Author: Claire

Claire Galea is the founder and director of Mariposa Holistic Care, providing personalised, holistic care services that prioritise individual needs, dignity and wellbeing. With formal nursing education and extensive clinical training at the University of Malta, Claire brings a strong foundation in healthcare to her work. Passionate about health education, person-centred care and lifelong learning, she uses her blog Student Nurse Life to share knowledge, encourage reflection and inspire a more informed, compassionate and positive approach to health and everyday life.

Peripheral Vascular Access – Sites, Indications & Contraindications

Peripheral vascular access is commonly sought through the non-dominant upper extremity due to a reduced risk of dislodgement, thrombosis and thrombophlebitis. However, peripheral venous line cannulation can be done successfully through various sites in the body.

Peripheral Vascular Access Sites

Upper Extremity: The metacarpal veins on the dorsum of the hand drain proximally through the dorsal venous arch into the cephalic and basilic veins in the forearm. These connect by the median cubital and median antebrachial veins in the antecubital fossa region, prior to continuing up the arm.

Lower Extremity: lines may be placed from the dorsal venous plexus of the foot which become the great and small saphenous veins in the leg.

Retrieved from https://www.jaypeedigital.com/book/9789351524229/chapter/ch18 on 1st June 2021

Scalp: may be appropriate in neonates or infants. Sites include the frontal, occipital, superficial temporal or posterior auricular veins.

Preferred veins for cannulation are straight, distal and non-branched (since venous valves are usually located close to branching points). When accessing a vein, a tourniquet is to be placed proximally to the site to create engorgement in the vein. Vein should feel spongy and should not pulsate on palpation (indication of an artery rather than a vein). Avoid veins that are hard to the touch due to possible thrombosis.

Indications for Peripheral Vascular Access

administration of IV medications
administration of IV fluids
phlebotomy (prior to medication and/or fluids to avoid dilution or contamination of blood samples)

Contraindications for Peripheral Vascular Access

While there are no absolute contraindications for cannulation, there are relative contraindications for which clinical judgement on benefits and risks of procedure is warranted. These include:

coagulopathy
local infection
burns
compromised skin at planned insertion site
previous lymphatic nodal clearance
arteriovenous fistula formation
deep vein thrombosis

In the case of extended treatment, it is best to opt for a central venous catheter rather than peripheral vascular access, as this offers lower failure rates in relation to long-term use.

Optimum PVA Outcome

prompt placement of peripheral vascular access when required
regular monitoring of line function
consideration regarding need for venous access
removal of lines when no longer indicated
early intervention in the case of complications

Below you can find a collection of videos that can help provide a more visual approach to peripheral vascular access.

IV Cannulation OSCE

BD Venflon I IV Cannula

IV Insertion Common Mistakes

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Geeky Medics, BD and Practical Anesthesia Techniques.

Reference:

Beecham, G.B. & Tackling, G. (2020). Peripheral Line Placement. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK539795/ on 2nd June 2021

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Chemotherapy Administration

Cancer is a disease in which some body cells start to divide rapidly, leading to a spread to other parts of the body. Tumour cells tend to grow in a much more rapid way than normal cells. Chemotherapy administration stops this cell division process by killing them.

Chemotherapy administration routes include oral, subcutaneous, intramuscular, intravenous, intrathecal (into the spinal fluid) , intravesical (into the bladder to treat bladder cancer) and topical (eg. in melanoma).

A Chemotherapy Treatment Chart includes:

chemotherapy name
dosage
route
date and time for each chemotherapy administration (be it on the same day or on different days)
patient details
medications to be administered along with chemotherapy eg. antiemetics to counteract nausea caused by chemotherapy
signature, name or initials of medical officer prescription in chemotherapy administration chart

Excerpt from a Chemotherapy Protocol – Retrieved from http://nssg.oxford-haematology.org.uk/lymphoma/documents/lymphoma-chemo-protocols/L-80-r-chop-21.pdf on 31st May 2021

In reference to the above protocol excerpt:

R-CHOP-21 is the name of the protocol
The letters RCHOP refer to the chemotherapies being administered
P is referring to Prednisolone
21 refers to the number of days per chemotherapy cycle
The protocol outlines all details related to the chemotherapies being administered and how all medications should be administered to one specific patient

Prior To Chemotherapy Administration

Medical assessment needs to be carried out and documented on file (patient has to be deemed fit for chemotherapy prior to treatment start)
Parameters as well as height and weight need to be taken as baseline (patient shouldn’t be given when or if patient is severely unwell, as chemotherapy worsens patient condition)
Informed consent should be acquired from the patient and placed in file
Routine tests such as blood tests, allergies and pregnancy result should be acquired and checked by the medical officer
Re-discuss side effects with patient
Get chemotherapy from designated locations

First Check – Prior to Chemotherapy Administration

Patient identity details
Name of Chemotherapy
Dose of Chemotherapy
Route of administration
Date and Time of administration
Chemotherapy drugs sequence
Duration of infusion
Rate of administration
Pharmacist signature
Expiry date and time
Uncompromised integrity of chemotherapy bag
Known drug allergies
Protect from light if required

With reference to the above, the information on the chemotherapy treatment chart and the chemotherapy plastic bag must be compared and matched. Check should be carried out independently by two different nurses at the patient’s side immediately prior to administration.

Second Check – Prior to Chemotherapy Administration

Patient identity details
Name of chemotherapy
Chemotherapy dose and volume
Route of administration
Date and Time of administration
Expiry date and time
Pharmacist signature
Check for precipitation in chemotherapy container

With reference to the above, the information on the chemotherapy plastic bag and the chemotherapy container inside must be compared and matched. Check should be carried out independently by two different nurses at the patient’s side immediately prior to administration.

Third Check – Prior to Chemotherapy Administration

Patient identity details
Known drug allergies

With reference to the above, the information on the chemotherapy container must be checked with patient. Check is usually carried out by the nurse administering the chemotherapy.

Once all checks are performed, the two nurses sign on the treatment chart, indicating that the chemotherapy administration can be started.

Preparation – Prior to Chemotherapy Administration

Anaphylactic reaction/shock tray (Hydrocortisone, Chlorphenamine – antihistamine, Ventolin for bronchospasms, flushes, oxygen masks etc.)
CPR trolley
Emergency call bell
Hypersensitivity tray
Extravasation kit
Hot and Cold pack
Chemotherapy spillage kit
Emergency shower

Oral Chemotherapy

compliance with prescribed drug schedule
check dietary requirements in relation to oral drug administration
handle with gloves
do NOT crush chemotherapy tablets/capsules

Drug Administration

Administer chemotherapy preferably via a central line
If a cannula is being used (eg. if chemotherapy needs to be administered urgently), insert cannula immediately before chemotherapy administration in large veins in the upper limbs (use either the pink or the blue cannulas for chemotherapy administration); chemotherapy should NOT be administered via cannulas in the lower limbs or over bony prominences or in small veins
Avoid repeated punctures to the same vein during the same venepuncture session as this increases the risk of extravasation
Use clear dressing over insertion site to see any leakages immediately (do not use bandages or occlusive dressings)
Tell patient to report immediately any signs or symptoms such as stinging, burning sensation, tenderness, pain or any other sensation at the infusion site
Check for venous return (back-flow) prior to chemotherapy administration

Personal Protective Equipment

gloves (one set of gloves is enough)
use double gloving only in the case of chemotherapy spillage or topical application of chemotherapy
cover cuts and scratches with waterproof dressing to avoid infiltration of the skin by chemotherapy
gloves should be worn at all times when in contact with bodily fluids from patient receiving chemotherapy
plastic apron or if available, gown during chemotherapy administration
gown should be used in the case of chemotherapy spillage
goggles or full face visor should be used when dealing with spillages (if chemotherapy is splashed into eyes, rinse continuously with cold running water for 10-20 minutes and seek medical advice)
masks should be worn in chemotherapy spillage event
shoe covers should be worn for spillage management
handle chemotherapy below waist level to avoid spillages on face
pregnant nurses should avoid administering chemotherapy
items that come into contact with chemotherapy should be discarded into the appropriate chemotherapy waste bins

Chemotherapy cannot be cleaned by alcohol handrub…use soap and water instead.

