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Work Book Nsmp 311 2023

The NSMP 311 workbook provides a comprehensive guide for nursing students on the physical examination of the respiratory and cardiovascular systems, including procedures, assessments, and evaluations. It outlines learning outcomes, indications, contraindications, and medico-legal risks associated with various clinical procedures. The document serves as a portfolio of evidence for practical demonstrations and evaluations conducted in a simulated lab environment.

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0% found this document useful (0 votes)

3 views

Work Book Nsmp 311 2023

Uploaded by

Charlise Du Preez

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

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NSMP 311

WORK BOOK
(PORTFOLIO OF EVIDENCE)
2023
(Compiled by BNursing Team)
Contents
1 STUDY UNIT 1: THE RESPIRATORY SYSTEM ................................................ 5
1.1 Physical examination of the respiratory system .......................................................... 5
1.2 Maintenance of an underwater drainage system ...................................................... 22
1.3 Interpretation of an arterial blood gas ....................................................................... 38
2 STUDY UNIT 2: THE CARDIOVASCULAR SYSTEM ....................................... 54
2.1 Physical examination of the cardiovascular system .................................................. 54
2.2 Recording of electrocardiogram (ECG) .................................................................... 66
2.3 Administration of intravenous medication ................................................................. 79

2
NSMP 311 PROCEDURE LIST
Student name and surname:

Student number:

PROCEDURES SIMLAB DEMONSTRATIONS

Date Patient Name Formal Procedures Signed by Lecturer/Preceptor
1. SIMLAB DEMONSTRATION Physical examination of the respiratory system
2. SIMLAB DEMONSTRATION Maintenance of an underwater drainage system
3. SIMLAB DEMONSTRATION Interpretation of an arterial blood gas
4. SIMLAB DEMONSTRATION Physical examination of the cardiovascular system
5. SIMLAB DEMONSTRATION Recording of an electrocardiogram
6. SIMLAB DEMONSTRATION Administration of intravenous medication (Piggy-bag & bolus)
Date Patient Name Informal Procedures Signed by Lecturer/Preceptor
1. SIMLAB DEMONSTRATION Oxygen therapy and closed suctioning
2. SIMLAB DEMONSTRATION Collection of sputum specimen in an adult patient
3. SIMLAB DEMONSTRATION Basic identification of structures on a Chest X-ray
4. SIMLAB DEMONSTRATION Basic interpretation of an electrocardiogram (12-lead ECG)
5. SIMLAB DEMONSTRATION Checking of the emergency trolley and defibrillator
Utilization of emergency equipment and application of
6. SIMLAB DEMONSTRATION
resuscitation principles

3
FORMAL PROCEDURES:
LECTURER/PRECEPTOR/FACILITATOR EVALUATIONS
Signed by Lecturer/
Date Patient Name Procedures Hospital Ward
Preceptor/Facilitator
1. Physical examination of the respiratory system
2. Maintenance of an underwater drainage system
3. Interpretation of an arterial blood gas (PowerPoint)
4. Physical examination of the cardiovascular system
5. Recording of an electrocardiogram
6. Administration of intravenous medication (Bolus)
7. Administration of intravenous medication (Piggy-bag)

4
STUDY UNITS

1 STUDY UNIT 1: THE RESPIRATORY SYSTEM

1.1 Physical examination of the respiratory system

Learning outcomes

At the end of this study section, you should be able to:

• Provide a description of the respiratory system
• Name indications, contra indications and medico-legal risks associated with the procedure
• Perform the physical examination of the respiratory system correctly by utilizing of the steps of
assessment, planning, implementing, evaluating, and documenting
• Competently utilize the techniques of inspection, palpation, percussion, and auscultation during
the physical examination of the respiratory system

Study material

Hinkle, J.C. & Cheever, K.H. 2018. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.
13th Edition. New York: Lippincott.
Mogotlane et al., 2018. Juta's Complete Textbook of Medical Surgical Nursing. 2nd ed. Juta.
Mulder et al., 2020. Practical guide for general nursing science. 2nd Edition. Pearson: South Africa
Viljoen, M.J. & Sibiya, N. 2009. History Taking and Physical Examination. 2nd Edition. Cape Town:
Pearson.

5
PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM

Outcome:
After completion of the practical programme, the student should be able to perform
a physical examination of the respiratory system in a competent manner

Assessment scale:

The student should familiarise him/herself with the following scale prior to the
assessment

0 1 2 3
Not done Done, incorrectly Done correctly Done correctly with a
without provision of a rational for actions
rational for actions
• Unable to • Conduct • Displays some • Displays initiative
function assessment initiative and and creativity.
independently criteria but creativity • Acts
• Does not possess incorrectly • Acts independently in
scientifically based • Forgot some independently in an ethically
knowledge or assessment an ethically responsible
skills. criteria but responsible manner.
• Has not mastered remember when manner. • Possesses above
set skills the preceptor • Possess average average
probe student or scientifically based scientifically based
give a hint knowledge. knowledge.
• Integrates theory • Integrates theory
and practice and practice
moderately outstandingly

You must obtain 50% of the outcome criteria to master the clinical skill and be declared competent.

Outcome criteria marked with an “A”, “B” or “C is considered a critical point. A critical point is any
aspect of a procedure which could severely jeopardise patient safety or result in patient death.
A = 25%
B = 15%
C = 5%

6
THE PURPOSE OF A FULL EXAMINATION OF THE RESPIRATORY SYSTEM
To assess the functional status of the respiratory tract and lungs, utilizing skills of inspection,
palpation, percussion, and auscultation

INDICATIONS FOR THE PROCEDURE

• To detect any respiratory problems before it becomes an emergency
• Patients with known respiratory pathology

POSSIBLE CONTRA-INDICATIONS
• Active resuscitation

MEDICO-LEGAL RISKS INVOLVED:

• Misdiagnosing due to poor examination skills

EQUIPMENT/STAFF
• Non-sterile gloves
• Stethoscope
• Webcol swab
• Alcohol hand rub
• Watch with a second hand

PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM

ACTION RATIONAL
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. • Identify the patient • Verification of the patient’s identity ensures
that the correct procedure is being done on
the correct patient
2. • Introduce yourself to the patient and • To alleviate anxiety and fear that might be
explain the procedure to be done (utilizing experienced by patient and;
easy terms and not medical terms) • To facilitate cooperation during the
procedure
3. • Obtain verbal consent from the patient • Verbal or written consent is a legal
requirement for all procedures
4. • Wash your hands socially • To prevent the transmission of micro-
organisms (a universal precaution)
5. Assess the following in the patient’s file:
a. • Medical / Surgical history • Provide information on the patient’s
respiratory status
b. • Check the patient’s prescription chart • Provides information regarding possible
medications used for respiratory conditions
7
ACTION RATIONAL
c. • Evaluate the patient’s nursing care plan • The care plan will determine the related
(Where applicable to in-hospital patients) factors for the nursing diagnoses based on
the patient’s current health status
d. Diagnostic tests:
• Chest X-ray results (if available) • CXR confirm any pathology already
identified
• Arterial blood gas (ABG) results (if • An ABG result will provide information with
available) regards to acid base balance and adequate
gas exchange
6. Assess the patient for the following
a. • Physical and psychological ability to • Disorientation might compromise
participate cooperation during the procedure
b. • Assess patient’s basic needs e.g. • To decrease any discomfort and possible
experience of pain or the need to use a disturbances during the procedure
bedpan/urinal
PLANNING
1. • Gather all equipment as indicated •For effective time management
2. • Provide patient with privacy where •Patient always has a right to privacy
needed •To prevent unnecessary exposure during the
procedure
IMPLEMENTATION
1. • Wash your hands socially • To prevent the transmission of micro-
organisms (a universal precaution)
2. • Assist patient to undress where applicable • To ensure adequate visualisation of the
chest during inspection and the abdomen
for use of accessory muscles
3. • If not contra-indicated position patient • To have access to the anterior, lateral and
accordingly for the procedure ensuring posterior areas of the chest
comfort at all times
4. GENERAL ASSESSMENT
a. • Evaluate patient’s most recent vital data, • To detect any abnormal values within the
including the blood pressure, heart rate, vital data information that can indicate any
temperature, respiration and SA02 respiratory abnormalities
5. INSPECTION
Inspect the patient for the following
a. • Breathing rate, rhythm, and depth of • Normal breathing rate for adults is 12 – 20
breathing breaths per minute. Breathing must be
regular, not clearly audible with no use of
accessory neck or abdominal muscles
b. • Symmetrical breathing • Asymmetrical movement of the chest
during breathing can be an indication of
unilateral consolidation, a pneumothorax,
pleural effusion, fractured ribs or other
pathological changes within the respiratory
system
c. • Distress signs • Distress signs might include an increase in
breathing rate, nose flaring, pursing of lips,
rib retractions, using of abdominal muscles
are all indicative of possible pathology of
the respiratory system

8
ACTION RATIONAL
d. • Position of the trachea • Normal position of the trachea is central
with a slight deviation to the right due to
the presence of large vasculature in the
mediastinum. If not, an indication of
possible pathology within the thorax
e. • Skin, bones and muscles of the spine, • Inspection of the skin will reveal the
shoulder blades and back presence of lesions, rashes or masses
f. • Shape of the chest for the following:
o Normal chest shape • Normal chest shape is symmetrical and
elliptical in cross section.
o Kyphosis – forward bending of vertebral • Severe kyphosis can deform the chest and
column affect the lungs and the heart, leading to
breathing difficulties, fatigue, and even
cardiac failure
o Scoliosis – Lateral bending of ventral • In severe scoliosis the rib cage can press
column against the lungs and the heart causing
breathing difficulties and inability of the
heart to pump effectively
o Barrel shaped chest – Increase in antero- • Barrel shaped chest is seen in patients who
posterior diameter (seen in patients who suffers from COPD. With COPD the lungs are
suffers from COPD). chronically overinflated with air and
therefor the rib cage stays partially
expanded all the time.
6. PERCUSSION
a. • Percuss only the posterior thorax • Anterior thorax percussion is done during
cardiac examination and large structures in
the chest cavity will lead to a dull sound
during percussion of the lungs
b. • Ensure that your hands are warm prior to • To decrease the experience of any
touching the patient discomfort for the patient
c. • Ask patient to keep his arms folded in a • For maximum access to the posterior chest
position of “hugging himself” as the scapula rotates out of the way in this
position
d. • The middle finger of the left/right hand is To ensure optimal percussion technique
placed firmly on the posterior chest in the
intercostal space and then struck with the
tip of the middle finger of the right/left
hand
e. Compare the percussion note (resonant) with • Side to side and superior to inferior
that of the corresponding area on the approach increases the possibility of
opposite side of the chest. (See illustration detecting abnormalities
1 below)
Illustration 1

9
ACTION RATIONAL

f. • Identify the different sounds that might be present during percussion

o Resonant • Normal sound in healthy lungs
o Dull • A dull sound might be an indication of a
pleural effusion, consolidation, or mucus
plug (with collapse).
o Stony-dull / flat sound • A stony-dull note is duller than the standard
dull sound and suggests the virtual absence
of air directly beneath the percussed finger
in pleural effusions, empyema’s, or solid
material in the pleural space or atelectasis.
o Hyper-resonance • Hyper-resonance will be present with
emphysema (hyperinflation of alveoli) and
an acute pneumothorax (trapping of air
between pleurae)
7. PALPATION
Palpation is only done if any other sound than a resonant sound was percussed above.
Palpation will include the following:
a. • Determines the tracheal position by • The spaces between the trachea and the
placing your fingers at the side of the sternocleidomastoid muscles must be
trachea in the space between the trachea symmetrical. If not, pathology are present
and the sternocleidomastoid muscle (See
illustration 2 below)
Illustration 2

b. • Palpate patients skin temperature with • To determine any alterations in systemic

the dorsum of the hand temperature, local inflammation, or cold
and clammy skin indicative of shock
c. • Palpate the skin with finger pads of the • Might reveal abnormal findings such as
middle three fingers for: excessively dry or moist skin

10
ACTION RATIONAL
o Moistness,
o Elasticity, and
o Sensitivity of the skin
d. • Palpate muscles and ribs • Pain, tenderness and masses might be
indications of muscle injury, growths like
cancer and rib fractures
e. • Palpate the sternum and costo-sternal • Pain, tenderness or swelling might indicate
joint pathology of bone and joint
f. • Thoracic vertebrae • Pain, tenderness and swelling can be an
indication of spine pathology
g. • Palpate for tactile fremitus if dullness was Tactile fremitus is the vibration detected by
present during percussion (if felt, palpation with palms of the hand on the
interpret in relation to the patient’s lower part of the posterior chest when the
condition) patient is asked to repeat “ninety-nine”
(See illustration 3 below) Uses the palm of the hands and move it
systemically over the chest, while client says
one-one-one with every change of position
of the palm
In a normal healthy adult, the vibrations felt in
the corresponding areas on the two sides of
the chest are equal in intensity.
Increased on consolidation.
Reduced or absent in present of air.
Illustration 3

h. • Chest expansion (See illustration 4 below) • Places hands flat on bilateral aspects of the
lower chest over approximately the tenth
ribs – thumbs 2 cm away from the midline
• Thumbs move simultaneously and equally
away
Illustration 4

