HESI MATH

Chest tube Implementaion

-Review orders ----Suction vs. water seal ----Amount and quality of drainage appropriate ----I & O ----X-Rays -Administer pain meds -Reposition -Drainage system below -Level of chest

Suction Chamber

-Wet suction- 15-20 cm of water -Dry suction- set dial to ordered amount of suction -Wet suction- gentle bubbling in suction chamber -Should see orange float in center window

A patient with low potassium must have an IV potassium infusion. The pharmacy sends a 250-mL IV bag of dextrose in water with 40 mEq of potassium. The label is marked "to infuse over 1 hour." What is the nurse's best action?

Double-check the provider's order and call the pharmacy.

How should the nurse monitor for complications of subcutaneous emphysema after the insertion of chest tubes.

Palpate around the tube insertion sites for crepitus.

Which nursing interventions apply to patients with hypercalcemia? (Select all that apply.)

a. Administer IV normal saline (0.9% sodium chloride). c. Measure the abdominal girth. e. Monitor for ECG changes.

Which conditions cause a patient to be at risk for hypocalcemia? (Select all that apply.)

a. Crohn's disease b. Acute pancreatitis c. Removal or destruction of parathyroid glands d. Immobility

Patients with which conditions are at greatest risk for deficient fluid volume? (Select all that apply.)

a. Fever of 103° F b. Extensive burns c. Thyroid crisis e. Continuous fistula drainage f. Diabetes insipidus

Chest Tube Removal

-When deemed appropriate by provider, chest tube will be removed. -Pre-medicate for pain -Breath in & hum out -Provider quickly removes chest tube -Occlusive dressing applied over insertion site -Pleura seals itself off and heals within a weeks time

The physician has ordered that a chest tube be placed with suction set to 20 cm. The nurse's responsibilities related to insertion of a chest tube system with "dry" suction for this patient includes the following (choose all that apply):

-obtaining a sterile chest tube system -filling the water seal chamber with 70 ml (2 cm) of sterile water -connecting the system to 80 mm Hg wall suction -securing all connections with zip ties or cloth tape -turning the dial on the suction chamber to 20 cm of H20

Caution:

•Don't mix 2 drugs in syringe, even if compatible •Do not wait until later to use - give immediately •Label all syringes •Always give IV push meds under the direct supervision of your instructor or RN •Don't throw the ampule/vial away - need to scan

spontaneous pneumothorax

-Primary spontaneous pneumothorax: No underlying cause/disease -Secondary spontaneous pneumothorax: Underlying disease process

Goals of Chest Tube Drainage

-Remove air or fluid from pleural space -Prevent reflux into the chest cavity -Re-expand lungs and restore normal negative intrapleural pressure

Cuff Manometer

**Facility Specific** May measure and record cuff pressure every 8 hours for cuffed tracheostomy tubes -Cuff pressure must be maintained at 14 to 20 mmHg -Excessive cuff pressure may cause complications: ●Tracheomalacia ●Tracheal Stenosis ●Tracheoesophageal Fistula

Purpose of CVC

+Administering fluids, drugs, nutrients, blood and blood products +Infusion of irritants, vesicants, and hyperosmolar solutions (TPN and Lipids) +Administration of a variety of products in multiple catheters +Enables monitoring of central venous pressure +Blood draws

incompatabilities

1. Physical: visible precipitation forms. 2. Chemical: changes in molecular structure or pharmacological properties; may or may not be physically observable. 3. Therapeutic: therapeutic effect of a drug altered (increased or decreased) by another

Intravenous Fluid and IVPB Admin

1. Review orders 2.Verify date and time solutions were last changed (solutions must be changed every 24 hours) 3.Verify when tubing was last changed; gather new tubing if tubing is due to be changed (check facility policy for tubing change policy, usually 72-96 hours) 4.Determine compatibility of current fluids and new solution to be administered. 5. Check solution with orders/MAR to verify correct solution, rate, labeling, expiration, sterility, and intact seals. 6. KWIIPES 7. Assess IV access site for pain, patency, warmth, color, and edema. 8. To change primary (maintenance) IV bag or "carrier" solution: a. Hang new solution and remove cover from new solution, preserving sterility of the insertion site. b. Press "HOLD" on the IV Pump c. Remove old solution from IV pole, invert bag, and remove spike without touching the tip. d. Insert tip of spike directly into the new fluid container, firmly e. Set IV pump to reflect new volume to be delivered and change rate, if order indicates. f. Press "Primary RUN" on the IV Pump Observe solution dripping in the drip chamber, assure there are no kinks and tubing is unclamped 9. To hang piggyback or secondary solution: a. Hang piggyback solution and remove cover from the solution, preserving sterility of the insertion site. b. Remove secondary tubing set from package and engage (clamp) the roller clamp immediately. c. Remove cap from spike and Insert tip of spike directly into the piggyback solution firmly. d. "Scrub the Hub" of the Y site on the primary tubing that is located ABOVE (before) the pump for a minimum of 10 seconds e. Remove cap from end of secondary tubing and connect secondary tubing to the Y site, maintaining sterility of tubing end. f. Prime or "back flush" the secondary tubing to ensure all air is removed from the secondary tubing: 1. Lower secondary (piggyback) solution below the level of the primary solution and release the roller clamp on the secondary tubing 2. Once the drip chamber of the secondary tubing is filled halfway, clamp the secondary tubing and return the secondary solution to the IV pole OR 1. Squeeze drip chamber to fill approximately half way 2. Prime secondary tubing SLOWLY until fluid reaches the end of the tubing 3. Remove cap and connect secondary tubing to the Y site after completing a "Scrub the Hub" for 10 seconds. a. Remove the solution hanger from the secondary IV tubing package and lower the primary solution, so that the piggyback or secondary solution is higher. b. Set IV pump to reflect the IVPB or secondary solution with the ordered rate and volume. c. Press "secondary RUN" for the secondary solution on the IV Pump. d. Unclamp the roller clamp on the secondary IV solution tubing. Observe the drip chamber of the secondary (piggyback) solution for dripping, observe the primary bag for NO dripping 10. Check tubing for air and patency of system 11. Dispose of used equipment in correct containers; hand hygiene 12. Document