In the case of Extravasation…

STOP infusion and DISCONNECT tubing
WITHDRAW as much drug from cannula or central line as possible
DO NOT FLUSH!
Inform medical officer
Open extravasation kit

Extravasation – Retrieved from https://www.pinterest.com/pin/504966176945168896/ on 1st June 2021

In the case of Hypersensitivity Reaction…

Hypersensitivity reaction manifests as uticaria, bronchospasm, rash, abdomen cramping and hypotension, usually with treatments such as Rituximab. If the patient has a high risk of hypersensitivity reaction, premedication is given as steroids and antihistamines.

Further information about different chemotherapy drugs can be found at https://www.macmillan.org.uk/

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Central Venous Access Devices – CVCs & PICC Line Insertion & Care

Central Venous Access Devices (CVAD) are catheters inserted into a vein through the venous system, which are then advanced to the lower third of the superior vena cava, which has a higher blood flow than any other peripheral vein. This allows irritant drugs and fluids to get diluted quickly, thus avoiding damage to the vein.

A Central Venous Access Device is a central venous catheter which is inserted either through a peripheral vein (PICC Line) or through a proximal central vein, usuall through the internal jugular vein, subclavian vein or femoral vein (CVC).

A CVAD is inserted using a sterile technique in a theatre setting.

Indications for Central Venous Access Devices

ACCESS FOR DRUGS:

irritant drug infusion (eg. Chemotherapy & Total Parenteral Nutrition)
poor peripheral access (eg. patient is experiencing a hypovolaemic shock)
long term drug administration (eg. IV antibiotic treatment for weeks)

ACCESS FOR EXTRACORPOREAL BLOOD CIRCUITS:

renal placement therapy (dialysis)
plasma exchange

Both of the above are high-flow procedures for which peripheral venous access cannot be chosen.

ACCESS FOR INTERVENTION MONITORING:

central venous pressure
central venous O2 saturation
pulmonary artery pressure
temporary transvenous pacing
targeted temperature management
frequent blood sampling

Central Venous Access Devices Contraindications

site trauma
site infection
vein thrombosis or stenosis (narrowing)
coagulopathy (impaired ability to clot blood, leading to increased risk of bleeding) and thrombocytopaenia (decreased number of platelets in blood, leading to increased risk of bleeding)
vessel haemorrhage
proximal vascular injury eg. blunt or penetrating injury on site

CVAD Classification

Site (jugular or subclavian or femoral or brachial)
Lumens (single or double or triple or quad)
Time (short term or mid term or long term)
Type (central or peripheral)
Tunnelling (tunnelled or non-tunnelled <6 weeks or totally implantable port-a-cath for years)

Complete table can be retrieved from Smith and Nolan, 2013. Central venous catheters. *BMJ : British Medical Journal,* 22(7933), E44277-32.

Retrieved from https://edu.cdhb.health.nz/Hospitals-Services/Health-Professionals/pdu/Documents/CENTRAL%20VENOUS%20ACCESS%20DEVICE%20%20Resource%20Book%202011.pdf on 30th May 2021

Central Venous Catheter Insertion

May be inserted under ultrasound directed technique
Inserted by an anaesthetist in a theatre setting
Anatomical landmarks can be used in emergency situations
Trendelburg position (supine with head declined) is used during procedure to avoid air embolus

CVC (central venous catheter) is inserted through the internal jugular vein, subclavian vein or femoral vein.

PICC (peripherally inserted central catheter) is inserted through a peripheral vein eg. basilic vein or cephalic vein.

Protective Measures and Protective Equipment for Insertion

Sterility and an aseptic technique with PPEs including sterile gown, sterile gloves and sterile drape. In case of increased risk of contact with blood or body fluids, eye and/or full protection should be used.

2% Chlorhexidine Gluconate in 70% Isopropyl alcohol should be used and allowed to dry (in case of patient sensitivity use Povidone-Iodine instead).

Dressing used should be sterile, semi-permeable and transparent to allow insertion site observation.

Blood is aspirated from all lumens to confirm lumen patency.

Chest x-ray is to be performed prior to use so as to rule out pneumothorax and confirm correct placement.

Central Venous Access Devices Tip Placement

CVAD position must be verified through an x-ray prior to use
CVC distal tip inserted into the upper body must be placed in the cavoatrial junction (the point in which the superior vena cava meets the right atrium)
CVC distal tip inserted through the femoral vein must be placed in the inferior vena cava right above the diaphragm level
PICC line distal tip inserted into a peripheral vein must be placed resting in the superior vena cava

Incorrect catheter tip placement increases the risk of mechanical and thrombotic complications. Tip positioning depends on the indications for catheterisation and the chosen site of insertion in the patient.

CVC Care

Use an aseptic technique for CVC care
Needleless injection ports must be changed once a week
Catheter site must be cleaned at least once a week using 2% chlorhexidine in 70% alcohol unless visibly soiled
Ports should be cleaned with 2% chlorhexidine in 70% alcohol prior to use
Use a gauze dressing if entry site is bleeding or oozing until resolved; otherwise use a transparent semi-permeable dressing for easy observation of entry site
Push-pause technique with 0.9% saline in a 10ml syringe is recommended for flushing of lumens, as this technique creates turbulence and allows the flushing of any debris in the lumens
Apply positive pressure (hold plunger down) when disconnecting syringe to avoid air entering the catheter
Apply central line dressing using aseptic technique; Use a sterile dressing pack and sterile gloves (since you’re accessing entry site); Disinfect skin with 2% Chlorhexidine in 70% Alcohol foam; Write date of dressing change on dressing
Replace administration set immediately after blood products administration; after 24 hours after total parenteral nutrition containing lipids; otherwise within 72 hours
Remove catheter if no longer required

CVC Blood Sampling

CVC blood sampling must be performed using a Vacutainer via a needleless injection cap to maintain a closed system and prevent being contaminated with patient blood. Following blood sampling from a CVC, flush using at least 20ml 0.9% sodium chloride using a 10ml and another 10ml syringe.

CVAD Care in the Community

Patient family members may be required to care for a CVAD within the community setting. Teaching correct procedures is crucial in avoiding unnecessary infections.

Change dressing weekly unless soiled or not intact, cleaning insertion site with 2% chlorhexidine in 70% alcohol prior to dressing change
Aspirate and flush lumens weekly if not regularly used
Take a shower, not a bath, to reduce infection risk
Swimming (submerging of CVC) is not recommended
Avoid vigorous physical activity so as not to dislodge CVC
Implanted ports require no such restrictions

CVC Complications

DELAYED: central line dysfunction and/or infection

IMMEDIATE: vascular, cardiac and/or pulmonary

INFECTIOUS : sepsis (widespread infection) and/or site infection

EMBOLIC: thrombosis (eg. air embolus)

MECHANICAL: dislodgement, incorrect plaement, catheter damage and/or catheter migration

If occlusion within the catheter is noted, ask patient to cough and take deep breaths and raise arm over head, as occlusion can be a positional issue.

Central Venous Catheter Blood Stream Infection (CVCBSI)

A CLABSI (central line associated bloodstream infection) is an infection that develops within 48 hours of a central line insertion, which is unrelated to any other infection site.

EXTRALUMINAL COLONISATION – originating from skin insertion site, commonly occurring in non-tunnelled CVCs

INTRALUMINAL COLONISATION – originating from catheter hub, commonly occurring in long-term lines eg. tunnelled CVCs

HEMATOGENOUSLY COLONISED – originating from a distant infection site

Retrieved from https://slideplayer.com/slide/10175240/ on 31st May 2021

Below you can find a collection of videos that can help provide a more visual approach to Central Venous Access Devices.

Ultrasound Guided Subclavian Central Lines

Applying a Central Line Dressing

Blood Culture from Central Venous Access Devices

Drug Administration via Central Venous Access Devices

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels American Thoracic Society, SmithandNephewUKI and Infection Prevention and Control – Malta.

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Phlebotomy – Withdrawing Venous Blood for Blood Testing Purposes

Phlebotomy is the introduction of a needle into a vein to withdraw a sample of blood for haematology (to assess blood cell composition eg. Complete Blood Count CBC), biochemistry (to assess electrolytes) or bacteriology (blood cultures) reasons.