11
ACTION RATIONAL
8. AUSCULTATION
Auscultation is only done on the posterior aspects of the thorax and will include the following:
a. • Auscultate only the posterior aspect of the • Optimal auscultation will be possible on the
thorax posterior aspect of the thorax with no other
structures of the thorax in the way.
Anterior auscultation will be done during
cardiac examination
b. • Ensure that your stethoscope is warmed • To decrease the experience of any
prior to auscultation discomfort for the patient
c. • Ask patient to keep his arms folded in a • For maximum access to the posterior chest
position of “hugging himself” as the scapula rotates out of the way in this
position as lung sounds cannot be heard
through bone
d. • Auscultate the posterior lung fields with • The diaphragm of the stethoscope
the diaphragm of the stethoscope (See selectively filters low-frequency sounds.
Illustration 5 below) Since sounds produced by breathing tend to
be of relatively high pitch, the chest is
auscultated with the diaphragm.
Illustration 5

e. • Identify normal breathing sounds as •

follow:
o Vesicular sounds • Vesicular sounds are soft, blowing, or
rustling sounds that originate in the larger
airways and are produced by the passage of
air in and out of normal lung tissues.
• Inspiratory sounds last longer than
expiratory sounds
o Bronchial sounds • Expiratory sounds last longer than
inspiratory sounds. Location where heard
normally is over the manubrium if heard at
all
o Broncho-vesicular sounds • Inspiratory and expiratory sounds are about
equal. Can be heard in the posterior chest
between the scapulae
Illustration 6 and 7

12
ACTION RATIONAL

f. • Identify abnormal breathing sounds as follow:

• Bronchial breathing in areas other than • Presence of bronchial breathing in areas
over the bronchi other than the bronchi would suggest a
massive pleural effusion with complete
atelectasis of lung.
• Wheeze • Wheezing is continuous high-pitched
musical sounds associated with airway
narrowing or partial obstruction
• With expiration = asthma
• With inhalation = bronchitis
• Other conditions include: Allergies, COPD
etc.
• (watch the link below)
https://www.youtube.com/watch?v=T4qNgi4V
rvo
• Stridor • A harsh high-pitched sound heard on
inspiration (usually without the need of a
stethoscope) secondary to upper airway
obstruction
• Can be caused by an object blocking the
airway, allergies, tumours, vocal cord
problems
• In childhood - laryngotracheobronchitis, or
viral croup.
• (watch the link below)
https://www.youtube.com/watch?v=JSdEK79J
4dw
• Crepitations / Crackles • Fine crepitations are present in interstitial
lung disease
• Course crepitations are present during
infection in the larger airways
• (watch the link below)
https://www.youtube.com/watch?v=LHqqvrm
2j6g
• Pleural friction rub • Localised grating or creaking sound caused
by the rubbing together of inflamed parietal
and visceral pleurae
• (watch the link below)
https://www.youtube.com/watch?v=zm0jaBH
mm10
13
ACTION RATIONAL
g. • Listen for vocal fremitus (only if and The resonant sound that is heard with the
where dullness was percussed) stethoscope when the patient is asked to
repeat “ninety-nine”.
This depends on the loudness and the depth of
the patient’s voice and the conductivity of
the lungs.
9. • Remove gloves (if used) and disinfect •To prevent the transmission of micro-
hands organisms
10. • Make patient comfortable • Patient has a basic right to optimum
comfort
11. • Ensure patient safety by placing the bell • Patients need to be able to call for
within easy reach assistance STAT in case of abnormalities
• Patient always has the right to be in a safe
environment
12. • Report any abnormalities and action • To reduce medico-legal risks, the nursing
student always need to report
DOCUMENTATION
1. Document the following in the progress report
a. Date, time, procedure done • If not written, not done. For complete and
b. Any abnormalities found accurate documentation
c. Actions taken

14
PEER EVALUATION:

EVALUATION INSTRUMENT: PHYSICAL EXAMINATION OF THE RESPIRATORY

SYSTEM

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE

OUTCOME CRITERIA 0 1 2 3 REMARKS

COGNITIVE COMPONENT
1. Define the respiratory system
2. Provide 2 indications for the procedure
3. Discuss the history and management of the patient
4. Discuss action in case of abnormalities
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. Identified patient
2. Introduced self, and procedure explained
3. Obtained verbal consent
4. Washed hands socially
5. Patient’s file assessed for the following:
a. • Medical / Surgical history
b. • Prescription chart for specific instructions
c. • Patient care plan
d. Diagnostic tests:
• Chest X-ray result (if available)
• Arterial blood gas result (if available)
6. Patient assessed for:
a. • Physical and psychological ability to participate
b. • Basic needs
PLANNING
1. All needed equipment gathered
2. Privacy provided
IMPLEMENTATION
1. Hands washed socially
2. Patient assisted to undress (if applicable)
3. Positioned accordingly ensuring comfort at all times
4. GENERAL ASSESSMENT:
Patient assessed for:
a. Most recent vital data evaluated (NB respiration rate
and O2 saturation)
5. INSPECTION:
Inspection done with regards to the following:

15
OUTCOME CRITERIA 0 1 2 3 REMARKS
a. Breathing rate, rhythm, and depth of breathing
b. Symmetrical breathing
c. Distress signs
d. Position of the trachea
e. Skin, bones and muscles of the spine, shoulder
blades and back
f. Shape of the chest for the following:
• Normal chest shape
• Kyphosis – forward bending of vertebral column
• Scoliosis – Lateral bending of ventral column
• Barrel shaped chest
6. PERCUSSION
a. Only the posterior thorax percussed
b. Hands warmed prior to touching patient
c. Patient positioned correctly
d. Percussion done in the correct manner
e. Comparison of left and right side of the posterior
thorax done correctly
f. Different sounds were identified as follow:
• Resonant
• Dull
• Stony-dull / Flat sound
• Hyper-resonant
7. PALPATION
Palpation is only done if any other sound, then a resonant sound was percussed above.
Palpation included the following:
a. Tracheal position
b. Skin temperature
c. Moistness, elasticity and sensitivity of the skin
d. Muscles and ribs
e. Sternum and costo-sternal joint
f. Thoracic vertebrae
g. Tactile fremitus determined (only if dullness was
percussed)
h. Chest expansion
8. AUSCULTATION
a. Only the posterior thorax auscultated
b. Stethoscope warmed prior to auscultation
c. Patient positioned correctly
d. Auscultation of the posterior thorax done correctly
e. Normal breathing sounds identified as follow:
• Vesicular sounds
• Bronchial sounds
• Broncho-vesicular sounds
f. Abnormal breathing sounds identified as follow (and where applicable)
• Bronchial breathing in areas other than over the
bronchi identified
• Wheezing
• Stridor
• Crepitations / Crackles
• Pleural friction rub

16
OUTCOME CRITERIA 0 1 2 3 REMARKS
g. Auscultated for vocal fremitus (only if dullness was
percussed)
9. Gloves removed and hands disinfected
10. Patient made comfortable
11. Bell provided within easy reach
12. Actions and abnormalities reported
DOCUMENTATION
1. The following was documented
• Date and time
• Procedure done
• Abnormalities found and actions taken
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

____ X 100 = %
= 1
(Subtract N/A from total)
REMARKS
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________

17
PROCEDURE SIGNED OFF BY THE REGISTERED NURSE

PHYSICAL EXAMINATION OF THE RESPIRATORY SYSTEM

Yes No

1. Student identified patient

2. General assessment done

3. Inspection done correctly

4. Percussion done correctly

5. Palpation done correctly

6. Auscultation done correctly

7. Breathing sounds identified

Signature of RN: ___________________________

Signature of student: ___________________________

Remarks: (student competent/not yet competent/needs guidance)

__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________________

18
FORMAL EVALUATION:

EVALUATION INSTRUMENT: PHYSICAL EXAMINATION OF THE RESPIRATORY

SYSTEM

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE

OUTCOME CRITERIA 0 1 2 3 REMARKS

19
OUTCOME CRITERIA 0 1 2 3 REMARKS
c. Distress signs
d. Position of the trachea
e. Skin, bones and muscles of the spine, shoulder
blades and back
f. Shape of the chest for the following:
• Normal chest shape
• Kyphosis – forward bending of vertebral column
• Scoliosis – Lateral bending of ventral column
• Barrel shaped chest
6. PERCUSSION
a. Only the posterior thorax percussed
b. Hands warmed prior to touching patient
c. Patient positioned correctly
d. Percussion done in the correct manner
e. Comparison of left and right side of the posterior
thorax done correctly
f. Different sounds were identified as follow:
• Resonant
• Dull
• Stony-dull / Flat sound
• Hyper-resonant
7. PALPATION
Palpation is only done if any other sound then a resonant sound was percussed above.
Palpation included the following:
a. Tracheal position
b. Skin temperature
c. Moistness, elasticity and sensitivity of the skin
d. Muscles and ribs
e. Sternum and costo-sternal joint
f. Thoracic vertebrae
g. Tactile fremitus determined (only if dullness was
percussed)
h. Chest expansion
8. AUSCULTATION
a. Only the posterior thorax auscultated
b. Stethoscope warmed prior to auscultation
c. Patient positioned correctly
d. Auscultation of the posterior thorax done correctly
e. Normal breathing sounds identified as follow:
• Vesicular sounds
• Bronchial sounds
• Broncho-vesicular sounds
f. Abnormal breathing sounds identified as follow (and where applicable)
• Bronchial breathing in areas other than over the
bronchi identified
• Wheezing
• Stridor
• Crepitations / Crackles
• Pleural friction rub
g. Auscultated for vocal fremitus (only if dullness was
percussed)

20
OUTCOME CRITERIA 0 1 2 3 REMARKS
9. Gloves removed and hands disinfected
10. Patient made comfortable
11. Bell provided within easy reach
12. Actions and abnormalities reported
DOCUMENTATION
1. The following was documented
• Date and time
• Procedure done
• Abnormalities found and actions taken
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

21
1.2 Maintenance of an underwater drainage system

Recommended time to master the outcomes of this study section: 10 hours

Learning outcomes

At the end of this study section, you should be able to:

• Provide a detailed description of an underwater drainage system
• Describe the indications for the insertion of an underwater drainage system
• Describe the medico-legal risks associated with the maintenance of the drainage system
• Perform the maintenance of the underwater drainage system correctly by utilizing of the steps of
assessment, planning, implementing, evaluating, and documenting

Study material

22
MAINTENANCE OF AN UNDERWATER DRAINAGE SYSTEM

Outcome:
After completion of the practical programme, the student should be able to
maintain an underwater drainage system safely and competently

Assessment scale:

The student should familiarise him/herself with the following scale prior to the
assessment

You must obtain 50% of the outcome criteria to master the clinical skill and be declared competent.

A = 25%

B = 15%

C = 5%

23
DEFINITION
An underwater drainage system is a closed system designed to drain air or fluid from the pleural cavity
while restoring or maintaining the negative intra-pleural pressure needed to keep the lungs properly
expanded.

