Essentials Exam 3

How do you store oxygen tanks?

In a special holder or lying down on the floor -never let them stand alone just on the ground

Face Tent

- good for claustraphobic patients -8-12L or 28-100% O2 -needs to be humidified -cant monitor delivery as closely, because O2 concentration depends on the depth of the patients breath

Fenestrated Tracheostomy

-allows the patient to talk -does not allow the maximal o2 support -may be difficult to suction

Dangers of Suctioning

-desaturation- a problem if they don't come back up right away after suctioning O2= less than 90 or more than 5% less than their baseline -Hypotension -Hospital Acquired Infection -Bradycardic- more than 20 below normal -Tachycardic- more than 40 bpm over normal -Arrhythmias -Trigger bronchospasm -Stimulate gag reflex -Aspiration -Irritation/bleeding of mucous membranes

What can you do as the nurse if the patient is unable to achieve their target volume on the incentive spirometer?

-encourage them to attempt to use it more often and then rest -adminsiter pain medicine 30 minutes before -teach cough-control exercise -have them splint their surgical incision to protect it during deep breathing

What can you do if a patient complains of claustrophobia with a NIV?

-explain the reason for the system again -demonstrate the use of the quick release straps on the mask -then have patient demonstrate the use of quick release straps as well

Uncuffed tracheostomy tube

-for infants and children due to their risk for mucosal injury, tissue edema and growth of fibrous tissue

Cuffed tracheostomy tube

-prevents aspiration -must check the cuff pressure regularly to prevent over inflation which could cause impaired circulation -cuff pressure should not exceed 20mmHG

What do you do if someones o2 saturation is low?

-see if the tubing is occluded in anyway -make sure its fully in their nose -make sure the tubing is connected to the wall

How do administer meds through an enteral tube?

1. Check accuracy and completeness of each MAR or computer printout with health care provider's written medication order. Check patient's name, medication name and dosage, route of administration, and time for administration. Clarify incomplete or unclear orders with health care provider before administration. 2. Review pertinent information related to medication, including action, purpose, normal dose and route, side effects, time of onset and peak action, indication and nursing implications. 3. Assess for any contraindications to receiving enteral medications, including presence of bowel inflammation, reduced peristalsis, recent gastrointestinal (GI) surgery, and gastric suction that cannot be turned off. 4. Avoid complicated medication schedules that often interrupt enteral feedings. Use alternative routes of medication administration if possible (e.g., transdermal, rectal, IV). a. Determine where medication is absorbed and ensure that point of absorption is not bypassed by feeding tube. For example, some medications such as antacids are absorbed in stomach, not jejunum. b. Determine whether medication interacts with enteral feeding. If so, hold the feeding for at least 30 minutes before giving the medication (see agency policy or consult pharmacist). 5. Assess patient's medical, medication, and diet history and history of allergies. List patient's food and medication allergies on each page of the MAR, and prominently display it on the patient's medical record per agency policy. When patient has allergy, provide allergy bracelet. If you identify contraindications, withhold medication and inform health care provider. 6. For a postoperative patient, review the postoperative orders for type of enteral tube care. 7. Perform hand hygiene. Gather and review physical assessment data (e.g., bowel sounds, abdominal distention) and laboratory data (e.g., renal and liver function) that may influence medication administration. 8. Check with pharmacy for availability of liquid preparation for patient's medications. The health care provider may need to change dosage form. 9. Before administration of enteral medications, verify placement of feeding tube according to agency policy and determine that tube is placed in the stomach or small intestine correctly. 10. Assess patient's or family caregiver's knowledge, experience, and health literacy. 11. Perform hand hygiene. Collect equipment and MAR. 12. Prepare medications for instillation into feeding tube. Attend to procedure and avoid distractions. Check medication label against MAR two times—when removing medication from unit dose or automated medication dispensing system (AMDS) and before leaving medication preparation area. These are the first and second checks for accuracy. Fill graduated container with 50 to 100 mL of tepid water. Use sterile water for immunocompromised or critically ill patients (Boullata et al., 2017). CLINICAL DECISION: Whenever possible, use liquid medications instead of crushed tablets. If you must crush tablets, flush the tubing before and after the medication administration to prevent the medication from adhering to the inside of the tube. In addition, make sure that concentrated medications are thoroughly diluted. Never add crushed medications directly to a tube feeding (Boullata et al., 2017). a. Tablets: Crush each tablet into a fine powder, using pill-crushing device or two medication cups. Dissolve each tablet in separate cup of 30 mL of warm water. b. Capsules: Apply clean gloves. Ensure that contents of capsule (granules or gelatin) can be expressed from covering (consult with pharmacist). Open capsule or pierce gel cap with sterile needle and empty contents into 30 mL of warm water (or solution designated by drug company). Gel caps dissolve in warm water, but this may take 15 to 20 minutes. Remove and dispose of gloves. c. Prepare liquid medication (prepared by pharmacy in appropriate syringe). d. Perform hand hygiene. 13. Take medication(s) to patient at correct time (see agency policy). Consider if medication is time critical. During administration apply seven rights of medication administration. 14. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. Compare identifiers with information on patient's MAR or medical record. 15. At patient's bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient whether he or she has allergies. This is the third check for accuracy. 16. Explain procedure to patient and discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions about medications. 17. Assist patient to sitting position. Elevate head of bed to minimum of 30 degrees and preferably 45 degrees (unless contraindicated) or sit patient up in a chair (Boullata et al., 2017). 18. If continuous enteral tube feeding is infusing, adjust infusion pump setting to hold tube feeding. 19. Perform hand hygiene. Apply clean gloves. Check placement of feeding tube by observing gastric contents and checking pH of aspirate contents. Gastric pH less than 5.0 is a good indicator that tip of tube is correctly placed in stomach (Boullata et al., 2017; Clifford et al., 2015). 20. Check for gastric residual volume (GRV). Draw up 10 to 30 mL of air into a 60-mL syringe and connect syringe to feeding tube. Flush tube with air and pull back slowly to aspirate gastric contents. Determine GRV using either scale on syringe or a graduated container. If GRV exceeds 500 mL, hold feeding for 2 hours and recheck (Boullata et al., 2017) (check agency policy). When GRV is excessive, hold medication and contact health care provider. 21. Irrigate the tubing. a. Pinch or clamp enteral tube and remove syringe. Draw up 30 mL of water into syringe. Reinsert tip of syringe into tube, release clamp, and flush tubing. Clamp tube again and remove syringe. b. Using the appropriate enteral connector, attach to enteral tube. 22. Remove bulb or plunger of syringe and reinsert syringe into tip of feeding tube. 23. Administer dose of first liquid or dissolved medication by pouring into syringe. Allow to flow by gravity. CLINICAL DECISION: Verify that the connector meets the ISO tubing connector standards (Boullata et al., 2017; TJC, 2014). Do not attach the enteral tubing to a standardized Luer syringe or needleless device (Guenther, 2015; TJC, 2014). CLINICAL DECISION: Sometimes it is necessary to transfer oral medications into a medication cup for enteral administration. If medication does not flow freely, raise the height of the syringe to increase the rate of flow or try having the patient change position slightly because the end of the feeding tube may be against the gastric mucosa. If these measures do not improve the flow, a gentle push with bulb of Asepto syringe or plunger of the syringe may facilitate flow of fluid. a. If giving only one dose of medication, flush tubing with 30 to 60 mL of water after administration. b. To administer more than one medication, give each separately and flush between medications with 15 to 30 mL of water. c. Follow last dose of medication with 30 to 60 mL of water. 24. Clamp proximal end of feeding tube if tube feeding is not being administered, and cap end of tube. 25. When continuous tube feeding is being administered by infusion pump, follow medication administration policy for turning off feedings prior to administering medications. If medications are not compatible with feeding solution, hold feeding for additional 30 to 60 minutes (Boullata et al., 2017). 26. Help patient to comfortable position and keep head of bed elevated, if not contraindicated, for 1 hour (see agency policy). 27. Be sure nurse call system is in an accessible location within patient's reach. 28. Raise side rails (as appropriate) and lower bed to lowest position. 29. Dispose of soiled supplies, rinse graduated container and syringe with tap water, remove and dispose of gloves, and perform hand hygiene. 30. Document name of medication, dose, route, and time administered on MAR. Document patient's response in nurses' notes of MAR in the electronic health record (EHR) or chart. 31. Record patient teaching and validation of patient's understanding on flow sheet or nurses' notes in electronic health record (EHR) or chart. 32. Observe patient for signs of aspiration such as choking, gurgling, gurgling speech, breath sounds, and difficulty breathing. 33. Return within 30 minutes to evaluate patient's response to medications. 34. Use Teach-Back: "I want to be sure I explained clearly why your father must take his medications through his feeding tube. Tell me why he is receiving his medications through his feeding tube." Revise your instruction now or develop a plan for revised patient/family caregiver teaching if patient/family caregiver is not able to teach back correctly. Determines patient's/family caregiver's level of understanding of instructional topic.