Venepuncture is a highly invasive common diagnostic advanced skill regulated by institutional or ward protocols.

Blood investigations are required for:

evaluating treatment progress
screening for specific diseases
ensuring that a drug is within its therapeutic level (eg. checking digoxin levels to prevent digoxin toxicity)
checking for the patient’s wellbeing

Venepuncture Preferred Sites:

Basilic Vein
Cephalic Vein
Medial-Cubital Vein

The basilic vein on the dorsum of the hand can also be accessed, whilst foot veins should be accessed only as a last resort.

AVOID:

amputation, mastectomy or lymphoedema sides
fractured limb
paralysis sides
AV graft or fistula
IV infusion sites
frequently used areas for venepuncture

DO NOT USE:

pulsating vessels (they are probably arteries)
haematoma
oedema
inflammation or infection
fibrous veins (rigid, cordlike veins that roll)

phlebotomy — Veins and cutaneous nerves in the antecubital fossa. Median cubital vein near the cephalic vein is the first choice for a routine venipuncture to cause nerve damage least likely. Retrieved from https://www.researchgate.net/figure/Veins-and-cutaneous-nerves-in-the-antecubital-fossa-Median-cubital-vein-near-the_fig1_316596433 on 29th May 2021

Factors Influencing Venous Circulation

VASOCONSTRICTION – anxiety, stress, shock, cold
VASODILATION – warm, mechanical irritation, chemical irritation
BLOOD PRESSURE DROP
THROMBOSIS
LOW IV COMPONENT – dehydration, haemorrhage

Phlebotomy Procedure

Equipment Needed for Venepuncture

tourniquet
alcohol swabs
non-sterile gloves
vacutainer OR syringe & needle
blood sample bottles
sharps container
gauze swab
adhesive dressing

Nurse Safety Procedures:

hand hygiene
gloves
dispose of used items correctly
handle needles safely
dispose of needles in the sharps box

Patient Safety Procedures:

confirm patient identity
perform skill only if needed
cross-contamination prevention
disinfect skin

In the case of difficult venous access:

tap gently onto the vein
put arm in warm water to encourage vasodilation
lower arm below the level of the heart
ask for assistance
use advanced imaging techniques

NOTES:

When taking blood, mix sample bottle between 8-10 times after withdrawal.

Bleeding following venepuncture can take up to 10 minutes to stop, thus, tell patient to apply pressure to avoid haematoma formation.

Phlebotomy Problems:

ARTERIAL STAB:

immediately remove needle
apply firm pressure and elevate for more than 5 minutes until bleeding stops
assess movement, sensation and circulation of affected limb
consult physician

NERVE DAMAGE:

immediately remove needle
examine movement, sensation and circulation of affected limb
consult physician

HAEMATOMA PREVENTION:

insert needle at correct angle to avoid opposite vein wall perforation
hold vacutainer and needle steadily whilst taking blood
remove tourniquet prior to removing needle
apply pressure on puncture site immediately following needle removal

Below you can find a collection of videos that can help provide a more visual approach to Phlebotomy.

Phlebotomy

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels OSHVideo08 and RegisteredNurseRN.

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Respiratory Conditions

In this blogpost we will be going through some respiratory conditions, namely Pulmonary Embolism (PE), Pneumothorax, Empyema, Pleurisy, Pulmonary Oedema and Pleural Effusion.

Pulmonary Embolism (PE)

Pulmonary Embolism (PE), which is a life threatening emergency, is the result of an obstruction of the pulmonary artery or one of its branches caused by a thrombus, which starts anywhere within the venous system or in the right side of the heart. This obstruction compromises gas exchange in the affected part of the lung.

Pulmonary Embolism clinical manifestations include:

dyspnoea
tachypnoea
chest pain
anxiety
fever
tachycardia
apprehension (feeling something wrong is about to happen)
cough
diaphoresis (excessive sweating)
haemoptysis (coughing up blood)
shock

Pulmonary Embolism assessment may include:

chest x-ray
ECG
ABGs
pulmonary angiogram (CT PA)

Pulmonary Embolism prevention:

ambulate
encourage leg exercises if patient is on bed rest
advise against prolonged sitting, immobility and constrictive clothing
advise against leg dangling and/or leg crossing
do not leave IV catheters in situ for long periods
use compression stockings
administer anti-coagulation therapy

Pulmonary Embolism Management:

oxygen therapy – relieves hypoxaemia, respiratory distress & central cyanosis; assess for signs of hypoxaemia and monitor pulse oximetry; teach deep breathing exercises; if necessary administer nebuliser therapy or percussion and postural drainage to help with secretions
anti-coagulation therapy
place patient in semi fowler’s position and administer analgesics if patient experiences severe chest pain

Pulmonary Embolism complications:

cardiogenic shock (heart becomes unable to pump enough blood to meet the body’s needs)
right sided heart failure (right side of the heart is not pumping enough blood to the lungs a.k.a. cor pulmonale or pulmonary heart disease)

Pneumothorax

Pneumothorax happens when the parietal or visceral pleura is breached, causing air to enter the pleural cavity, leading to partial or full lung collapse. Similarly, haemothorax results from a collection of blood within the pleural cavity due to torn intercostal vessels or laceration of the lungs through trauma.

Simple Pneumothorax (does not shift the mediastinal structures)
Traumatic Pneumothorax (caused by an injury that tears the lung and allows air to enter the pleural space)
Tension Pneumothorax (life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function)

Pneumothorax clinical manifestations include:

sudden onset of pleuritic pain
minimal respiratory distress (in small pneumothorax) or acute respiratory distress (in large pneumothorax)
anxiety
hypotension
tachycardia
profuse diaphoresis (excessive sweating)
dyspnoea & air hunger
use of accessory muscles during breathing
central cyanosis (in severe hypoxaemia)
diminished or absent breathing sounds
normal or hyperresonant percussion on pneumothorax side (depending on its size)
decreased chest expansion
shifting of the trachea to one side (depending on pneumothorax size)

Pneumothorax assessment is done through a chest x-ray.

Pneumothorax medical management:

thoracentesis with suction
antibiotics (due to contamination infection)
oxygen therapy
thoracotomy (a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax)

Pneumothorax nursing management includes:

assist chest tube insertion
assess chest drainage process and water seal
monitor respiratory status and lung re-expansion with the use of pulmonary support interventions
provide information and reassurance to the patient and family members

Empyema

Empyema refers to a collection of thick purulent (infected) fluid in the pleural space.

Empyema clinical manifestations:

fever
night sweats
pleural pain
cough
dyspnoea
anorexia
weight loss

Empyema assessment:

auscultation of the chest for decreased or absent breathing sounds in the affected area
dullness on chest percussion
CT scan
thoracentesis

Empyema medical management:

drain pleural cavity to promote complete lung re-expansion
administer antibiotics
needle thoracentesis (if fluid amount is small and not too thick)
tube thoracostomy
open chest drainage via thoracotomy to remove thickened pleura, pus and debris as well as diseased pulmonary tissue

Empyema nursing management should be done in the same way as in pneumonia.

Pleurisy

Pleurisy happens when there is inflammation of the visceral and parietal pleurae. When these two rub together, the individual experiences severe sharp knife-like pain during breathing, which increases on inspiration. Pleurisy may develop when the individual has pneumonia, plumonary embolism and other respiratory conditions.

Pleurisy clinical manifestations:

pain that worsens with deep breathing, coughing or sneezing, and which is usually focused on one side only
pain may be localised as well as radiating towards the shoulder or the abdomen
pain decreases when the individual holds breath
on auscultation, friction rub can be heard
pain diminishes once pleural fluid develops again

Pulmonary Oedema

Pulmonary Oedema refers to an accumulation of fluid in the interstitial spaces of the lungs that diffuses into the alveoli.

Pulmonary Oedema clinical manifestations:

restlessness
anxiety
breathlessness
sense of suffocation
cyanotic nail beds
greyish skin tone
cold and moist hands
weak and rapid pulse
jugular vein distension
coughing
increasing foamy sputum
confusion and stuporous (as pulmonary oedema progresses)
rapid noisy moist-sounding breathing
significant decrease in oxygen saturation level

Pulmonary Oedema assessment includes crackles on auscultation.