INDICATIONS FOR THE PROCEDURE

• Haemothorax (bleeding into the pleural cavity)
• Pneumothorax (entry of air into the pleural cavity)
• Pleural effusion (serous fluid in the pleural cavity)
• Empyema (puss in the pleural cavity)
• Cardiothoracic surgery

MEDICO-LEGAL RISKS INVOLVED

• Injury due to poor technique
• Not identifying and reporting abnormalities
• Failure to provide health education

EQUIPMENT/STAFF
• Dressing trolley
• One pair of sterile gloves
• Linen saver
• Normal Saline 1 litre pour bottle
• Artery forceps x 2
• New sterile underwater drainage bottle (tubing are attached to the bottle)
• 1 x roll of Elastoplast or any other adhesive tape
• Masking tape
• Alcohol swabs x 2
• Scissors

24
PROCEDURE: MAINTENANCE OF AN UNDERWATER DRAINAGE
SYSTEM

25
ACTION RATIONAL
• Tachycardia, hypotension, • Drastic changes in vital data may indicate
dysrhythmia, chest pain the presence of a tension pneumothorax
• Restlessness and anxiety • Might indicate presence of tension
pneumothorax
c. • Level of consciousness (LOC) • Patients with tension pneumothorax or
hypoxia will have a deteriorated LOC
d. • Physical and psychological ability to • Disorientation might lead to accidental
participate pulling out of drainage system
e. • Assess patient’s basic needs e.g. the • To decrease any discomfort and possible
need to use a bedpan/urinal disturbances during the procedure
7. Assess current dressing for the following:
• Dryness • If the current dressing at the insertion site
• Being intact and is saturated with drainage and not occlusive
• Occlusive anymore the dressing needs to be replaced
aseptically after changing of the bottle as a
separate procedure. (Aseptic wound care
procedure
8. Assess the underwater drainage system for the following: (with unsterile gloves on)
a. • Secured connections with no loops or • Loose connections might cause additional
kinks pneumothorax and loops or kinks will
prevent patency of the tube
b. • Surgical emphysema (crunch, • Evidence of an air leak into the
spongy, popping over skin with subcutaneous tissue – may lead to a life-
palpation) threatening situation
c. • Swinging • Swinging indicates that the chest tube is
patent.
d. • Bubbling • Bubbling indicates the presence of a
pneumothorax
e. • Drainage (colour and consistency) • Drainage will be present in case of a
haemothorax, pleural effusion and
empyema therefor the colour and
consistency need to be assessed
f. • Amount of drainage (measure • To assess for active bleeding / to
drainage output: determine whether the pathology are
total volume – saline in bottle = resolved.
actual drainage) • 500ml Saline are poured into the
underwater drainage system during
preparation of the system.
• Anything more than 500ml = drainage.
1200ml (total) – 500ml (Saline) = 700ml
(actual drainage)
9. • Excuse yourself from patient, remove • Keeping patient informed regarding actions
gloves and wash hands socially will enhance cooperation
PLANNING
1. • Gather all equipment as indicated • For effective time management
2. • Provide patient with privacy where • Patient always has a right to privacy
needed • To prevent unnecessary exposure e.g.
abdominal drainage systems
3. • Prepare new underwater drainage • To save time during implementation phase
system without contaminating the
inside of the bottle area

26
ACTION RATIONAL
4. • Apply masking tape vertically next • Not all unit change underwater bottle
measurement values on drainage systems daily, therefor the masking tape
bottle will provide an area to write the date and
time when drainage was checked
IMPLEMENTATION
1. • Position patient accordingly • If not contra-indicated patient may sit in
semi-fowler position with his arm on the
affected side out of the way (ensure that
patient remain in an optimal comfortable
position)
2. • Place a linen saver underneath • To protect linen against possible drainage
connection area
3. • Apply the two artery forceps • To prevent air from entering the pleural
approximately 2.5cm above the chest space through the chest tube when
tube connection area in opposite changing the underwater drainage bottle
directions (NB! Not the tube insertion site.
4. • Remove plaster around the • To facilitate the changing to the new
connection between the chest tube bottle
and underwater drainage system
5. • Wipe area of connection (without • To reduce the possibility of micro-organism
disconnecting the two tubes) with an transmission
alcohol swab and left to dry
6. • Perform alcohol rub of hands • To prevent the transmission of micro-
organisms
7. • Put on sterile gloves • Protection against possible drainage
• Also in an attempt to perform the
procedure as clean as possible
8. • Keeping the end of the chest tube • The inside of the chest tube is sterile
sterile, insert the end of the new
drainage system into the chest tube
9. • Secure the connection area again • Help prevent disconnection of the chest
with Elastoplast tube and the underwater drainage system
10. • Remove the two artery forceps • To allow for drainage of air, fluid or blood
11. • Assess the drainage system STAT for • This will confirm functioning of the system
swinging/bubbling/drainage as it was prior to changing the bottle
according to patient’s diagnosis
12. • Remove gloves and disinfect hands • To prevent the transmission of micro-
organisms
13. • Make patient comfortable • Patient has a basic right to optimum
comfort
14. Provide health education regarding the following: NB! NB! NB!
a. • Keep bottle at all times at a level • Gravity is needed for system to be
lower than chest effective.
• Lifting the bottle above the chest will cause
re-entry of fluids into the chest
b. • Do not tilt the bottle or let it lie on • The tube inside the bottle needs to be
its side on the floor “UNDER WATER” at all times otherwise the
patient will create a pneumothorax for him
/ herself
c. • Do not disconnect any tubing • Disconnecting any tubing will cause
atmospheric air to enter the thoracic cavity
= pneumothorax

27
ACTION RATIONAL
d. • No pulling on tubing • Might cause disconnection between chest
tube and underwater drainage system or
trauma at the insertion site
e. • Deep breathing exercises and • Will help with lung expansion and will
encourage mobilising promote healing time
15. • Ensure patient safety by placing the • Patient needs to be able to call for
bell within easy reach assistance STAT in case of abnormalities
• Patient has the right to be always in a safe
environment
16. • Report any abnormalities and action • To reduce medico-legal risks, the nursing
student need to always report
DOCUMENTATION
Document the following on the DOCTOR’S NOTES (IN TSHEPONG HOSPITAL)
1. • Date, time and amount • Doctor then immediately see amount
drained, when writing on notes for the day
• Complete documentation needed for all
patients
Document the following on the FLUID BALANCE CHART:
2. • Amount measured under the correct • For complete and accurate documentation
column, at the correct time space regarding drainage

Document the following in the PROGRESS REPORT:

3. • Date and time • For complete and accurate documentation.
• Procedure done • NB! If not written, it is considered as not
• Whether swinging, drainage or being done
bubbling was observed
• Type of drainage
• Amount of drainage
• Surgical emphysema
• Insertion site wound dressing (where
applicable)
• Patient’s reaction
• Health education provided

28
PEER EVALUATION

EVALUATION INSTRUMENT: MAINTENANCE OF AN UNDERWATER DRAINAGE

SYSTEM

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE (%)

OUTCOME CRITERIA 0 1 2 3 REMARKS

COGNITIVE COMPONENT
Provide the evaluator with the following:
1. Indications (2) for the procedure
2. Possible medico-legal risks (2) involved
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. Identified patient A
2. Introduced self, and procedure explained
3. Obtained verbal consent
4. Washed hands socially
5. Patient’s file assessed for the following
a. Medical / Surgical history
b. Prescription chart for specific instructions B
c. Patient care plan
d. Fluid balance chart C
e. Diagnostic test evaluated:
• Chest X-ray result
• Arterial blood gas results
6. Patient assessed for:
a. Respiratory system:
• Breathing rate, rhythm and depth C
• Cyanosis C
• Lung sounds C
• Asymmetrical chest movement C
b. Vital data:
• Tachycardia, hypotension, dysrhythmia,
C
chest pain
c. Restlessness and anxiety
d. Level of consciousness (LOC)
e. Physical and psychological ability to participate
f. Basic needs
7. Current dressing assessed for:
• Dryness, being occlusive and dry
8. Underwater drainage system assessed for the following: (with unsterile gloves on)
a. Connections and loops C
b. Surgical emphysema C

29
OUTCOME CRITERIA 0 1 2 3 REMARKS
c. Swinging C
d. Bubbling C
e. Colour and consistency of drainage C
f. Amount of drainage C
9. Gloves removed and hands washed
PLANNING
1. All needed equipment gathered
2. Privacy provided
3. Underwater drainage system prepared in the
correct way (no contamination)
4. Masking tape applied correctly on the drainage
bottle
IMPLEMENTATION
1. Patient positioned accordingly
2. Linen saver placed in position
3. Two artery forceps applied correctly A
4. Plaster between chest tube and underwater
drainage system removed
5. Connection area cleaned with alcohol swab and
left to dry
6. Hands disinfected
7. Sterile gloves put on
8. New underwater drainage system connected to
B
the chest tube without contamination
9. Connection area secured with Elastoplast
10. Both artery forceps removed / unclamped A
11. Drainage system assessed STAT for swinging,
C
draining and bubbling
12. Gloves removed and hands disinfected
13. Patient made comfortable
14. Health education provided as indicated B
15. Bell placed within easy reach
16. Abnormalities and actions reported to RN
DOCUMENTATION
The following was documented:
1. Doctor’s notes (where applicable)
C
Date and time, amount drained
2. Fluid balance chart:
C
• Correct time, correct amount
3. Progress report:
• Date and time,
• Procedure done,
• Whether swinging, drainage or bubbling was
observed
• Type and amount of drainage
• Surgical emphysema
• Insertion site wound dressing (where
applicable)
• Patient’s reaction
• Health education provided
AFFECTIVE COMPONENT

30
OUTCOME CRITERIA 0 1 2 3 REMARKS
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

____ X 100 = %
= 149 1
(Subtract N/A from total)
REMARKS
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________

31
PROCEDURE SIGNED OFF BY THE REGISTERED NURSE

MAINTENANCE OF AN UNDERWATER DRAINAGE SYSTEM

Yes No

1. Student identified patient

2. Underwater drainage system assessed for swinging, bubbling and draining

3. Subcutaneous tissue assessed for surgical emphysema

4. Drainage amount and consistency of drainage provided

5. Artery forceps applied and removed correctly

6. Drainage system changed without contamination

7. Documentation done correctly

Signature of RN: ___________________________

Signature of student: ___________________________

Remarks: (student competent/not yet competent/needs guidance)

32
FORMAL EVALUATION

EVALUATION INSTRUMENT: MAINTENANCE OF AN UNDERWATER DRAINAGE

SYSTEM

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE (%)

OUTCOME CRITERIA 0 1 2 3 REMARKS

33
OUTCOME CRITERIA 0 1 2 3 REMARKS
• Dryness, being occlusive and dry
8. Underwater drainage system assessed for the following: (with unsterile gloves on)
a. Connections and loops C
b. Surgical emphysema C
c. Swinging C
d. Bubbling C
e. Colour and consistency of drainage C
f. Amount of drainage C
9. Gloves removed and hands washed
PLANNING
1. All needed equipment gathered
2. Privacy provided
3. Underwater drainage system prepared in the
correct way (no contamination)
4. Masking tape applied correctly on the drainage
bottle
IMPLEMENTATION
1. Patient positioned accordingly
2. Linen saver placed in position
3. Two artery forceps applied correctly A
4. Plaster between chest tube and underwater
drainage system removed
5. Connection area cleaned with alcohol swab and
left to dry
6. Hands disinfected
7. Sterile gloves put on
8. New underwater drainage system connected to
B
the chest tube without contamination
9. Connection area secured with Elastoplast
10. Both artery forceps removed / unclamped A
11. Drainage system assessed STAT for swinging,
C
draining and bubbling
12. Gloves removed and hands disinfected
13. Patient made comfortable
14. Health education provided as indicated B
15. Bell placed within easy reach
16. Abnormalities and actions reported to RN
DOCUMENTATION
The following was documented:
1. Doctor’s notes (where applicable)
C
Date and time, amount drained
2. Fluid balance chart:
C
• Correct time, correct amount
3. Progress report:
• Date and time,
• Procedure done,
• Whether swinging, drainage or bubbling was
observed
• Type and amount of drainage

34
OUTCOME CRITERIA 0 1 2 3 REMARKS
• Surgical emphysema
• Insertion site wound dressing (where
applicable)
• Patient’s reaction
• Health education provided
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

35
VISUAL ILLUSTRATIONS TO UNDERSTAND THE MAINTENANCE OF AN UNDERWATER
DRAINAGE SYSTEM BETTER

Figure 1: Diagram of an “underwater” seal Figure 2: Chest tube wound dressing and suturing

Figures 3: Different types of chest tubes

36
Figure 4: Blood in the pleural space (hemothorax) Figure 5: Air trapped in the pleural space
(pneumothorax)

Figure 6: Accumulation of serous fluid in the

pleural space

Figure 7: Accumulation of pus in the pleural space (Empyema)

Figure 8: Surgical Emphysema around the eye Figure 9: Surgical Emphysema on a Chest X-Ray

37
1.3 Interpretation of an arterial blood gas

Recommended time to master the outcomes of this study section: 10 hours

Learning outcomes

At the end of this study section, you should be able to:

• Identify the different sites for the insertion of an arterial line
• Provide a detailed description of possible indications for an ABG
• Describe the medico-legal risks related to the insertion of an arterial line
• Perform the analysis of an arterial blood gas correctly

Study material

38
INTERPRETATION OF AN ARTERIAL BLOOD GAS

Outcome:
After completion of the practical programme, the student should be able to
interpret an arterial blood gas in a competent manner

Assessment scale:

The student should familiarise him/herself with the following scale prior to the
assessment

You must obtain 50% of the outcome criteria to master the clinical skill and be declared competent.