How do you do a fecal occult blood test?

1. Identify patient using at least two identifiers (e.g., name and birthday or name and account number) according to agency policy. 2. Explain purpose of test and ways patient can help. Patient can collect own specimen if possible. 3. Perform hand hygiene and apply clean gloves. 4. Use tip of wooden applicator (see illustration) to obtain a small part of stool specimen. Be sure that specimen is free of toilet paper and not contaminated with urine. STEP 4 Equipment needed for fecal occult blood testing. 5. Perform Hemoccult slide test: a. Open flap of slide and, using a wooden applicator, thinly smear stool in first box of the guaiac paper. Apply a second fecal specimen from a different part of the stool to second box of slide (see illustration). b. Close slide cover and turn the packet over to reverse side. After waiting 3 to 5 minutes, open cardboard flap and apply 2 drops of developing solution on each box of guaiac paper. A blue color indicates a positive guaiac or presence of fecal occult blood. c. Interpret the color of the guaiac paper after 30 to 60 seconds. d. After determining whether the patient's specimen is positive or negative, apply 1 drop of developer to the quality control section and interpret within 10 seconds. e. Dispose of test slide in proper receptacle. 6. Wrap wooden applicator in paper towel, remove gloves, and discard in proper receptacle. 7. Perform hand hygiene. 8. Record results of test; note any unusual fecal characteristics. (Submit only one sample per day.)