Pulmonary Oedema medical and nursing management:

oxygen therapy (patient may need to be intubated and provided with mechanical ventilation)
position patient in an upright position or with legs and feet down or ideally dangling over the side of bed to promote better circulation
reassure patient to reduce anxiety
administer diuretics (monitor for medication effects)

Pleural Effusion

Pleural Effusion is a collection of fluid within the pleural space, commonly seen in pneumonia, congestive heart failure and respiratory infections.

Pleural Effusion clinical manifestations:

dullness/flatness to percussion over affected area
minimal or absent breathing sounds
decreased fremitus (vibratory sensation felt on chest during speech)
tracheal deviation to the unaffected side
dyspnoea may not be present in small to moderate effusions
shortness of breath leading to acute respiratory distress (in large effusions)

Pleural Effusion assessment:

physical examination
chest x-ray
CT scan
thoracentesis with pleural fluid analysis (culture, chemistry and cytology)

Pleural Effusion medical and nursing management:

thoracentesis
chemical pleurodesis (a procedure to achieve symphysis between the two layers of pleura by sclerosing agents)
the nurse should monitor chest tube drainage and water seal system, as well as document the amount of drainage

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels RadiometerMedical, MotionLit, RegisteredNurseRN, SurgEdVidz, Dr Aishwarya Kelkar, Respiratory Therapy Zone, Larry Mellick and FSUMedMedia.

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Arterial Blood Gases – Interpreting ABGs

Arterial Blood Gases provide a measurement of an individual’s pH (acidity) as well as the oxygen and carbon dioxide level in arterial blood: blood which is aspirated from an artery, namely from the radial, brachial or femoral artery. In other words, when interpreting arterial blood gases, one can determine the capability of gaseous exchange within the lungs (oxygen going into the blood and carbon dioxide going out of the blood).

Arterial Blood Gases Fundamentals

Human cells require oxygen. Breathing allows oxygen to be absorbed into the bloodstream through the alveoli in the lungs and expels carbon dioxide out from the lungs.

Haemoglobin molecules, which have 4 binding sites, act as carriers of oxygen to the tissues. Other molecules can also attach to the oxygen binding sites, and if this happens, hypoxia can happen (eg. if carbon dioxide attaches in the binding sites instead of oxygen).

Haemoglobin molecule + 4 O2 molecules = Oxyhaemoglobin

Interpreting Arterial Blood Gases — Retrieved from https://www.toppr.com/ask/question/the-protein-part-in-haemoglobin-is/ on 26th May 2021

When Carbon Monoxide attaches to the Haemoglobin binding sites instead of Oxygen, blood will become cherry red in colour. This is called Carboxyhaemoglobin, and it can be measured in ABGs.

Haemoglobin molecule + 4 CO molecules = Carboxyhaemoglobin

Haemoglobin may also be affected by a genetic condition or when exposed to certain poisons. This produces Methaemoglobin, which shows up in a brownish shade, and which can also be measured in ABGs.

O2’s affinity to haemoglobin is much more than CO2’s affinity to haemoglobin, thus when both are available, O2 attaches to haemoglobin first. Oxygen binding however can be affected by the levels of O2, CO2 and blood pH.

Where there is lack of O2 within the tissues, haemoglobin carries CO2, forming Carbaminohaemoglobin due to low levels of O2, high levels of CO2 and decreased blood pH.

Carbon Dioxide Transportation

Carbonic Acid – Bicarbonate Buffer System (Reversible System)

ABG Components

Retrieved from https://www.slideshare.net/kerolus/basic-abg-notes on 26th May 2021

Arterial Blood pH

Normal ABG Values

respiratory acidosis — CO2 builds up and reacts with the water in the blood, forming carbonic acid – Retrieved from https://healthjade.net/respiratory-acidosis/ on 26th May 2021

respiratory alkalosis — Body removing more CO2 than is being produced by the tissues – Retrieved from https://www.pinterest.com/pin/532761830894111979/ on 26th May 2021

metabolic acidosis — Retrieved from https://www.pinterest.com/pin/427349452111640534/ on 26th May 2021

metabolic alkalosis — Retrieved from https://healthjade.net/hyperchloremic-acidosis/ on 26th May 2021

Indications for ABGs

assessing acid-base status (measuring pH in the body to assess for respiratory alkalosis/acidosis)
assessing ventilation (effective gaseous exchange in the body)
assessing for electrolyte imbalances (through ABGs testing, electrolyte balance reading is available in just a few minutes)
assessing for treatment response (eg. following asthma exacerbation treatment)

ABGs Contraindications

bleeding disorders (eg. patients undergoing anticoagulation therapy)
arteriovenous fistula (an abnormal connection between an artery and a vein)
peripheral vascular disease (a pre-known problem with circulation)
infection on site

Retrieved from https://en.wikipedia.org/wiki/Arteriovenous_fistula on 26th May 2021

ABGs Complications

Haematoma – apply pressure on site for 2-3 minutes to avoid
Thrombus formation within the artery due to the bleeding
Infection on site – introduction of pathogens into the patient’s artery causes infection; use chlorhexidine swab to clean skin thoroughly and allow to dry prior to puncturing skin)

Equipment Needed

a 23G (blue) needle
2ml syringe with heparin and a plastic bung (to avoid blood clotting in the needle and ABGs testing machine)
sharps bin
gloves
gauze
alcohol wipe

Below you can find a collection of videos that can help provide a more visual approach to Arterial Blood Gases Interpretation.

Arterial Blood Gases Balance Animation

Arterial Blood Gases Made Easy

Partially vs Fully Compensated & Uncompensated Arterial Blood Gases

Respiratory Acidosis

https://www.youtube.com/watch?v=X0VjnFKDNI0

Respiratory Alkalosis

Metabolic Acidosis

Metabolic Alkalosis

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media and RegisteredNurseRN.

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Tuberculosis – Nursing Care for the Patient with TB

Tuberculosis, which is caused by Mycobacterium Tuberculosis, is a chronic respiratory disease usually lasting for more than 3 months. It is commonly associated with poverty, malnutrition, overcrowding, substandard housing and inadequate healthcare.

Tuberculosis is an infection which primarily affects the lung parenchyma, but it can also spread to other areas within the body, such as the meninges, kidneys, bones and lymph nodes.

Tuberculosis Pathophysiology

Inhalation: Tuberculosis is a highly infectious airborne disease that is first acquired through inhalation, when a person inhales the Mycobacterium Tuberculosis (bacteria) and becomes infected.

Transmission: Once inhaled, it is then transmitted through the airways, to the alveoli, and then transported via the lymphatic system and the bloodstream to other areas within the body.

Defence: In response, the body’s immune system causes an inflammatory reaction and phyagocytes engulf many of the bacteria, whilst lymphocytes break down the bacteria.

Protection: Masses of live and dead bacteria called Granulomas become contained (stopped from multiplying and/or spreading) as they are then surrounded by macrophages which form a protective wall around them.

Ghon’s Tubercle: They transform into a mass of fibrous tissue, of which the central portion is called a Ghon’s Tubercle. At this stage, the infected individual shows no signs and symptoms of having Tuberculosis.

Scarring: The bacteria and macrophages turn into a cheesy mass, becoming calcified before forming into a collagenous scar. At this stage, the bacteria is considered to be dormant, stopping any further progression of the disease.

Primary TB Infection: No symptoms are evident up to this stage.

Activation: A compromised or inadequate immune system (eg. individuals on steroids, with cancer, HIV etc.) may cause the disease to activate when dormant bacteria is reactivated and starts multiplying (reactivation TB), becoming also drug resistant. The individual is now symptomatic.

Progression: If no immediate action is taken, Tuberculosis can progress from diagnosis to death in just 4-6 weeks.