On admission, a patient with pulmonary edema weighed 151 lbs.; now the patient's weight is 149 lbs. Assuming the patient was weighed both times with the same clothing, same scale, and same time of day, how many milliliters of fluid does the nurse estimate the patient has lost?

1000

After a partial gastrectomy is performed, a client is returned from the postanesthesia care unit to the surgical unit with an IV solution infusing and a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There is an order for instillation of the nasogastri tube prn. The nurse should instill.

30 mL of normal saline and continue the suction.

A patient in the hospital has a severely elevated magnesium level. Which intervention should the nurse complete first?

A patient in the hospital has a severely elevated magnesium level. Which intervention should the nurse complete first?

Purpose of PICC

Administration of fluids, drugs, nutrients, blood or blood products Infusion of irritants, vesicants, and hyperosmolar solutions (TPN and Lipids) Administration of a variety of products in multiple catheters Long term antibiotic therapy for Home Care patients

Insertion

After the tracheal cartilage

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client?

Air will move from the lung into the pleural space

Central line dressing change

A-Septic (sterile stays sterile, clean stays clean) (Sterile) a. Validated physician's order (or agency protocol). b. Obtained central line dressing kit, clean gloves, new cap for each lumen, saline for groshong catheter, heparin for non-groshong catheter c. Placed garbage and tray table near patients bed d. KWIPES, raise bed to working height, lower side rail BEFORE putting clean gloves on. e. Performed hand hygiene, donned clean gown, opened kit using sterile principles, donned face mask and lastly applied first pair of sterile gloves. Explained procedure to client.Instruct patient to turn head away from insertion site, no talking.If patient has a respiratory infection, he/she may have to don a mask. 1. Removed soiled dressing ---Removed soiled dressing in direction of insertion site with dominant hand while stabilizing central line device with non-dominant hand. ---Held old dressing in dominant hand and used non-dominant hand to pull glove of dominant hand over dressing. ---Removed other glove and discarded both in garbage can. Performed hand hygiene a second time!!!! 2. Cleaned the site. ---Donned sterile gloves (in kit) ---Cleaned insertion site with alcohol swab if clot is visible Started at site of IV access and swabbed Choraprep solution back and forth for 30 seconds, allowed to dry 1. Dressed site. a. Applied transparent occlusive dressing so that IV access device was in center of dressing. b. Changed each injection cap. Made sure each lumen is clamped off prior to removing cap. c. Taped tubing to patient's chest to avoid tension at exit site. d. Labeled dressing with initials, date and time. e. Removed gloves, discarded materials, washed hands, lowered bed, raised side rail. Asked patient 6 p's: pain, "personal needs", position, pathway, pump, plan Documented procedure.

The nurse identifies the priority problem of potential for injury for a patient with hyponatremia. What is the etiology of this priority patient problem?

Altered mental capabilities

chest tube assessment

Assessment -Patency/function (kinks, clamps, dependent loops, assess from patient to end point) -Dressing, crepitus -Quantity and quality of drainage -Pain control -Respiratory status, vital signs

An older adult patient needs an oral potassium solution, but is refusing it because it has a strong and unpleasant taste. What is the best strategy the nurse uses to administer the drug?

Ask the patient's preference of juice and mix the drug with a small amount.

The nurse is assessing the chest tube system and observes continuous bubbling in the water seal chamber. The nurse's priority action is to

Assess the patient for signs of respiratory distress

IV push (Direct IV; IV injection; IV bolus)

Bolus = concentrated medication or solution given rapidly over a short period of time

The nurse administering potassium to a patient carefully monitors the infusion because of the risk for which condition?

