PC2 [Exam 1] Enteral Feeding(NG tubes), Oxygenation, Urinary w/Latex
Additional teaching is required when the nurse evaluations the administration of the intermittent tube feeling by the family caregiver? A. Begins the feeding before checking tube placement B. Keeps open formula refrigerated between feedings C. Irrigates the tube w/30mL of water before & after feedings D. Keeps the feeding tube capped between feedings
A
Q: Which intervention is most appropriate for a client with functional urinary incontinence? A. Provide normal fluids intake & establish a toilet schedule B. Increase fluid intake to "flush" the kidneys C. Restrict fluid intake to decreased the episodes of incontinence D. Insert an indwelling catheter
A
Define atelectasis and list nursing interventions to prevent and treat.
- condition where lungs collapse partially or completely, could be one single lung or both lungs. Interventions:
Explain the purpose and procedure for IS use (covered in Chapter 50 in more depth)
1 Q r/t objective 9
Urinary retention P P
1103, 1110t, post op 1291t, 1292t
Describe the steps of inserting an indwelling or in and out catheter. note steps from procedure in Potter and Perry and note differences for males and females. Pay particular attention to clinical decisions
1.Perform hand hygiene 2. Provide privacy: close room door and bedside curtain 3. Raise bed to appropriate working height. If side rails in use, raise side rail on opposite side of bed and lower side rail on working side 4. Place waterproof pad under patient 5. Provide perineal hygiene if needed (apply clean gloves, complete cleansing, discard gloves and perform hand hygiene) 6. Position and drape patient a.Female patient: help to dorsal recumbent position. Ask patient to relax thighs to externally rotate hip joints. Alternate female position: position side-lying position with upper leg flexed at knee and hip. Ensure that rectal area is covered with drape. support patient with pillows b. Male: position supine with legs extended and thighs slightly abducted. c. drape pt Position light to illuminate genitals or have assistant available to hold light source to visualize urinary meatus 8. Perform hand hygiene 9. Open catheterization kit, place opened on bedside table or between patient's legs. 10. Open sterile wrap covering box using sterile techniques Indwelling catheter open system. Open separate package containing drainage bag, check to make sure that clamp on drainage port is closed, and place drainage bag and tubing easily accessible. Open outer package of sterile catheter, maintaining sterility of inner wrapper Indwelling catheter closed systems: all supplies are in sterile tray. Once sterile gloves put on, check clamp on drainage bag to make sure it's closed. 11. Apply sterile gloves. Drape perineum, keeping gloves and working surface of drape sterile. 12. Arrange supplies on sterile field, maintaining sterility of gloves. Place sterile tray with cleaning medium on sterile drape. 13. Cleanse urethral meatus a. Female patient Ø Gently separate labia with fingers of nondominant hand to expose meatus Maintain position of nondominant hand throughout remainder of procedure Ø Use forceps to hold one cotton ball or hold one swab stick at a time. Clean labia and meatus from clitoris toward anus. Use new cotton ball or swab for each area you cleanse. Cleanse by wiping far labial fold and directly over center of urethral meatus b. Male patient Ø With dominant hand retract foreskin and gently grasp penis at shaft just below glans. Hold shaft of penis at right angle to body. This hand remains in this position for remainder procedure. Ø With uncontaminated dominant hand cleanse meatus with cotton balls/ swab sticks, using circular strokes, beginning at meatus and working outward in spiral motion. Repeat three times using clean cotton ball/stick each time. 14. Pick up and hold catheter 7.5 to 10 cm (3 to 4 inches) from catheter tip wit catheter loosely coiled in palm of hand. If catheter is not attached to drainage bag, make sure to position urine tray so end of catheter can be placed there once insertion begins. 