accumulation of fat in
diluted. the liver and sludge in the biliary system
- Higher concentration is used for TPN due to more DISADVANTAGES
rapid dilution in superior vena cava. • Compared with continuous nutrition, a higher
- It is used when nutritional requirements are high infusion rate is required to provide the same
and anticipated need is relatively long 3 liters of volume of feed. This may be less well-tolerated,
10% dextrose provides only 1020 kcal with a higher risk of problems such as:
o Fluid overload (and frequent urination during
INDICATIONS infusion, inconvenient especially at night).
1. Severe malnutrition. o Electrolyte Fluctuations.
2. Gl abnormalities: due to obstruction, peritonitis, o Unstable blood glucose levels.
severe acute pancreatitis
3. After surgery or trauma especially that involving X. PN INFUSION RATE
extensive burns, sepsis. • All patients require individual assessment for
4. Need for supplementation of inadequate oral determining the rate of delivery of nutritional
uptake in patients who are being treated support, which depends on the patient's nutritional
aggressively for cancer. requirements and medical condition.
5. Bone marrow transplantation • Typical infusion rates vary between 40-150 ml/h,
but cyclic infusions may be delivered at rates as
IX. CHOICE OF NUTRITION REGIMEN high as 300 ml/h
CONTINUOUS
• Infuses for 24 hours continuously. XI. MONITORING
• This is the most common type of regimen in the WHAT SHOULD BE MONITORED, AND THE
hospital setting. FREQUENCY WILL DEPEND ON:
• Infusion rates usually range between 40- 50 ml/h. • Expected duration of treatment.
ADVANTAGES • Health care setting
• Allows the lowest possible hourly infusion rate to • Patient's disease state.
meet nutrient requirements • Presence (and severity) of any abnormal results
• Better control of blood glucose levels due to • Whether the patient is stable.
continuous carbohydrate input. AREAS OF MONITORING
• May result in better utilization of nutrients. • Anthropometry.
DISADVANTAGES
• Biochemistry./Hematology
• Physical attachment to the pump (may affect
• Liver tests.
quality of life).
• Iron studies.
• Higher risk of biliary stasis (if no oral / enteral
• Lipid studies.
intake).
• Vitamins, minerals and trace elements
• Promotes continuous high insulin levels, which
may increase risk of fatty liver. • Indicators of protein status.
• Clinical assessment and monitoring:
CYCLIC/ INTERMITTENT o Nutritional assessment
• It is commonly used in long-term parenteral o Dietary intake.
nutrition. COMMON PROBLEMS
• The patient is fed for 12-18 hours during the night 1. Line problems
and fasts during the day or given only on some - Blocked intravenous line
days of the week. This gives the long-term TPN - Suspected line infection.
patient freedom from the machinery to lead a less 2. Blood vessel problems
restricted life during the day. - Phlebitis.
- Thrombosis.
ALVAERA, M.E. 3
- Line displacement. 18. Document observation and intervention as

3. Formulation problems necessary.
- Stability problems.
- Drug - nutrient interactions. XIII. PARENTERAL NUTRITION INFUSION
4. Intolerance UTILIZING THE CENTRAL VASCULAR
- Allergic reaction to parenteral nutrition ACCESS
infusion. 1. Follow procedure in Peripheral Access
- Nausea or vomiting from steps 1-9.
- Appetite problems
2. Assist surgeon in Open or Closed Central
- Constipation.
5. Metabolic Abnormalities Vascular Access Procedures (Maintain
- Re-feeding syndrome. asepsis throughout the procedure).
- Overfeeding. 3. Connect the IV administration set to the
- Dehydration. central vascular access catheter
- Fluid overload aseptically and regulate flow rate as
prescribed.
XII. PARENTERAL NUTRITION INFUSION 4. Assess dressing over central vascular
UTILIZING THE PERIPHERAL ACCESS access for swelling, redness, pain and foul-
1. Verify doctor's prescription.
2. Explain the procedure to reassure patient and
smelling discharges.
significant other (benefits, risks, duration, changes 5. Monitor/reassure patient.
in volume and flow rate, etc.). 6. Document observations and
3. Secure consent from patient or/ and authorized circumstances as necessary.
member of the family. 7. Discard waste materials according to
4. Prepare parenteral solution and all other devices Health Care Waste Management
needed for the parenteral administration, taking
into consideration the mode of administration such
(DON/DENR).
as: XIV. DISCONTINUING PARENTERAL
a. Peripheral access INFUSION SOLUTION
b. Central access
5. Check the integrity and functionality of the 1. Verify written prescription (Discontinues
parenteral solution and IV devices. upon completion of TPN requirements,
6. Observe 10 rights in safe drug administration. (e.g., 24 hours, 12 hrs. or in the occurrence
7. Assess patient and choose suitable vein, location of any adverse reaction).
and get baseline vital signs 2. Observe 10 rights.
8. Do hand hygiene and maintain asepsis throughout
3. Explain procedure to the patient and
the procedure.
9. Prepare Parenteral Nutrition solution (follow significant others.
procedure of VT Setting Up). 4. Prepare the necessary materials to be
10. Insert IV catheter aseptically (large, bore catheter. used in discontinuing TPN utilizing
Follow procedure for IV insertion). Peripheral/Central Vascular Access
11. Connect the tubing to the prepared parenteral (Prepare sterile dressing set and stitch
solution and regulate flow rate as prescribed.
scissor for Open Central Vascular Access).
12. Dress IV sites as per IV standard.
13. Label IV site and solution as per IV standard. 5. Follow doctor's prescription, (e.g.,
14. Continue to reassure patient and do pertinent electrolyte; weight; blood laboratory
health education. monitoring).
15. Dispose waste materials according to Health Care 6. Monitor patient closely and document
Waste Management (DOH/DENR). observation and intervention.
16. Document procedure and observations with
7. Refer to MD for any unusual observations.
corresponding nursing intervention in the patient's
chart like I and O, weigh daily, etc. 8. Discard waste materials according to
17. Monitor patient periodically and report unusual Health Care Waste Management
findings if there are signs of infection, hyper and (DOH/DENR).
hypoglycemia, change of color and consistency of
solution, etc.
ALVAERA, M.E. 4
SKILLS (CVP) | REVIEWER | BATCH 2023
References: SUBCLAVIAN VEIN

• Nursing PowerPoint (FEU Version) • Recognizable anatomical landmarks, making
• Lecture Notes insertion of the device easier
• Risk of pneumothorax during insertion
OUTLINE • More comfortable for the patient
I. Definition FEMORAL VEIN
II. CVP Catheter • Provides rapid central access during an
A. Equipment emergency such as a cardiac arrest
III. Factors that affect CVP • Increased risk of associated infection
IV. Insertion Sites • Reported to be uncomfortable and may
V. CVP Recording discourage the conscious patient from moving
A. Manometer
B. Transducer V. CVP RECORDING
VI. Potential Complications • Mid-axillary line where the manometer arm or
transducer is level with the phlebotomid axis
I. DEFINITION • Fourth intercostal space and midaxillary line
- Blood pressure in the vena cava near the right atrium cross each other
of the heart • Close to the right atrium as possible
- Reflects the amount of blood returning to the heart USING A MANOMETER
and the ability of the heart to pump the blood back 1. Explain the procedure to the patient to gain informed
into the arterial system consent
II. CVP CATHETER 2. If IV fluid is not running, ensure that the CVC is
- Assess the right ventricular function and systemic patient by flushing the catheter
fluid status 3. Place the patient flat in a supine position if possible
- Rapid infusion (for Hypovolemic Shock) 4. Line up the manometer arm with the phlebostatic
- Infusion of hypertonic solutions and medications that axis ensuring that the bubble is between the two lines
could damage veins of the spirit level.
5. Move the manometer scale up and down to allow the
- Serial venous Blood Assessment
bubble to be aligned with zero on the scale. This is
- Fluid Shifting
referred to as ‘zeroing the manometer’
EQUIPMENT
1. Intravenous Access Device 6. Turn the three-way tap off on the patient and open to
the manometer
2. Manometer
3. Transducer 7. Open the IV fluid bag and slowly fill the manometer
to a level higher than the expected CVP
III. FACTORS THAT AFFECT CVP 8. Turn off the flow from the fluid bag and open the
• Normal CVP is 2-6 mmHg three-way tap from the manometer to the patient
• The condition of the patient and the treatment 9. When the fluid stops falling the CVP measurement
being administered determine how often CVP can be read. If the fluid moves with the patient’s
measurement should take place breathing, read the measurement from the lower
CVP IS ELEVATED BY number
• Overhydration 10. Document the measurements and the report any
• Heart Failure changes or abnormality
• PA Stenosis USING A TRANSDUCER
• Straining 1. Explain the procedure to the patient to gain informed
CVP DECREASES WITH consent
• Hemorrhage 2. The CVC will be attached to intravenous fluid within
• Fluid Shift a pressure bag. Ensure that the pressure bag is
• Dehydration inflated up to 300 mmHg
• Retractions 3. Place the patient flat in a supine position if possible.
4. Catheters differ between manufacturers, however,
IV. INSERTION SITES the white or proximal lumen is suitable for measuring
CVP
INTERNAL JUGULAR VEIN
5. Tape the transducer to the phlebostatic axis or near
• High rate of successful insertion
to the right atrium as possible
• Low incidence of complications such as 6. Turn the tap off to the patient and open to the air by
pneumothorax removing the cap from the three-way port opening
• Catheter occlusion may occur as a result of the system to the atmosphere.
head movement and may cause irritation in 7. Press the zero button on the monitor and wait while
conscious patients calibration occurs
ALVAERA, M.E. 1
SKILLS (CVP) | REVIEWER | BATCH 2023
8. When ‘zeroed’ is displayed on the monitor, replace