A = 25%

B = 15%

C = 5%

39
DEFINITION:

An arterial blood gas assesses the ability of the lungs to provide adequate oxygen and remove carbon
dioxide, reflecting ventilation. An ABG also assess the ability of the kidneys to reabsorb or excrete
bicarbonate ions to maintain normal body pH, reflecting the metabolic status. To obtain arterial
blood for the purpose of an ABG an arterial puncture of the radial, brachial or femoral artery can be
done or through an indwelling arterial line (Hinkle & Cheever, 2018:502)

INDICATIONS:

• To determine the respiratory or metabolic status of a patient

• To determine the response to a disease process
• For diagnosis and treatment during mechanical ventilation, respiratory distress and change
level of consciousness (Altman et al., 2010:1168)

POSSIBLE COMPLICATIONS DURING THE PUNCTURE OF AN ARTERY OR INSERTION OF AN

ARTERIAL LINE:

• Pain due to nerve injury or noxious stimulation

• Infection
• Haematoma
• Haemorrhage
• Compartment syndrome (Hinkle & Cheever, 2018:502)

MEDICAL-LEGAL RISKS:

• Incorrect interpretation of the blood gas leading to incorrect management

EQUIPMENT AND STOCK NEEDED:

• An arterial blood gas result

• Pen
• Calculator (where kPa must be converted to mmHg)

40
PROCEDURE: INTERPRETATION OF AN ARTERIAL BLOOD GAS

ACTION RATIONAL
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. • Identify the patient • Verification of the patient’s identity ensures
that the correct procedure is being done on
the correct patient
2. • Wash your hands socially • To prevent the transmission of micro-
organisms (a universal precaution)
3. Assess the following:
a. • Check the patient’s prescription • For specific instructions regarding actions for
chart blood gas results
b. • Current medication • Certain medications e.g., Maxalon can
influence O2 delivery at tissue level
IMPLEMENTATION
1. • Wash hands socially • To prevent the transmission of micro-
organisms (universal precaution)
2. • Provide normal ABG values to the evaluator
a. pH 7.35 -7.45 • Normal values will enable student to identify
b. PaCO2 35 – 45 mmHg abnormal values
c. PaO2 80 – 100 mmHg
d. Standard HCO3 22 – 26 mEq/L
e. Base excess -2 to +2 mEq/L
f. SaO2 95-100%
3. Patients’ ABG values provided as follow:
a. • Evaluate the temperature corrected • Normal pH = 7.35 - 7.45.
pH on the blood gas result
• A pH below 7.35 reflects acidaemia.
• A pH above 7.45 reflects alkalemia.
• Patient presenting with more than one acid-
base imbalance at work, the pH identifies the
process in control

b. • Evaluate ventilation – the • Normal partial pressure of arterial CO2

temperature corrected PaCO2 (PaCO2) 35 - 45 mmHg.
• A PaCO2 greater than 45mm Hg indicates
ventilatory failure and respiratory acidosis.
• A PaCO2 less than 35 mm Hg indicates alveolar
hyperventilation and respiratory alkalosis.

c. • Evaluate metabolic processes – the • Normal Standard HCO3 = 22 - 26 mEq/L

Standard Bicarbonate (HCO3) and • HCO3 less than 22 mEq/L reflect metabolic
the Base excess (Be) acidosis.

41
ACTION RATIONAL
• HCO3 greater than 26 mEq/L reflects
metabolic alkalosis
• Normal BE = -2 to +2
• BE less than -2 mEq/L reflects metabolic
acidosis
• BE greater than 2 mEq/L reflects metabolic
alkalosis
• Both the HCO3 and the BE will always move in
the same direction
d. • Evaluate the temperature corrected • Normal PaO2 = 80 -100 mmHg
Oxygenation – PaO2
• A PaO2 between 60 - 80 mmHg reflects mild
hypoxemia.
• A PaO2 between 40 - 60 mmHg reflects
moderate hypoxemia
• A PaO2 below 40 mmHg reflects severe
hypoxemia
e. • Evaluate the Oxygen Saturation • Normal SaO2 = 97% - 100%
level - SaO2
• The SaO2 level is NB as the affinity of Hb for
oxygen are influenced by acidosis and
alkalosis
4. • Determine the primary and • Often, two acid-base imbalances coincide; one
compensatory disorder is primary, the other is the body’s attempt to
return the pH to normal.
• In most cases, when both the pCO2 and the
HCO3 are abnormal, one reflects the primary
acid-base disorder and the other reflects the
compensating disorder.
• To decide which is which, check the pH. Only a
process of acidosis can make the pH acidic; only
a process of alkalosis can make the pH alkaline.
For example, if Steps 2 and 3 indicate that the
patient has respiratory acidosis and metabolic
alkalosis and the pH is 7.25, the primary
disorder must be respiratory acidosis. The
remaining disorder is compensating for the
primary problem
5. • Determine the three states of compensation
a. • Uncompensated ABG • Reflected in an alteration of only pCO2 or HCO3
with an abnormal pH
b. • Partially compensated ABG • When both the PaCO2 and the HCO3 are
abnormal and, because compensation is
incomplete, the pH is also abnormal

42
ACTION RATIONAL
c. • Complete compensated ABG • When both pCO2 and HCO3 – are abnormal but
because compensation is complete, the pH is
normal.
6. • Provide a diagnosis for the ABG • After evaluating all the important values, a
diagnosis is needed to guide further actions
• The final analysis should include the degree of
compensation, the primary disorder, and the
oxygenation status, for example, “partially
compensated respiratory acidosis with
moderate hypoxemia.”
DOCUMENTATION
Document the following in the PROGRESS REPORT OR ICU CHART
1. • Date, time and procedure done and • If not written, it is assumed not done
actions taken

43
PEER ASSESSMENT:

EVALUATION INSTRUMENT: INTERPRETATION OF AN ARTERIAL BLOOD GAS

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE

OUTCOME CRITERIA 0 1 2 3 REMARKS

COGNITIVE COMPONENT
Provide the evaluator with the following:
1. Indications (2) for the procedure
2. Possible complications (2) associated with the
drawing of an arterial blood gas
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. Identified patient A
4. Washed hands socially
5. Student assessed the following
a. Prescription chart for specific instructions B
b. Medication prescribed
IMPLEMENTATION
1. Hands disinfected
2. Normal ABG values provided
a. pH
b. PaCO2
c. PaO2
d. Standard HCO3
e. Base Excess
f. SaO2
3. Patients’ ABG values provided as follow and interpretated correctly
a. Temperature corrected pH provided
(normal/acidotic/alkaline)
b. Temperature corrected PaCO2 provided
(normal/acidotic/alkaline)
c. Standard HCO3 and Base excess provided
(normal/acidotic/alkaline)
d. Temperature corrected PaO2 provided
(normal/hyperoxia/hypoxemia)
e. SaO2 provided correctly
4. Provided the primary and compensatory
disorder
5. The status of compensation determined C
correctly
6. Provide a diagnosis for the ABG

44
OUTCOME CRITERIA 0 1 2 3 REMARKS
7. Discuss 3 actions to be taken regarding the
diagnosis for the ABG
DOCUMENTATION
The following was documented in the progress
report / ICU chart
1. The date, time, and procedure done
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

45
PROCEDURE SIGNED OF BY A REGISTERED NURSE

INTERPRETATION OF AN ARTERIAL BLOOD GAS

Yes No
+
Student can give normal values for pH, PaCO2, Std HCO3, BE, PaO2, SaO2, S-K ,
1.
Lactate
2. Student can analyse values as acidotic/alkalotic

3. Student can determine respiratory or metabolic cause

4. Student can determine if there is compensation

5. Student can give diagnosis of blood gas

6. Student can determine applicable nursing actions

Signature of RN: ___________________________

Signature of student: ___________________________

Remarks: (student competent/not yet competent/needs guidance)

46
FORMAL EVALUATION:

EVALUATION INSTRUMENT: INTERPRETATION OF AN ARTERIAL BLOOD GAS

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE

OUTCOME CRITERIA 0 1 2 3 REMARKS

47
OUTCOME CRITERIA 0 1 2 3 REMARKS
7. Discuss 3 actions to be taken regarding the
diagnosis for the ABG
DOCUMENTATION
The following was documented in the progress
report / ICU chart
1. The date, time, and procedure done
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

48
WORKSHEET FOR ARTERIAL BLOOD GAS INTERPRETATION
INTERPRET THE FOLLOWING BLOOD GAS SAMPLES ON THE SHEET PROVIDED UNDER EACH
ABG SAMPLE

ARTERIAL BLOOD GAS - 1

ACID/BASE BALANCE AT 37oC
pH 7.25
PaCO2 50 mmHg
PaO2 140.9 mmHg
HCO3 act 23 mmol/L
HCO3 std 25 mmol/L
Be(B) +1 mmol/L
Be(ecf) +0.5 mmol/L

CO-OXIMETRY
Hct 30 %
tHb 10 g/dL
SO2 98.3 %

TEMPERATURE CORRECTED VALUES AT 36.3oC

pH(T) 7.28
PaCO2(T) 49 mmHg
PaO2(T) 136.7 mmHg
PaO2 (A-a) (T) 63.7 mmHg
PaO2 (a / A) (T) 0.68

ELECTROLYTES
Na+ 136 mmol/L
K+ 4.6 mmol/L
Ca++ 1.15 mmol/L
Cl 107 mmol/L

METABOLITES
Gluc 7.4 mmol/L
Lac 1.03 mmol/L

Temperature
pAtm 760 mmHg
FiO2 35 %

49
ARTERIAL BLOOD GAS - 1
Parameters Normal values
1. pH
2. PCO2
3. PO2 (80 - 100 mmHg)
4. HCO3
5. Base excess or deficit
6. SaO2
7. K+
8. Hgt
9. Lactate
Parameter Patient values
1. pH
2. PCO2
3. PO2
4. HCO3
5. Base excess or deficit
6. SaO2
7. K+
8. Hgt
9. Lactate
10. Identified whether the patient is acidotic or
alkalotic
11. Identify whether the pH disturbance is
metabolic or respiratory in nature
12. Provided a diagnosis for the arterial blood
gas

50
ARTERIAL BLOOD GAS - 2
ACID/BASE BALANCE AT 37oC
pH 7.20
PaCO2 40 mmHg
PaO2 140.9 mmHg
HCO3 act 18 mmol/L
HCO3 std 19 mmol/L
Be(B) -5 mmol/L
Be(ecf) -6 mmol/L

CO-OXIMETRY
Hct 30 %
tHb 10 g/dL
SO2 98.3 %

TEMPERATURE CORRECTED VALUES AT 36.3oC

pH(T) 7.21
PaCO2(T) 39 mmHg
PaO2(T) 136.7 mmHg
PaO2 (A-a) (T) 63.7 mmHg
PaO2 (a / A) (T) 0.68

ELECTROLYTES
Na+ 136 mmol/L
K+ 4.6 mmol/L
Ca++ 1.15 mmol/L
Cl 107 mmol/L

METABOLITES
Gluc 7.4 mmol/L
Lac 1.03 mmol/L

Temperature
pAtm 760 mmHg
FiO2 35 %

51
ARTERIAL BLOOD GAS - 2
Parameters Normal values
1. pH
2. PCO2
3. PO2 (80 - 100 mmHg)
4. HCO3
5. Base excess or deficit
6. SaO2
7. K+
8. Hgt
9. Lactate
Parameter Patient values
1. pH
2. PCO2
3. PO2
4. HCO3
5. Base excess or deficit
6. SaO2
7. K+
8. Hgt
9. Lactate
10. Identified whether the patient is acidotic or
alkalotic
11. Identify whether the pH disturbance is
metabolic or respiratory in nature
12. Provided a diagnosis for the arterial blood
gas

52
INFORMAL PROCEDURES (RESPIRATORY SYSTEM)

RESPIRATORY CLINICAL SKILLS

PROCEDURE DATE WARD/UNIT SIGNATURE: PRECEPTOR/RN/DOCTOR
Observe a patient going for a chest X-ray
Identify the following images on a Chest X-ray: 1.
• Trachea and carina
• Lungs 2.
• Cardiac shadow
• Aorta 3.
• Ribs
Nurse a patient on high flow nasal cannula (if found)

Nurse a patient on a mechanical ventilator (if found)

Perform closed suctioning of a patient (if found)

Perform open suctioning of a patient (if found)

Monitors a patient diagnosed with respiratory pathology

1.
Collect a sputum specimen from a patient
2.

53
2 STUDY UNIT 2: THE CARDIOVASCULAR SYSTEM

2.1 Physical examination of the cardiovascular system

Learning outcomes

At the end of this study section, you should be able to:

• Provide a description of the cardiovascular system
• Name indications, contra indications and medico-legal risks associated with the procedure
• Perform the physical examination of the cardiovascular system correctly by utilizing of the steps
of assessment, planning, implementing, evaluating, and documenting
• Competently utilize the techniques of inspection, palpation, percussion, and auscultation during
the physical examination of the cardiovascular system

Study material

54
PHYSICAL EXAMINATION OF THE CARDIOVASCULAR SYSTEM

Outcome:
After completion of the practical programme, the student should be able to do a
cardiovascular assessment in a safe and competent manner

Assessment scale:

The student should familiarise him/herself with the following scale prior to the
assessment

You have to obtain 50% of the outcome criteria to master the clinical skill and be declared
competent.