Retrieved from https://www.semanticscholar.org/paper/Diagnosis-of-Latent-Tuberculosis-Infection.-Lardizabal-Reichman/bfdc2674a60777b44081d0412f658fcfe9ced420/figure/0 on 20th May 2021

Tuberculosis Causes

Contact – close contact with an individual with active TB
Low Immunity – individuals considered immunocompromised
Substance Abuse – alcoholic individuals and individuals who make use of IV drugs
Inadequate Healthcare – individuals who are poor, homeless etc.
Immigration – individuals coming from countries in which there is a high prevalence of TB
Overcrowding – eg. in substandard housing and poor living conditions

Tuberculosis Signs & Symptoms

Primary TB Infection – following a 4-8 week incubation period, patient is usually asymptomatic

Once bacteria becomes active, the patient starts exhibiting signs and symptoms of TB…

Non-Specific Symptoms – fatigue, weakness, anorexia, weight loss, night sweats and low-grade fever, with the latter two being the most common

Cough – productive

Haemoptysis – patient may occasionally start coughing up blood (blood may be visible in the patient’s saliva)

Chest Pain – caused by discomfort due to respiratory distress and infection. Inflammation due to bacteria causes inflammation of the pleural membrane, which then increases the friction in the pleural membrane, resulting in chest pain on coughing.

Tuberculosis Prevention

Identification and Treatment
Prevention using infection control principles eg. handwashing, isolating patients with active TB infection, wearing of PPEs
Surveillance among healthcare workers through periodic testing for TB infection

Tuberculosis Complications

Respiratory Failure
Pneumothorax
Pneumonia (one of the most fatal complications of TB since it may cause infection all over the lungs, leading to TB Pneumonia)

Tuberculosis Assessment & Diagnostic Findings

Sputum Culture – positive result for Mycobacterium Tuberculosis during the active TB stage (no longer contained by macrophages)
Mantoux Test – positive reaction indicates a history of infection; it is not a direct indication of active TB (reaction in a healthy person usually indicates dormant TB, while a reaction in a clinically ill patient indicates that active TB cannot be dismissed as a diagnostic possibility
Chest X-ray – shows evidence of scar /fibrotic tissue
Bronchoscopy – shows evidence of inflammation; also allows sputum sample collection if needed for further testing
Needle Biopsy of Lung Tissue – provides positive testing for TB granulomas
Pulmonary Function Studies – indicates decreased vital capacity (caused by inflammation of the lungs that leads to difficulty in expelling air from the lungs), increased dead space (areas not involved in gaseous exchange), decreased oxygen saturation (TB affects gaseous exchange in the lungs leading to less oxygen saturation), and increased ratio of residual air vs total lung capacity (due to respiratory distress) – can also be indicative of other respiratory conditions so this isn’t used alone to diagnose TB
TB Blood Test

Tuberculosis Medical Management

TB is primarily treated with antituberculosis agents for 6-12 months…

First Line Agents:

Isoniazid (INH) – Side Effects include Peripheral Neuritis (nerve inflammation), Hepatitis (inflammation of the liver) and Hypersensitivity to the drug eg. rash, fever, SOB following medication intake.
Rifampin (RIF) – Side Effects include turning body secretions (eg. urine) into orange or red coloured secretions, Hepatitis, Fever, Purpura (small bruises forming on skin), Nausea and Vomiting.
Ethambutol (EMB) – Side Effects include Optic Neuritis (inflammation of the optic nerve) and Skin Rash; use with caution in patients with renal disease
Pyrazinamide – Side Effects include Hyperuricaemia (increased uric acid in the blood), Hepatotoxicity (damage in the liver), Skin Rash, Arthralgias (joint pain) and GI distress.

In adults with Active TB, treatment consists of all 4 drugs (this avoids the microorganism from becoming resistant to the antibiotic) usually administered daily for 2 months, followed by 4 months of INH and RIF.

In adults with Latent TB, treatment with INH is usually administered daily for 9 months.

Nursing Assessment

past and present medical history to identify the possibility of exposure to someone with active TB
assess physical appearance with emphasis on dramatic loss of weight
SPO2 and ABGs

Nursing Care

for patients with TB…

promote airway clearance
treatment adherence
promote activity and adequate nutrition
prevent TB infection spread

for patients with risk of TB infection…

identify interventions to prevent and reduce risk of infection spread
educate patient about airborne spreading of TB infection
identify patient’s close contacts at risk of contracting TB eg. associates, household members etc (these may require a course of drug therapy eg. Isoniazid, to prevent infection development
instruct patient to use tissue when coughing and sneezing
educate patient about proper tissue disposal as well as infection control measures eg. handwashing
isolate patient if needed esp. if infection control measures are not being adhered to (nurse should wear PPEs to protect self from TB infection eg. N95 mask)
monitor temperature due to febrile reaction being a sign of active TB infection
identify risk factors for reactivation of TB eg. use of alcohol, malnutrition, cancer, diabetes mellitus, steroid use etc.
emphasise importance of uninterrupted drug therapy
emphasise importance of follow-up and periodic re-culturing of sputum during drug therapy stage
emphasise importance of periodic liver function tests to monitor treatment side effects
notify Public Health Department regarding TB infection (similar to what happens in individuals with COVID-19 for contact tracing purposes)

If patient has a fever:

administer antipyretics
start IV if patient is unable to tolerate fluids to avoid dehydration

Sometimes a patient with TB is unable to clear secretions from the respiratory tract due to thick, viscous or bloody secretions as well as fatigue and poor coughing. Here the nurse should focus on the following objectives for the patient:

maintain patent airway
expectorate secretions without assistance
follow treatment regimen
identify possible complications and initiate appropriate actions

The nurse should…

assess respiratory function eg. breathing sounds (rhonchi and wheezing), respiratory rate, rhythm and depth, as well as for use of accessory muscles during breathing
assess patient’s ability to expectorate mucus and cough effectively
document amount of sputum, character and haemoptysis if present
place patient in semi or high fowler’s position
teach coughing and deep breathing exercises
clear secretions from mouth and trachea if required
maintain fluid intake of 2500ml per day (unless contraindicated)
administer mucolytic agents and bronchodilators when necessary

In patients at risk for impaired gas exchange, the nurse should focus on the following objectives for the patient…

absence or decreased dyspnoea
improved ventilation and adequate oxygen saturation through acceptable ABG results
no symptoms of respiratory distress

The nurse should…

assess for dyspnoea, tachypnoea, abnormal/diminished breath sounds, increased respiratory effort and fatigue
assess for cyanosis including in mucous membranes and nail beds
teach pursed lip breathing
promote bed rest / limit activity and assist with self care to decrease oxygen consumption
check PEFR (would be low due to lack of gaseous exchange)
monitor ABGs (for respiratory alkalosis) and pulse oximetry
administer supplemental oxygen if necessary

Patients with imbalanced nutrition usually show a drastic decrease in weight (10-20% less than their ideal weight), and complain about an altered taste sensation and lack of interest in food. They also have evident poor muscle tone. In patients with evident imbalanced nutrition, the nurse should focus on the following outcomes…

show an increase in weight
show no signs of malnutrition
show behavioural changes aiming to regain/maintain appropriate weight

The nurse should…

document patient’s nutritional status
take note of the patient’s normal dietary pattern and include in food selection
monitor weight during hospital stay
investigate anorexia, nausea and vomiting, and check for possible connection with medication intake
ensure proper oral hygiene to improve taste sensation and thus, appetite, plus reducing the chance of developing oral thrush and infection (mucocytis)
encourage small frequent high protein and high carbohydrate meals (helps reduce gastric irritation)
encourage patient’s family members to bring in food from home to help increase patient’s appetite and nutritional intake
refer patient to dietitian
administer antiemetics if patient is experiencing nausea and vomiting

Discharge Planning

provide patient with written instructions regarding scheduling of medications and follow-up sputum testing following therapy
teach patient about symptoms which should be reported to healthcare if present eg. haemoptysis, chest pain, fever and dyspnoea
emphasise importance of a high protein high carbohydrate diet and adequate fluid intake
provide information about side effects of treatments being given on discharge
encourage smoking cessation and alcohol cessation

Below you can find a collection of videos that can help provide a more visual approach to Tuberculosis nursing care.

Tuberculosis Animation

Tuberculosis Symptoms, Treatment, Causes and Nursing Management

Inactive Tuberculosis on Chest X-Ray

Active Tuberculosis on Chest X-Ray

Mantoux Test

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, RegisteredNurseRN, hammadshams and GreyBruceHealthUnit.