15. Insert catheter: a. Female: ask patient to bear down gently and slowly insert catheter through urethral meatus. Advance catheter total 2 to 3 inches in adult or until urine flow out end of catheter. Release labia but maintain hold on catheter b. Male: gently apply upward traction to penis as it is held in 90 degree angle from body, ask patient to bear down as if to void and slowly insert catheter through urethral meatus, advance catheter 7 to 9 inches or until urine flows out end of catheter 16. Allow bladder to empty fully unless institution policy restricts maximum volume of urine drained 17. Collect urine specimen as needed by holding end of catheter over cup. Fill to desired level, label and bag specimen 18. Straight/intermittent catheterization. When urine flow stops, withdraw catheter slowly and smoothly until removed. 19. Indwelling catheterization: inflate catheter balloon. 20. Secure catheter with catheter securement device at catheter bifurcation. Allow enough slack to allow leg movement and avoid traction on catheter 21. Clip drainage tubing to edge of mattress. Position drainage bag lower than bladder by attaching to bedframe. NOT to side rails of bed 22. Check to make sure that there is no obstruction to urine flow, coil excess tubing on bed and fasten to bottom sheet with clip or other securement device. 23. Provide hygiene as needed. Help patient to comfortable position 24. Dispose of used equipment in appropriate receptacles 25. Label specimen container correctly for culture with patient present, place in biohazard container, and send to lab with completed requisition 26. Measure urine and record 27. Remove gloves and perform hand hygiene 28. Remove indwelling foley catheter Ø Review medical order for removal of catheter. Perform hand hygiene, put on clean gloves, and provide privacy Ø Prepare the patient: provide an explanation of procedure, position patient with waterproof pad under buttocks and cover with bath blanket, exposing only genital area and catheter. Position females in dorsal recumbent position and male patients in supine position, remove catheter securement device and free drainage tubing Ø If needed, provide hygiene of genital area with soap and water Ø Move syringe plunger up and down to loosen and then withdraw plunger to 0.5 mL. insert hub of syringe into inflation valve. Allow balloon fluid to drain into syringe by gravity. Make sure that the entire amount of fluid is removed by comparing removed amount to volume needed for inflation Ø Pull catheter out smoothly and slowly. Examine it to ensure that it is whole. Catheter should slide out easily. Do not force. If you not any resistance, repeat previous step to remove remaining water. Notify health care provider if balloon does not deflate completely. Ø Wrap contaminated catheter in waterproof pad. Unhook collection bag and drainage tubing from bed Ø Reposition patient as necessary. Provide hygiene as needed. Lower level of bed and position side rails accordingly Ø Empty, measure and record urine present in drainage bag, discard in appropriate receptacle, remove and discard gloves, perform hand hygiene. Ø Encourage patient to maintain or increase fluid intake Ø Initiate voiding record or bladder diary. Instruct patient to report when urge to void occurs and that all urine needs to be measured, make sure that patient understands how to use collection container Ø Ensure easy access to toilet, commode, bedpan, or urinal. Place urine hat on toilet seat if patient is using toilet. Place call bell within easy reach
A client reports during sensation & pain while passing urine, as well as fever & chills. What should the nurse include in this assessment? A. Ask if other family members are sick B. Look for presence of blood in urine C. Assess for a history of hypertension D. Determine height & weight
B
Describe the uses and advantages of different types of tubes including NG tubes, g-tubes, J-tubes, small bore feeding tubes.
NG tube: A: D: G tube: A: D: J tube A: D: Small bore feeding tubes: PAGE 636-637 ADMINISTERING MEDS THROUGH THE TUBES (CHART)
Describe the steps of inserting and removing an NG tube.