Outcome criteria marked with an “A”, “B””or “C is considered a critical point. A critical point is any
aspect of a procedure which could severely jeopardise patient safety or result in patient death.

A = 25%

B = 15%

C = 5%

55
DEFINITION OF THE CARDIOVASCULAR SYSTEM
The cardiovascular system transports oxygen, nutrients and other substances to the body tissues
and removes metabolic waste products to the kidneys and the lungs and therefor an assessment of
the cardiovascular system is of extreme importance

INDICATIONS FOR A CARDIOVASCULAR ASSESSMENT OR EXAMINATION

• Newly admitted patients as part of the complete physical examination of the patient
• Patients with known cardiovascular conditions

MEDICO-LEGAL RISKS INVOLVED

• Exposing the patient unnecessarily
• Anxiety and discomfort experienced by patient
• Not identifying and reporting abnormalities

EQUIPMENT / STAFF
• A towel to cover patient during examination
• Stethoscope
• Unsterile gloves

56
PROCEDURE: PHYSICAL EXAMINATION OF THE
CARDIOVASCULAR SYSTEM

INTERVENTION RATIONAL
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. • Identify the patient • Verification of the patient’s identity ensures
that the correct procedure is being done on
the correct patient
2. • Introduce yourself to the patient • To alleviate anxiety and fear that might be
and explain the procedure to be experienced by patient and,
done • To facilitate cooperation during the
procedure
3. • Obtain verbal consent from the • Verbal or written consent is a legal
patient requirement for all procedures
4. • Wash your hands socially • To prevent the transmission of micro-
organisms (a universal precaution)
PLANNING
1. • Gather all equipment as indicated • For effective time management
2. • Provide patient with privacy where • Patient always has a right to privacy
needed • To prevent unnecessary exposure of patient
IMPLEMENTATION
1. • Wash your hands socially • Universal precaution
2. • Remove linen without exposing the • Medico-legal requirement to protect
patient unnecessary patient’s rights at all times
3. • Put on unsterile gloves • To protect yourself from contact with bodily
fluids or excessive sweating from patient
4. GENERAL ASSESSMENT
• Evaluate patient’s most recent vital • To detect any abnormal values within the
data, including the blood pressure, vital data information that can indicate any
heart rate, temperature, and cardiovascular abnormalities
respiration
5. INSPECTION
• Inspect the chest wall anteriorly, • Providing baseline information regarding
laterally and posteriorly for any previous cardiac surgery or injuries to the
scars or previous surgery chest
• Inspect the chest wall for any • Patient might have a central venous line in
invasive lines or devices situ or a permanent pacemaker due to
cardiac conduction pathology
• Inspect the neck for distention of • Jugular vein distention is associated with
the jugular veins heart failure and fluid volume overload
• Inspect the precordium (the portion • Normally no pulsations must be seen except
of the body over the heart and for the apical impulse
lower thorax for any pulsations
• Inspect for visible veins over the • If present it is a sign of underlying liver
liver area disease and portal hypertension
6. C. PALPATION

57
INTERVENTION RATIONAL
• Palpate the trachea to determine • The trachea may deviate slightly to the right
whether it is central or displaced due to pressure from large vasculature in
the mediastinum. Tracheal deviation is
mostly caused by injuries or conditions that
cause pressure to build up in your chest
cavity or neck which will affect the hearts
ability to fill and contract effectively
Palpate the: • Palpation of these areas are done to detect
• mitral valve, any dysrhythmias, gallop rhythms and
• tricuspid valve, murmurs
• pulmonary valve, o Mitral valve: 5th intercostal space, mid-
• aortic valve clavicular (same area for apex beat)
o Tricuspid valve: 4th – 5th intercostal
space left side of the sternal border
o Pulmonary valve: 2nd intercostal space,
left side of the sternal border
o Aortic valve: 2nd intercostal space, right
side of the sternal border

• Palpate Erb’s point (see image • Erb’s Point is located at the 3rd intercostal
above) space left of the sternal border and it is the
point auscultated to locate heart sounds and
heart murmurs
• Palpate for parasternal heaving (a • If heaves are present you should feel the
precordial impulse that can be heel of your hand being lifted with each beat
palpated) by placing the heel of and this indicates right ventricular
your hand parallel to the left sternal enlargement
edge (fingers vertical).

• Palpate the liver • Pathology of the liver causes major changes

in the hemodynamic status of the patient by
increasing the blood pressure and heart rate
• Palpate radial pulse for one minute • A weak radial pulse can be an indicate that
and compare with other radial pulse blood flow to vital organs is reduced due to
(Volume, rate and rhythm) cardiac dysfunction. A fast or slow rate and
a irregular rhythm might indicate cardiac
conduction problems. Absent pulses might
indicate arterial occlusion.
• Palpate the carotid, inguinal, • To confirm that all pulses are equal in
popliteal, dorsalis pedal arteries volume, rate, and rhythm. Volume might
and compare left with right differ depending on the distance from the
heart

58
INTERVENTION RATIONAL
• Locate and palpate the apex • The apex beat is the heart's impact against
beat/impulse in the precordium, 5th the chest wall during systole.
intercostal space

• Evaluate the capillary refill by firmly • Pressure forces blood from the capillaries
pressing with your thumb on a and by releasing the pressure the return and
nailbed of a finger / toe (do this resupply of blood to the area is observed.
with each limb) for 5 seconds, then When return of blood takes longer than 3
release the pressure and observe seconds it might indicate underlying
the time it takes for normal colour circulatory compromise
to return to the skin
• Palpate for peripheral pitting • Indication of cardiac dysfunction
oedema

• Palpate for sacral pitting oedema • Sacral oedema is a sign of right cardiac
failure

7. D. AUSCULTATION
• Auscultate the mitral, tricuspid, • Mitral valve: 4th - 5th intercostal space, mid-
pulmonary and aortic valves (you clavicular (same area for apex beat)
do not need to diagnose • Tricuspid valve: 4th – 5th intercostal space
abnormalities in this regard) left side of the sternal border
• Pulmonary valve: 2nd intercostal space, left
side of the sternal border
• Aortic valve: 2nd intercostal space, right side
of the sternal border
• Auscultate for: Normal heart • S1 sound is produced by the closure of the
sounds: tricuspid and mitral valve
• S1 - auscultate at the 4th – 5th • S1 is produced by the closure of the aortic
intercostal space left of the sternal and pulmonary valves
border

• S2 – auscultate at the 2nd intercostal

space left of the sternal border

59
INTERVENTION RATIONAL
• Auscultate for abnormal heart • Any other heart sound than “lub-dub” is
sounds like extra beats, gallop seen as abnormal and must be reported to
rhythm, dysrhythmia, murmur the registered nurse in charge of the unit
• Basal crepitations • Basal crepitations can be an indication of
left-sided cardiac failure / congestive
cardiac failure
8. • Wash your hands socially • Universal precaution
9. • Report any abnormalities and • To reduce medico-legal risks, the nursing
action student need to report at all times
DOCUMENTATION
The following was documented in progress report
• Correct date, time and that
• Legal requirement for all interventions. Not
procedure was done, and
written not done
abnormalities reported

60
PEER EVALUATION:

EVALUATION INSTRUMENT: PHYSICAL EXAMINATION OF THE

CARDIOVASCULAR SYSTEM

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE (%)

OUTCOME CRITERIA 0 1 2 3 REMARKS

COGNITIVE COMPONENT
Provide the evaluator with the following:
1. Provide 2 indications for performing the
procedure
2. Provide 2 medico-legal risks involved for this
procedure
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. Identified patient
2. Introduced self, and procedure explained
3. Obtained verbal consent
4. Washed hands socially
PLANNING
1. All needed equipment gathered
2. Privacy provided
IMPLEMENTATION
1. Hands washed socially
2. Linen removed without exposing patient
3. Non-sterile gloves put on
4. GENERAL ASSESSMENT
• Most recent vital data evaluated
5. INSPECTION
• Chest wall inspected for scars and previous
surgery
• Chest wall inspected for any invasive lines or
devices
• Patient inspected for jugular vein distention
• Precordium inspected for any pulsations
• Abdomen inspected for any visible veins
over the liver area
6. PALPATION
• Trachea palpated for displacement

61
OUTCOME CRITERIA 0 1 2 3 REMARKS
• Mitral, tricuspid, pulmonary and aortic valve
area palpated for any dysrhythmias, galop
rhythms and murmurs
• Erb’s point palpated
• Palpated for parasternal heaving
• Liver palpated
• All peripheral pulses palpated
• Apical impulse palpated
• Capillary refill determined correctly
• Palpated for peripheral non-pitting oedema
• Palpated for sacral oedema
7. AUSCULTATION
• Mitral, tricuspid, pulmonic and aortic valves
auscultated
• Normal heart sounds S1 and S2 auscultated
• Auscultated for abnormal heart sounds
• Auscultated for basal crepitations
8. Hands washed socially
9. Abnormalities and actions reported
DOCUMENTATION
1. Date, time, procedure, and abnormalities
documented correctly
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-
verbal communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

____ X 100 = %
1
(Subtract N/A from total)
REMARKS
__________________________________________________________________________________
______________________________________________________________

62
PROCEDURE SIGNED OFF BY REGISTERED NURSE:

Yes No

1. Student identified patient

2. General assessment done

3. Inspection done correctly

4. Palpation done correctly

5. Auscultation done correctly

6. Heart sounds identified correctly

Signature of RN: ___________________________

Signature of student: ___________________________

Remarks: (student competent/not yet competent/needs guidance)

63
FORMAL EVALUATION:

EVALUATION INSTRUMENT: PHYSICAL EXAMINATION OF THE

CARDIOVASCULAR SYSTEM

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE (%)

OUTCOME CRITERIA 0 1 2 3 REMARKS

64
OUTCOME CRITERIA 0 1 2 3 REMARKS
• Mitral, tricuspid, pulmonary and aortic valve
area palpated for any dysrhythmias, galop
rhythms and murmurs
• Erb’s point palpated
• Palpated for parasternal heaving
• Liver palpated
• All peripheral pulses palpated
• Apical impulse palpated
• Capillary refill determined correctly
• Palpated for peripheral non-pitting oedema
• Palpated for sacral oedema
7. AUSCULTATION
• Mitral, tricuspid, pulmonic and aortic valves
auscultated
• Normal heart sounds S1 and S2 auscultated
• Auscultated for abnormal heart sounds
• Auscultated for basal crepitations
8. Hands washed socially
9. Abnormalities and actions reported
DOCUMENTATION
1. Date, time, procedure, and abnormalities
documented correctly
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-
verbal communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

____ X 100 = %
1
(Subtract N/A from total)
REMARKS
__________________________________________________________________________________
______________________________________________________________

65
2.2 Recording of electrocardiogram (ECG)

Recommended time to master the outcomes of this study section: 10 hours

Learning outcomes

At the end of this study section, you should be able to:

• Provide a description of an electrocardiogram
• Name indications, contra indications and medico-legal risks associated with the procedure
• Perform the recording of a electrocardiogram correctly by utilizing of the steps of assessment,
planning, implementing, evaluating, and documenting

Study material

66
RECORDING OF AN ELECTROCARDIOGRAM (12-LEAD ECG)

Outcome:
After completion of the practical programme, the student should be able to record
an ECG safely and competently

Assessment scale:

The student should familiarise him/herself with the following scale prior to the
assessment

You have to obtain 50% of the outcome criteria to master the clinical skill and be declared
competent.

Outcome criteria marked with an “A”, “B””or “C is considered a critical point. A critical point is
any aspect of a procedure which could severely jeopardise patient safety or result in patient
death.
A = 25%
B = 15%
C = 5%

67
DEFINITION OF AN ECG
An ECG is the visual recording of the electrical activity of the heart through electrode placement on
designated areas of the body. 12 views of electrical activity from the 4 cardiac chambers are
represented on the recording. Cardiac electrical current is transmitted through surrounding body
tissue to the body surface and the current is detected by the placed electrodes (Smeltzer, et al.
2010:721)

INDICATIONS FOR THE PROCEDURE

• Baseline cardiac status prior to medical or surgical interventions of high risk patients, e.g.
history of cardiac conditions, hypertension or pacemaker.
• Chest pain (using the chest pain scale of 1-10) or any complaints of “heaviness” or
“pressure” on the chest of unknown origin
• Patients older than 50 years of age
• Myocardial infarction/ischemia
• Thrombolytic therapy
• Daily when continuous infusions of cardiac drugs like Adrenaline are administered
• Pre- and Post-elective cardioversion
• Post resuscitation
• Dysrhythmias
• Changes in patients vital signs, e.g. tachycardia and any signs of acute coronary syndrome,
e.g. sudden nausea, cold and clammy skin, light-headedness and sudden fatigue
• Electrolyte disturbances

POSSIBLE CONTRA-INDICATIONS
• Lethal dysrhythmias like ventricular tachycardia and ventricular fibrillation
• During active resuscitation

MEDICO-LEGAL RISKS INVOLVED:

• Incorrect patient identification
• Injury due to poor technique
• Not identifying and reporting abnormalities
• Inability to identify need for recording of an ECG
• Failure to provide health education

EQUIPMENT/STAFF
• ECG machine with adequate specialised paper
• 10 - 13 ECG disposable electrodes (when a patient is admitted to a specialised unit, the
patient need to be first connected to a cardiac monitor for continuous cardiac monitoring
during ECG recording).
• Razor (if needed for men)
• Non-sterile gloves (When patient is sweating excessively or when bodily fluids are present)
• Paper towel (where applicable to remove oil, ointments or sweat).