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Thoracentesis and Bronchoscopy – Respiratory Procedures Nursing Care

Sometimes certain respiratory procedures may be needed for diagnostic and/or therapeutic reasons. Thoracentesis and Bronchoscopy are two of these respiratory procedures.

Thoracentesis

Thoracentesis is a respiratory procedure performed with the aim of removing pleural effusion. A needle is inserted through the back of the chest wall and into the pleural space to extract pleural effusion for diagnostic (where pleural fluid is examined a.k.a. cytological examination) and/or therapeutic (where pleural fluid is removed to provide relief) reasons.

Thoracentesis Complications

Intercostal Vessels Laceration – leads to Haemothorax if undetected post procedure through ultrasound
Pneumothorax – lung laceration by needle or plastic catheter during procedure
Re-expansion Pulmonary Edema (RPE) – uncommon complication following procedure. Symptoms, usually noticed within 24 hours post procedure, include cough, chest discomfort and hypoxaemia. May be fatal.
Infection – risk can be reduced through correct infection control procedures
Hypotension – may happen if too much fluid is extracted too quickly

Nursing Responsibilities Prior to Thoracentesis

Obtain informed consent
Explain and emphasis the importance of having the procedure done
Inform patient that mild pain is experienced in situ
Check patient history with reference to anticoagulation therapy and/or known bleeding disorders
Area to be punctured may be shaved
Monitor vital signs
Ask patient to remove anything that may interfere with the procedure such as jewellery and clothing around insertion site
Prior to the procedure, a chest x-ray, ultrasound or CT scan may be performed to identify the exact location of pleural fluid that needs to be extracted
A sedative may be administered to reduce anxiety and help the patient relax during the procedure
Position patient in a sitting position with arms and head resting supported on an adjustable bedside table. If this is not possible, the patient should be placed in a lying position on the unaffected side and at the edge of the bed (attn patient safety!)
During needle insertion, teach patient not to cough, breathe deeply or move, as doing any of this may lead to lung puncturing

Nursing Responsibilities During Thoracentesis

Thoracentesis is performed using a sterile technique
The thoracentesis needle is usually inserted in the posterolateral aspect of the back, over the diaphragm but under the fluid level
Clean puncture site with an antiseptic solution
Local anaesthetic is administered at the area to be punctured
Monitor vital signs
Observe for distress signs such as dyspnoea and pallor
Administer supplemental oxygen if needed
If being performed for diagnostic purposes, fluid is aspirated; if being performed for therapeutic purposes, chest tube should be well secured
DO NOT drain more than 1000ml of pleural fluid within the first 30 minutes as this may lead to hypotension
Cover puncture site with a small sterile dressing

Nursing Responsibilities After Thoracentesis

Close drain for 4 hours after draining 1000ml of fluid into the Wolves bottle (you can reopen drain after the 4 hours are over…repeat if necessary)
Elevate head of bed to promote better breathing
Monitor vital signs
Observe for changes in patient’s cough, sputum and respiratory rate and for chest pain complaints
Document procedure including physician name, date and time of performed procedure and the amount and colour of the drained pleural fluid
Monitor dressing for bleeding or other drainage
Transport specimen to the lab if it is being evaluated
Chest x-ray should be performed 6 hours after procedure is done

Bronchoscopy

Bronchoscopy is an invasive procedure that allows direct examination of the larynx, trachea and bronchi either under general or local anaesthetic for diagnostic and/or therapeutic purposes. This is done using a bronchial brush, forceps and/or needle which are passed through the bronchoscope to retrieve tissue samples which can then be tested. This procedure can be done using either a flexible fiberoptic bronchoscope (provides a wider view of the tracheobronchial tree) or a rigid metal bronchoscope (ideal for foreign body removal and massive haemoptysis control a.k.a. blood coughing control.

Local anaesthetic is sprayed in the patient’s throat. Following effect of sedative, a bronchoscope is inserted through the patient’s mouth or nose. Anaesthetic is then sprayed through the scope’s inner channel to the vocal cords surrounding area. The anatomical structure of the trachea and bronchi is then examined; mucosal lining colour is noted, along with inspection for visible tumours or inflammation. Bronchoalveolar lavage may also be performed, where sterile water is injected into a segment of the lung and suctioned back before being sent for further testing.

thoracentesis bronchoscopy — Retrieved from https://www.pedilung.com/pulmonary-tests-procedures/flexible-bronchoscopy/ on 15th May 2021

Diagnostic Bronchoscopy allows:

Visualisation of the tracheobronchial tree to detect any abnormalities, including but not limited to inflammation, tumours or strictures
Visualisation of the larynx to detect vocal cord paralysis presence
Aspiration of sputum specimen for microscopy, culture and sensitivity
Biopsy of tissue from suspected tumours
Identification of bleeding site in haemoptysis (blood coughing)

Therapeutic Bronchoscopy allows:

Removal of excessive secretions and mucus plugs
Removal of foreign objects
Bleeding control
Resection of benign or malignant tumours

Bronchoscopy Contraindications

Uncooperative patients
Patients with coagulopathy problems
Patients with severe acute respiratory failure
Recent head trauma prone to developing an increase in intracranial pressure
Severe tracheal obstruction

Nursing Responsibilities Prior To Bronchoscopy

Withhold food and fluids for 6 to 12 hours prior to bronchoscopy to reduce aspiration risk
Obtain baseline vital signs and inform physician regarding any abnormal findings
Provide oral hygiene
Instruct patient to remove any dentures if present
If local anaesthesia is being administered, inform patient of its use and that it may have a bitter taste
Reassure patient that airway blockage doesn’t happen with the procedure to relieve associated anxiety
Prepare emergency resuscitation equipment at bedside to be prepared to resuscitate in case of bronchospasms and hypoxaemia during or following the procedure

Nursing Responsibilities During Bronchoscopy

Position patient in a sitting or supine position
Provide supplemental oxygen as required (usually via nasal cannula)
Assist in tissue specimen collection, removal of foreign body, bronchoalveolar lavage and aspiration of retained secretions
Send specimen to the lab with proper labelling
Monitor parameters repeatedly to detect any significant decrease in oxygen saturation during bronchoscopy

Nursing Responsibilities Following Bronchoscopy

Place patient in a semi-fowlers position
Reassure patient that hoareseness, loss of voice and sore throat may happen temporarily. This helps provide comfort and relieve anxiety
Maintain NBM (nil by mouth) until anaesthesia wears off and cough reflex is returned; resume normal diet gradually, starting with sips of water or ice chips
Observe patient sputum and report any excessive bleeding (minimum blood streak is expected and is considered normal for a few hours post procedure
Instruct patient to spit out any saliva in a provided emesis basin instead of swallowing it so as to prevent aspiration
Assess respiratory status to detect any signs of bronchospasm or bronchial perforation (hypoxaemia, haemorrhage and chest tightness)
Monitor vital signs (changes or discomforts may indicate possible complications)

Complications following Bronchoscopy

Bleeding from biopsy site
Fever – low grade fever (<38°C) is common due to an acute inflammatory response, high white blood cell count, elevated C-reactive protein and absence of infection
Bronchospasm
Pneumothorax – happens if lung is punctured during the procedure
Infection
Hypoxaemia – low blood oxygen saturation; common during the procedure, but is usually restored without any intervention; a higher risk of hypoxaemia is associated with the patient being in a sitting position, patients with chronic obstructive disorders and patients requiring supplemental oxygen prior to the procedure (suctioning can exacerbate hypoxaemia)
In patients with significant desaturation (>4% decrease or <90% saturation), oxygen supplementation should be administered to reduce complications related to hypoxaemia

Findings Following Bronchoscopy

Lung Disease eg. TB, Carcinoma or fungal infection
Foreign Substances eg. mucus plugs, blood and foreign objects
Endotracheal Abnormalities eg. narrowing or compression in the trachea
Bronchial Wall Abnormalities eg. swelling, inflammation or ulceration

Below you can find a collection of videos that can help provide a more visual approach to Thoracentesis and Bronchoscopy.

Thoracentesis

Thoracentesis Using Thoracic Ultrasonography

Bronchoscopy

https://www.youtube.com/watch?v=XTC3AKmtrcs

Bronchoscopy Segmental Anatomy

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Pulmonary Resident Essentials, UW Wish, Nucleus Medical Media and HansDaniels.