Position pt in HIGH FOWLERS w/ pillows behind head and shoulders. Raise bed to horizontal level comfortable for nurse b. HAVE PT BLOW NOSE. Bath towel over pt chest. Give pt facial tissue. Place emesis basin w/n reach c. Pull curtain or close door d. Stand on pt's right side if rt handed, left side if left handed e. Hand hygiene/gloves f. Instruct pt to relax and breathe normally while occluding one nare. Repeat for other nare. Select nostril w/ greater air flow g. Measure distance to insert tube: -Traditional method: measure distance from tip of nose to earlobe to xiphoid process *Hanson method: mark 20 inch point on tube and measure traditionally. Tube insertion is at midway point between 20 in and traditional mark h. Mark length of tube to be inserted by placing small piece of tape so it can be removed easily i. Curve 10-15 cm (4-6 inches) of end of tube tightly around index finger and release j. Lubricate 3-4 inches of end of tube with water soluble lubricating jelly k. Initially instruct pt to extend neck back against pillow; insert tube gently and slowly through naris, aiming end of tube downward l. Cont to pass tube along floor of nasal passage, aiming downward toward pt's ear. If resistance is met, apply gentle pressure to advance tube. Don't force m. If you meet resistance, rotate tube and see if it advances. If still resistant, withdraw tube, allow pt to rest, relubricate, and insert tube into other naris n. Continue inserting tube until just past nasopharynx by gently rotating it toward opposite nostril and passing it just above oropharynx. -Stop tube advancement, allow pt to relax, and provide tissues -Explain to pt that next step requires that he or she swallow. Give pt glass of water unless contraindicated. (CLINICAL DECISION: IF UNABLE TO INSERT TUBE IN EITHER NARIS, STOP PROCEDURE AND NOTIFY HCP) o. With tube just above oropharynx, instruct pt to flex head forward, take small sip water, and swallow. Advance tube 1-2 inches with each swallow of water. If pt is not allowed fluids, instruct to dry swallow or suck air through straw. p. If pt begins to cough, gag or choke, w/draw tube slightly (don't remove it) and stop advancement. Instruct pt to breathe easily and take sips of water (CLINICAL DECISION: IF VOMITING OCCURS, HELP PT CLEAR AIRWAY; USE ORAL SUCTIONING IF NEEDED. DO NOT PROCEED UNTIL AIRWAY IS CLEARED) q. If pt cont to gag and cough/complain tube feels it is coiing back of throat, check back of oropharynx w/ tongue blade. If tube has coiled, w/draw it until tip is back in oropharyns. Reinsert w/pt swallowing After pt relaxes, cont to advance tube w/ swallowing until tape or mark is reached . temporarily anchor tube to pts cheek w/ piece of tape until tube placement is verified. s. Verify tube placement. Check agency policy for preferred methods for checking NG tube placement. 1. Inspect posterior pharynx for presence of coiled tube 2. Attach asepto or cath-tipped syringe to end of tube and aspirate gently back on syringe to obtain gastric contents, observing color 3. Measure pH of aspirate with color coded pH paper w/ range of whole numbers from 1.0-11.0 or greater 4. Hae ordered xray film exam performed of chest/abdomen 5. If tube not in stomach, advance another 1-2 inches and repeat S steps to check tube positioning t. Anchoring tube: 1. After tube is properly inserted and positioned, either clamp end or connect it to drainage bag or suction source 2. Tape tube to nose, avoiding putting pressure on nares Ø Apply small amt of tincture of benzoin to lower end of nose and allow to dry -Apply tape to nose, leaving split ends free. Be sure top end tape over nose is secure -Carefully wrap two split ends of tape around tube -Alternative: apply tube fixation device using shaped adhesive patch 2. fasten end of NG tube to pt gown by looping rubber band around tube in slipknot. Pin rubber band to gown u. unless hcp orders otherwise, elecate head of bed 30 degrees. v. Once placement is confirmed: Place red mark on tube to indicate where it exits nose -Measure tube length from nares to connector as alt method -Document tube length in pt record w. Remove gloves/ hand hygiene x. Tube irrigation: -Hand hygiene/ gloves -Check for tube placement in stomach. Reconnect NG tube to connecting tube -Draw up 30 mL normal saline into Asepto or catheter-tipped syringe. -Clamp NG tube. Disconnect from connection tubing and lay end of connection tubing on towel. -Insert tip of irrigating syringe into end of NG tube. Remove clamp. Hold syringe w. tip pointed at floor and inject saline slowly and evenly. Dont force solution -If resistance, check for kinks in tube. Turn pt onto left side. Report repeated resistance to hcp -After instilling saline, immediately aspirate or pull back slowly on syringe to w/draw fluid. If amt aspirated is greater than amt instilled, record difference as output. If amt aspirated is less than amt instilled, record difference as intake. -Reconnect NG tube to drainage or suction. -Remove gloves. Hand hygiene.