Cardiac dysrhythmia

Care of Central Lines

Change dressing q week if chloraprep is used Change dressing every 72 hours if alcohol/betadine prep is used Change all caps with each dressing change

The nurse is caring for a psychiatric patient who is continuously drinking water. The nurse monitors for which complication related to potential hyponatremia?

Change in mental status/increased intracranial pressure

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?

Check the tube to ensure that it is not kinked.

Compatibility

Consider any drug NOT listed as compatible to be INCOMPATIBLE until consulting a drug guide or pharmacist.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately?

Continuous bubbling in the water-seal chamber.

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern?

Decreased filling of the right heart

Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's nasogastric tube is bright red. What should the nurse do first?

Determine that this is an expected finding

The nurse is caring for a patient who takes potassium and digoxin. For what reason does the nurse monitor both laboratory results?

Digoxin toxicity can result if hypokalemia is present.

When converting a chest drain system from suction to gravity drainage:

Disconnect suction tubing from wall suction and leave port on collection unit uncapped

Which component has a high content of potassium and phosphorus?

Intracellular fluid

A patient has a chest tube in place. What does the water in the water seal chamber do when the system is functioning correctly.

Fluctuates with the patient's respirations.

Expiration

Intrapleural pressure: 4-5 cm H2O below atmospheric pressure during

The nurse is giving discharge instructions to the patient with advanced heart failure who is at continued risk for fluid volume excess. For which physical change does the nurse instruct the patient to call the health care provider?

Greater than 3 lbs. gained in a week or greater than 1 to 2 lbs. gained in a 24-hour period

A client is to have gastric gavage. In which position should the nurse place the client when the nasogastric tube is being inserted?

High fowlers

A hospitalized patient who is known to be homeless has been diagnosed with severe malnutrition, end-stage renal disease, and anemia. He is transfused with 3 units of packed red blood cells. Which potential electrolyte imbalance does the nurse anticipate to occur in this patient?

Hyperkalemia

A young adult patient is in the early stages of being treated for severe burns. Which electrolyte imbalance does the nurse expect to assess in this patient?

Hyperkalemia

The nurse is evaluating the lab results of a patient with hyperaldosteronism. What abnormal electrolyte finding does the nurse expect to see?

Hypernatremia

The nurse is taking care of a trauma patient who was in a motor vehicle accident. The patient has a history of hypertension, which is managed with spironolactone (Aldactone). This patient is at risk for developing which electrolyte imbalance?

Hypernatremia

A patient with a recent history of anterior neck injury reports muscle twitching and spasms with tingling in the lips, nose, and ears. The nurse suspects these symptoms may be caused by which condition?

Hypocalcemia

A patient has a low potassium level and the provider has ordered an IV infusion. Before starting an IV potassium infusion, what does the nurse assess?

Intravenous line patency

Lung collapse / pneumothorax

If intrapleural pressure = atmospheric pressure then

A patient has hyperkalemia resulting from dehydration. Which additional laboratory findings does the nurse anticipate for this patient?

Increased hematocrit and hemoglobin levels

The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for this patient, what does the nurse expect to find on assessment?

Increased respiratory rate, because the body perceives hypovolemia as hypoxia

Complications of Central Lines

Infiltration Site infection Circulatory overload Pneumothorax Air embolism Thrombosis Blood stream infection

The physician has ordered that the chest tube suction be decreased from 20 to 15 cm. To accomplish this, the nurse should:

Insert a syringe with a 20G needle into the rubber stopper on the suction control chamber and withdraw fluid until the water level is at 15 cm

Which statement best explains how ADH affects urine output?

It increases permeability to water in the tubules causing a decrease in urine output.

The nurse is caring for a patient with a chest tube in place. Over the past hour the drainage from the tube was 110 mL. What is the nurse's best action?

Notify the surgeon immediately.

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client?

Observe for fluid fluctuations in the water-seal chamber.

The nurse is working in a long-term care facility where there are numerous patients who are immobile and at risk for dehydration. Which task is best to delegate to the unlicensed assistive personnel (UAP)?

Offer patients a choice of fluids every 1 to 2 hours.

Anatomy of Trach Tube:

Outer Cannula: The outer cannula stays in the neck, and we clean around this site frequently. This part should never be removed with routine nursing cares - this trach tube can be changed out by the provider at the bedside - and eventually home care would be able change this out about once a month. Cuff: The trach may or may not have a cuff. If it does have a cuff, it will be present at the the base of the outer cannula. When the trach is in the patient, you are unable to see this, so checking the cuffs attached balloon will be important (inflated vs deflated) . The cuff helps to stop fluid from getting into the lungs. Inner Cannula: The inner cannula fits into the outer cannula. The majority of these are disposable (don't really use metal trachs anymore). The inner cannulas must be removed, cleaned, and reinserted, unless it is disposable. Obturator: The obturator has a rounded tip for smoothly inserting the outer tube and avoiding trauma to the tracheal wall. It is important to keep the obturator near the bedside in case of an emergency.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for the client?