inserting and maintaining an NG tube

1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. Ensures correct patient. Complies with The Joint Commission standards and improves patient safety (TJC, 2020). 2. Verify health care provider order for type of NG tube to be placed and whether tube is to be attached to suction or drainage bag. Requires order from health care provider. Adequate decompression depends on NG suction. 3. Perform hand hygiene (apply clean gloves if risk of body fluid exposure). Inspect condition of skin integrity around patient's nares and nasal and oral cavity. Provides baseline data on the condition of the patient's skin before NG tube insertion. All patients with any medical device are at risk for pressure injury (Delmore and Ayello, 2017). 4. Assess patient's or caregiver's knowledge, experience, and health literacy. Ensures patient or family caregiver has the capacity to obtain, communicate, process, and understand basic health information (CDC, 2019). 5. Ask whether patient has history of nasal surgery or congestion and allergies, and note whether deviated nasal septum is present. Alerts nurse to potential obstruction. Insert tube into uninvolved nasal passage. Procedure may be contraindicated if surgery is recent. 6. Auscultate for bowel sounds. Palpate patient's abdomen for distention, pain, and rigidity. Remove and discard gloves if applied and perform hand hygiene. In presence of diminished or absent bowel sounds, auscultate abdomen in all four quadrants (Ball et al., 2019). Documents baseline for any abdominal distention, gastrointestinal (GI) ileus, and general GI function, which later serves as comparison once tube is inserted. 7. Assess patient's level of consciousness and ability to follow instructions. Determines patient's ability to help in procedure. Clinical Decision: If patient is confused, disoriented, or unable to follow commands, get help from another staff member to insert the tube. 8. Determine whether patient had previous NG tube, and if so, which naris was used. Patient's previous experience complements any explanations and prepares patient for NG tube placement. Planning 1. Provide privacy by closing curtains around bed or closing door, and prepare bedside environment for patient safety. Respects patient's right to privacy. Preparing the environment helps the nurse think about the steps needed; removing clutter from over-bed table removes barriers to completing procedure. 2. Prepare and organize NG tube equipment at bedside. Ensures organized approach to NG tube insertion. 3. Explain NG tube insertion procedure to patient and/or caregiver. Inform patient that procedure may cause gagging and that there may be a burning sensation in nasopharynx as tube is passed. Develop hand signal with patient if too much discomfort occurs. Decreases patient anxiety and promotes patient cooperation. If patient is too uncomfortable or unable to tolerate procedure, the use of a hand signal will alert the nurse. Implementation 1. Raise the bed to working height. Position patient upright in high-Fowler's position unless contraindicated. If patient is comatose, raise head of bed as tolerated in semi-Fowler's position with head tipped forward, chin to chest. Promotes patient's ability to swallow during procedure. Good body mechanics prevent injury to you or patient. 2. Perform hand hygiene and place bath towel over patient's chest; give facial tissues to patient. Allow to blow nose if necessary. Place emesis basin within reach. Prevents soiling of patient's gown. Tube insertion through nasal passages may cause tearing and coughing with increased salivation. 3. Wash bridge of nose with soap and water or alcohol swab. Dry thoroughly. Removes oils from nose to allow fixation devices to adhere completely. Table Continued1225 Step Rationale 4. Stand on patient's right side if right-handed, left side if left-handed. Lower side rail. Allows easiest manipulation of tubing. 5. Instruct patient to relax and breathe normally while occluding one naris. Then repeat this action for other naris. Select nostril with greater airflow. Tube passes more easily through naris that is more patent. Clinical Decision: Insertion of a nasogastric tube is a painful procedure. Research provides evidence that in some instances, topical lidocaine, either as a gel or spray, significantly reduces pain ( Solomon and Jurica, 2017 ). 6. Determine length of tube to be inserted, and mark location with tape or indelible ink. Ensures organized procedure and estimation of the proper length of tube to insert into patient. a. Option for adults: Measure distance from tip of nose to earlobe to xyphoid process (NEX) of sternum (see illustration). Mark this distance on tube with tape. Most traditional method. Length approximates distance from nose to stomach. Research has shown this method may be least effective compared with others, though more research is needed (Santos et al., 2016). b. Option for adults: Measure distance from tip of nose to earlobe to mid-umbilicus (NEMU); also used for pediatric patients. Promotes placement of the tube end holes in or closer to the gastric fluid pool (Boullata et al., 2017). c. Option for adults: Measure distance from xyphoid process to earlobe to nose (XEN) + 10 cm (Taylor et al., 2014). Shown to be more accurate than NEX (Taylor et al., 2014). d. Option for children: Use the NEMU method (Hockenberry et al., 2019). Estimates proper length of tube insertion for the pediatric patient. Clinical Decision: Tip of NG tube must reach stomach to avoid the risk for pulmonary aspiration, which occurs when tubes terminate in the esophagus. Research has mixed findings in regard to the best technique for estimating tube length ( Santos et al., 2016 ). Confirmation of placement via x-ray immediately after completed insertion is still needed. 7. With small piece of tape placed around tube, mark length that will be inserted. Indicates length of tube you will insert. 8. Prepare materials for tube fixation. Tear off a 7.5- to 10-cm (3- to 4-inch) length of hypoallergenic tape or open membrane dressing or another fixation device (see Step 22a[2]). Fixation devices allow tube to float free of nares, thus reducing pressure on nares and preventing medical device-related pressure injuries (MDRPI) (Pittman et al., 2015). 9. Perform hand hygiene and apply clean gloves. Reduces transmission of infection. 10. Apply pulse oximetry/capnography device and measure vital signs. Monitor oximetry/capnography during insertion. Provides objective assessment of respiratory status before and during tube insertion. 11. Option: Dip tube with surface lubricant into glass of room temperature water or lubricate 7.5 to 10 cm (3-4 inches) of end of tube with water-soluble lubricant (see manufacturer directions). Water activates lubricant, minimizes friction against nasal mucosa, and aids in insertion of tube. Water-soluble lubricant is less toxic than oil-based lubricant if aspirated. 12. Hand an alert patient a cup of water if able to hold cup and swallow. Explain that you are about to insert tube. Swallowing water facilitates tube passage. Explanation decreases patient anxiety and increases patient cooperation. 13. Explain next steps. Insert tube gently and slowly through naris to back of throat (posterior nasopharynx). Aim back and down toward patient's ear. Natural contour facilitates passage of tube into GI tract and reduces gagging. 14. Have patient relax and flex head toward chest after tube is passed through nasopharynx. Closes off glottis and reduces risk of tube entering trachea. 