the cap on the three-way tap and turn the tap on to
the patient.
9. Observe the CVP trace on the monitor. The
waveform undulates as the right atrium contracts and
relaxes, emptying and filling with blood
10. Document the measurement and report any changes
or abnormalities
VI. POTENTIAL COMPLICATIONS
1. Hemorrhage from the catheter site
2. Catheter occlusion
3. Air Embolus
4. Catheter displacement
ALVAERA, M.E. 2
SKILLS (DIALYSIS) | REVIEWER | BATCH 2023
References: EXTERNAL AV SHUNT

• Nursing PowerPoint (FEU Version) Access is formed by the surgical insertion of 2 silastic
cannulas into an artery or vein in the forearm or leg to
• Lecture Notes
form an external blood path
OUTLINE ADVANTAGES DISADVANTAGES
I. Definition Can be used External danger of
II. Intermittent Hemodialysis immediately after disconnecting or
III. Peritoneal Dialysis insertion dislodging the shunt
IV. CRRT (Continuous Renal Replacement No venipuncture Risk of hemorrhage,
Therapy) necessary for infection or clotting
A. Table Of Comparison dialysis
Skin erosion around
I. DIALYSIS the catheter site
Process of removing waste and excess water from the
blood and is used primarily as an artificial replacement for INTERNAL AV FISTULA
lost kidney function in people with renal failure Preferred method of a permanent access is an
INDICATIONS arteriovenous fistula (AVF)
For patients with… Maturity: veins become engorged due to the flow of
• Fluid overload arterial blood into the venous system; takes 1-2 weeks
• Increasing levels of serum K+ ADVANTAGES DISADVANTAGES
• Impending pulmonary edema Less danger of Cannot be used
• Increasing acidosis clotting and immediately after
• Poisoning or medication overdose bleeding insertion
• Uremia Can be used Venipuncture is
indefinitely required for dialysis
II. INTERMITTENT HEMODIALYSIS Decreased Infiltration of needles
- Used for patients who are acutely ill and require incidence of -> hematoma
short-term dialysis (days to weeks) and for patients infection
with advanced CKD and ESRD who require long- No external Aneurysm in the
term or permanent renal replacement therapy dressing is required fistula
- Patients who receive intermittent dialysis involves Arterial steal
having the treatment three times a week with an syndrome
average treatment duration of 3 to 4 hours in an
outpatient setting INTERNAL AV GRAFT
FUNCTIONS - For chronic dialysis clients who do not have
1. Cleanses the blood of accumulated waste products adequate blood vessels for the creation of a fistula
2. Removes the by-products of protein metabolism - Gore-Tex or a bovine (cow) carotid artery as artificial
(urea, creatinine & uric acid) vein for blood flow
3. Removes excessive fluids - Procedure involves the anastomosis of the graft to
4. Maintains or restores the buffer system of the body the artery, a tunneling under the skin, and
5. Maintains or restores electrolyte levels anastomosis to a vein.
ACCESS - Can be used 2 weeks after insertion
• Subclavian and Femoral Catheter - Complications: clotting, aneurysms and infection
• External Arteriovenous Shunt ADVANTAGES DISADVANTAGES
• Internal Arteriovenous Fistula Less danger of Cannot be used
• Internal Arteriovenous Graft clotting and immediately after
SUBCLAVIAN (VEIN) CATHETER bleeding insertion
- May be inserted for short-term or temporary use in Can be used Venipuncture is
acute renal failure indefinitely required for dialysis
- Usually filled with heparin & capped to maintain Decreased
patency between dialysis treatments incidence of
- May be left in place for up to 6 weeks if complications infection
do not occur No external
FEMORAL (VEIN) CATHETER dressing is required
- May be inserted for short-term or temporary use in HEMODIALYSIS COMPLICATIONS
acute renal failure • Chest pain
- Clients should not sit up more than 45 degrees or • Dysrhythmias
lean forward, or the catheter may kink and occlude • Air Embolism
- An IV infusion pump with micro drip tubing should be • Anemia
used if a heparin infusion is used • Gastric Ulcer
• Patients with uremia report a metallic taste
ALVAERA, M.E. 1
• Nausea & Vomiting 2. Assemble the administration set & tubing. Fill
• Bone Pain & Fractures the tubing with the prepared dialysate to reduce
• Itchiness the amount of air entering the catheter &
• Sleep Disturbances peritoneal cavity.
• SOB III. Inserting the Catheter:
• Hypotension Ideally, the peritoneal catheter is inserted in the
• Painful Muscle Cramps operating room to maintain surgical asepsis &
minimize the risk of contamination.
• Disturbances of Lipid Metabolism
IV. Performing the Exchange
(Hypertriglyceridemia)
(1-4 hours, depending on the prescribed dwell time)
• Heart failure, Coronary Heart Disease, Angina,
1. Infusion- dialysate is infused by gravity into the
Stroke, and Peripheral Vascular Insufficiency’
peritoneal cavity for a period of 5-10 mins to
NURSING MANAGEMENT
infuse 2L of fluid.
1. Promote Pharmacologic Therapy
2. Dwell- allows diffusion & osmosis to occur
2. Promote Nutritional and Fluid Therapy
(peaks in the first5-10 minutes)
3. Meeting Psychosocial Needs
DRAINAGE
4. Teach Patient Self-care
1. The tube is unclamped and the solution drains
5. Continuing of Care
from the peritoneal cavity through a closed
III. PERITONEAL DIALYSIS system (10 to 30 minutes).
- The peritoneal membrane that covers the abdominal 2. The drainage fluid is normally colorless or straw-
organs and lines the abdominal wall serves as the colored and should not be cloudy. Bloody
semipermeable membrane drainage may be seen in the first few exchanges
- Sterile dialysate fluid is introduced into the peritoneal after the insertion of a new catheter but should
cavity through an abdominal catheter at intervals not occur after that time.
CONTINUOUS AMBULATORY 3. The removal of excess water during peritoneal
PERITONEAL DIALYSIS (CAPD) dialysis is achieved by using a hypertonic
• Can be performed in any clean and convenient place dialysate with a high dextrose concentration that
• Requires no machinery creates an osmotic gradient (Dextrose solution
• The dialysate is left in the abdomen for up to 8 hours of 1.5%, 2.5%, and 4.25%)
PERITONEAL DIALYSIS COMPLICATIONS
• The manual exchanges use gravity to drain the used
fluid out of the peritoneal cavity and replace it with ACUTE LONG TERM
fresh fluid Peritonitis Hypertriglyceridemia
• Dialysis takes place while patient continues normal Leakage Anorexia
activities Bleeding Low Back Pain
• Most CAPD patients need to do 4 bag exchanges per
NURSING MANAGEMENT
day
I. Pre-dialysis Care
• 1.5 to 2.5 Liters of fluid per exchange
1. Document vital signs
• Each exchange takes 30-40 minutes 2. Weigh daily or between dialysis
AUTOMATED PERITONEAL DIALYSIS (APD) 3. Note BUN, serum electrolytes, creatinine, pH, &
• Aka Continuous Cyclic Peritoneal Dialysis (CCPD) het levels
• Uses a machine to exchange the fluids 4. Measure and record abdominal girth
• Each session lasts from 10-12 hours 5. Maintain fluid & dietary restrictions as ordered
• Usually done at night while patient sleeps 6. Have the patient empty the bladder prior to
• Machine has 3 main functions: catheter insertion
o Heats PD fluid to body temperature 7. Warm the prescribed dialysate solution to body
o Controls time of exchange & amount of fluid temperature
used 8. Explain all procedures & expected sensations.
o Monitors treatment (safety alarms) II. Intra-dialysis Care
PROCEDURE FOR PERITONEAL DIALYSIS 1. Use a strict aseptic technique
I. Preparing the Patient: 2. Add prescribed medication into the dialysate.
1. Explain the procedure & obtain a signed consent Prime the tubing with solution & connect it to the
2. Record baseline vital signs, weight & serum peritoneal catheter, taping connections securely
electrolytes and avoiding kinks to avoid leaking and
3. Encouraged to empty bladder &bowel contamination.
4. Administer broad-spectrum antibiotic agents as 3. Instill dialysate into the abdominal cavity over a
ordered to prevent infection. period of approximately 10 minutes. Clamp the
II. Preparing the Equipment: tubing and allow the dialysate to remain in the
1. Consult physician re-concentration of dialysate abdomen for the prescribed dwell time.
& Medications to be added to it. (Heparin, KCI, 4. Dialysate should flow freely into the abdomen if
antibiotics etc.) the peritoneal catheter patent.
ALVAERA, M.E. 2
5. Troubleshoot for possible problems during