Discuss the procedure for a closed urinary catheter irrigation and for CBI (Continuous Bladder irrigation)
A closed system catheter is a self-contained pre-lubricated catheter housed within its own collection bag. Closed catheter irrigation: (cant delegate this task to assistive personnel) 1. Review pt's record a. Purpose of bladder irrigation. Confer w/ hcp as needed b. Prescriber's order for method (continuous vs. intermittent), type and amt of irrigation c. Type of catheter used 2. ID pt using 2 identifiers (name/DOB, name/MR#) 3. Assess pt: a. Hand hygiene and gloves b. Inspect urine for color, amts, and clarity and presence of mucus, blood clots or sediment c. Palpate bladder for distention and tenderness d. Observe pt for ab pain, spasms, sensation of bladder fullness or cath bypassing (leaking) 4. Review input and I&O record 5. Remove gloves 6. Assess pts knowledge and experience about irrigation IMPLEMENTATION: 1. HAND HYGIENE 2. PROVIDE PRIVACY (DOORS, CURTAINS) 3. RAISE BED TO APPROP WKN HEIGHT, LOWER SIDE RAILS ON WORKING SIDE, RAISE ON NON WORKING SIDE. 4. Position pt in DORSAL RECUMBENT or SUPINE POSITION & EXPOSE CATHETER JUNCTIONS. 5. REMOVE CATHETER SECUREMENT DEVICE 6. ORGANIZE SUPPLIES ACCORDING TO TYPE OF IRRIGATION PRESCRIBED 7. CLOSED INTERMITTENT IRRIGATION OR INSTILLATION WITH DOUBLE LUMEN CATH. (CLINICAL DECISION: Closed intermittent irrigation should be done only in cases in which catheter is occluded and health care provider deems that removal of cath can injure pt) a. Draw up in syringe prescribed amt of med or sterile solution. Place sterile cap on tip of needle syringe b. Clamp indwelling retention cath just below specimen port c. Using circular motion, thoroughly clean injection port with antiseptic swab (same port used for specimen collection). Allow to dry (30 secs) d. Insert tip of needleless syringe with twisting motion into irrigation port e. Slowly and evenly inject fluid into catheter and bladder (CLINICAL DECISION: AVOID IRRIGATING WITH OR INSTILLING COLD SOLUTION BC IT RESULTS IN BLADDER SPASM AND DISCOMFORT) (CLINICAL DECISION: IF CATH DOESN'T IRRIGATE EASLIY, STOP THE IRRIGATION. THE CATH MAY BE TOTALLY OCCLUDED OR THE END OF THE CATH MAY HAVE BEEN DISPLACED INTO THE URETHRA. CONTACT THE PRESCRIBER, THE CATH MAY NEED REMOVED AND REPLACED) f. Withdraw syringe, cleanse port with antiseptic swab, remove clamp, and allow solution to drain into drainage bag. Some medicated irrigants may need to dwell in bladder for a prescribed period of time, requiring cath to be clamped temp. 8. Closed cont irrigation a. Close clamp on tubing and hang bag of solution on IV pole. Insert spike tip of sterile irrigation tubing into designated port of irrigation solution bag using aseptic technique. b. Fill drip chamber half full by squeezing chamber, then open clamp and allow solution to flow (prime) through tubing, keeping end of tubing sterile. Once fluid has completely filled tubing, close clamp and recap end of tubing. c. Use aseptic tech to wipe off irrigation port of triple lumen cath and attach to irrigation tubing d. Be sure that drainage bag and tubing are securely connected to drainage port of triple lumen cath e. Calculate drip rate and adjust rate at roller clamp. If urine is bright red or has clots, increase irrigation rate until drainage appears pink f. Observe for outflow of fluid into drainage bag. Empty catheter drainage bag as needed. g. Compare u.o. w/infusion of irrigation solution ever HR 9. When procedure is completed, disposed of contaminated supplies in appropriate receptacle, replace cath securement device if removed, remove gloves, help pt to safe and comfortable position w bed in low position, and perform hang hygiene.
