nclex tubes and drains

daily or soiled

how often are trach ties changed

every 4 hours

how often is NG tube checked for proper placement

every 4 hours

how often is jackson pratt drain checked on a wound for suction, drainage

every 2 hours

how often should oral care for ETT tube be done

daily

how often should the ETT tube be moved from one side of mouth to the other and secured

4 hours

how often should we assess breath sounds, spo2, and comfort for chest tube drain system

sterile water

if chest tube system breaks plut chest tube into this contrainer until new system is replaced

it is normal and patent, do nothing

if fluxuation of water in water seal chamber is seen - do this

sterile water

if level is low in suction control chamber add this to fluid system

6 or greater

if pH is this for NG placement it is then in the intestines

cuffed trach

if pt with trach has mechanical ventilation and cannot speak. this type of trach is needed

blocked T-tube

if pt. has jaundice, pale colored stools and absence of drainage shows the T-tube is __

one hour after meal

if pt. wants food orally, must have pt. sit up, inflate cuffed trach and have them sit up __ after meal.

apply occlussive dressing(petroleum gauze, dry gauze and tape)

if tube is pulled out of chest must pinch skin together then ___ then call physician

this proper function of chest tube, monitor

intermittent bubbling with inspiration indicates drainage of air from pleural space (caring for pneumothorax) which means

do not clamp tube

maintain patency with nephrostomy or ureteral tube but never do this to a urinary tube.

humidified O2

patient with trach needs O2 given in this way.

on right side

position pt. after a nasoenteric (intestinal ) tube on this side to facillitate passage into pyloric sphincter.

gentle continuous bubbling

proper function of the suction control chamber will show this

long term use

pt. with cuffless trach and no mechanical ventilation has this type of trach

infection

purulent secretions from trach indicate this

while cleaning port with alcohol

reestablish suction of wound drain after emptying by compressing device then __, cap port then relase pressure

less than 30ml/hr

report this amount of urine output to physician if it is less than __

reinflating lung more quickly

suction control chamber allows suction for negative pressure to drain air, blood, pus so the lungs can do this

while exhales for comfort

tell client to do this respiration before removal of urinary catheter

cough and deep breath

tell the client to do these two procedures after removal of ETT tube.

reduce risk of aspiration

the reason for the NG tube is to decompress stomach, enteral feedings or medications, irrigate stomach or __

less than 4

to test proper placement of tube besides xray, aspirate contents and if pH is this level it correctly in stomach

8 hours

trach care is done every __

fenestrated trach

trach with holes to allow air flow between larynx and trachea, used during weaning, and allow them to speak

heimlich valvle

valve allows air to escape from chest during exhalation but closes during inhalation to preven pneumothorax or tension pneumo.

inhale and exhale (tidaling)

water moves up and down in the water seal chamber to signify

2 cm

water seal chamber has this much water in it and allows air to escape but not re-enter.

nare-earlobe-xyphoid process. place tape to mark end

what are hte three landmark sites to size up NG tube.

collection, water seal, and suction

what are the three compartments of chest tube drain system

dont clamp tube or milk tube

what are two things that are not allowed for nurses to do for a chest tube patient

evaporate water but not increase suction

what does it mean if vigorous bubbling in suction control chamber is heard

air leak

what if continuous bubbling in water seal chamber

tube obstruction, kink - correct it

what if no fluxuation in water seal chamber is seen - what does it mean

higher suction and pleural tissue damage

what if the water level in water seal chamber falls below 2 cm.

stop bleeding esophageal varices

what is the purpose of an esophageal/gastric tube with gastric balloon and esophageal balloon

premedicate

what should be given to client 30 minutes before planned chest tube removal

water seal chamber stops fluxuating, xray shows lung expansion, return baseline resps

what three s/s must be present before chest tube is removed

100 ml/hr of drainage, bright red blood, sudden increase in drainage

what three things need to be reported to physician if these are seen in the chest tube system

lidocaine or water gel not oil based gel

what type of lube is placed on distal end of NG tube before insertion

exhalation

when planned removal of trach, must suction, deflate cuff, and withdraw tube during__ and dry sterile dressing over stoma.

12 inches below chest

where should chest tube system be placed by patient

short term or no respiratory secretions

why would patient have a single lumen trach

common bile duct

T-tube is inserted into this to maintain patency and allow drainage following cholecystectomy until edema decreases

30 minutes

after client has ET tube removed pt. should be monitored for this long, to monitor-rate, spo2, distress.

hold breath

ask pt. to do this respiration prior to removal of NG tube

hyperoxygenate, elevate head and suction

before removal of ETT tube or trach must do these two procedures.

deep breath and hold it

before removing chest tube client is told to do perform this type of respiration prior to removal

negative pressure to intrapleural space

besides draining fluids from chest, the chest tube is to restore __ to intrapleural space

placement confirmed by xray

can not give enteral feedings by NG tube unless placement confirmed by this

every 2

change client position every __ hours and encourage deep breathing and coughing

every 2 hours

check mouth of NG tube placement every __ due to mouth breathing and dryness

atelactasis

collapsed lung aka

atelactasis and pneumonia

cough and deep breath on trach to avoid these two problems

not changed

elastoplast or wide tape must secure dressing of chest tube insertion site but the dressing may not be __

inhale

for ET tube removal, deflate cuff, ask client to __ and at that peak, remove ETT tube.

airway management

gastric lavage is to remove toxins from drug OD or poison but this is priority

10-14 days

how long should an ETT tube stay in trachea