15. Encourage patient to swallow by taking small sips of water when possible. Advance tube as patient swallows. Rotate tube gently 180 degrees while inserting. Swallowing facilitates passage of tube past oropharynx. A tug may be felt as patient swallows, indicating that tube is following desired path. 16. Emphasize need to mouth breathe during procedure. Helps facilitate passage of tube and alleviates patient's anxiety and fear during procedure. Step 6a Determine length of tube to be inserted. Table Continued1226 Step Rationale 17. Do not advance tube during inspiration or coughing because it is likely to enter respiratory tract. Monitor oximetry/capnography. When tube inadvertently enters airway, changes in oxygen saturation or end-tidal CO2 (capnography) occur. 18. Advance tube each time patient swallows until you reach desired length. Reduces discomfort and trauma to patient. Clinical Decision: Do not force NG tube. If patient starts to cough or has a drop in O 2 saturation or an increased CO 2 , withdraw tube into the posterior nasopharynx until normal breathing resumes. 19. Using penlight and tongue blade, check to be sure that tube is not positioned or coiled in back of throat. Tube could become coiled, kinked, or enter trachea. 20. Temporarily anchor tube to nose with small piece of tape. Securing tube prevents movement of tube and subsequent gagging. Allows for verification of tube placement. 21. Verify tube placement. Check agency policy for recommended methods of checking tube placement. a. Follow order for bedside x-ray film and notify radiology for examination of chest and abdomen. Radiography remains the gold standard for verification of initial placement of tube (McFarland, 2017; Mordiffi et al., 2016). This must be done before any medication or liquid is administered (ENA, 2015). b. While waiting for x-ray film to be performed, follow these procedures: Attach Asepto or catheter-tipped syringe to end of tube. Aspirate gently back on syringe to obtain gastric contents, observing amount, color, and quality of return. Observation of gastric contents is useful to determine initial tube placement. Gastric contents are usually green but are sometimes off-white, tan, bloody, or brown in color. Other common aspirate colors include yellow or bile stained (duodenal placement) or possibly saliva-appearing (esophagus) (Mordiffi et al., 2016). c. Use pH test paper to measure aspirate for pH with color-coded pH paper. Be sure that paper range of pH is at least from 1.0 to 11.0 (see illustration). Evidence supports pH test to be used as indicator for placement (McFarland, 2017; Tho et al., 2011). A pH of 1.0 to 4.0 is a good indicator of gastric placement. 22. After tube is properly inserted and positioned, either clamp end or connect it to drainage bag or suction source. Anchor tube with a fixation device, avoiding pressure on the nares. Select one of the following fixation methods. Drainage bag is used for gravity drainage. Intermittent low suction is most effective for decompression. Proper anchoring and marking of tube helps prevent migration of tube and pressure injury formation. a. Apply tape. (1) Apply tincture of benzoin or other skin adhesive on bridge of patient's nose and allow it to become "tacky." Helps tape adhere better. Protects underlying skin. (2) Tear small horizontal slits at one-third and two-thirds length of tape without splitting tape (see illustration). Fold middle sections toward one another to form a closed strip. The strip holds tubing to lessen rubbing against soft palate and naris. (3) Print date and time on tape and place top end of tape over bridge of patient's nose. (4) Wrap bottom end of tape around tube as it exits nose (see illustration). b. Apply tube fixation device using shaped adhesive patch (see manufacturer directions). Secures tube and reduces friction on nares, and decreases risk for MDRPI (Delmore and Ayello, 2017). Step 21c Checking pH of gastric aspirate. Step 22a(2) Taping method. A, Start with piece of tape. B, Make two slits on both sides of tape. C, Fold middle section inward. D, Tear a new slit in bottom of tape. Top part (A) should attach to patient's nose; bottom part (B) should be wrapped around tube. Table Continued1227 Step Rationale (1) Apply wide end of patch to bridge of nose (see illustration). (2) Slip connector around tube as it exits nose (see illustration). CLINICAL DECISION: Assess at least twice daily the condition of the naris and mucosa for inflammation, blistering, excoriation, or any type of skin or tissue injury. Injury can develop for many reasons: rigidity of device rubbing against mucosa, difficulty in securing or adjusting the device to the body, increased moisture surrounding the tubing, tight securement of the device, and poor positioning or fixation of the device ( Delmore and Ayello, 2017 ). 23. Fasten end of nasogastric tube to patient's gown with piece of tape (see illustration). Do not use safety pins to fasten tube to gown. Anchors tubing to prevent pulling on nose. 24. Keep head of bed elevated 30 to 45 degrees (preferably 45 degrees) unless contraindicated (AACN, 2017). Patients receiving nasogastric tube feedings have an increased risk for aspiration (AACN, 2017). Head-of-bed elevation reduces risk for aspiration of stomach contents (Metheny, 2016). CLINICAL DECISION: If inserting a Salem sump tube, keep the blue "pigtail" of the tube above level of the stomach. This prevents a siphoning action that clogs the tube. The blue "pigtail" is the air vent that connects with the second lumen When the main lumen of the sump tube is connected to suction, the air vent permits free, continuous drainage of secretions. Never clamp off the air vent, connect to suction, or use for irrigation. 25. Assist radiology as needed in obtaining ordered x-ray film of chest and abdomen. X-ray verification is the gold standard for NG tube verification (ENA, 2018; McFarland, 2017; Mordiffi et al., 2016). Step 22a(4) A, Tape applied to anchor nasogastric tube. B, Nares are free of pressure from tape and tube. Step 22b(1) Apply patch to bridge of nose. Step 22b(2) Slip connector around nasogastric tube. Step 23 Fasten nasogastric tube to patient gown. Table Continued1228 Step Rationale 26. Remove and dispose of gloves, perform hand hygiene, and help patient to comfortable position. Reduces transmission of microorganisms. 27. Once placement is confirmed, measure amount of tube that is external and mark exit of tube at nares with indelible marker as guide for any tube displacement. Record this information in nurses' notes in electronic health record (EHR) or chart. The mark alerts nurses and other health care providers to possible tube displacement, which will require confirmation of tube placement. Clinical Decision: Never reposition an NG tube of a gastric surgical patient since positioning can rupture the suture line. 28. Attach NG tube to suction as ordered. Suction setting is usually ordered low intermittent, which decreases gastric irritation from NG tube. Clinical Decision: If lumen of tube is narrow and secretions are thick, NG will not drain as desired. Irrigate tube (see Step 29). Consult with health care provider for higher suction setting if unable to irrigate tube because of thick secretions. 