A client is receiving 35% oxygen via a Venturi mask. What intervention should a nurse perform to ensure that the correct amount of oxygen is delivered to the client?
ANS: Apply mask over clients face to have a tight seal. You must have a tight seal for this mask to fit correctly to get a precise concentration. Venturi mask: air-entrainment mask, is a medical device to deliver a known oxygen concentration to patients on controlled oxygen therapy. **it provides precise concentration of O2 (purpose), moist air, color coded.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min. While in the supine position for a bath, the client complains of shortness of breath. Which is the most appropriate first nursing action? Increase the flow of O2? No - takes away their drive to breath Report to health care provider? No Perform tracheal suctioning? Not related Assist client in semi fowlers - Yes
ANS: Assist client in semi fowlers!! Be less invasive
Your client has been newly diagnosed with emphysema. In discussing this condition with the nurse which of his statements would indicate a need for further education?
ANS: If I get sob ill turn up my O2 level to 6L/min (^Not good; increasing CO2 drives us to breath. Our pt would be resigning CO2 with their condition, their levels are always abnormally high)
Describe the application of the correct oxygen delivery device > n/c, non-rebreather > simple face mask > venturi mask
All O2 therapy is used to prevent or relieve hypoxia Nasal cannula (tubing with 2 prongs) Safe, comfortable, & well tolerated Extended use may lead to skin break down & dry mucous membranes delivers an FiO2 of 24% to 44% at a flow rate of 1-6 L/min Non-rebreather: Covers clients nose & mouth RN must make sure client using nasal cannula during meals delivers an FiO2 of 80%-95% @ a flow rate of 10-15 L/min Simple face mask: -Assists in providing *humidified O2* *delivers an FiO2 of 40%-60% @ a flow rate of 5-8 L/min ...exact FIO2 is difficult to estimate, another disadvantage as that pt inhales room air through the sides of the holes in the mask -covers the client's nose & mouth, comfortable & easy to apply. More comfortable than a nasal cannula. Not good for clients who have anxiety/claustrophobia. You can not eat/drink as it covers mouth. RN must make sure client using nasal cannula during meals & assess proper fit of face mask when on client. Venturi mask: covers client's nose & mouth, **delivers most precise oxygen concentration** Humidification is not required. **delivers an FiO2 of 24%-50% @ a flow rate of 4-12 L/min It is best for client's w/chronic lung disease Controls the amount of specified O2 concentration, delivers humidity with O2 concentration, great b/c it does not dry mucous membranes Negative: interferes with eating & talking, it is hot & confining, if mask fits poorly the specific flow rate which is needed to deliver a specific FIO2 will be decreased.