dialysis
o Slow dialysate installation > Increase the
height of the container reposition the patient
o Poor dialysate drainage > lower drainage
container, reposition
o Check abdominal dressing. Check tubing or
catheter obstruction.
III. Post-dialysis Care
1. Assess vital signs. Compare pre and post-
dialysis vital signs.
2. Identify the beneficial and adverse effects of the
procedure.
3. Time meals to correspond with dialysis outflow
4. Teach the client and family about the procedure.
Nursing Responsibilities
1. Meeting Psychosocial Needs
2. Teaching Patient Self-Care
3. Continuing Care
IV. CONTINUOUS RENAL REPLACEMENT

THERAPIES (CRRT)
methods used to replace normal kidney function by
circulating the patient's blood through a filter and
returning it to the patient
TYPES
• Continuous arteriovenous hemodialysis
(CAVHD)
• Continuous hemodialysis (CWVHD)
• Slow continuous ultrafiltration (SCUF)
• Continuous arteriovenous hemodiafiltration
(CAVHDE)
• Continuous venovenous hemodiafiltration
(CVVHDF)
SPECIAL CONSIDERATIONS: NURSING
MANAGEMENT OF THE HOSPITALIZED PATIENT
ON DIALYSIS/ RRT
1. Protecting vascular access
2. Taking precautions during Intravenous therapy
3. Monitoring symptoms of Uremia
4. Detecting cardiac and respiratory complications
5. Controlling electrolyte levels and diet
6. Managing discomforts & pain
7. Monitoring blood pressure
8. Preventing infection
9. Caring for the catheter site
10. Administering medications
11. Providing psychological support
TABLE OF COMPARISON
ALVAERA, M.E. 3
ABBREVIATION NAME PURPOSE VASCULAR DESCRIPTION

ACCESS
REQUIRED
SCUF Slow Continuous Fluid Removal Venous blood is circulated
Ultrafiltration through hemofilter and
returned to the patient
through a venous catheter;
ultrafiltrate fluid removed is
collected in a drainage bag
as it exits the hemofilter
CVVHF Continuous Fluid and some Venous Blood is circulated
Venovenous uremic waste through a hemofilter and
Hemofiltration product removal returned to the patient
through a venous catheter;
replacement fluid is used to
increase flow through the
hemofilter; ultrafiltrate (fluid
removed) is collected in a
Dush-lumen drainage bag as it exits the
venous hemofilter
CVVHD Continuous Fluid and catheter or two Venous blood is circulated
Venovenous maximal uremic large venous through a hemofilter
Hemodialysis waste product catheters (surrounded by a dialysate
removal solution) and returned to the
patient through a venous
catheter; replacement
solution may be used to
Improve convection;
ultrafiltrate (fluid and waste
products removed is
collected in a drainage bag
as it exits the hemofilter
CVVHDF Continuous Maximal fluid and Venous blood is circulated
Venovenous uremic waste through a hemofilter
Hemodiafiltration product removal (surrounded by a dialysate
solution and returned to the
patient through a venous
catheter, replacement
solution is used to maintain
fluid balance; ultrafiltration
(fluid and waste products
removed) is collected in a
drainage bag as it exits the
hemofilter
ALVAERA, M.E. 4
CRITICAL CARE NURSING (MS3)
MECHANICAL VENTILATOR (SKILLS) | REVIEWER | BATCH 2023
References: • Provide comfortable breathing pattern to

• Nursing Powerpoint (FEU Version) patients experiencing shortness of breath
• Lecture Notes • To breathe for patients who are seriously
• Professor examples – blue text compromised ventilation such as in comatose,
brain damaged, or patients with spinal cord
OUTLINE injuries.
I. Care for Patient with Mechanical Ventilator
II. Purpose of Mechanical Ventilation
III. Indication for Mechanical Ventilator Use
IV. Contraindications
V. Principles of Mechanical Ventilation
VI. Benefits of Mechanical Ventilation
VII. Complications of Long-Term Ventilation
VIII. Types of Mechanical Ventilation
IX. Ventilator Modes
X. Ventilator Control Variables
XI. Ventilator Settings and Control
XII. Alarms
A. How to troubleshoot Ventilator Alarms?
a. Low-Pressure Alarm
b. High-Pressure Alarm
XIII. What are the Bundles of Care to Avoid
Ventilator-Associated Pneumonia (VAP)?
XIV. How to perform Closed System Suctioning?
c. Equipment
d. Procedure
XV. Plan of Care for Ventilated Patients
I. CARE FOR PATIENT WITH MECHANICAL
VENTILATOR
Patients who can’t breathe, for any reason, need
to.be attached on a mechanical ventilator. This machine
helps critically ill patients achieve the needed oxygen to
survive. The patient is then connected to the ventilator
with a tube that passes into the mouth and down to the
trachea. There is some point of complexity on this type of
procedure that is why Nurses who are assigned in the
intensive or critical unit should be competent in caring for
the patient with mechanical ventilator. III. INDICATION FOR MECHANICAL
MECHANICAL VENTILATION VENTILATOR USE
• lifesaving intervention for pts who are unable to 1. Continuous decrease in oxygenation
breathe on their own 2. Increase arterial carbon dioxide
3. Persistent acidosis
VENTILATION 4. Respiratory failure:
• process of taking O2 and releasing CO2 a. Apnea / respiratory arrest
INTUBATION b. Inadequate ventilation (acute vs
• the process of inserting a tube into the trachea chronic) (If CO2 is not excreted =
respiratory acidosis)
windpipe) in order to establish an airway for
mechanical ventilation. c. Inadequate oxygenation
d. Chronic respiratory insufficiency with
II. PURPOSE OF MECHANICAL VENTILATION FTT
• The patient does not have to work as hard to e. Compromised airway patency (Acute
breathe – their respiratory muscles rest lung injury, severe asthma, upper
• Helps the patient get adequate oxygen and airway obstruction, inability to protect
clears carbon dioxide airway-risk for aspiration)
• Preserves a stable airway and preventing injury 5. Cardiac insufficiency (Severe Hypotension)
from aspiration a. Eliminate the work of breathing
• Air is delivered in patients with compromised b. To reduce the oxygen consumption
ventilation 6. Neurologic dysfunction
• Oxygenate the different organs of the body a. Central hypoventilation and frequent
apnea
• Expel the carbon dioxide in the lungs
1
b. Comatose patient with GCS < 8 because the body is dying, this includes the
c. Inability to protect the airway lungs.
7. ABG Results
8. If the patient is under the following VIII. TYPES OF MECHANICAL VENTILATION
conditions: POSITIVE PRESSURE VENTILATION
a. Multiple trauma • The most common type mechanical ventilation.
b. Shock • It's known as "conventional mechanical
c. Multi-organ failure ventilation" and is generally what people are
d. Drug overdose talking about when they say that "someone is on
e. Thoracic or abdominal surgery the ventilator.'
f. Neuromuscular disorders
g. Inhalation injury NEGATIVE PRESSURE VENTILATION
h. COPD • Not as common as positive-pressure ventilation,
but it may still be used in certain situations.
IV. CONTRAINDICATIONS • Generates negative pressure outside of the
• Do Not Resuscitate/Do Not Intubate – signed thoracic cavity that is less than atmospheric
every 24 hours (depending on the hospital pressure.
policy)
• almost none, benefits of mechanical vent INVASIVE MECHANICAL VENTILATION
outweigh inability to breathe • Involves the insertion of an artificial airway into
the trachea.
V. PRINCIPLES OF MECHANICAL • Establishes a direct connection between the
VENTILATION ventilator and the patient's lungs.
• Ventilation • ET tube and tracheostomy (used commonly w
• Oxygenation smokers)
• lung compliance
NON-INVASIVE VENTILATION
• airway resistance
• Indicated lo improve oxygenation and ventilation
• dead space ventilation
and to provide relief for respiratory distress prior
• Respiratory failure to intubation and conventional mechanical
VI. MECHANICAL VENTILATION BENEFITS ventilation.
• CPAP, BIPAP, CONTINUOUS POSITIVE
• Decreases work of breathing
AIRWAY PRESSURE (CPAP), BILEVEL
• maintains adequate O2
POSITIVE AIRWAY PRESSURE
VII. COMPLICATIONS OF LONG-TERM IX. VENTILATOR MODES
VENTILATION A selling that determines how the machine will
INFECTIONS deliver breaths to the patient. The characteristics of each
mode determine how the ventilator functions.
• A foreign object such as the endotracheal tube
in the trachea makes the patient more
susceptible to bacteria entering the lungs. This
is treated with the use of antibiotics.
PNEUMOTHORAX
• This is the condition when the lung/s collapses.
It is a complication when the lungs are damaged
because of gets over-expansion. If this
happened, a chest tube is inserted on the
collapsed lung to allow it to re-expand and seal
the leak.
LUNG DAMAGE
• The air forced in the lungs can increase the risk
for injury. PRIMARY VENTILATOR MODES
SIDE EFFECTS OF MEDICATIONS ASSIST/CONTROL (A/C)