29. NG tube irrigation: a. Perform hand hygiene and apply clean gloves. Reduces transmission of microorganisms. b. Verify tube placement in stomach by disconnecting NG tube, connecting irrigating syringe, and aspirating contents (see Step 21b). Temporarily clamp NG tube or reconnect to connecting tube and remove syringe. pH of gastric aspirate must measure between 1.0 and 4.0 to ensure that NG tube is in the stomach (McFarland, 2017). Prevents accidental entrance of irrigating solution into lungs. c. Empty syringe of aspirate and use it to draw up 30 mL of normal saline. Use of saline minimizes loss of electrolytes from stomach fluids. d. Disconnect NG from connecting tubing and lay end of connection tubing on towel. Reduces soiling of patient's gown and bed linen. e. Insert tip of irrigating syringe into end of NG tube. Remove clamp. Hold syringe with tip pointed at floor, and inject saline slowly and evenly. Do not force solution. Position of syringe prevents introduction of air into vent tubing, which causes gastric distention. Solution introduced under pressure causes gastric trauma. Clinical Decision: Do not introduce saline through blue "pigtail" air vent of Salem sump tube. f. If resistance occurs, check for kinks in tubing. Turn patient onto left side. Repeated resistance should be reported to health care provider. Tip of tube may lie against stomach lining. Repositioning on left side may dislodge tube away from stomach lining. Buildup of secretions causes distention. g. After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. If amount aspirated is greater than amount instilled, record difference as output. If amount aspirated is less than amount instilled, record difference as intake. Irrigation clears tubing, so stomach should remain empty. Measure and document amount of irrigant fluid inserted in tube as intake. h. Use an Asepto syringe to place 10 mL of air into blue pigtail. Ensures patency of air vent. i. Reconnect NG tube to drainage or suction. (Repeat irrigation if solution does not return.) Reestablishes drainage collection; may repeat irrigation or repositioning of tube until NG tube drains properly. 30. Removal of NG tube: a. Verify order to remove NG tube. A health care provider order is required for procedure. b. Per agency policy, auscultate abdomen for presence of bowel sounds or clamp the tube for a short period of time, assessing for nausea or discomfort. Verifies return of peristalsis. Early removal of the NG tube helps to restore normal anatomy and physiology of the GI system (Goudar et al., 2017). c. Explain procedure to patient and reassure that removal is less distressing than insertion. Minimizes anxiety and increases cooperation. Tube passes out smoothly. d. Perform hand hygiene and apply clean gloves. Reduces transmission of microorganisms. e. Turn off suction and disconnect NG tube from drainage bag or suction. With irrigating syringe, insert 20 mL of air into lumen of NG tube. Remove tape or fixation device from bridge of nose and patient's gown. Have tube free of connections before removal. Clears gastric fluids from tube to prevent aspiration of contents or soiling of clothing and bedding. f. Hand patient facial tissue; place clean towel across chest. Instruct patient to take and hold breath as tube is removed. Some patients wish to blow nose after tube is removed. Towel keeps gown from soiling. Temporary airway obstruction occurs during tube removal. Table Continued1229 Step Rationale g. Clamp or kink tubing securely and pull tube out steadily and smoothly into towel held in other hand while patient holds breath. Clamping prevents tube contents from draining into oropharynx. Reduces trauma to mucosa and minimizes patient's discomfort. Towel covers tube, which is an unpleasant sight. Holding breath helps to prevent aspiration. h. Inspect intactness of tube. i. Measure amount of drainage and note character of content. Dispose of tube and drainage equipment into proper container. Provides accurate measure of fluid output. Reduces transfer of microorganisms. j. Clean nares and provide mouth care. Promotes comfort. k. Position patient comfortably and explain procedure for drinking fluids if not contraindicated. Instruct patient to notify you if nausea occurs. Sometimes patients are not allowed anything by mouth (NPO) for up to 24 hours. When fluids are allowed, orders usually begin with small amount of ice chips each hour and increase as patient is able to tolerate more. 31. For all procedures, clean equipment and return to proper place. Place soiled linen in utility room or proper receptacle. Proper disposal of equipment prevents spread of microorganisms and ensures proper exchange procedures. 32. Remove and discard gloves and perform hand hygiene. Reduces transmission of microorganisms. Evaluation 1. Observe amount and character of contents draining from NG tube. Ask if patient feels nauseated. Determines if tube is decompressing stomach of contents. 2. Auscultate for presence of bowel sounds. Turn off suction while auscultating. Assess for nausea and patient discomfort if tube is clamped for short trial period. Sound of suction apparatus is sometimes misinterpreted as bowel sounds. Nausea and discomfort will occur if peristalsis is not returned. 3. Palpate patient's abdomen periodically. Note any distention, pain, and rigidity. Determines success of abdominal decompression and return of peristalsis. 4. Inspect condition of nares, nose, and all skin and tissue around NG tubing. Evaluates onset of skin and tissue irritation. 5. Observe position of tubing. Prevents tension applied to nasal structures. 6. Explain that it is normal if patient feels sore throat or irritation in pharynx. Result of tube irritation. 7. Use Teach-Back: "I need to be sure I explained the importance of letting me know if you are nauseated. Tell me why it is important for me to know if you feel nauseated." Revise your instruction now or develop a plan for revised patient/family caregiver teaching if patient/family caregiver is not able to teach back correctly. Determines patient's/family caregiver's level of understanding of instructional topic. Unexpected Outcomes and Related Interventions 1. Patient complains of nausea, or patient's abdomen is distended and painful. • Assess patency of tube. NG tube may be occluded or no longer in stomach. • Irrigate tube. • Verify that suction is on as ordered. • Notify health care provider if distention is unrelieved. 2. Patient develops irritation or erosion of skin around naris. • Provide frequent skin care to area. • Use taping method designed to reduce MDRPI (see taping methods, Step 22). • Consider switching tube to other naris. 3. Patient develops signs and symptoms of pulmonary aspiration: fever, shortness of breath, or pulmonary congestion. • Perform complete respiratory assessment. • Notify health care provider. • Obtain chest x-ray film examination as ordered. Recording and Reporting • Record length, size, type of gastric tube inserted, and naris in which tube was introduced. Also record patient's tolerance of procedure, confirmation of tube placement, character and pH of gastric contents, results of x-ray film, whether the tube is clamped or connected to drainage bag or to suction, and amount of suction supplied. • Document your evaluation of patient learning. • When irrigating NG tube, record difference between amount of normal saline instilled and amount of gastric aspirate removed on I&O sheet. Record amount and character of contents draining from NG tube every shift in nurses' notes or flow sheet. • Record removal of tube "intact," patient's tolerance to procedure, and final amount and character of drainage. • Report occurrence of abdominal distention, unexpected increase or sudden stoppage in gastric drainage, and patient complaining of gastric distress to health care provider.