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Pneumonia – Nursing Care for Patients with Lung Parenchyma Infection

Pneumonia is an infection in the lung parenchyma, particularly in the bronchioles and alveoli, which is caused by pathogens such as bacteria, fungi and viruses. On the other hand, Pneumonitis is an inflammation in the lung tissue which increases the patient’s risk of developing pneumonia.

Community-Acquired Pneumonia – pneumonia acquired within the community or within the first 48 hours post hospitalisation or institutionalisation. Patient hospitalisation for pneumonia depends solely on the acquired pneumonia severity (may be treated at the patient’s home unless severe). CAUSES: Streptococcus Pneumoniae, Haemophilus Influenzae & Mycoplasma Pneumoniae.

Hospital-Acquired Pneumonia a.k.a. Nosocomial Pneumonia – pneumonia acquired more than 48 hours after hospital admission with no prior infection symptoms exhibited. This type of pneumonia carries a higher mortality rate. CAUSES: Staphylococcus Aureus, Impaired Host Defenses, Comorbid Conditions (eg. Asthma, COPD), Supine Positioning & Prolonged Hospitalisation.

Immunocompromised Patient Pneumonia – patients who are immunocompromised (have AIDS, Immune Disorders, Haematological Malignancies, or who make use of Corticosteroids, Chemotherapy or other immunosuppressive agents) can easily develop pneumonia from organisms of low virulence (organisms who don’t cause pneumonia in healthy individuals).

Aspiration Pneumonia – pneumonia acquired from entry of endogenous (bacteria from within the body aspirated in the lung such as gastric contents) or exogenous (bacteria from outside the body eg. from a drink causing aspiration or from chemical contents or irritation gases) substances into the lower respiratory tract. Aspirated substances impair the lung defenses (eg. removal of mucus, mucociliary escalator), cause inflammation changes which then lead to bacterial growth, causing pneumonia. This type of pneumonia happens within the community or hospital setting.

Pneumonia Pathophysiology

When pathogens enter the respiratory tract and descend into the sterile lower respiratory tract, an inflammation occurs.
Exudate (pus) is then produced, which in turn interferes with gases exchange within the alveoli. Instead, white blood cells migrate to the alveoli and fill the spaces which otherwise would have been filled with air.
Furthermore, the same inflammation causes the lining of the bronchioles to swell i.e. mucosal oedema. Additionally, the inflammation also causes the goblet cells to secrete even more mucus.
Both mucosal oedema and excessive secretions cause narrowing of the bronchioles, interfering with the diffusion of oxygen and carbon dioxide, causing hypoventilation, leading to hypoxia due to less oxygen perfusion within the body tissues.

pneumonia nursing care — Retrieved from https://schoolworkhelper.net/pneumonia-pathophysiology-complications/ on 5th May 2021

Retrieved from https://www.tacomacc.edu/UserFiles/Servers/Server_6/File/him/Eastabrooks/2011-2012%20Academic%20Year/Fall%202011/HIM%20160%20-%20F11/Lectures/HIM160_Chapter19/HIM160_Chapter19_print on 5th May 2021

Commonly used Terms

Bronchopneumonia: patchy consolidated areas
Consolidation: solidified tissue resulting from the infectious process
Lobar Pneumonia: consolidated lobe/s

Prevention

Promote Coughing Exercises in patients with excessive mucus production conditions such as COPD and Asthma. This helps clear mucus that if left there could lead to pneumonia.
Promote Smoking Cessation in patients who smoke, as smoking disrupts mucociliary clearance and white blood cell activity, both of which increase the risk.
Raise Head of Bed in unconscious patients since unconsciousness causes decrease in cough reflex and airway protection.
Frequent Repositioning, Breathing and Coughing Exercises, Suctioning and Chest Physiotherapy can help prevent pneumonia in long-term immobile patients.
Oral Hygiene, NGT Placement Check and Proper Patient Positioning can help prevent it in patients making use of an NGT.
Nutritious Diet, Frequent Turning, Ambulation and Coughing Exercises help prevent it in older adults.
Infection Control helps in the reduction of organism transmission by healthcare providers.
Pneumococcal Vaccine should be encouraged.

Pneumonia can be spread by infected respiratory droplets in person to person contact, thus, normal infection control practices should be encouraged and adhered to by the patient and his/her family members, as well as by healthcare staff using recommended PPEs.

Complications

Septic Shock – bacteria may end up in the bloodstream, leading to a septic shock.
Respiratory Failure – hypoventilation causes the patient to compensate for lack of oxygen by increasing Respiratory Rate. This causes the patient’s breathing muscles to get tired, leading to respiratory failure.
Pleural Effusion – may be caused by the fluid that is caused by the inflammatory process
Confusion – may be caused due to hypoxia

Pneumonia Clinical Manifestations

Rapidly Rising Fever is caused due to the infection of the lung parenchyma.
Pleuritic Chest Pain is caused by deep breathing and coughing.
Rapid Bounding Pulse is caused due to the body trying to compensate for the low oxygen perfusion in the body.
Tachypnoea is caused due to the body trying to compensate for the low oxygen perfusion in the body.
Bradypnoea is caused when the accessory muscles get tired.
Increased Cough (productive or not productive in dehydrated patients)
Purulent Sputum is caused by pus-filled sputum due to the infection in the lung parenchyma (greenish sputum).
Percussion Dullness can be heard where there is consolidation in the lungs.
Decreased Breath Sounds is caused by the narrowing of the lower respiratory tract leading to less movement of air.
Whispering Pectoriloquy can be noted due to consolidation in the lungs.
Crackles can be heard if there is pleural effusion.

A Chest X-ray can confirm the presence of pneumonia, since pneumonia’s symptoms are very similar to other chronic conditions such as Chronic Heart Failure and so it is difficult to identify its type based on the clinical manifestations only.

pneumonia xray — Retrieved from https://www.wikidoc.org/index.php/Pneumonia_chest_x_ray on 6th May 2021

Pneumonia Patient Assessment and Diagnostics

History of a recent respiratory tract infection as this predisposes the patient to pneumonia.
Physical Examination to note clinical manifestations.
Chest X-ray can confirm pneumonia.
Blood Culture helps determine any bloodstream invasion of the pathogen.
Sputum Examination helps identify the pathogen responsible for infection, test sensitivity of the pathogen and determine treatment.

Sputum Examination should be done on a sputum sample, for which the following steps are necessary:

Prior to being started on an antibiotic, instruct patient to rinse mouth with water so as to minimise contamination with oral microorganisms;
Ask the patient to breathe deeply for several times;
Ask the patient to cough deeply and expectorate the raised sputum into a sterile container;
Send sputum sample for microscopy, culture and sensitivity.

Retrieved from https://wexnermedical.osu.edu/blog/what-does-the-color-of-your-phlegm-mean on 6th May 2021

pneumonia clinical manifestations — Retrieved from https://nurseslabs.com/pneumonia/ on 5th May 2021

Pneumonia Medical Management

If suspected, start patient on a broad spectrum antibiotic eg. Tazobactam;
Assess patient after 72 hours based on his/her clinical condition, sputum sample and blood culture results;
Based on findings, continue same treatment or escalate treatment eg. Meropenem, or start on antiviral or antifungal medication if required.

Upon diagnosis:

start patient on IV fluids since fever causes fluid loss
administer antipyretic medications to control fever
administer antitussive medications to control cough
administer analgesia for pleural chest pain
administer oxygen therapy for hypoxia

Pneumonia Nursing Care

Improve Airway Patency through secretion removal by deep breathing and coughing exercises, chest physiotherapy and frequent position changes; adequate hydration to help thin and loosen secretions; humidification through oxygen therapy to help loosen secretions and improve ventilation; suctioning (SPO2 monitoring is required during suctioning as it can cause hypoxia).
Promote Rest and Energy Conservation by encouraging avoidance of overexertion and symptom exacerbation; place in Semi Fowler’s Position to promote a comfortable position whilst improving breathing; changing positions frequently so as to promote secretion clearance, pulmonary ventilation and perfusion.
Promote Adequate Fluid Intake and Nutrition – fluid intake should be increased to at least 2L per day to replace fluid loss; fluids with electrolytes help provide fluid, calories and electrolytes; and nutrition enriched beverages help in restoring proper nutrition with less effort.
Monitor patient for changes in pulse and temperature, amount and colour of secretions, and chest x-rays to confirm whether or not patient condition is improving.