68
PROCEDURE: RECORDING OF AN ELECTROCARDIOGRAM (12-LEAD
ECG)
ACTION RATIONAL
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. • Identify the patient • Verification of the patient’s identity
ensures that the correct procedure is being
done on the correct patient
2. • Introduce yourself to the patient and • To alleviate anxiety and fear that might be
explain the procedure to be done experienced by patient and;
• to facilitate cooperation during the
procedure
3. • Obtain verbal consent from the • Verbal or written consent is a legal
patient requirement for all procedures
4. • Wash your hands socially • To prevent the transmission of micro-
organisms (a universal precaution)
5. • Check the patient’s prescription • For specific instructions, e.g., do ECG BD or
chart daily, etc.
• ECG changes might be caused by certain
medications
6. • Evaluate the patient’s nursing care • To ensure that you know the specific
plan indications for the recording of the ECG,
e.g. “Daily ECG due to cardiac
failure/cardiac medications”
7. • Assess the patient’s basic needs, e.g. • To decrease any discomfort and possible
the need to use a urinal, pain disturbances during the recording of the
experience, etc. ECG
PLANNING
1. • Prepare the ECG machine by • The ECG machine need to be plugged into
assembling all equipment needed, wall electricity at all times with enough
e.g. sufficient ECG recording paper, specialised paper in the machine to ensure
all lead wires must be intact and ECG that it is ready for use and for optimum
machine must be plugged in time management during an emergency
situation
2. • Provide the patient with privacy • To prevent unnecessary exposure of
patient.
• Patient has a right to privacy at all times
3. • Position the patient in an anatomical • When patient is lying in a supine position
position with his arms next to his body, palms facing
upwards, it provides easy access for lead
placement. Comfort is also increased with
the possibility of a better tracing during
recording
4. • Clean the patient’s chest and limb • Removing all moisture, oil and excess hair
sites for electrode placement from the electrode sites will promote the
adherence of electrodes to the chest and
extremities

69
ACTION RATIONAL
IMPLEMENTATION
1. • Plug ECG machine in and switched • To prevent interruptions due to low battery
on at the patient’s bed area function of ECG machine
2. • Remove or switch off all cellular • A cellular phone might cause disturbances
phones near the patient’s bedside with regards to the ECG tracing
3. • Disinfect your hands with an alcohol- • Universal precaution
based solution
4. Apply precordial electrodes correctly: • Proper lead placement is necessary for
• V1 = 4 intercostal space right of the
th
accurate test results
sternum
• V2 = 4th intercostal space left of the
sternum
• V3 = between V2 and V4
• V4 = 5th intercostal space,
midclavicular area
• V5 = 5th intercostal space, anterio-
axillary
• V6 = 5th intercostal space, mid-
axillary
5. Apply limb lead electrodes correctly: • Proper lead placement is necessary for
• RL (Right leg) = on the medial aspect accurate test results
of the (R) malleolus / (R) iliac region • NB information:
• LL (Left leg) = on the medial aspect of • If you place RL on the (R) malleolus, medial
the (L) malleolus / (L) iliac region aspect, you need to place RA on the medial
• RA (Right arm) = (R) medial aspect of aspect of the wrist
the wrist / (R) mid-subclavian area • If you place RL on the (R) iliac region, you
• LA (Left arm) = (L) medial aspect of need to place RA on the mid-subclavian
the wrist / (L) mid-subclavian area area
6. • Do not place electrodes over bony • Bony areas do not allow for optimum
areas electrical conduction to take place.
7. • Do not place electrodes over areas • Muscle movement might lead to
with excessive muscle movement interference on the ECG
8. • Secure precordial lead wires • For correct interpretation of the ECG
correctly to disposable electrodes
according to colour coding /
numbering
9. • Secure limb lead wires correctly to • For correct interpretation of the ECG
disposable electrodes according to
colour coding / numbering
10. • Ensure that the paper speed is set at • This is the standard speed for recording a
25mm/sec 12-lead ECG. If not set at 25mm/sec, each
small block on the ECG paper will not be
0.04sec (any deviation from this must be
documented on the ECG)
11. • Check that calibration waveform is • The calibration wave form need to be
correct. 10mm (1mv) in height and 5mm in breadth
to ensure accurate interpretation of the
ECG. 90˚ angles

70
ACTION RATIONAL
12. • Ask patient to relax, lie still and • Lying still and not talking produces a better
breath normally during recording tracing with less disturbances.
13. • Record the ECG correctly • To ensure accurate interpretation of the
ECG
14. • Assess the quality of the recording • Poor quality might lead to the inability to
prior to disconnecting the wires interpret the ECG correctly and ECG might
have to be repeated.
15. • Keep electrodes in position when • To reduce financial costs to the patient and
applicable to provide the same lead placement for
future ECG recordings
16. • Ensure that patient is comfortable • Comfort is a basic right of the patient
17. • Ensure that patient is safe • Patient has a right to be in a safe
environment at all times.
18. • Provide health education to the • To reduce medico-legal risks e.g., patient
patient with severe chest pain must remain on
bedrest
19. • Prepare ECG machine for future use • For optimum time management in
emergency situations e.g., enough
specialized paper in machine, disposable
electrodes readily available on the ECG
trolley
20. • Disinfect hands • Universal precaution
21. • Report any abnormalities and action • To reduce medico-legal risks, the nursing
student need to report at all times
DOCUMENTATION
1. Document the following information on the ECG paper
d. Patient name (or patient • To ensure correct identification of the ECG.
information sticker), surname, date • Date and time is important for future
and time reference between different ECGs.
e. Mention the indication for the ECG • For future reference if patient needs to be
transferred
f. Vital data during the procedure (ICU • To correlate findings on the ECG with the
patients) clinical data of the patient.
• Blood pressure will indicate if patient is still
stable or unstable which will influence
treatment options.
g. Cardiac medication: orally or • To take into account the possible effect of
intravenously if applicable medication on the ECG recorded.
h. Chest pain on a scale of 0 - 10 • Chest pain might provide important
information that can be useful for future
comparison of ECGs
2. • Document in patients progress • Legal requirement for all actions and
report procedures done. If not written, not done

71
PEER EVALUATION:
EVALUATION INSTRUMENT: RECORDING OF AN ELECTROCARDIOGRAM (12-
LEAD ECG)
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE

OUTCOME CRITERIA 0 1 2 3 REMARKS

COGNITIVE COMPONENT
1. Define an ECG
2. Provide indications (5) for the recording of an ECG
3. Discuss the history and management of the patient
4. Discuss action in case of abnormalities
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. Identified patient
2. Introduced self to patient and procedure explained
3. Obtained verbal consent
4. Washed hands socially
5. Checked prescription chart
6. Checked patient care plan
7. Assessed basic needs
PLANNING
1. Prepared ECG machine correctly and assembled all
equipment
2. Provided privacy
3. Positioned patient correctly
4. Cleaned sites for electrode placement cleaned
IMPLEMENTATION
1. ECG machine plugged in, switched on
2. Cell phones removed or switched off
3. Washed hands socially
4. Precordial lead electrodes applied correctly C
5. Limb lead electrodes applied correctly C
6. No bony areas used for electrode placement
7. No areas with excessive muscle movement used for
electrode placement
8. Precordial lead wires secured to electrodes correctly C
9. Limb lead wires secured to the electrodes correctly C
10. Correct paper speed checked C
11. Correct calibration waveform checked C
12. Patient advised to lie still and to breath normally
during recording
13. Recording done correctly

72
OUTCOME CRITERIA 0 1 2 3 REMARKS
14. Quality of recording assessed prior to disconnecting
of equipment
15. Electrodes kept in position when applicable
16. Ensured patient comfort
17. Ensured patient safety
18. Health education provided
19. ECG machine prepared for future use
20. Hands washed / Disinfected
21. Abnormalities and actions reported
DOCUMENTATION
1. Relevant details recorded on ECG paper:
• Patient details / Patient sticker, date & time
• Indication for ECG
• Vital data during procedure (ICU patient)
• Relevant cardiac medication orally or IVI
• Chest pain on scale of 0 - 10
2. Recorded in patient progress report
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

73
PROCEDURE SIGNED OFF BY REGISTERED NURSE:

RECORDING OF AN ELECTROCARDIOGRAM Yes No

1. Student identified patient

2. Student positioned patient dorsal

3. Electrodes placed in correct positions

4. Leads connected correctly according to colours

5. Good quality ECG recording done

6. Paper speed and calibration checked

7. ECG identified correctly and relevant information written on the ECG

8. Abnormalities reported to Professional Nurse

Signature of RN: ___________________________

Signature of student: ___________________________

Remarks: (student competent/not yet competent/needs guidance)

74
FORMAL EVALUATION:
EVALUATION INSTRUMENT: RECORDING OF AN ELECTROCARDIOGRAM (12-
LEAD ECG)
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE

OUTCOME CRITERIA 0 1 2 3 REMARKS

75
OUTCOME CRITERIA 0 1 2 3 REMARKS
13. Recording done correctly
14. Quality of recording assessed prior to disconnecting
of equipment
15. Electrodes kept in position when applicable
16. Ensured patient comfort
17. Ensured patient safety
18. Health education provided
19. ECG machine prepared for future use
20. Hands washed / Disinfected
21. Abnormalities and actions reported
DOCUMENTATION
1. Relevant details recorded on ECG paper:
• Patient details / Patient sticker, date & time
• Indication for ECG
• Vital data during procedure (ICU patient)
• Relevant cardiac medication orally or IVI
• Chest pain on scale of 0 - 10
2. Recorded in patient progress report
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

76
VISUAL ILLUSTRATIONS TO UNDERSTAND THE ECG RECORDING BETTER

Figure 1: The calibration wave form, standard Figure 2: Placement of limb leads
voltage, standard paper speed

Figure 3: The left and right iliac region for Figure 4: Precordial lead placement
placement of limb leads

77
WORK SHEET FOR ECG RECORDING

Identify the mistake on the ECG example above Identify the correct calibration wave form in the examples above

In the recorded ECG above the patient was _________________ After recording of the ECG what would you say was the problem
_______________________________________________________

78
2.3 Administration of intravenous medication

Recommended time to master the outcomes of this study section: 10 hours

Learning outcomes
At the end of this study section, you should be able to:
• Provide the 5 golden rules during the administration of intravenous medication
• Name indications, contra indications and medico-legal risks associated with the procedure
• Perform the administration of intravenous medication correctly by utilizing of the steps of
assessment, planning, implementing, evaluating, and documenting

Study material

Hinkle, J.C. & Cheever, K.H. 2018. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.
13th Edition. New York: Lippincott.
Mogotlane et al., 2018. Juta's Complete Textbook of Medical Surgical Nursing. 2nd ed. Juta.
Mulder et al., 2020. Practical guide for general nursing science. 2nd Edition. Pearson: South Africa
Procedure Manual provided on eFundi
Extra study material on eFundi

79
ADMINISTRATION OF INTRAVENOUS MEDICATION (PIGGY-
BAG AND BOLUS)

Outcome:
After completion of the practical programme, the student should be able to provide
a patient with intravenous medication as a ‘Piggy-bag’ infusion in a safe and
competent manner

Assessment scale:

The student should familiarise him/herself with the following scale prior to the
assessment

You have to obtain 50% of the outcome criteria to master the clinical skill and be declared
competent.