• Intubated patients are most of the time given • Used to deliver a minimum number of preset
sedatives to allow easier ventilation of the mandatory breaths by the ventilator, but the
machine. These medications keep the patient patient can also trigger assisted breaths.
calm and sleepy. • This mode provides full ventilatory support;
Therefore, il is commonly used when
MAINTENANCE OF LIFE mechanical ventilation is fist initiated.
• The ventilator sometimes serves as the only
reason why the patient is alive. Organs fail
2
SYCHRONOUS INTERMITTENT MANDATORY enhancing gas exchange and preventing

VENITLATION (SMV) atelectasis. Not all clients with mechanical
• Delivers a preset minimum number of ventilator is attached to PEEP.
mandatory breaths, but it also allows the patient • A typical initial applied PEEP is 5 cmH2O.
to initiate spontaneous breaths in between the However, up to 20 cmH2O may be used in
preset breaths. patients undergoing low tidal volume ventilation
• Since the patient can initiate spontaneous for acute respiratory distress syndrome (ARDS)
breaths, it means they are contributing to some
CONTINUOUS POSITIVE AIRWAY PRESSURE
of their minute ventilation. Therefore, SIMV is
(CPAP)
indicated when a patient only needs partial
• Used for spontaneously breathing clients.
ventilatory support.
Positive airway pressure is introduced during the
• Used when weaning off ventilator
respiratory cycle.
X. VENTILATOR CONTROL VARIABLES SENSITIVITY
VOLUME CONTROL (VC) • Used to describe the ventilator’s
• Allows the operator to regulate the patient’s responsiveness to the patient’s breathing effort.
minute ventilation Sensitivity adjusts the level of negative pressure
• Peak inspiratory pressure (PIPI) will vary required to trigger the ventilator. With assisted
depending on their lung compliance and airway ventilation, the sensitivity typically is set at -1 to
resistance. -2 cm H2 O.
PRESSURE CONTROL (PC) XII. ALARMS
• The patient’s tidal volume will vary depending on • Equipped with alarms that act as safety
their lung compliance and airway resistance. mechanisms to alert caregivers when there is a
• it protects the lungs from overinflation due to too problem related to the patientventilator
much pressure, which prevents barotrauma and interaction.
ventilator- induced lung injuries. HOW TO TROBULESHOOT VENTILATOR
XI. VENTILATOR SETTINGS AND CONTROL ALARMS?
Specific parameters that are set on the machine Alarms are designed to warn nurses that there is
in order to provide the pt with optimal ventilation. something wrong either to the patient or to the
TIDAL VOLUME (TV) mechanical ventilator. But sometimes, alarms can give
• Air that the client receives per breathing. nurses apprehensions especially if the alarm is non-stop
Percentage in the mechanical ventilator is and we don’t know how to troubleshoot the problem.
adjusted depending on client’s needs (40- So as a nurse, how will you manage if there’s an
100%). The normal value of tidal volume is ½ L alarm? First, assess the patient if he/she is in distress.
or 500 ml. Identify the alarm whether high pressure or low pressure.
FRACTION OF INSPIRED OXYGEN (FiO2) Some mechanical ventilators have their own indicators
• The oxygen concentration delivered to the client. and shows the cause of the alarm, so it’s important to
ABG is usually determined before adjusting check your machine as well.
FiO2 levels. It is adjusted from 40%-100%. LOW PRESSURE ALARM
PEAK FLOW RATE (PFR) • Low pressures alarm may indicate leak in the
• The peak flow rate is the maximum flow patient’s tube, disconnection of the tube, or the
delivered by the ventilator during inspiration. patient stops to breath.
Peak flow rates of 60 L per minute may be INTERVENTIONS FOR LOW PRESSURE ALARM
sufficient, although higher rates are frequently 1. Check the tube connections.
necessary. 2. Reconnect patient to the ventilator.
3. Replace leaking tubes by manually ventilating
BACK-UP RATE (BUR) the patient.
• For spontaneous or time mode ventilator, back- 4. Auscultate patient’s lung fields for bilateral lung
up rate is set so that the client may receive a sounds.
minimum number of breaths per minutes if the 5. Monitor respiratory rate and breathing patterns.
client fails to breath. If the client’s breathing rate 6. Evaluate cuff pressure. Re-inflate if needed.
is slower, it will cycle inhale / exhale pressure at HIGH PRESSURE ALARM
the set rate. High pressure alarm may indicate displacement of
• The usual setting for BUR ranges from 12-22 the ET tube, increased secretions, obstruction in the tube,
breaths per minute, depending on the bronchospasms, or the patient is coughing or biting the
physician’s order. tube.
1. Assess your patient.
PRESSURE END-EXPIRATORY PRESSURE (PEEP)
2. Auscultate lung fields for secretions. This should
• is exerted during the expiration phase of
be done at least every 2 hours or more.
ventilation, which improves oxygenation by
3
3. Suction secretions as needed. Oxygenate 5. Wear personal protective equipment. Perform