Palpate the surround area for crepitus.

The nurse is caring for several patients with electrolyte imbalances. Which intervention is included in the plan of care for a patient with hypocalcemia?

Placing the patient on seizure precautions

Which serum laboratory value does the nurse expect to see in a patient with hyperkalemia?

Potassium greater than 5.0 mEq/L

Which serum laboratory value does the nurse expect to see in a patient with hyperkalemia?term-26

Potassium greater than 5.0 mEq/L

Which precaution or intervention does the nurse teach a patient at continued risk for hypernatremia?

Read labels on canned or packaged foods to determine sodium content.

IV push Med through a Central Line

Remember with Central line: 10 mL syringe or larger syringe for flushes! •Saline to assess patency •Administer medication slowly •Saline (administer slowly) •Positive pressure access device: •Remove syringe, then clamp tubing

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung.

Remove the air that is present in the intrapleural space.

A client with emphysema experiences a sudden episode of pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration?

Rupture of a subpleural bleb

Groshong

SAS Saline 10 ml Administer medication Saline 10 ml (Typically PICC)

Non-Groshong

Saline 10 ml Administer medication Saline Heparin 100 units (Typically CVC)

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply

Shortness of breath Unilateral chest pain

Stoma Care

Skin breakdown around the trach stoma is a great risk - this is a highly valued assessment from nursing staff. Goal is to keep stoma as dry as possible. Looking for: Redness, irritation, openings in the skin Supplies: Drain sponge, marathon skin barrier, barrier prep (ie. Cavalon) Call in back-up: specialized wound care nurses (ie. consult WOC at SCH)

The physician's prescriptions indicate an increase in the suction to -20 cm for a patient with a chest tube. To implement this, the nurse performs which intervention?

Stops the suction, adds sterile water to the level of -20 cm in the water seal chamber, and resumes the wall suction.

Which changes on a patient's electrocardiogram (ECG) reflect hyperkalemia?

Tall peaked T waves

The nurse is assessing the patient with a risk for hypocalcemia. What is the correct technique to test for Chvostek's sign?

Tap the patient's face just below and in front of the ear to trigger facial twitching of one side of the mouth, nose, and cheek.

The client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response

The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism.

Bubbling in the water seal chamber of a chest drain indicates

an air leak

A client who was involved in a motor vehicle collision sustained multiple internal organ injuries, and thoracic surgery was performed

The nurse should palpate the area around a chest tube insertion site for the presence of a crackling sensation felt beneath the fingertips, indicating that air is trapped in the tissues.

The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient?

The patient is encouraged to cough and do deep-breathing exercises frequently.

Upon observation of a chest tube setup, the nurse reports to the provider that there is a leak in the chest tube and system. How has the nurse identified this problem?

There was onset of continuous vigorous bubbling in the water seal chamber.

A client is admitted to the surgical unit from the postanesthetia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client?

Use normal saline to irrigate the tube.

A patient's potassium level is low. What change in the cardiovascular system does the nurse expect to see related to hypokalemia?

Weak, thready pulse

Vascular irritation, pain at insertion site:

may need to dilute more, or give slower. (assuming site w/out phlebitis).

Fenestrated vs nonfenstrated

not getting into the details - but fenestrated has an extra opening at the top of the tube, in order to pass more air through the nasopharynx and clear secretions/talk more effectively

The nurse knows that when a patient with a chest tube is on "water seal"

the chest tube system has been disconnected from the wall suction

The fluctuation of the water level in the small arm of the water seal chamber with respirations is called

tidaling

On a chest drainage system, the "air leak" monitor is located in the:

water seal chamber

Inspiration

¨Intrapleural pressure: 8-10 cm H2O below atmospheric pressure during

Medication Administration NG tube

■Verify medication can be crushed; request liquid if available -Notify pharmacy of need to administer via NG tube ■Gather supplies: -Pill crusher -60 mL catheter tip syringe -Chux or towel -8-10 ounces room temperature water -Stethoscope -Tape

Central Venous Catheter

+Flexible catheter placed into a client's central veins through the subclavian or the internal or external jugular veins. The tip ends up in the Superior Vena Cava. +Number of lumens vary - often 3 +Xray is needed after insertion to verify placement. +Sterile insertion is done by a physician +Short term placement

Flushing Central Lines

+Flush each lumen of a CVC with 100 units (100 units/ml) of heparin to maintain patency +Flush PICC lines with normal saline - 10 cc (check orders) ---Groshong - valved catheter that prevents backflow of blood into catheter lumen, saline used for irrigation ---Non-groshong - catheter without a valve, saline and heparin used for irrigation +Use 10cc or larger syringe for flushing

PICC Line Measurements

+Circumference of the upper arm measured daily. Compare measurement to baseline taken immediately after insertion +Measure catheter length from insertion site daily. Compare to baseline