A = 25%

B = 15%

C = 5%

80
DEFINITION

• PIGGY-BAG
Medication administered intravenously through a continuous or intermittent intravenous infusion.
The medication is mixed with a certain amount of intravenous solution (Sodium Chloride 0.9% /
Dextrose 5%) (50 – 500ml) and then administered over a certain period of time at the prescribed
interval, for e.g., Rocephin 2 gr in 50 ml Sodium Chloride 0.9% every 8 hours / Cordorone X 900mg in
200ml Dextrose 5% at 8.5ml/h as continuous infusion.
• BOLUS
Providing intravenous medication through bolus administration involves a single injection of a
concentrated or diluted solution directly into an IV line (never into an artery), for e.g., Maxalon
10mg (already in fluid form)

INDICATIONS FOR THIS PROCEDURE

• To provide fast acting and slower acting effect of medication

• Administration of emergency drugs during resuscitation

POSSIBLE CONTRA-INDICATIONS
• Infiltrated intravenous line (remove line STAT)
• Medication not indicated for IV use, e.g., Largactil
• Known allergy to the specific medication

MEDICO-LEGAL RISKS INVOLVED

• Incorrect patient identification
• Incorrect dosage calculation
• Anaphylactic shock. Clinical manifestations include:
o Generalised flushing of the skin
o Rash anywhere over body
o Sense of impending doom
o Swelling of throat and mouth
o Difficulty in swallowing or speaking
o Changes in heart rate
o Severe clinical manifestations of asthma
o Abdominal pain, nausea and vomiting
o Sudden feeling of weakness
o Loss of consciousness
• Injury due to poor technique, e.g., tissue damage, infection
• Changes in vital data due to fast administration of drug, e.g., Perfalgan, cardiac drugs.
• Not identifying and reporting abnormalities
• Failure to provide health education

81
EQUIPMENT/STAFF
• Prescription chart
• Emergency trolley (functional in the unit)
• Non-sterile gloves (where possible exposure are evident)
• Correct medication vial or ampoule
• Reconstitution fluid, were applicable (e.g. sterile water)
• Applicable piggy-bag (50ml, 100ml, 200ml or 500ml)
• Add-A-line set where applicable
• Syringes, needles, alcohol swabs and sharps container

Additional stock for bolus administration

• 10ml syringe with Sodium Chloride 0.9% flush (when patient has a short drip in situ)
• Watch and sharps holder

82
ADMINISTRATION OF INTRAVENOUS MEDICATION (PIGGY-BAG
AND BOLUS)
ACTION RATIONAL
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. • Identify the patient • Verification of the patient’s identity
ensures that the correct procedure is being
done on the correct patient
2. • Introduce yourself to the patient and • To alleviate anxiety and fear that might be
explain the procedure to be done experienced by patient and;
• to facilitate cooperation during the
procedure
3. • Obtain verbal consent from the • Verbal or written consent is a legal
patient requirement for all procedures
4. • Wash your hands socially • To prevent the transmission of micro-
organisms (a universal precaution)
Assess the following in the patient’s file:
5. • Medical/surgical history • This will provide the indication for the
administration of the medication e.g.,
pneumonia and the administration of
antibiotics
6. • Prescription chart for the five golden • This will ensure that the correct patient is
rules: provided with the correct medication, the
- Patient’s name correct dosage thereof, at the correct time
- Medication to be provided and through the correct route, preventing
- Dosage to be provided medico-legal risk
- Time of administration
- Route of administration
7. • Check whether patient has any • To prevent any anaphylactic reactions and
allergies possible lethal consequences in patient
8. • Evaluate the patient’s nursing care • The nursing care plan will provide you with
plan nursing diagnosis, interactions, and
specific indications for the administration
of the medication e.g., pain due to …
9. • Laboratory results • Laboratory results might indicate the
reason for the specific medication provided
or side-effects caused by the medication
e.g., elevated creatinine level and the
administration of Furosemide bolus / piggy-
bag
10. • Vital data • Certain medications might affect vital data,
e.g., if patient is already hypotensive,
certain analgesia might decrease blood
pressure more, e.g., Tramal (piggy-bag) and
Toradol (bolus)
Assess patient for the following:
11. • Knowledge of the medication • Patient has the right to participate in
decision making regarding treatment

83
ACTION RATIONAL
12. • Infusion site for: • Medication may only be given directly into
- infiltration, a vein for safe administration.
- leakage or • Clinical manifestations of
- pain infiltration/phlebitis might include swelling,
redness, pain or burning, blanching and
coldness (infiltration) or warmness
(phlebitis)
Check package insert or drug reference manual in the unit for the following:
13. • Goal of the medication • Adequate knowledge regarding the specific
• Action of medication medication is needed to ensure safe
• Indication for this patient administration thereof
• Recommended dosage
• Possible side-effects
• Contra-indications
• Reconstitution of the medication
• Compatibility with infusion solution
• Medication interaction
• Nursing implications
PLANNING
1. • Ensure the presence of a functional • For effective management of anaphylactic
emergency trolley in the unit shock.
2. • Obtain the correct stock and • For effective time management
medication (on a clean medicine • Medical-legal requirement to provide the
trolley or in a kidney dish) correct dose of medication to the correct
patient at the correct time
3. • Check prescribed medication with • Medical-legal requirement to provide the
Registered Nurse against the correct dose of medication to the correct
prescription chart (1st check) patient at the correct time
4. • Check the expiry date of the • To ensure the correct therapeutic effect of
medication with the Registered medication prior to administration thereof
Nurse • Medical legal requirement for nursing
students to check with Registered Nurse
5. • Calculate the correct dosage and • To ensure administration of the correct
confirm with Registered Nurse (2nd amount of medication.
check) Formula includes the following:
• Dosage required (mg) X Diluted volume
(ml)
Dosage in stock (mg) 1
= Dosage in ml
6. • Provide patient with privacy where • Patient has a right to privacy at all times
needed • Some patients might have a femoral
central line in situ and therefor privacy
must be provided to prevent exposure
7. • Prepare medication for one patient • Preventing the administration of wrong
at a time medication to the wrong patient
IMPLEMENTATION

FOR PIGGY-BAG ADMINISTRATION

84
ACTION RATIONAL
1. • Wash your hands socially • To prevent the transmission of micro-
organisms (a universal precaution)
2. • Ampoule usage: Utilise the correct • To ensure that the correct dosage of
amount of medication from the medication is administered to patient
ampoule
3. • Powder vial usage: Use appropriate • To ensure that the correct dosage of
correct amount of reconstitution medication is administered to patient
fluid to inject into the vial. Swirl the • (Appropriate correct amount of
vial to mix content and withdraw the reconstitution fluid = mostly Sodium
correct amount of medication for Chloride 0.9% or Sterile Water. NB! Read
injection. instructions regarding reconstitution of
medication
4. • Add the medication to the piggy-bag • Contamination might lead to the
in an aseptic manner introduction of micro-organisms directly
into the intravascular space
5. • Complete a medication label/sticker • The content of a medication IV bag must be
and attach to the piggy-bag identified at all times to prevent medico-
(medication IV bag) legal risks
6. • Check medication again against the • Ensuring the correct patient receives the
prescription chart before taking it to correct medication, at the correct dosage
the patient (3rd Check) at the correct time, preventing medico-
legal risks
7. • Connect piggy-bag to the Add-A-line • When the Add-A-line set are not clamped
set (roller clamp closed) in an aseptic before connection of diluted medication,
manner medication will run through system and
will be wasted.
• Contamination might lead to the
introduction of micro-organisms directly
into the intravascular space
8. • Full the Add-A-line fluid chamber, • Priming the line prevents the introduction
open the roller clamp and slowly of air into the intravascular space.
prime the medication through the
Add-A-line set
9. • Clamp roller clamp of the Add-A-line • Wasting medication will prevent
set immediately after priming line to therapeutic effect thereof
prevent wasting of the medication
10. • Hang the piggy-bag on the IV pole, • The higher position of the Piggy-bag will
positioning it higher than the ensure the flow of medication into the
primary infusion (using a plastic or primary infusion line
metal hook to lower primary IV
infusion.
11. • Use an alcohol swab to clean area • This prevents the entry of micro-organisms
where the Add-A-line will be when Add-A-line are connected to the port
connected to the primary IV infusion
port
12. • Remove the cap of the Add-A-line set • Add-A-line set might have a needle
and connect to primary IV infusion attached to it or be needleless. (NB not to
port (this might differ between insert a needle into a needleless primary
facilities)

85
ACTION RATIONAL
infusion set as this will cause a continuous
leak when Add-a-line are removed)
13. • Open Add-A-line roller clamp and • A delivery over 30 – 60 minutes can be
regulate the flow at prescribed seen as a safe method of administering the
delivery rate (or set for secondary medication.
infusion on infusion pump) • (Please verify the safe administration rate
for all medication to prevent adverse
effects)
14. • Monitor the medication infusion at • To ensure that the medication is
periodic intervals administered in a safe time frame
15. • Clamp the Add-A-line roller clamp • Not clamping the Add-A-line set will cause
when medication is infused and keep primary IV infusion fluids to run into piggy-
connected to primary infusion line bag again.
for future use • Keeping the Add-A-line connected will
prevent contamination of the system
16. • Readjust the flow rate of the primary • Administering medication via the piggy-bag
IV infusion may interrupt normal flow rate of the
primary IV infusion and rate re-adjustment
may be needed
17. • Observe the injection area for • For early detection of tissue infiltration or
swelling, redness, blanching or pain the presence of phlebitis
during administration of medication
18. • Dispose medical waste in the correct • To prevent any medico-legal risks
manner
19. • Disinfect your hands •
Universal precaution
20. • Ensure that patient is comfortable •
Comfort is a basic right of the patient
21. • Ensure patient safety by placing the •
Patients need to be able to call for
bell within easy reach assistance STAT in case of anaphylactic
shock.
• Patient has the right to be in a safe
environment at all times
22. • Provide health education to the • To prevent medico-legal risks, e.g., to stay
patient in bed after administration of analgesia
23. • Report any abnormalities and action • To reduce medico-legal risks, the nursing
student need to report at all times
IMPLEMENTATION

FOR BOLUS ADMINISTRATION

1. • Wash your hands socially • To prevent the transmission of micro-

organisms (a universal precaution)
2. • Ampoule usage: Utilise the correct • To ensure that the correct dosage of
amount of medication from the medication is administered to patient
ampoule
3. • Powder vial usage: Use appropriate • To ensure that the correct dosage of
correct amount of reconstitution medication is administered to patient
fluid to inject into the vial. Swirl the • (Appropriate correct amount of
vial to mix content and withdraw the reconstitution fluid = mostly Sodium
Chloride 0.9% or Sterile Water. NB! Read

86
ACTION RATIONAL
correct amount of medication for instructions regarding reconstitution of
injection. medication
4. • Expel all air from the syringe • To prevent the injection of air (air
embolism) into the intravascular system
5. • Check medication again against the • Ensuring the correct patient receives the
prescription chart before taking it to correct medication, at the correct dosage
the patient (3rd Check) at the correct time, preventing medico-
legal risks
In case of an infusion via an intravenous infusion pump:
6. • Pause the intravenous infusion pump • To prevent activation of intravenous
infusion pump alarm as you will cause
additional pressure in the intravenous line
which will be detected by the IVAC
7. • Use the injection port closest to the • To inject the medication directly into the
IV insertion site vein, minimising the dilution of IV
medication with IV solution
8. • Clean the injection port with an • To prevent the administration of micro-
alcohol swab organisms into the intravascular system
9. • Fold the tubing with non-dominant • To directly administer the medication into
hand just above the injection port the vein without the chance of medication
moving up in the line
10. • Slowly inject medication over 2-3 • To prevent side effects caused by rapid
minutes or according to medication infusion of medication
package insert
11. • Restart infusion again at the • To provide patient with the intravenous
prescribed infusion rate by restarting fluid volume as prescribed by the doctor
the intravenous infusion pump
In case of an infusion line with a Dial-a-flow:
12. • Close the roller clamp of the infusion • To prevent the back-flow of medication
line
13. • Open the Dial-a-flow to maximum • If Dial-a-flow is not at maximum flow rate
flow rate there will be a pressure resistance when
injection the medication
14. • Use the injection port closest to the • To inject the medication directly into the
IV insertion site vein, minimising the dilution of IV
medication with IV solution
15. • Clean the injection port with an • To prevent the administration of micro-
alcohol swab organisms into the intravascular system
16. • Fold the tubing with non-dominant • To directly administer the medication into
hand just above the injection port the vein without the change of medication
moving up in the line
17. • Slowly inject medication over 2-3 • To prevent side effects caused by rapid
minutes or according to medication infusion of medication
package insert
18. • Restart infusion again at the • To provide patient with the intravenous
prescribed infusion rate by turning fluid volume as prescribed by the doctor
the Dial-a-flow back to the
prescribed rate e.g., 125ml/h
In case of a short intravenous line:

87
ACTION RATIONAL
19. • Clean the injection port with an • To prevent the administration of micro-
alcohol swab organisms into the intravascular system
20. • Connect the 10ml Sodium Chloride • To confirm patency of the intravenous
flush to the injection port and pull catheter in the vein.
back slightly on the plunger until
blood appears in the tubing
21. • Slowly flush the line with 5 ml of • To confirm patency of the line. (This is not
Sodium Chloride 0.9% applicable with a continuous infusion)
22. • Slowly inject medication over 2-3 • To prevent side effects caused by rapid
minutes or according to medication infusion of medication
package insert
23. • Short line flush again slowly with • This will ensure that all medication are
Sodium Chloride 0.9% provided to the patient with no medication
accumulated in the tubing of the short line.
17. • Observe the injection area for • For early detection of tissue infiltration or
swelling, redness, blanching or pain the presence of phlebitis
during administration of medication
18. • Dispose medical waste in the correct • To prevent any medico-legal risks
manner
19. • Disinfect your hands • Universal precaution
20. • Ensure that patient is comfortable • Comfort is a basic right of the patient
21. • Ensure patient safety by placing the • Patient must be able to call for assistance
bell within easy reach STAT in case of anaphylactic shock.
• Patient has the right to be always in a safe
environment
22. • Provide health education to the • To prevent medico-legal risks, e.g., to stay
patient in bed after administration of analgesia
23. • Report any abnormalities and action • To reduce medico-legal risks, the nursing
student need to always report

EVALUATION FOR PIGGY-BAG AND BOLUS ADMINISTRATION

1. • Observe the patient for any allergic • For effective management of anaphylactic
reactions shock
2. • Observe the IV site 1, 2 to 4 hourly • To identify infiltration a.s.a.p. and to
for: prevent tissue damage
• Swelling • To identify disconnection between the
• Bleeding Jelco and infusion line
• Skin colour

DOCUMENTATION FOR PIGGY-BAG AND BOLUS

Document the following on the PRESCRIPTION CHART:

1. Administration of the medication with • Ensuring that the medication is provided at
• time, the correct time and date, the correct
• date, dosage and indicating who administered
• dosage and the medication.
• signature • To prevent confusion and faulty actions
from other nursing personnel

88
ACTION RATIONAL
Document the following in the progress report
2. • Time and date • If not documented, it is not done.
• Type of medication provided • Legal requirement for all interventions
• Dosage provided
• Route of administration
• Patient’s reaction
• Signature
3. • Document scheduled drug in the • Legal requirement
applicable register (together with
Registered Nurse

89
PEER EVALUATION:
EVALUATION INSTRUMENT: ADMINISTRATION OF INTRAVENOUS
MEDICATION (PIGGY-BAG & BOLUS ADMINISTRATION)
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE (%)

OUTCOME CRITERIA 0 1 2 3 REMARKS

COGNITIVE COMPONENT
Provide the evaluator with the following:
1. Indications (2) for administering medication IVI
2. Possible medico-legal risks (3) involved
3. Clinical manifestations (3) of anaphylactic shock
4. Clinical manifestations (3) of tissue infiltration
5. Formula to calculate medication dosage
PSYCHOMOTOR COMPONENT
ASSESSMENT
1. Identified patient A
2. Introduced self, and procedure explained
3. Obtained verbal consent
4. Washed hands socially
Patient’s file assessed for the following
5. Medical/surgical history
6. Prescription chart:
• Patient’s name B
• Medication to be provided B
• Dosage to be provided B
• Time of administration B
• Route of administration B
7. Checked for allergies A
8. Patient care plan checked
9. Laboratory results
10. Vital data
Patient assessed for:
11. Knowledge regarding the specific medication
12. Infusion site for infiltration, leakage or pain
According to package insert / drug reference manual:
13. Provided good knowledge regarding the
medication to be administered e.g., indications,
contra-indications, side-effects, etc.
PLANNING
1. Functional emergency trolley present A
2. Correct stock and medication obtained A

90
OUTCOME CRITERIA 0 1 2 3 REMARKS
3. Prescribed medication checked with RN (1st
B
check)
4. Expiry date of medication checked with RN B
5. Correct dosage calculated and confirmed with
A
RN (2nd check)
6 Provided privacy
7. Medication prepared for one patient only

IMPLEMENTATION – PIGGY-BAG ADMINISTRATION

1. Wash hands socially

2. Ampoule usage: correct amount of medication
A
withdrawn
3. Powder vial usage: Correct amount of
reconstitution fluid injected into vial and correct A
amount of medication withdrawn
4. Medication added to piggy-bag in an aseptic
B
manner
5. Piggy-bag labelled with medication sticker C
6. Checked medication again against prescription C
chart (3rd check)
7. Piggy-bag connected to Add-A-line set in an
C
aseptic manner with roller clamp closed
8. Fluid chamber of Add-A-line filled with fluid,
roller clamp opened, and line primed slowly
9. Add-A-line clamped immediately after priming
the line
10. Piggy-bag hanged higher than primary IV
infusion
11. Insertion port for Add-A-line cleaned with
alcohol swab
12. Add-A-line connected correctly to primary IV
infusion line
13. Flow of piggy-bag regulated at prescribed
delivery rate
14. Infusion of medication monitored at periodic
C
intervals
15. Add-A-line set clamped when medication is
infused and kept connected to primary IV
infusion line
16. Flow rate of the primary IV infusion readjusted
17. Injection area observed for swelling, redness,
blanching and pain during administration of B
medication
18. Medical waste disposed in the correct manner
19. Hands disinfected
20. Patient made comfortable
21. Bell placed within easy reach
22. Health education provided as indicated

91
OUTCOME CRITERIA 0 1 2 3 REMARKS
23. Abnormalities and actions reported to RN

IMPLEMENTATION – BOLUS ADMINISTRATION

1. Wash hands socially

2. Ampoule usage: correct amount of medication
withdrawn
3. Powder vial usage: Correct amount of
reconstitution fluid injected into vial and correct
amount of medication withdrawn
4. All air expelled from syringe A
5. Checked medication again against prescription C
rd
chart (3 check)
In case of an infusion via an intravenous infusion pump:
6. Intravenous infusion pump paused
7. Injection port closest to the IV insertion site
used
8. Injection port cleaned with an alcohol swab
9. Tubing folded with non-dominant hand above
injection port
10. Medication administered over a period of 2-3
minutes
11. Infusion restarted at prescribed rate
In case of an infusion line with a Dial-a-flow
12. Roller clamp of infusion line closed
13. Dial-a-flow opened to maximum flow rate
14. Injection port closest to the IV insertion site
used
15. Injection port cleaned with an alcohol swab
16. Tubing folded with non-dominant hand above
injection port
17. Medication administered over a period of 2-3
minutes
18. Dial-a-flow turned back to prescribed rate
In case of a short intravenous line:
19. Injection port cleaned with an alcohol swab
20. 10ml Sodium Chloride connected correctly to
the injection port and plunger pulled back
slightly until blood appears.
21. Line flushed slowly with 5ml of Sodium Chloride
solution
22. Medication administered over a period of 2-3
B
minutes
23. Short line flushed again slowly with 5ml of
Sodium Chloride 0.9%
For intravenous infusion pump, Dial-a-flow and short line:
24. Injection area observed for swelling, redness,
blanching and pain during administration of
medication

92
OUTCOME CRITERIA 0 1 2 3 REMARKS
25. Medical waste disposed in the correct manner
26. Hands disinfected
27. Patient made comfortable
28. Bell placed within easy reach
29. Health education provided as indicated
30. Abnormalities and actions reported to RN

EVALUATION FOR PIGGY-BAG AND BOLUS ADMINISTRATION

1. Patient observed for any allergic reactions

2. IV site observed 1, 2 to 4 hourly for:
• Swelling
• Bleeding
• Skin colour

DOCUMENTATION FOR PIGGY-BAG AND BOLUS ADMINISTRATION

1. The following was documented:

• Administration of the medication on the
prescription chart with date, time, dosage B
and signature present
• Administration of medication in the
progress report with all relevant information C
clearly indicated
• Scheduled drugs documented in applicable
register (where applicable)
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
• Professional in behaviour
• Friendly and approachable
• Reassuring patient

CALCULATION OF MARK: Total marks on Evaluation scale

93
PROCEDURE SIGNED OF BY A REGISTERED NURSE:

ADMINISTRATION OF INTRAVENOUS MEDICATION (PIGGY-BAG

Yes No
& BOLUS)
1. Student identified patient

2. Student checked prescription card for 5 golden rules and legal aspects

3. Student checked for allergies

4. Student obtained correct medication

5. Student calculated dosage correctly according to formula

Student assessed infusion site for signs of infiltration / phlebitis before
6.
administrating medication
7. Student checked for patency of infusion

8. Medication was administered correctly

9. Sterility was maintained throughout the procedure

10. Patient evaluated for signs of side effects/ allergic reactions

11. Documentation on prescription done correctly

12. Abnormalities reported to Professional Nurse

Signature of RN: ___________________________

Signature of student: ___________________________

Remarks: (student competent/not yet competent/needs guidance)

94
FORMAL EVALUATION:
EVALUATION INSTRUMENT: ADMINISTRATION OF INTRAVENOUS
MEDICATION (PIGGY-BAG & BOLUS ADMINISTRATION)
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE (%)

OUTCOME CRITERIA 0 1 2 3 REMARKS

95
OUTCOME CRITERIA 0 1 2 3 REMARKS
3. Prescribed medication checked with RN (1st
B
check)
4. Expiry date of medication checked with RN B
5. Correct dosage calculated and confirmed with
A
RN (2nd check)
6 Provided privacy
7. Medication prepared for one patient only

IMPLEMENTATION – PIGGY-BAG ADMINISTRATION

1. Wash hands socially

96
OUTCOME CRITERIA 0 1 2 3 REMARKS
23. Abnormalities and actions reported to RN

IMPLEMENTATION – BOLUS ADMINISTRATION

1. Wash hands socially

97
OUTCOME CRITERIA 0 1 2 3 REMARKS
25. Medical waste disposed in the correct manner
26. Hands disinfected
27. Patient made comfortable
28. Bell placed within easy reach
29. Health education provided as indicated
30. Abnormalities and actions reported to RN

EVALUATION FOR PIGGY-BAG AND BOLUS ADMINISTRATION

1. Patient observed for any allergic reactions

2. IV site observed 1, 2 to 4 hourly for:
• Swelling
• Bleeding
• Skin colour

DOCUMENTATION FOR PIGGY-BAG AND BOLUS ADMINISTRATION

1. The following was documented:

CALCULATION OF MARK: Total marks on Evaluation scale

98
VISUAL ILLUSTRATIONS TO UNDERSTAND THE ADMINISTRATION OF INTRAVENOUS
MEDICATION BETTER

Figure 1: Clinical manifestations of infiltration Figure 2: Example of infiltration of intravenous

fluid

Figure 3: Visual illustration of blanching Figure 4: A femoral (vein) central line

Figure 5: Phlebitis

99
Figure 6: V.I.P Score of phlebitis

100
CARDIOVASCULAR CLINICAL SKILLS
PROCEDURE DATE WARD/UNIT SIGNATURE: PRECEPTOR/RN/DOCTOR

1.
Checking of the emergency trolley and defibrillator
2.
Utilize emergency equipment and apply resuscitation
principles
Prepare a trolley for an invasive procedure (UWD, CVP etc)
(if found)
1.
Attend an academic round
2.

1.
Ward / patient hand over
2.

101
ECG INTERPRETATION WORKSHEETS:
(Please note the basic ECG interpretation will be done in a workshop session in SIMLAB)

Worksheet 1:

Use the ECG paper below to work on.

1. Colour in one small block.
2. How many seconds does this small coloured-in block represents? __________
3. If the P-wave for example stretched over 2 small blocks, how long did it take for the atria to
depolarize? __________
4. If that same P-wave was 2 small blocks high, what was the strength of the electrical current?
__________
5. Colour in one large block
6. How many seconds does this large coloured-in block represents? __________
7. If one P-QRS-T wave form for example stretched over 4 large blocks, how long did it take for
the atria and ventricles to depolarize and repolarise? __________
8. If the R-wave was 2 large blocks high, what was the strength of the electrical current?
__________

Figure 1: Specialized ECG paper

102
Work sheet 2:

Figure 1. Normal P-QRS-T wave form

Indicate the P-waves, QRS-complex and T-waves, PR-interval, QT-interval, PR-segment and ST-
segment in Figure 2 below (you may be very creative and also colour code it)

Label the P-waves, QRS-complexes and T-waves in the ECG below

103
Figure 3: Example of a 12-lead ECG

Worksheet 3:

Have a look at the rhythm strip in Figure 1 below: (remember your ruler with mm on it)

1. Is the rhythm regular or irregular? __________

2. Determine the heart rate of this patient __________
3. Calculate the heart rate if the patients’ RR interval was:
a) 18mm __________
b) 25mm _________________
c) 32mm _________________
d) Between 15mm and 24mm _____________________

Figure 1: A rhythm strip

4. Calculate the heart rate of each of the following rhythm stripes

104
Figure 2: Rhythm strip

Heart rate = _________________

Figure 3: Rhythm strip

Heart rate = _________________

105

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