The Cather slips into the vagina during a straight cauterization of a female client. Which action should the nurse perform? A. leave the catheter in place & ask another nurse to attempt the procedure B . Leave the catheter in place & get a new new sterile catheter C. Remove the catheter, wipe it with a sterile gauze, & redirect it to the urinary meatus D. Remove the catheter & redirect it to the urinary meatus
B
What is an appropriate technique for the nurse to use when inserting a nasogastric (NG) tube? A. Position the client supine B. Advance the tube while the client swallows C. Measure the tube length from nose to sternum D. Apply oil based lubricant
B
A client reports that he is unable to pass urine completely. Even after voiding, the client does not feel that the bladder is empty. What tests can be done to assess the postpaid residual (PVR) in the client? A. Cystoscopy B. X ray of abdomen C. Portable noninvasive bladder ultrasound devide D. Intravenous pyelogram (IVP)
C
Which technique is appropriate for the nurse to implement during nasogastric (NG) tube insertion? A. Advance the tube quickly when the client coughs B. Use sterile gloves C. Have the client mouth breathe D. Bend the client's head backward after the tube is through the nasopharynx
C
A patient with chronic obstructive pulmonary disorder (COPD) is administered oxygen therapy using a simple oxygen face mask. After some time, the patient's blood analysis reveals abnormally high levels of carbon dioxide. Which should be the nurse's immediate next step? A)Remove the mask and apply a new oxygen mask. B)Reset the mask to cover the patient's nose only. C)Remove the mask and use a nasal cannula for oxygen supply. D)Reset the mask to cover the patient's mouth and nose.
C Simple face masks are designed to deliver 6 L/min or more of oxygen. However, in patients with chronic obstructive pulmonary disorder (COPD), this results in hypoventilation. These patients have adapted to a high level of carbon dioxide so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Because the stimulus to breathe is a decreased arterial oxygen level, administration of oxygen greater than 1 to 3 L/min prevents the PaO2 from falling to a level that stimulates the peripheral receptors. This destroys the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide. Additionally, the patient may inhale exhaled carbon dioxide retained in the mask. Therefore, masks are contraindicated in patients with COPD. However, a nasal cannula does not cause rebreathing of exhaled carbon dioxide and allows for safe delivery of lower rates of oxygen. Hence, the nurse should immediately remove the mask and use a nasal cannula for oxygen supply. Applying a new mask or resetting the mask will not improve the patient's condition.
A nurse is teaching a client who has a prescription for a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use fo the nasogastric tube should the nurse include in the teaching? A. Administer medications B.Supply nutrients via tibe feedings C.Determine the pH of the gastric secretions D. Decompress the stomach
D
The nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should the nurse do to definitely ascertain that the tube is in the stomach or intestine? A. Test the pH of the contents B. Lower the head of the bed to 5 degrees C. Utilize a carbon dioxide sensor D. Obtain an order for a chest x-ray
D
Urinary cauterization is performed only when absolutely necessary. Which of the following candidates/situations would not warrant the need for this procedure? A. A client this is completely paralyzed B. A client in need of decompression of the bladder C. A client having abdominal surgery D. To collect a random urine specimen for evaluation
D
Identify risks and complications of enteral feedings.
Displaced tubes, aspiration, and diarrhea are the most common complications of enteral feedings.
Develop a teaching plan for a patient with an indwelling urinary catheter.
First, explain why the catheter is there and how it is inserted and removed. -Explain the steps. -Explain that sometimes people feel as though they are not peeing, but they are. Show them an example catheter and demonstrate how the procedure is done. -Explain how the catheter works -Develop a teaching plan for a patient with an indwelling urinary catheter. -Assess their knowledge -Assess readiness to learn -What do you think they need to know? -Infection prevention? -Purpose of the catheter? -How long will they need it? (This is what they want to know) -How to perform catheter care? -Where does the bag need to hang? (Can they walk around with a bedside drainage bag?
The nurse is caring for a client who has decreased mobility. Which interventions is a simple cost -effective method for reducing the risks of status of pulmonary secretions and decreasing chest wall expansion?