Triple Lumen CVP Line

+Proximal Lumen (farthest from heart) ---Drawing blood samples ---Medications ---Blood administration +Middle Lumen ---Total Parenteral Nutrition (TPN) ---Medications +Distal Lumen (closest to heart) ---CVP monitoring ---Blood administration ---High volume fluids ---Colloids ---Medications

Tension Pneumothorax

-Air enters pleural space and cannot escape -Results in buildup of positive pressure quickly -Lung becomes collapsed and pressure is transmitted to mediastinum -Mediastinum is "shifted" away from affected side, thus compressing large vessels of the heart -Venous return is reduced, leading to decreased cardiac output - drop in BP -LIFE THREATENING

Hemothorax

-Blood in the pleural space -Trauma, anticoag therapy -Flail chest- 3 or more broken ribs in 2 or more places- free floating section: Paradoxical chest wall movement Stabilize flail segment

Disposable Chest Drainage Device

-Collection chamber- collects drainage -Water seal chamber- low resistance one-way valve (allows air to leave chest but prevents atmospheric air from being pulled into chest) -Suction chamber- provides suction to inflate lung and pull fluid/air from pleural space: Wet and dry suction

Drainage Chamber - care/assessment

-Drain air or fluid from pleural cavity -Monitor chest tube every hour for 1st 24 hours and then every 2 hours -Assess color, amount, and consistency of drainage -Mark drainage level according to facility policy -Be aware of changes and when to notify provider

Water Seal Chamber

-Fill to 2cm water level -Fluid may fluctuate with inspiration and expiration: ----Tidaling -------Absence of tidaling indicates a change- need to assess -Constant bubbling à air leak!

Administering an IV push Med

1. Checked medication order and assessed client allergies. Prepared medication (review 7 rights) and brought materials to bedside. 2. Checked client identity, assessed IV site 3. Administered medication through existing IV line. ---With alcohol swab, wiped IV additive port of primary line nearest to client.(Scrubbed the hub) ---Injected medication at manufacturer's recommended rate, using watch with second hand to time the injection. Assessed patient's response during drug administration. ---Removed syringe, and assessed client tolerance of medication. ---If IV push medication is NOT compatible with running IV fluid, put IV pump on HOLD, scrubbed the hub of the port closest to the patient, flushed port with 10 ml saline, administered IV push medication slowly, and then flushed with another 10 ml of saline very slowly. 4. Administered medication through an intermittent infusion device (Saline Lock) a. Obtained two 3 ml normal saline syringes b. Scrubbed hub of intermittent infusion device with alcohol swab. c. Inserted 3 mls normal saline into hub and injected saline slowly monitoring site for infiltration. Removed syringe. d. Scrubbed hub again with alcohol swab. Inserted syringe with medication into hub and injected at manufacturer's recommended rate. Used watch with second hand to ensure accurate timing. Assessed site and patient during injection. e. Scrubbed hub again with alcohol swab.Inserted second normal saline flush syringe into port and injected slowly at same rate as medication was injected. Withdrew syringe and correctly disposed of all supplies. 5. Document

The nurse is reviewing the laboratory calcium level results for a patient. Which value indicatesmild hypocalcemia?

8.0 mg/dL

Pleural Effusion

Accumulation of fluid within pleural space compressing the lung S/S: SOB, tachypnea, decreased O2 stats, absence of lung sounds on affected side, Crepitus present, lack of movement on affected

17. The nurse is reviewing orders for several patients who have risk for fluid volume excess. For which patient condition does the nurse question an order for diuretics?

End-stage renal disease

The nurse assessing a patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs, and increasing peripheral edema. What fluid disorder do these findings reflect?

Fluid volume excess

An older adult patient at risk for fluid and electrolyte problems is vigilantly monitored by the nurse for the first indication of a fluid balance problem. What is this indication?

Mental status changes

Nursing Care: Providing Humidification

Most common inpatient: • Ambient or cold water humidification • Heat and moisture exchangers (unit specific) •Stoma protectors(closer to discharge

Which serum laboratory value does the nurse expect to see in the patient with hypokalemia?

Potassium less than 3.5 mEq/L

Passy Muir Valve

Speaking Valve -Client must be able to control secretions before deflation of cuff and speaking valve attempted -Placed on the hub or end of a tracheostomy tube to allow air to enter on inspiration -Air is directed around the tube and out the upper airway, through the vocal cords upon expiration, allowing speech -May assist with swallowing

PICC - Peripherally Inserted Central Venous Catheter

Special type of non-tunneled central venous catheter that is less invasive than a CVC Placement falls within the realm of nursing PICCs are placed into the client's basilic or cephalic vein Placed 3 inches above or below the antecubital fossa and advanced so the tip ends in the SVC (20 in or 60 cm on length) Xray is necessary to confirm placement Can be left in for up to a year

Tracheostomy:

The actual opening (stoma) resulting from a tracheotomy Can be temporary or permanent