patient manually before suctioning. hand washing.
4. If patient is biting the tube, provide bite block. 6. Attach closed suction catheter system between
5. Sedate patient if necessary especially when ventilator circuit and patient airway.
patient is fighting the vent. Make sure this is 7. Ensure that wall or portable suction is turned on
ordered by the attending physician or hospitalist (no higher than 120 mmHg). Set vacuum setting
on duty. according to policy of your unit.
6. Monitor pulse oximeter continuously if cardiac 8. Attach suction tubing from setup to suction port
monitor and pulse oximeter devices are present. of catheter.
9. Hyper-oxygenate patient to 100% 02 for 2 – 5
XIII. WHAT ARE THE BUNDLES OF CARE TO minutes.
AVOID VENTILATOR-ASSOCIATED 10. Attach saline to irrigation port. You may use also
PNEUMONIA (VAP)? a 10 cc syringe for introducing saline irrigation or
Bundles of care for VAP should be strictly observed depending upon the set-up of your closed-
by the Critical Care Nurses or nurses in any department. suction kit.
1. Strict hand washing. The best way to prevent 11. Introduce catheter before instilling saline –
cross-contamination of any disease is hand lavage on inspiration.
washing. 12. Introduce catheter until a restriction is met or
2. Oral hygiene. Nurses should always perform until you can stimulate cough reflex.
oral care to patient attached to mechanical 13. Withdraw the catheter slowly while applying
ventilator. Know your hospital policies regarding intermittent suction. Suction should not be
your standard oral hygiene procedures. applied for more than 15-20 seconds.
3. Initiate closed suction system. Change the 14. Upon completion of suctioning, withdraw
system at least every 72 hours or as catheter, ensuring that tip is completely
indicated/needed. withdrawn from airway.
4. Avoid pressure ulcers. Turn patient to sides 15. Rinse suction catheter after each suctioning by
every 2 hours or as needed. Apply cream or depressing thumb control and squeezing a new
ointment to bony prominences or as indicated by saline irrigation using the 10cc syringe or
the physician. depending on the set-up of your close suction
5. Elevate head of bed >30 degrees. Always kit.
observe aspiration precaution. 16. Repeat suctioning process until the patient’s
6. Assess patient daily for extubation airway is clear.
readiness. Early extubation can greatly prevent 17. Discard personal protective equipment and
VAP. wash hands.
7. Daily interruption of sedation. 18. Evaluate patient’s condition by auscultating the
lung fields and by monitoring patient’s
XV. HOW TO PERFORM CLOSED SYSTEM oxygenation using pulse oximeter.
SUCTIONING?
XVI. PLAN OF CARE FOR VENTILATED
EQUIPMENT
1. Sterile Closed Suction Kit
PATIENTS
2. Normal Saline Irrigation • Promote effective breathing pattern
3. Suctioning machine or device: wall or portable • Promoted adequate gas exchange
4. Oxygen source • Improve the nutritional status that the body
5. Personal protective equipment needs
6. 10 cc syringe • Prevent patient from developing pulmonary
7. Pulse oximeter infection.
8. Stethoscope • Prevent patient from developing problems
related to immobility.
PROCEDURE • Patient and/or family will demonstrate
1. Check the guidelines or standard procedure of understanding of the purpose for mechanical
your unit for closed-suctioning system. ventilation.
2. Prepare all needed equipment. Position all
supplies so that they are easily accessible.
Check suction setup for correct functioning.
Read instructions of the closed-suction kit.
3. Explain the procedure to the client. Explain the
benefits of closed-suctioning system and how it
can prevent infection.
4. Assess patient first. Auscultate patient’s lung
fields for abnormal breath sounds. Attach patient
to continuous pulse oximeter monitoring device.
4
SKILLS (ET, DEFIB, ECART) | REVIEWER | BATCH 2023
REFERENCE: Why Should Intensivists Intubate:
• Hinkle, Janice and Cheever, Kerry H. 2018 • It’s the ‘A’ in ABC
Brunner and Suddarth’s Medical Surgical • Competent to perform vast majority of
Nursing 14th Edition. Walters Kluwer. intubations.
• FEU-IN ABC Teams PowerPoint • Will be expected in many settings
OUTLINE • Complications mostly not related to airway itself.
I. Endotracheal Intubation AIRWAY ASSESSMENT
A. Indications • Can be more challenging in critically ill.
B. Benefits • Must be avoid “cannot intubate” and “cannot
C. Airway Assessment ventilate” scenario.
D. Assess for Difficult Intubation • Must assess:
E. Additional Considerations o Risk for difficult mask ventilation.
F. Risks o Risk for difficult intubation
G. Materials to Prepare BAG MASK VENTILATION
H. Procedure • Crucial airway management skill
I. Nursing Management • Takes practice to perform correctly
II. Defibrillation • Gives time for well-planned approach to
A. Defibrillations definitive airway management.
B. Parts of Defibrillator • 3 keys:
C. Precautions o Patient airway
D. Steps in Using Defibrillator o Good mask seal
III. Emergency Cart o Proper ventilation
A. Purpose Bag Mask Ventilation: Open Airway
B. Used in cases like 1. HEAD TILT AND CHIN LIFT
C. Crash Cart Check list • One hand applies downward pressure
D. Steps in Using Defibrillator
to forehead and index and middle
I. ENDOTRACHEAL INTUBATION finger of the secondhand lift at chin.
• Advanced airway management • Lifts tongue from posterior pharynx
• A medical procedure in which a flexible plastic 2. JAW THRUST
tube is placed into the windpipe (trachea) • For unstable cervical spine
through the mouth or nose to help the patient • Place heels of hands on parieto-
breathe. occipital area.
• It is placed into the mouth in most emergency • Grasp angles of mandible with fingers
case situations. and displace jaw anteriorly.
• It maintains an open airway and help prevent 3. ONE HANDED TECHNIQUE
suffocation.
• Three facial landmarks that must be
• Commonly used for balloon: 7.5 – 10 cc of air.
covered by mask:
INDICATIONS
1. Respiratory Failure o Bridge of the nose
• E.g. Hypoxia, Hypercapnia, Tachypnea, or o Two malar eminences
Apnea (Asthma, ARDS, Pulmonary edema, o Mandibular alveolar ridge
Infection, COPD, Exacerbation, Severe 4. TWO HANDED TECHNIQUE
hypoxemia) • Small tidal volumes
2. Inability to ventilate unconscious patients • Squeeze steadily – don’t force air too
3. Maintenance or protection of an intact airway quickly.
4. Hemodynamic instability • 10-12 breaths/minute
• Facilitate mechanical ventilator, such as • Assess for rise and fall of chest
Shock, Cardiac Arrest 5. ADJUNCTS FOR OPENING AIRWAY
5. Medication Administration
• Need to size properly
6. Airway obstruction
• Avoid pushing tongue into posterior
• Maintain airway patency. E.g. Laryngeal pharynx.
edema, burn, tumor, trauma
• Start with curve of OPA (oral
7. For supporting ventilation during general
pharyngeal airway) inverted and rotate
anesthesia
180 degrees as tip reaches posterior
BENEFITS
pharynx.
1. Necessary if the patient requires mechanical
• Avoid in awake patient aspiration risk.
ventilation
2. To protect the lungs from aspiration
3. To get enough oxygen into the blood stream
4. To remove secretions
SKILLS | EMERGENCY 1
ASSESS FOR DIFFICULT INTUBATION a. Personnel are well-trained
b. Personnel perform intubation frequently
“LOOK”
c. Personnel receive frequent refresher training
• External skill, continuous quality improvement to detect
o Facial trauma frequent and minimize complications
o Unusual anatomy MATERIALS TO PREPARE
• Internal 1. Endotracheal tube – sizes differ with client
o Foreign body 2. Sterile gloves
o Obstruction mass 3. Lubricating jelly
• Sensitive but not specific 4. ET stylet (guidewire)
EVALUATE: 3-3-2 RULE 5. Ambu bag – for ventilation
• Mouth opening 6. Leucoplast or ET holder
• Access to airway and obtaining glottic 7. 10 cc syringe – for anchor
view. 8. Stethoscope
• Tip of mentum to hyoid bone 9. Bite block and Oropharyngeal airways
• Can tongue be deflected to PROCEDURE
accommodate laryngoscope.
STEP ACTION
• Thyromental distance 1 Patient Preparation:
• Predicts location larynx to vase of the Provide oxygenation and ventilation and
tongue. If larynx high angles difficult. position the patient.
OBESITY 2 Prepare the Equipment:
• Redundant tissue in upper airway may obscure Assemble and check all the materials needed
glottis. 3 Insertion:
• Controversial about how often difficult airway. a. Choose appropriate size of ET tube.
• Proper positioning key (Size common for adult: 7.5 – 8.0
NECK MOBILITY mm)
• Decreased cervical spine mobility compromises b. Choose the appropriate type of
sniffing position. laryngoscope blade. (Straight or
• Impairs alignment of axis and glottic view. curve)
• Degenerative or rheumatoid arthritis c. Test the ET tube cuffs. (No leaks
• Cervical immobilization when inflating)
• Test: extending neck/touching chest d. Wear sterile gloves
e. Secure the stylett inside the ET
ADDITIONAL CONSIDERATIONS tube.
IN CRITICALLY ILL f. Lubricate the ET tube
• Complications intubation higher than ICU (20- g. Place the head in the “sniffing
40%) position”. Open the mouth of the
o Limited physiologic reserve patient by using the thumb and
o Pre-existing hypoxemia or index finger.
hemodynamic instability. h. Assist doctor in inserting ET tube.
o Inability to properly assess airway. Clear the airway if needed. (Use
• Special considerations in ICI: 3 H’s suction machine)
o Hypoxemia i. Once inserted, inflate the ET tube
o Hypertension cuff to properly seal the ET tube.
o Hemodynamics Use 10cc syringe (air only)
(hypotension/pulmonary j. Remove the stylet from the ET tube
hypertension). then secure it with tape.
RISKS k. Attach to ambu bag
1. Injury to teeth, or dental work l. Squeeze the bag to give breaths (1
2. Injury to the throat second each) while watching chest
3. A buildup too much fluid in organs or tissues rise
4. Bleeding m. Assess proper placement by
5. Lung complications or injury auscultating for breath sounds
6. Aspiration (stomach contents and acids that end bilaterally.
up in the lungs) n. Secure the ET tube in place by tube
7. Lacerated lips or tongue from forceful pressure holder or leucoplast tape.
laryngoscope blade and the tongue or cheek o. Provide ventilation and continue to
8. Injury to the vocal cords monitor. Suction if needed.
9. Brain damage or death – wrong placement of ET p. Document: ET tube placement;
tube Consent signed; Who; When; and
NOTE: Skilled healthcare provider must perform this Time it was inserted.
procedure provided he/she meet the following criteria:
• Cardiac arrest and death within minutes. By
NURSING MANAGEMENT shocking the heart with electricity, defibrillation
1. Ensure that the required oxygen support restored a regular heartbeat.
indicated for the patient is provided. • A treatment for life-threatening cardiac
2. Assess the client’s respiratory status at least dysrhythmias, specifically for ventricular
every 2 hours or frequently as indicated. Note fibrillation and non-perfusing ventricular
the lung sounds and presence of secretions. tachycardia.
3. Ensure that adequate humidity is provided to • A defibrillator delivers a dose of electric current
avoid feeling of dryness in the oropharynx. (counter-shock) to the heart.
4. Suction secretions orally to prevent aspiration. TYPES OF DEFIBRILLATORS
This also decreases the risk for infection. • Automatic External Defibrillators (AEDs)
5. Assess nasal and oral mucosa for redness and • Standard Defibrillators with monitor
irritation. o MONOPHASIC
6. Secure the ET tube with tape or ET holder to § Current travels only in one
prevent movement or deviation fo the tube in the direction from one paddle to
trachea. the other
7. Place the patient in a side-lying position or semi- § Rate of first shock success in
fowler’s position if not contraindicated to avoid cardiac arrest due to a
aspiration. Reposition patient every 2 hours. shockable rhythm is only 60%
This will allow the lungs to expand better and § Associated with fewer burns
prevent secretions stagnation. and less myocardial damage
8. Ensure the ET for placement. Note lip line o BIPHASIC
marking and compare it with the desired § Current travels towards the
placement (18, 20, 22 cm). positive paddle and then
9. Closely monitor cuff pressure, maintaining a reverses and goes back
pressure of 20-25 mmHg to minimize the risk of § Delivers one cycle every “10
tracheal necrosis. milliseconds”
10. Move the oral ET tube to the opposite of the § Increase to 90% Associated
mouth every 8 hours or depending on the with fewer burns and less
protocol of the hospital. This it to prevent myocardial damage
irritation to the oral mucosa. Safety Precautions of AED:
11. Provide oral care at least every 4 hours using an • Perspiration
antibacterial or antiseptic solution, use a bite • Patches
block to avoid patient from biting down.
• Pendants
Frequent oral care in intubated patients will
• Piercings
decrease the risk of ventilator-acquired
pneumonia. • Pacemaker
12. Use a bite block to avoid patient from biting • Shaving
down.
13. Turn patient’s head to the side to reduce the risk
for aspiration.
14. Communicate frequently with the client. Give
patient means to communicate using a
whiteboard or communication board.
II. DEFIBRILLATION
• It is the treatment for immediately life-
threatening arrythmias with which the patient
does not have a pulse.
• By shocking the heart with electric current
restores a regular heartbeat.
• It causes all the heart cells to contract
simultaneously.
• Interrupting and terminating the abnormal; PLACEMENT OF PADDLES
electrical rhythm without damaging the heart
and thus allowing the sinus node to resume PARTS OF DEFIBRILLATOR
pacemaker activity. 1. Machine
• It is the treatment for ventricular fibrillation and 2. Paddles – for adult and pediatric
other life-threatening arrhythmias (abnormal 3. ECG printout
heartbeats). The heart stops pumping blood to 4. Alarm knob for selecting energy
the brain and body when it is ventricular 5. Synchronizer
fibrillation. If not treated immediately, it will
induce.
STEPS IN USING A DEFIBRILLATOR
AUTOMATIC DEFIBRILLATION
Step 1:
- Turn the defibrillator on by pressing the green
button and follow its instructions.
Step 2:
- Peel off the sticky pads and attach them to the
patient’s skin, one on each side of the chest.
Step 3:
- Once the pads have been attached, stop CPR,
and don’t touch the patient. The defibrillator will
then analyze the patient’s heart rhythm.
Step 4:
MANUAL AND HANDS-FREE DEFIBRILLATOR
- The defibrillator will assess whether a shock is
needed and if so, it will tell you to press the shoc
• Defibrillator used to require holding the paddles
button. An automatic defibrillator will shock the
and placed them on the chest (if using the old
patient without prompt. Do not touch the patient
type of defibrillator). The defibrillator’s pads or
while they are being shocked.
paddles are positioned to surrounds as much
Step 5:
myocardium as feasible.
- The defibrillator will tell you when the shock has
• A conductive substance, such as jelly pads
been delivered and whether you need to
should always be utilized to prevent skin
continue CPR.
damage. In hands-free device, the gel Step 6:
component is already present in the pads given
- Continue with chest compressions and rescue
in most Emergency Departments. breaths until the patient shows sihms of life or
• To enhance conduction and prevent arcing of the defibrillator tells you to stop so it can analyze
electrical current, good contact with the chest is the heartbeat again.
essential. If you’re going to use the paddles,
make sure they are firmly placed over the jelly MANUAL DEFIBRILLATION
pads. • If identify VF/Pulses or VT, immediately deliver
Precautions: 1 shock using the following:
• Defibrillation should not be performed on patient 1. Biphasic
who has a pulse or is alert, as this could cause o First dose: 120 Joules to 200 Joules.
lethal heart rhythm disturbance or cardiac 2. Monophasic
arrest. o If Ventricular Fibrillation persists after
• The paddles used in the procedure should not shock, second and subsequent shocks
be placed on a woman’s breasts or even over an of 360 Joules should be given.
internal pacemaker. • After delivering single shock, immediately
INDICATIONS resume CPR, pushing hard and fast at a rate of
• Ventricular Fibrillation 100 to 120 compressions per minute. Minimize
interruption of CPR and allow full chest recoil
after each compression.
III. EMERGENCY CART
• Also known as Crash Cart Code Cart
• a set on wheels with trays, drawers, and shelves
used in hospitals for transporting and
administering emergency
medication/equipment at the scene of a
medical/surgical emergency for life support
protocols (ACLS/ALS) to potentially save
someone's life.
PURPOSE
1. To assure availability of drugs, equipment, and
supplies necessary to initiate advanced life
• Ventricular Tachycardia support measures and assure uniformity of
emergency carts in hospitals
2. Provide immediate access to supplies and
medications.
3. Facilitate staff familiarity with equipment.
4. Ensure a properly stocked emergency cart that
is always ready.
5. Monitor the functions of defibrillator. Always
charged and ready to use.
6. Provide a fast and prevent waste time during o (1) 22-gauge angiocath
emergency situations. o Torniquet
USED IN CASES LIKE o Assorted butterflies
• Compromised airway • 3-way stopcock
• Respiratory distress/Respiratory Arrest • Assorted needles
• Cardiac Arrest/Abnormal Cardiac Rhythm • Band Aids
• Drug overdose • Betadine swabs
• Hypoglycemia • Alcohol swabs
• Anaphylactic reaction • Saline Lock
o Lidocaine topical solution
CRASH CART CHECK LIST o Radial artery catheterization set
• Tape
TOP
DRAWER 4
• Defibrillator with leads
• Electrodes
• Disposable gloves
• B/P cuff with stethoscope
• Sharp Containers
• Assorted sterile gloves
• Package of defibrillator pads
• (2) Packages of defibrillator pads
SIDE
• NG tube
• 02 tank
• 60 ml syringe
• Backboard
• Locks
DRAWER 1 – MEDICATION DRAWER
DRAWER 5
• (2) Amiodarone
• IV solutions: 1000 ml each of D5W, RL, NS
o Atropine 1 mg
o 500 ml each D5W, NS
• (2) Vasopressin
o (2) 100 ml NS
o (2) Calcium gluconate
o (2) 500 ml Lidocaine 2 grams
• (1) Dextrose 50% 5m
o Dobutamine
• (2) Isuprel
• Dopamine
• (4) Epinephrine 1 mg
• Amiodarone IVPB
• (3) Lidocaine 100mg
• Tubing
o Sodium Bicarbonate 50 meq
o (2) micro drips (60 drops/ml)
o Dopamine
o macro drips (15 drops/ml)
• (2) Lasix o Extension sets
• (2) Dobutamine • Medication additive labels
• (2) Tridil (nitroglycerin) DRAWER 6 (BOTTOM)
• (2) Pronestyl • Tracheostomy tray
• (2) Nipride • Transvenous Packing Electrode Kit
• (2) Verapamil • Ambu bags, Adult & Pedi
o Magnesium Sulfate • Suction set up (portable cart)
DRAWER 2 – AIRWAY MANAGEMENT DRAWER
• Airways, oral, assorted sizes
• Airways, nasal trumpet, assorted size
• Intubation tray – laryngoscopes, non-disposable and
disposable with blades
• K-Y jelly (2), viscous xylocaine (1)
• (2) 10 cc syringe
• Stylet
• Tape
• Batteries
• ET tubes – sizes 3.0, 6.5, 7.0, 7.5
• Yankauer suction
• Suction tubing
• Suction catheter tray
• 02 mask with tubing
• Nasal cannula
• (2) ABG kits
DRAWER 3 – VENIPUNCTURE TUBES AND
EQUIPMENT
• (1) 20 ml syringe
• (4) 3 ml syringe
• IV start equipment
o (4) 18-gauge angiocaths
o (4) 20-gauge angiocaths
SKILLS (EMERGENCY DRUGS) | REVIEWER | BATCH 2023
REFERENCE: III. INOTROPIC DRUG ADMINISTRATION