Frequent change of position
Discuss the purpose, how to collect, and transport urine specimens for C & S. (midstream and from indwelling urinary catheter or in and out cath)
If the patient has an indwelling catheter, collect a specimen by using sterile aseptic technique through the special sampling port found on the side of the catheter. Never collect the specimen from the drainage bag. Label specimens with patients name, date, time and type of collection. Most specimens need to reach lab within two hours of collection or preserved according to protocol. Ask patient to double void for clean specimen. Second void is one sent to lab. Purpose is to determine the presence of bacteria and to which antibiotic the bacteria are sensitive to. Clamp tubing below the port, allowing fresh, uncontaminated urine to collect in the tube. After wiping the port with an antimicrobial swab, insert a sterile syringe hub and withdraw at least 3 to 5 mL of urine. Using sterile aseptic technique, transfer the urine to a sterile container. Patients with a urinary diversion need to have the stoma catheterized to obtain an accurate specimen. A preliminary report will be available in 24 hours, but usually 48 to 72 hours are needed for bacterial growth and sensitivity testing
Identify appropriate use for indwelling Foley catheters. P. 1061 Box 45-7
Indwelling urinary catheters are for short or long-periods of time. They are not for one-time use. They can be used for monitoring of urine output before or after surgery, after gynecological or urologic procedures, and when inadequate emptying of the bladder occurs due to neurological conditions or blockage
Recognize altered patterns of breathing (Kussmaul's, Cheyne-Stokes, and apnea) and associated conditions.
Kussmaul's - hyperventilation, deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis Cheyne-Stokes- progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. Apnea- cessation of breath Biots respirations - abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. Orthopnea- shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. It is commonly seen as a late manifestation of heart failure Dyspnea- Uncomfortable sensation or awareness of breathing or needing to breathe. _________________________________________________ Alterations in respiratory rate: Tachypnea (rapid rate) Bradypnea (abnormally slow rate) Apnea (cessation of breathing) Alteration in Volume and Rhythm: Kussmaul's breathing Cheyne-Stokes respirations Biot's respirations Alterations in ease of breathing: Orthopnea Dyspnea
Describe the nurse's role in prevention and response to those complications.
Prevention of displacement: To identify displacement, follow confirmation and verification procedures before using the tube. Nursing measures to reduce the risk of aspiration: -Verifying tube placement, checking gastric residuals, assessing bowel function to confirm peristalsis, and elevating the head of the patient's bed to 30 degrees or more during feeding and at least 1 hour after feeding. -Monitor fluid and electrolyte balance carefully; additional water may be prescribed based on the patient's fluid status. -Providing mouth care is particularly important for patients receiving enteral feedings, as is addressing the psychosocial aspects of care. Management of the feeding tube's site includes routine inspection and implementation of measures to prevent skin breakdown. Apply tincture of benzoin or other skin adhesive on tip of patient's nose and tube. This will help tape adhere better and protect skin. Tubes inserted at the mouth or nares may require frequent rotation to prevent mucosal irritation. Check gastrostomy and jejunostomy tubes daily for signs of infection, pressure from the tube, and drainage of gastric secretions. Maintain vigilant wound care according to the facility's policies and procedures. Document all feeding-tube management procedures.
Identify parts of the urinary catheter and bag.
Refer to images
Describe the steps of administering an enteral feeding intermittent
Steps: 1.Prepare formula & a 60mL syringe 2.Remove the plunger from the syringe 3.Hold the tubing above the instillation site 4.Open the stopcock of the tubing & insert the barrel of the syringe with the end up 5.Fill the syringe with 40-50mL formula 6. If using feeding bag, fill the bag with the total amount of formula for one feeding & hang it to drain via gravity until empty (about 30-45min) 7. If using a syringe. hold it high high enough for the formula to empty gradually via gravity 8.Continue to refill the syringe until the amount for feeding is instilled. Follow with at least 30mL tap water to flush the tube & prevent clogging __________________________________________________________________________ Formula is administered every 4-6 hours in equal portions of 250-400mL to 400mL over a 30-60min time frame usually by gravity drip or an electronic pump. *Resembles normal pattern of nutrient intake *Often for noncritical clients (home tube feeding & clients in rehab)
Describe tracheostomy care and suctioning.