How do you check the PH of intermittent and continuous feedings?

1. Review agency policy and procedures for frequency of irrigation and frequency and method of checking tube placement. Do not insufflate air into tube to check placement. 2. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2020). 3. Review patient's medication record for orders for enteral feeding, a gastric acid inhibitor (e.g., ranitidine, famotidine, nizatidine), or a proton pump inhibitor (e.g., omeprazole). 4. Review patient's medical record for history of prior tube displacement. 5. Observe for signs and symptoms of respiratory distress during feeding: coughing, choking, or reduced oxygen saturation. 6. Identify conditions that increase risk for spontaneous tube migration or dislocation: altered level of consciousness, agitation; retching, vomiting; nasotracheal suction. 7. Perform hand hygiene. Assess bowel sounds and perform abdominal exam. 8. Obtain pulse oximetry reading. 9. Note ease with which previous tube feedings infuse through tubing. Monitor volume of continuous enteral formula administered during shift and compare with ordered amount. 10. Assess patient's or family caregiver's knowledge, experience, and health literacy level. Perform hand hygiene and apply clean gloves. Be sure pulse oximeter is in place. 11. Verify tube placement. CLINICAL DECISION: Listening for insufflated air instilled through tube to check tube tip position is unreliable (Boullata et al., 2017; Fan et al., 2017). a. Check tube placement at following times (1) For patients receiving intermittent tube feedings, test placement immediately before each feeding (usually a period of at least 4 hours will have elapsed since previous feeding) and before medications. (2) Follow agency policy regarding when to test pH for patients receiving continuous tube feedings. AACN (2016) recommends stopping continuous feedings for several hours to obtain reliable pH readings. However this is not always appropriate for a patient's therapeutic plan of care. (3) Wait to verify placement at least 1 hour after medication administration by tube or mouth. (4) Measure length of tube extending from nare. b.If tube feeding is infusing, turn off or place tube feeding on hold. Clamp or kink feeding tube and disconnect from end of infusion bag tubing. For intermittent feedings, remove plug at end of feeding tube. Draw up 30 mL of air into a 60-mL ENFit syringe. Place tip of syringe into end of gastric or small bowel feeding tube. Flush with air before attempting to aspirate fluid. Repositioning patient from side to side is helpful. In some cases more than one bolus of air is necessary. c. Draw back on syringe slowly and obtain 5 to 10 mL of gastric aspirate (see illustration). Observe appearance of aspirate. Aspirates from gastric tubes of patients receiving continuous tube feedings often look like curdled enteral formula. Gastric aspirates from patients receiving intermittent feedings typically are not bile stained (unless intestinal fluid has refluxed into stomach) (AACN, 2016). STEP 11C Obtain gastric aspirate. d. Gently mix aspirate in syringe. Expel few drops into clean medicine cup. Note color of aspirate. Measure pH of aspirated GI contents by dipping pH strip into fluid or applying few drops of fluid to strip. Compare color of strip with color on chart (see illustration) provided by manufacturer. STEP 11D Compare color on test strip with color on pH chart. (1) Gastric fluid from patient who has fasted for at least 4 hours usually has pH range of 5.0 or less. (2) Fluid from tube in small intestine of patient who is fasting usually has pH greater than 6.0 (Bourgault et al., 2015). (3) The pH of pleural fluid from the tracheobronchial tree is generally greater than 6.0. 12. If after repeated attempts it is not possible to aspirate fluid from tube that was confirmed by x-ray film to be in desired position and if (1) there are no risk factors for tube dislocation, (2) tube has remained in original taped position, (3) patient is not in respiratory distress, assume that tube is correctly placed. Continue with irrigation (AACN, 2016; Bourgault et al., 2015; Fan et al., 2017). 13. Irrigate tube. a. Irrigate routinely before, between, and after final medication (before feedings are reinstituted), and before an intermittent feeding is administered. b. Draw up 30 mL of water in ENFit syringe. Do not use irrigation fluids from bottles that are used on other patients. Patient should have individual bottle of solution. CLINICAL DECISION: Do not use cola or fruit juices for flushing tubing as these liquids can clog tube. c. Change irrigation bottle every 24 hours. Irrigation trays, which hold both irrigation fluid and syringe, are considered open systems and may be more easily contaminated than sterile water bottles. N ote : Be sure that syringe in tray has ENFit adapter. d. Kink feeding tube while disconnecting it from infusion tubing (continuous feeding) or while removing plug at end of tube (intermittent feeding). e. Insert tip of ENFit syringe into end of feeding tube. Release kink and slowly instill irrigation solution. f. If unable to instill fluid, reposition patient on left side and try again. g. When water or sterile saline has been instilled, remove syringe. Reinstitute tube feeding or administer medication as ordered. Then flush each medication completely through tube (see Chapter 31). 14. Help patient assume comfortable position. Raise side rails as appropriate and lower bed to lowest position. Remove and discard gloves; dispose of supplies in appropriate receptacle and perform hand hygiene. 15. Place nurse call system in an accessible location within patient's reach. Instruct patient in its use. 16. Observe patient for respiratory distress: persistent gagging, paroxysms of coughing, drop in oxygen (O2) saturation, or respiratory patterns (e.g., rate and depth) that are inconsistent with baseline measures. 17. Verify that external length of tube, pH, and appearance of aspirate are consistent with initial tube placement. 18. Observe ease with which tube feeding instills through tubing. 19. Monitor patient's caloric intake. 20. Use Teach-Back: "I want to go over what I explained earlier. Tell me why it is important for me to test the gastric pH and the color of the gastric secretions in your stomach before feedings." Revise your instruction now or develop a plan for revised patient/family caregiver teaching if patient/family caregiver is not able to teach back correctly.