The patient's potassium level is 2.5 mEq/L. Which clinical findings does the nurse expect to see when assessing this patient? (Select all that apply.)

a. General skeletal muscle weakness c. Lethargy e. Weak hand grasps

Which findings indicate that a patient may have hypervolemia? (Select all that apply.)

a. Increased, bounding pulse b. Jugular venous distention d. Presence of crackles f. Elevated blood pressure h. Skin pale and cool to touch

Which assessment findings are related to prolonged hypercalcemia? (Select all that apply.)

a. Prolonged bradycardia e. Shortened QT interval f. Impaired blood flow g. Profound muscle weakness

Nurse can clamp a chest tube when:

a. when the collection chamber is full and must be changed b. when the physician has ordered that the tube be clamped to "wean" the patient from the chest tube c. when attempting to locate an air leak

closed pneumothorax

air enters the pleural space through a rupture of the lung and visceral pleura (lung biopsy, thoracentesis, swan-ganz cath, endotrachial intubation

open pneumothorax

air in the pleural cavity - gun shot wound, stabbing, impalement, thoracic surgery

Which potassium levels are within normal limits? (Select all that apply.)

b. 3.5 mmol/L c. 4.5 mmol/L d. 5.0 mmol/L

The electrolyte magnesium is responsible for which functions? (Select all that apply.)

b. Carbohydrate metabolism c. Contraction of skeletal muscle e. Formation of ATP

Which foods will the nurse instruct a patient with kidney disease and hyperkalemia to avoid? (Select all that apply.)

b. Dried beans c. Potatoes e. Cantaloupe

The nurse is caring for an older adult patient whose serum sodium level is 150 mEq/L. The nurse assesses the patient for which common manifestations associated with this sodium level? (Select all that apply.)

b. Increased pulse rate e. Muscle weakness

A patient with hypokalemia is likely to have which conditions? (Select all that apply.)

b. Metabolic alkalosis c. Chronic obstructive pulmonary disease e. Paralytic ileus

A patient has an elevated potassium level. Which assessment findings are associated with hyperkalemia? (Select all that apply.)

b. Numbness in hands, feet, and around the mouth c. Frequent, explosive diarrhea stools d. Irregular heart rate and hypotension

Rapid onset of action:

don't have much (or any) time to reverse the effects, and can't call it back (like syrup of ipecac, gastric lavage w/ po)

chest tube indications

drain fluid or air from pleural space reinflate collapsed or partially collapsed lung Integrity of pleural space is compromised - loss of intrapleural pressure-air/fluid enter pleural space. -Surgery -Injuries (pneumothorax/hemothorax) Infection (empyema)

The physician has ordered that a patient's chest tube be set at 15 cm of suction. To achieve this level of suction using a chest tube system with "wet" suction control, the nurse knows s/he should:

fill the suction-control chamber with sterile water to a level of 15 cm H20

Tracheotomy

is the surgical procedure that creates an opening in the cervical trachea. It is rarely done as an emergency because oral or nasal intubation or cricothyrotomy is much faster and less complicated when managing respiratory arrest.

The nurse is caring for a patient with a chest tube. The nurse knows that generally the chest tube should never be clamped; however, the nurse also knows that s/he may clamp the chest drainage tubing in all but which of the following circumstances:

when collecting a specimen from the drainage tubing

How does chest tube work

¨Thin film of serous lubricating fluid ¨Allows pleural membranes to adhere to one another and allows for them to slide across each other during breathing ¨Intrapleural pressure is always negative compared to atmospheric pressure (-8 cm H2O during inspiration and -4 cm H2O during expiration) ¨The negative pressure allows for the lungs to stay expanded (keeps lungs sucked against chest wall) ¨When the intrapleural pressure is altered, the lung collapses

Risks

• Reactions to medication and anesthesia • Uncontrollable bleeding • Respiratory problems • Possibility of cardiac arrest

Tracheotomy indications

• To bypass an obstruction ---Blockage of the airway by a tumor, foreign object, soft tissue swelling or collapse of throat structure • To maintain an open airway • To remove secretions more easily • To oxygenate and/or provide mechanical ventilation on a long-term basis ●Severe throat, neck or mouth injuries ie. trauma patients involving the neck ●Control of pulmonary secretions ie. advanced cerebral palsy, cystic fibrosis ●Prolonged intubation/need for mechanical ventilation ●Post-operatively for certain surgeries of the neck ie. neck dissections for cancer

Additional Steps Prior to Giving an IV Push Medication

•Assessment of the IV site •Compatibility with fluids running •Allergies •Rate of administration - how fast to push it •Need to be diluted? •Reassessment of patient after administration of medication

Metoclopramide (Reglan) 10 mg IV push every 6 hours

•Dilution: •May be given undiluted if dose does not exceed 10 mg. For doses >10 mg dilute in at least 50 mL of D5W, NS, ..., and give as an infusion. •Rate of Administration: •Too rapid IV injection will cause intense anxiety, restlessness, and then drowsiness. •IV injection: 10 mg or fraction thereof over 2 minutes. •Infusion: Administer over a minimum of 15 minutes.