Tracheotomy: sterile surgical incision into trachea through the skin & muscles for the purpose of establishing an airway. This can be an emergency or scheduled procedure, can be temp or permanent (stoma=opening) Trach care: 1. hand hygiene & don PPE 2. raise bed to commutable working height put pt's bed in semi- or fowler's position. **laying flat would put pt @ an increased risk for respiratory distress** 3. increase supplemental o2; know agency protocol for hyper-oxygenation prior to & during the procedure 4. have pulse ox in place *open suction kit, if client can't breath spontaneously then ventilate client's lungs for at least 1 min using a manual resuscitation bag connected to a high flow oxygen source 5. moisten catheter w/sterile water (that was poured into the basin prior) & check suction (no greater than 120 mm of Hg) *don sterile gloves, verify suction source won't go over the 120 mm of Hg. Dip catheter into the basin of sterile salon solution... hold catheter between fingers... 6. Catheter inserted until pt coughs or meat resistance - then pull back about 1/2 - 1 inch 7. Suction intermittently no more than 10-15secs while rotating catheter & withdrawing
Transcribe telephone orders to medication administration record.
Transcribe telephone orders to medication administration record. Guidelines for telephone and verbal orders: clearly determine pts name, room #, and diagnosis; Use clarification questions to avoid misunderstandings; Write TO or VO (if verbal order) including date and time, name of pt, the complete order, sign the name of the physician or healthcare provider and nurse; read back any prescribed orders to the physician or healthcare provider, follow agency policies, some institutions require telephone orders to be reviewed and signed by two nurses *helps to have another nurse listen in on the conversation
Describe technique and rationale for IM injection using Z-Track method 3 acceptable injection sites/procedure and why we use ztrack
Why use z track? Use this technique for all IM injections because it is less painful & it prevents mediation from leaking back into subcutaneous tissue. Appropriate to use for medications that cause visible or permanent skin stains (ex iron preparations) (source: p7 ATI pharm) 3 acceptable injection sites/procedure: 1-Ventrogluteal 1 ½ 2-Deltoid 1-1 ½ 3-Vastus lateralis ⅝ - 1in Each pt is built differently so needle size for vastus lateralis can vary, needle must be long enough to reach muscle of another route will need to be prescribed. *adipose tissue influences needle size selection Very obese pts often require 3 inch needle & very thin may only require ½ to 1inch. IM injection- given at 90 degree angles to break through skin barrier and reach site IM - faster absorption than subQ b/c it has greater vascularity IM - used for influenza & pneumonia shots Procedure: Asses bony landmarks for all. Once area is identified displace skin, using side of non dominant hand [slide skin over] give injection like a dark, slowly administer 10 secs per 1 mL, wait 10 more secs to allow med to be absorbed THEN pull out needle. Displace skin, slide skin over, give injection, wait 10 secs and pull needle out. Have skin moved over to prevent med from seeping out needle hole then release once needle is out. WE CAN'T pull needle out right away, because it will end up on the skin tissue when it is supposed to be absorbed in muscle. Z track prevents medication from leaking out onto SubQ which will cause irritation!
Differentiate between tubes used for decompression and those uses for enteral nutrition
•Gastric DECOMPRESSION-nasogastric tubes •Gastric Decompression-NGT is connected to suction for decompression of stomach contents *Removal of gases or stomach contents to relieve distention, nausea, or vomitting •Indications: bowel obstruction, paralytic ileus, GI surgery FEEDING TUBES - ENTERAL NUTRITION: alternative to oral route to provide nutritional supplements Exs of feeding tubes: •PEG •Jejunal Tubes •Nasogastric-via nose into the stomach or intestine •Levin •Flexiflow •Gastric-inserted surgically directly into the stomach and has a DSD (dry sterile dressing) over insertion site- need for aseptic technique-cleansed with NSS/sterile q-tips and split DSD applied Purpose: •Direct delivery of nutrients into the GI system •Indicated in decreased level of consciousness or who cannot eat •Premature infants with inadequate sucking reflex, lack of strength