• Hinkle, Janice and Cheever, Kerry H. 2018 • Inotropic affects the heart contractility. They are
Brunner and Suddarth’s Medical Surgical usually administered as:
Nursing 14th Edition. Walters Kluwer. o (µgm/Kg/min) eg; Dopamine,
• FEU-IN ABC Teams PowerPoint dobutamine
o µgm/min eg; Adrenaline
OUTLINE o µgm/kg/hr eg; Pethidine,
I. 8 Client Rights of Medication Aminophylline
II. Basic Points to Remember • POSITIVE INOTROPIC – increase contractility
III. Inotropic Drug Administration • NEGATIVE INOTROPIC – decrease
IV. Points to Remember contractility
V. Nursing Responsibilities • CHRONOTROPIC – affects the heart rate
VI. Drug Strength & Dilution (increase/decrease)
VII. Inotropic Drug: Calculation of Doses In NOTES:
Mcg/Kg/Min • Inotropic drug administration is administered
VIII. Calculation of Infuse Rate in mL/hr via:
IX. Formula To Calculate How Many o Infusion pump
Mcg/Kg/Min Infused o Central line multi – potent and strong
X. Formula for Calculations medication
XI. IV Fluids Calculation • 5 cardinals of inflammation:
o RUBOR – redness
I. 8 CLIENT RIGHTS OF MEDICATION o TUMOUR – swelling
1. Right Client o CALOR – heat in extremities
2. Right Drug – check 3x shouldn’t give meds 30 o DOLOR – pain
mins after because it lowers the therapeutic o FUNCTIO LAESA – loss of function
level of mediation • INOTROPIC DRUGS: Drugs that increases the
3. Right Dose force of myocardial contractions. Digoxin
4. Right Time (Lanoxin), Dobutamine (Dobutrex), Epinephrine
5. Right Route Isoproterenol
6. Right Assessment • CHRONOTROPIC DRUGS: Drugs that
7. Right Evaluation increases the rate at which the heat beats.
8. Right Documentation (isoproterenol [Isuprel], epinephrine)
9. Right Patient Education • DROMOTROPIC DRUGS: Drugs that
10. Right to Refuse Treatment accelerate conduction (isoproterenol [Isuprel],
NOTES: phenytoin [Dilantin])
• Lowest level, extract blood 30 mins before
giving the medication IV. POINTS TO REMEMBER
• When patient reached toxic level you should do DO’S AND DON’T’S:
it 1 hour after • Inotropic drugs should never be administered
• Assess well in its original concentrated form
• Check the cardiac heart rate • It is always recommended to administer
• Evaluate patient right after the intervention (eg. through CVC line
Giving medication) – relieved, what happened • It should be always infused in a separate line
to patient? (not along with IV fluids, IV antibiotics etc.)
• When patient refused, inform the physician • The diluted medication should be used only
immediately for 24 hours, as the efficacy and potency of
the drugs is lost if administered after 24 hours
II. BASIC POINTS TO REMEMBER • Inotropes to be administered only through
WEIGHT infusion pumps, if not available through
• 1 Kilogram (kg) = 100 Gram (gm) microdrip sets
• 1 Gram = 1000 Milligram • Observe for drug-to-drug interaction while
• 1 Mg = 1000 Micro gram (mcg) administering with other inotropic drugs
FLUIDS (VOLUME) • Dilution and loading dose of the drugs will
• 1 Liter = 1000 Milliliter (ml) depend on the patient conditions, fluid status,
• 1 Pint = 500 ml dosage, and various of the factors
o Patient receiving dopamine for renal
• 1 Ounce = 30 ml
perfusion dosage, the loading dose
• 1 tablespoon = 15 ml
should be 200 mg (single
• 1 teaspoon = 5 ml concentration dose)
• 1 ml = 15 or 20 drops (based on the infusing o Patient having renal failure, be
set) cautious of the fluid receiving through
• 1 Drop = 4 Microdrops infusion
1
V. NURSING RESPONSIBILITIES Step 1: Calculate the loading dose of dopamine