How do you handle the emergency dislodgement of a trach?

1. call for help 2. raise the bed to 45 3. insert obturator, lubricated 4. insert tube at 45 degree angle to the neck 5. if unsuccessful place suction catheter into stoma to allow for air entry 6. if that is unsuccesful, cover stoma with bag-valve mask to ventilate

Suctioning Tips

1. only apply suction intermittently when pulling tube out 2. use smallest fr possible that can get the secretions 3. hyperoxygenate patient before suctioning for 30-60 sec 4. have pulse ox on the patient the whole time 5. Maximum of 3 passes 6. move the tube in a circular motion when pulling out 7. hyper oxygenate the patient between each pass and allow them one minute to rest 8. rinse catheter with sterile saline in between passes 9. never instill sterile saline in the patient

What do you do if patient has inflammation on their trach stomas?

Increase frequency of trach care -apply hydrocolloid dressing -apply antibacterial ointment -consult wound care nurse

How many times do you breathe in the incentive spirometer per hour?

10 times -can be delegated but need to be reporting to you -need to encourage the patient to do it

Partial rebreather mask

10-15 L/min 60-90% Only one valve is a one-way valve

Non-rebreather Mask

10-15L 60-90% -One-way valve so you can't breathe in room air -One-way valve between bag and mask -need to make sure bag is inflated 1/3 to 1/2

Each Liter is approximately want percent more than room air?

3% 1 L= 24% -room air is 21% Fio2

How many suction passes do you have at a time?

3, no more -1 minute between passes -rinse the catheter with sterile saline and hyper oxygenate between -only suction on the way out -twirl it on the way out

Gastric fluid PH from a patient who has fasted for a least 4 hours should be....

5.0 or less

Indications you need to suction

Increased RR, pulse, BP Dyspnea Decrease SaO2 Anxiety/apprehension Behavior change/irritability Pallor/Cyanosis Nasal secretions Drooling Gastric Secretions Adventitious breath sounds on auscultation

What do you do when you send a patient off with an oxygen tank?

Needs to be 3/4 full or completely full -need to ensure there is enough tubing as well for oxygenation -98' will deliver the prescribed O2 flow rate

Oropharyngeal and Nasopharyngeal Suction

Non-sterile procedure -used when patient can cough but cant clear secretions fully -suction after the patient coughs -used yanker suction -oropharyngeal suctioning CAN be delegated -nasopharyngeal can NOT be delegated

If a patient experiences a ventilator associated event what should the nurse do?

Notify provider Remain with the patient Conduct complete cardiac and resp assessment Be prepared for antibiotic therapy, re-intubation or a chest tube

If oxygen level is over 4L/min you need to give what kind of care?

Oral Care

soapsuds enema

Add soapsuds to tap water or saline to irritate the intestinal mucosa to stimulate peristalsis -use caution if giving to pregnant patients or older adults because it could cause an electrolyte imbalance High enemas- give from higher up, cleanse more of the colon, and ask the patient to roll around after giving so it gets to the large intestine Low enemas- only cleanse the rectum and the sigmoid colon

Humidification

Add sterile water to gas to add to O2 delivery -have to humidify oxygen over 4 L -also add humidification if environment is dry and arid

How far do you insert an enema?

Adults and Adolescents= 3-4 in Children= 2-3 in Infant= 1-1.5 in

What are the settings on a mechanical ventilator?

Amount of oxygen delivered, number of breaths per min, amount of tidal volume delivered, time for inspiration and expiration, the pressure at which each breath is delivered

How should the patient position their head during NG tube insertion?

Back until you reach the nasopharynx and then down towards their chest tucked

What does negative pressure do?

Brings air in- iron lung

What are the ways someone can get C. diff?