Indications:

•Rapid onset •Improved serum drug concentrations •Able to administer when NPO •IM route is painful •Some drugs can only be given IV •"Loading dose"

Prior to Giving an IV Push Med

•Review 11 patient rights •Know generic and brand name of drug •Know classification of drug •Why is pt getting drug - expected effects •Is this an appropriate dose? •Patient teaching •Onset & duration of action •Must look at watch seconds and patient's face

IV Push Med Through a Peripheral Saline Lock

•Saline (monitor IV site while giving) •Administer medication slowly •Saline slowly (medication still in catheter)

Speed shock

•a systemic reaction to a substance rapidly injected into the bloodstream. •Headache, syncope, flushed face, chest tightness, irregular pulse, shock. •Best tx: PREVENTION

Prepare for placement continued

■Apply water soluble lubricant to last 2-3 inches of NG tube ■Instruct patient you are about to begin; -Patients often feel some discomfort and may gag during tube insertion -Reassure them the gag reflex will diminish once tip is past pharynx -Patient should begin drinking water and swallowing when instructed as this facilitates tube passage past the pharynx and gag stimulation point ■Do not begin insertion until patient agrees to proceed ■Consider having a sign or signal if they need to abort or pause procedure; NG tube insertion can be frightening for some

Maintenance & Monitoring

■Assess for therapeutic effect: -Gastric content type, color, amount; any bleeding -Improved abdominal distention, no vomiting/nausea -Signs of bowel motility: flatus, stool, bowel sounds ■Assess exposed tube length; compare with baseline ■Salem sump NG tubes have a blue "pigtail", which is an air vent -DO NOT use pigtail for irrigation or medication administration -If contents leak from pigtail, attach an anti-reflux valve and ensure pigtail is above the level of the stomach ■Maintain head of bed at 30 degrees to prevent enteral nutrition aspiration if receiving nutrition ■Most common therapy is Low Intermittent Suction (LIS) -Suction unit will have a "LIS" setting and cycles suction on/off; pressure ranges from 80-100 mmHg

Prepare Supplies

■Determine type and size of NG tube needed -Enteral feeding typically requires a smaller, more flexible tube (Dubhoff, Keofeed), #8-12 -Gastric decompression or lavage typically requires larger, less flexible tube (Salem or Levin sump), #14-18 ■Necessary for maintaining adequate suction and ability to flush with water or saline ■Larger bore #18 tubes often necessary: -Cardiopulmonary arrest/trauma resuscitation with unknown gastric contents; undigested food will obstruct smaller bore tubes -GI bleeding; clots will obstruct smaller tubes -Cancer history; may have more tenacious secretions that can obstruct smaller bore tubes ■Select the smallest size tube given the therapeutic purpose* *Large tubes are more uncomfortable, but so is having to remove then reinsert a larger bore NG due to under sizing the initial tube

Nasogastric tube indications:

■Gastric decompression; abdomen often distended, vomiting, pain ■Gastrointestinal rest, typically post-operative (bowel resection) ■Monitor bleeding (upper GI bleed) - less common ■Post-operative healing promotion; minimize tension on suture lines in upper GI tract (bariatric surgery, gastrectomy, esophageal resection, etc) ■Gastric lavage - e.g. stomach pumping in cases of overdose, poison ingestion ■Enteral nutrition

NG Insertion

■Hold NG tube so curve follows anatomical curve of nasopharyngeal cavity ■Have patient tilt nose slightly upward ("sniff" position) to allow for visualization of the nare ■Slowly but steadily guide the tip into the nare, with a slight downward angle -Do not force insertion; if resistance is met, slightly rotate the tube and adjust the angle ■Once tube reaches the oropharynx, instruct patient to flex head toward chest and begin swallowing water -If oral intake is contraindicated, patient may dry swallow -STOP insertion if strong cough or cyanosis noted; pull tube back until normal breathing resumes and repeat insertion procedure when ready ■Continue to advance tube toward stomach until desired length is inserted ■Note presence of immediate gastric contents being expelled from tube (bowel obstruction)

NG Removal

■Instruct patient to hold their breath ■Steadily and swiftly withdraw tube in one motion (5-10 seconds) ■Inspect tube for intactness ■Provide oral and nasal care ■Inspect nare, pharynx, top of nose for irritation or breakdown ■Remove adhesive residue from nose ■Document removal

Placement Considerations

■May be inserted intraoperatively/during procedure; at bedside; under fluoroscopy -Bedside appropriate: ■Awake, alert, able to reliably follow directions, cooperative -Consider fluoroscopy: ■Lethargic, diminished gag reflex, uncooperative, combative ■Esophageal stricture or varices (chronic alcoholism, hepatic disease) ■History of upper GI or ENT/neck surgery: -Bariatric surgery -Nissen fundoplication -Gastrectomy -Nasal surgery -Head/neck malignancies