• Monitor the hemodynamic parameters • 200 mg/5ml, so if you are taking 400 mg then
(tachycardia, hypo/hypertension) total dopamine is 10 ml
• Maintain the CVP within normal limits while on Step 2: Calculate the amount of the diluents (5% of
inotropes. Patient must not be hypovolemic Dns)
• Monitor hourly urine output, balance with • The infusion is started in infusion syringe using
positive or negative balance 50 ml syringe, so if 10 ml is dopamine, so the
• Inotropes should not be stopped abruptly. The diluent is 40 ml.
infusion must be slowly tapered before being Step 3: The order is to provide the medication per
discontinue. minute, but the infusion pump infuses the medication per
NOTES: hour
• If patient has low BP, infuse IV to normalize Step 4: Apply the formula
fluid status of the patient.
• Flush normal saline and auscultate the lungs.
VI. DRUG STRENGTH & DILUTION
• For inotropes the concentration will determined CASE 2:
through doctor’s ordered and patient’s need. A doctor orders a patient in septic shock to receive an IV
Examples of concentrations/strength are as infusion of Norepinephrine 4mg diluted with 5% dextrose
follows: to make a total volume of 250 ml. The patient is to
Example: receive 8 micrograms/min. What will be the infusion ate
DRUG STRENG SINGLE DOUB DILU AMOUNT in ml/hr?
TH STREN LE ENT OF
AVAILAB GTH STREN DILUENT
LE GTH
Adrena 1 MG/ 1 10 MG 20 MG D5W SS – 40
line ML (10 ML) (20 ML) ML VIII. CALCULATION OF INFUSE RATE
DS – 30
ML IN (ML/HR)
Noradr 4 MG/ 4 10 MG – 20 MG D5W SS – 40
enaline ML 10 ML (2 – 20 ML The nurse receives an order to decrease IV
AMPOU ML (5 DS – 30 Nitroprusside (Nipride) infusion on a patient with
LES) AMPO ML aortic dissection by 0.15 mics/kg/min every hour.
ULES) The solution strength is Nipride 100 mg in 250 ml
Dopam 200 MG / 200 MG 400 N/SA SS – 45 Dextrose 5%. The patient weigh 98kg. The infusion
ine 5 ML (5 ML) MG (10 LINE ML will be decreased by what rate, in ml/hr, each hour?
ML) DS – 40
ML Solution:
Dobuta 250 MG / 250 MG 500 N/SA SS – 30 A patient weighing 46 kgs is receiving IV
mine 20 ML (20 ML) MG (40 LINE ML Dobutamine 5.5 micrograms/Kg/min. The strength
ML) DS – 10 of the solution 100 mg Dobutamine hydrochloride
ML (2ml) plus 48 ml of D5W. What is the rate of the
Dopamine infusion in ml/hr?
40 mg/ml – 5 ml = 200 mL
50 mg/ml – 5 ml (stock) = 250 ml
NOTES:
• D5W – not allowed for blood transfusion (cause
hemolysis or blood clotting).
• Nitropruside – vasodilator
VII. INOTROPIC DRUG: CALCULATION OF