Pneumonia Patient Discharge Planning

Teach proper administration and side effects of Antibiotic treatment
Teach signs and symptoms of worsening condition
Teach breathing and coughing exercises
Follow-up with Chest X-ray to ensure recovery
Warn patient that one episode of pneumonia leads to susceptibility of recurrent pneumonia episodes, thus, teach patient to avoid stress, fatigue, alcohol and smoking, all of which decrease the defense system of the lungs
Advise patient about adequate nutrition as well as to rest and avoid excessive activity to avoid recurrent pneumonia episodes
Encourage patient to take the yearly influenza vaccine to avoid getting influenza which can also lead to pneumonia

Below you can find a collection of videos that can help provide a more visual approach to Pneumonia Nursing Care.

Pneumonia – Animation

https://www.youtube.com/watch?v=aKduNgfePLU

Chest Percussion

Crackles

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, Stanford Medicine 25, Medicos Scientia and EMTprep.

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Administration of Blood and Blood Components

Administration of blood and blood components can be indicated to restore blood volume where there is inadequate tissue perfusion, to replace platelets, coagulation factors and other plasma proteins, as well as to increase the haemoglobin concentration and the blood oxygen carrying capacity.

Red Cell Concentrates – indicated for anaemia and acute blood loss: help increase oxygen carrying capacity through raising haemoglobin concentration in the patient. Can be stored in a temperature of 4 +/-2°C for 42 days (or for 28 days if irradiated). If unused or left for more than 30 minutes in the transport box, Red Cell Concentrates should be returned to the Blood Bank to minimise the risk of bacterial growth.

Fresh Frozen Plasma – indicated for warfarin reversal in a bleeding patient, in DIC (Disseminated Intravascular Coagulation) in a bleeding patient, or in Thrombotic Thrombocytopenia Purpura during plasma exchange. Can be stored in a temperature of less than -25°C for 3 years; must be used by 6 hours following thawing if stored in the blood transport box.

Platelets – indicated for massive haemorrhage / DIC, acute leukaemia, lumbar puncture, gastroscopy, biopsy, liver biopsy, laparatomy and eye operations: help prevent and/or treat haemorrhage in patients with Thrombocytopenia or Platelet Function Defect. Can be stored in a temperature of 22 +/-2°C for 5 days in an agitator. Platelets should be transfused immediately…they should NOT be stored outside the Blood Bank.

Special Requirements:

CMV (CytoMegaloVirus) Negative Blood: indicated for intrauterine transfusions, neonate transfusion (28 days post EDD) and pregnant women transfusion.

Irradiated Blood: indicated for intrauterine transfusion, BM/ stem cell transplantation, Hodgkin’s disease, etc.

Collection of Blood Units from HBB

Prior to blood units being collected from the Hospital Blood Bank, patient must be ready to be transfused: WEARING ID band; HAVING patent IV access; RECORDING of patient baseline observations.

Blood should be collected in the appropriate transport boxes with the necessary ice pack and separator. Platelets should NOT be packed with ice packs.

Collection should be done only when providing a legibly filled out Blood Issue Form.

Once collected, blood component should be delivered without delay to the responsible healthcare professional.

Haemolysis in RCC – Retrieved from https://profedu.blood.ca/sites/msi/files/VAG_en.pdf on 3rd May 2021

Clot Formation in RCC – Retrieved from https://profedu.blood.ca/sites/msi/files/VAG_en.pdf on 3rd May 2021

Procedure for Administration of Blood Products & Blood Components

Decision – potential risks and benefits as well as alternatives to blood transfusion should be considered during discussion between the doctor and patient. Information should be given so the patient can make an informed decision (leaflet should also be given to the patient or relatives prior to transfusion).
Prescription – blood components can only be prescribed by a medical practitioner.
Collection – prescribed blood components should be picked up from the HBB (Hospital Blood Bank) ONLY when the patient is ready to be transfused (See Collection of Blood Units from HBB)
Inspection – check expiry date, integrity of pack, discolouration or haemolysis, and that platelet pack does not show clumps or looks cloudy. Transfusion should be started immediately after being collected from HBB. DO NOT STORE in medicine fridges!
Transfusion – only qualified healthcare professionals with transfusion training can transfuse blood components. Procedure must be performed by 2 healthcare professionals, both of who need to sign the Nurses Record – Blood Product Transfusion Form. Overnight transfusions should be avoided unless absolutely necessary. Blood components should be gently mixed prior to administration. The blood administration set used for transfusion should contain an integral clot filter for all blood components (170-200 µm -micrometer). Blood administration set should be primed with the blood component or 0.9% normal saline. Platelets should NOT be transfused through an administration set which has already been used for blood transfusion. DO NOT flush out the blood in the administration line once transfusion is finished.
Administration Rate – RCC should be transfused over 90-120 minutes (less tolerant patients should be transfused at a slower rate with extra monitoring, not exceeding 4 hours of transfusion); Platelets should be administered over 30-60 minutes immediately following availability; Plasma should be infused at a rate of 10-20ml/kg/hr, not exceeding 4 hours of transfusion.
Note – administration set should be changed at least every 12 hours in RCC and FFP transfusion. Transfusion completion should happen within 4 hours following removal from temperature controlled storage. RCC and FFP exposed to temperatures of over 40° may cause a severe transfusion reaction.
End of Transfusion – wear gloves and remove empty blood bag and administration set (change set if infusion is to be continued); flush the cannula, document observations; fill in Traceability Form and send to HBB; dispose of blood administration set and bag in a yellow bag (clinical waste).

Patient Observation During Transfusion

Patient should be monitored by regular visual observations which should also be documented, throughout the transfusion phase of each transfused unit.
Record baseline observations of temperature, pulse, respiration and blood pressure prior to transfusion, 15 minutes into the transfusion and at the end of the transfusion plus more if needed.
Transfusion reaction signs include: fever, nausea, respiratory distress, back/flank or IV site pain, skin changes, uticaria, diarrhoea, shaking, headache, hypo/hypertension, chest pain, urine colour changes, tachycardia, oliguria, jaundice, unusual feelings.
Acute transfusion reactions include Acute Haemolytic Transfusion Reactions, Febrile Non-Haemolytic Transfusion Reactions FNHTR (mild or moderate fever, chills or rigors without any other known cause – if patient is otherwise stable administer paracetamol and restart transfusion at a slower rate), Acute Allergic & Anaphylactic Transfusion Reaction, Transfusion Associated Circulatory Overload (TACO), Transfusion Related Acute Lune Injury (TRALI) and Hypotensive Transfusion Reaction.
Delayed transfusion reactions include Delayed Haemolytic Transfusion Reaction, Transfusion-Associated Graft-Versus-Host Disease, Post Transfusion Purpura and Transfusion Transmitted Infection.
If transfusion reaction is suspected STOP/PAUSE immediately; report reaction to nursing officer, medical officer and the Blood Bank; assess airway, breathing and circulation and if need be call for resuscitation team; maintain venous access through slow normal saline administration; record observations (temperature, pulse, RR, BP, SPO2 and Urinary Output); if patient experiences temperature rise of <1.5°C, transfusion can be paused so patient can be administered necessary medication, and later on if symptoms subside can be restarted on transfusion.
Document reaction time, signs and symptoms, name of consulted physician, treatment and patient response, and plan.

The law stipulates that “Member States shall ensure that blood establishments, hospital blood banks, or facilities retain the data for at least 30 years in an appropriate and readable storage medium in order to ensure traceability” – Directive 2005/61/EC

Below you can find a collection of videos that can help provide a more visual approach to Administration of Blood and Blood Components.

Blood Types, Blood Group Systems and Transfusion Rule – Animation

Blood Types Explained

Administration of blood and blood components

Administration of blood and blood components – Method

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, RegisteredNurseRN and The Rotherham NHS Foundation Trust.

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