Securement

■Note tube insertion length, document as indicated ■Secure tube to nose -Tape with "split ends" or securement device (may depend on anticipated length of therapy) -Do not secure tube so that it maintains direct contact/pressure with side of nare -Add a tape tab to exposed tubing and secure the tab to patient's gown with safety pin; educate patient about importance of tube securement ■Connect to suction if ordered; most common is low intermittent suction setting

Placement

■Once desired length has been inserted, have patient open mouth and visually inspect oropharynx to ensure tube has not coiled or done a "U-turn" ■Verify tube placement is in the stomach: -Aspiration of gastric contents: ■Inject 30 mLs of air using 60 mL syringe and withdraw gastric contents ■Test pH of aspirate -Gastric content pH <5 (note: some medications may affect pH) -Pulmonary secretions >6 -Radiographic confirmation (abdominal x-ray)

Prepare for Placement

■Prepare supplies at bedside, within easy reach; water in or near patient's hand ■Reiterate procedure with patient ■Ensure suction set-up correct and in working order ■Position patient in high Fowler's position; must be at a 45 degree angle at minimum ■Determine length of NG tube to be inserted: -Measure tube length from tip of nose to lower earlobe tragus, and then on to xyphoid process -Mark tube with tape and/or marker once tube insertion length determined

NG Removal

■Provider order needed to remove NG tube ■Explain procedure to patient ■Place towel or chux across patient's chest ■Place patient in semi-Fowler's ■Don clean gloves ■Remove suction ■Unpin exposed tube from patient's gown and remove securement device/tape from nose

Supplies

■Water soluble lubricant ■Clean gloves ■pH test strips for gastric content aspirate testing ■Emesis basin (I prefer tubs for some patients) ■Catheter-tip 60 mL syringe ■Securement device or prepared tape ■Safety pin ■Tape ■Suction canister, head, and tubing ■Towel ■Glass of water with straw

Nursing Assessment

●Maintain clean and patent trach site ●Manage secretions ●Monitor lung sounds as well as continuous pulse oximetry ●Control pain ●Watch for subcutaneous emphysema (crepitus) Respiratory secretions will often temporarily increase in your patient after a tracheostomy. Observe for signs and symptoms of impaired gas exchange that can be created by mucus plugs. Encourage your patient to breathe deep and cough. Ensure adequate humidification and fluid intake to keep secretions thinned. A small amount of bleeding from the stoma is expected for a few days after a tracheostomy but constant oozing is abnormal and requires intervention. A blood vessel may need surgical litigation or the patient's physician may direct you to pack the wound around the tube to stop the bleeding. Slight inflammation commonly occurs at the surgical site too. There may also be redness, pain, and a small amount of drainage. Lower respiratory infection requires more frequent assessment and most likely antibiotic intervention. Air sometimes escapes into the tracheostomy incision creating subcutaneous emphysema around the stoma. This is generally of no clinical consequence but can be palpated around the stoma site. Excessive manipulation of the trach tube during coughing and suctioning can break improperly secured ties and dislodge the tube. Within the first 48 hours the freshly created stoma has a potential to close shut, constituting a medical emergency. To minimize this risk, trach ties are not usually changed for 24 hours. The first tube change is generally done by a physician after approximately one week. Each organization will have emergency policies and procedures to follow in the case of a dislodged fresh tracheostomy tube.

Keys to success

●Observe quality of secretions (consistency) as well as keeping humidification over the trach site ●Assess for the need to suction every 2 hours - ensure patent airway ●Assess the need to change inner cannula every 4-8 hours and PRN ●Ensure that the appropriate emergency trach supplies are ALWAYS with the patient ●Ensure you have enough supplies for cannula changes, as well as suction catheters and drain sponges ●Keep trach secure with trach ties, change those out every 24 hours and PRN Keep secretions thin and easy to expel/cough up -- encourage the patient to cough and deep breath as well as suction around the trach stoma

Indications for suctioning

●Rapid, shallow breathing ●Adventitious lung sounds (ie. crackles, coarse, congested) ●Decreased SPO2 levels (ie. <90%) ●Restlessness and agitation ●Copious secretions; moist cough

Decannulation (EMERGENT)

●Trach tube gets coughed out ●Patient has a mucus plug ●Patient is confused (or not) and pulls the trach tube out

Patient education/anxiety

●Use a calm demeanor and voice when talking with patient and providing them with education ●Provide options to the patient and allow them to take steps toward self care at their own pace ○(ie. looking at trach, suctioning self, and changing inner cannula per self) ●Include family/care takers in the ADL's with the patient to prepare them for transition to home ●Monitor patient's vital signs as well as objective signs of anxiety ○Be open with your patient about anxiety and what we can do to help resolve it ●Be sure call light within reach ●Provide writing board/paper/pen ●Set realistic goals, start small ●Provide encouragement and positive reinforcement