DOSES IN MCG/KG/MIN
CASE 1:
The nurse receives a order to start dopamine at 10
µgm/kg/min. His body weight is 75 kg. Available dosage
of dopamine is 200 mg/5ml. What is the infusion rate in
ml/ hr?
2
SHORT METHOD TECHNIQUE

Drops per mL Constant drops
10 gtts/mL 6
15 gtts/mL 4
20 gtts/mL 3
60 gtts/mL 1
XI. INTRAVENOUS FLUIDS CALCULATION

IX. FORMULA TO CALCULATE HOW MANY CASE 1:
MCG/KG/MIN INFUSED A patient is prescribed to received 2500 ml of 5%
dextrose normal saline over the next 24 hours.
Dopamine 200 mg in 50 ml is infusing at 5.2 ml/hr. The Calculate the flow rate on drops/min?
patient weights 58kgs. How many micrograms/Kg/min of
dopamine is being infused
Solution:
CASE 2:
A patient is prescribed to receive 5 pints of 5%
dextrose normal saline and 2 pints of normal saline.
The drop factor is 20 drops/ml. Calculate the flow
rate in drops/min?
Total fluids to be received by the patient

[ 5 X 500 = 2500, 2 X 500 = 1000]
EXAMPLE TO SOLVE
A patient with cardiogenic shock has a dobutamine
infusion running at 29ml/hr. The strength is Dobutamine
250 mg diluted with D5W to a total volume of 250 ml.
The patient weighs 64 kgs. Calculate the dose of
Dobutamine the patient is receiving in mcg/ kg/min
Dobutamine, Dopamine, Milrinone concentration can be
given single strength, double strength, triple strength,
quadruple strength. The concentration will be
determined through doctor’s orders, based on patient’s
need. Example of concentration strengths are as
follows:
Dobutamine Concentration
Single Strength 250 mg/250 cc (1000 mcg/ml)
Double Strength 500 mg/250 cc
X. FORMULA FOR CALCULATIONS Triple Strength 750 mg/250 cc

• Intravenous Fluids: Quadruple Strength 1,000 mg/250 cc
Dopamine Concentration
Single Strength 200 mg/250 cc (800 mcg/ml)
Double Strength 400 mg/250 cc
• Oral Medication
Triple Strength 600 mg/250 cc
Quadruple Strength 800 mg/ 250 cc
Milrinone Concentration
• Inotropic Drug: Single Strength 20 mg/ 100 cc (200 mcg/ml)
Double Strength 40 mg/100 cc (400 mcg/ml)
Triple Strength 60 mg/100 cc (600 mcg/ml)
Quadruple Strength 80 mg/100 cc (800 mcg/ml)
3
• To assess right ventricular function

XII. CLINICAL APPLICATION • Patient pollution
1st Line Agent 2nd Line
NOTES:
Agent
• Normal = 250 – 375
Septic Shock Norepinephrine Vasopress
• Lower than 250 is hypotonic (Levophed) in
• Higher than 375 is hypertonic Phenylephrine Epinephrin
• Between 230-275 is isotonic (Neosynephrine) e
(Adrenalin
)
Heart Failure Dopamine Milrinone
Dobutamine
Cardiogenic Norepinephrine
Schock (Levophed)
Dobutamine
Anaphylactic Epinephrine Vasopress
Shock (Adrenalin) in
Neurogenic Phenylephrine
Shock (Neosynephrine)
Hypotension Phenylephrine
(Anesthesia- (Neosynephrine)
induced)
o Suspicion of sepsis/septic shock
o Trauma or hypovolemic shock
o Anaphylactic shock
o Neurogenic shock
o Cardiogenic shock
o Respiratory Failure/ARDS
CASE:
Preassessment:
A patient is admitted in diabetic ketoacidosis with a
blood sugar of 20.0 mmol and is to be started on insulin - Previous CVP reading
infusion. Order is to start the infusion at 5 I u per hour. - Previous days fluid balance
Calculate and plan the infusion? - Signs and symptoms of fluid volume
excess/deficits
Step 1: load 50 i.u of insulin in 50 ml of normal saline - Drugs that affect fluid status such as
Step 2: 1 ml is 1 i.u of insulin Frusemide
Step 3: order is 5 i.u, hence the infusion should be
started at 5 ml/hr
NOTES:
• 80-100 normal sugar
• Do not administer insulin more than 100 ml
Tuberculin Syringe
0.1 = 10 units
0.2 = 20 units
0.3 = 30 units
0.4 = 40 units
0.5 = 50 units
CENTRAL VENOUS PRESSURE MONITORING
Definition:
• Central venous pressure monitoring measure
pressure in the right atrium or superior vena
cava. From this number, information regarding
blood volume, general fluid status, preload in
the right side of the heart, right ventricular
function and central venous return inferred.
Normal CVP is 2-6 mmHg
Indications:
• To monitor volume status

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CRITICAL CARE NURSING (MSN 3)

SKILLS (ECG) | REVIEWER | BATCH 2023

References: SA NODE • Primary pacemaker

ALVAERA, M.E., MEDALLO, A.M. 1

ALVAERA, M.E., MEDALLO, A.M. 2

• Varies with the HR shortens with • PEAKED- indicative of Hyperkalemia

ALVAERA, M.E., MEDALLO, A.M. 3

• HR: 60-100 bpm • A symptomatic px may be given drugs

• Sinus node creates an impulse at a slower

ALVAERA, M.E., MEDALLO, A.M. 4

ALVAERA, M.E., MEDALLO, A.M. 5

VENTRICULAR FIBRILLATION (V-FIB) • Drug induced – digitalis, quinidine, toxicity

ALVAERA, M.E., MEDALLO, A.M. 6

ALVAERA, M.E., MEDALLO, A.M. 7

References: ROUTES FOR ADMINISTRATION OF

- Line displacement. 18. Document observation and intervention as

References: SUBCLAVIAN VEIN

8. When ‘zeroed’ is displayed on the monitor, replace

References: EXTERNAL AV SHUNT

5. Troubleshoot for possible problems during

IV. CONTINUOUS RENAL REPLACEMENT

ABBREVIATION NAME PURPOSE VASCULAR DESCRIPTION

References: • Provide comfortable breathing pattern to

SIDE EFFECTS OF MEDICATIONS ASSIST/CONTROL (A/C)

SYCHRONOUS INTERMITTENT MANDATORY enhancing gas exchange and preventing

3. Suction secretions as needed. Oxygenate 5. Wear personal protective equipment. Perform

REFERENCE: III. INOTROPIC DRUG ADMINISTRATION

V. NURSING RESPONSIBILITIES Step 1: Calculate the loading dose of dopamine

VII. INOTROPIC DRUG: CALCULATION OF

SHORT METHOD TECHNIQUE

XI. INTRAVENOUS FLUIDS CALCULATION

Total fluids to be received by the patient

X. FORMULA FOR CALCULATIONS Triple Strength 750 mg/250 cc

• To assess right ventricular function

CENTRAL VENOUS PRESSURE MONITORING

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