By antibiotic therapy or contact with someone or something that is infected

Non-invasive ventilation

CPAP/BiPAP -purpose is to maintain positive air-way pressure and improve alveolar ventilation -keeps alveoli open at end expiration -improves alveolar ventilation without the need for an artificial airway

What has a stronger, more rapid effect on the intestines, cathartics or laxatives?

Cathartics

Mobilization of pulmonary secretions

Cough, turn, and deep breathe every hour -do not wake the patient up to this Cascade Cough- slow deep breathe in, hold for 2 seconds, and then force it out while coughing -helps with airway clearance and getting out large amounts of secretions Huff Cough- stimulates the natural cough reflex -breathe in and out 3 times and then breathe out while saying huff should stimulate the cough reflex -good for children with CF -with practice one can inhale more air and progress to the cascade cough Quad Cough- Have someone push on the diaphragm hard inward and upward at the top of your deep breath, causing the person to cough -good for people with spinal cord injuries -for those who lost control of their abdominal muscles Shove cough- if you have stomach troubles have someone pull you forward while coughing -good for people with spinal cord injuries Hydration- at least 1500-2000ml per day Humidify, warm drinks Nebulizers- aerosolized medication or just loosening secretions, need to be careful when giving can cause the increased heart rate -enhances mucociliary clearance Chest physiotherapy- Tappy tap the back Postural Drainage Suctioning Techniques

What are the purposes of an NG tube?

Decompression-removal of secretions and gas to relieve abdominal distention -Salem Sump, Levin, Miller-Abbott Enteral Feeding- to feed patients with impaired swallowing -Duo, Dobhoff, Levin Compression- internal application of pressure via balloon to prevent internal esophageal or GI hemorrhage -Sengstaken-Blakemore Lavage- Irrigation of the stomach in cases of poisoning, bleeding or dilation -Levin, Salem Sump, Ewald

What is the last result when someone has fecal impaction?

Digital Removal of the Stool -can irritate the mucosa, causing bleeding, and also stimulate the vagus nerve which can slow down the heart beat severely

How do you measure an oral airway?

Distance from corner of mouth to angle of the jaw just below the ear

Tap Water Enema

Hypotonic and exerts an osmotic pressure lower than that in the intestines -use caution if ordered to repeat because you could cause water toxicity or fluid overload

Invasive mechanical ventilation

Endotracheal tube- short-term Nasogastric Tube- short term Tracheostomy- long-term

How often do you perform tracheostomy care?

Every 8-12 hours -use a q-tip with sterile saline Perform before 8-12 hours if: -tracheostomy ties or dressing are soiled/loose -the tube is unstable -there is excessive secretions

Venturi Mask

Face mask with flow meter regulator 4-12L or 24-60% O2 -more precise oxygen concentration

Does general anesthesia or localized/regional anesthesia slow peristalsis?

General

What do you need to do after inserting an NG tube and before putting anything down it?

Get X-ray confirmation it is in the right place

Oxygen is always what color?

Green

When placing a trachestomy collar or ties you should what?

Have another person hold the tracheostomy in place

Diaphragmatic Breathing

Helps decrease respiratory rate -pull the diaphragm down with each breath -decreases air trapping and WOB -good for asthmatics

incentive spirometer

Helps patients deep breath -BREATHE IN

How should you position a patient for NG tube insertion?

High Fowlers position if not contraindicted

What are the alarms on a mechanical ventilator?

High-pressure, low-pressure, low-exhaled volume

What should you have the patient do when removing an NG tube?

Hold their breath

What is the most important part of tracheostomy?

KEEP THE AIRWAY OPEN

What does the oral airway do?

Keep the tongue from occluding the airway -above the trachea

Metal tracheostomy tube

Long-term -uncomfortable, not really used anymore -no MRIs or metal detectors

Peak Flowmeter

Measures how much your breathing out -used for asthmatics -max flow that a patient forces out during one quick, forced expiration -objective indicator of a patients current status or effectiveness of treatment

Can the care of someone with a NIV be delegated?

NO, can only delegate positioning, coughing and mask application

Parts of a tracheostomy tube

Outer Cannula- keeps the stoma open, never remove, secured with trach ties Inner Cannula-can be disposable or reusable and cleaned Cuff-prevents secretions from entering the lungs Obturator- used to insert the tracheostomy tube

Whats a worry with positive airway pressure ventilation?

Pnuemothorax

How can you care for a patient with an artificial airway?

Provide humidification with a T-tube or tracheostomy collar

Hypertonic enemas

Pulls fluid out of the interstitial spaces -good because it is low volume -contraindicated in dehydrated patients and infants EX: Fleet enema

Normal saline enema

Safest due to equal osmotic pressure Volume stimulates peristalsis -lessens the danger of fluid absorption

What should you have the patient do when inserting an NG tube?

Sip water and swallow Mouth breath

What should you do if a patient complains about cramping when giving an enema?

Slow the rate of infusion by lowering the height of the bag

No smoking around oxygen at all?

TRUE -oxygen supports combustion

mechanical ventilation

Takes over the physical work of moving air into and out of the lungs -does not replace or alter the physiologic function of the lung -should remain on for only as long as necessary

What do you need to consider when sending an ambulatory patient home with oxygen?

The length of the tubing

What can the nurse delegate to the NAP regarding applying an O2 delivery device?

The nurse can delegate the safe adjustment of the device on the patients face, but NAP can NOT change the flow rate -can tell NAP to inform them about any changes in vitals or LOC or discomfory -can delegate skin care

Which nares should you insert the NG tube in?

The one with greater airflow or that has not been through surgery

Should you perform tracheal or pharyngeal suctioning first?

Tracheal whenever possible

The blue pigtail needs to stay above the level of the stomach. T OR F

True

Do not administer an enema on the toilet. T OR F

True, can damage the rectum -the patient needs to be left side in Simms position with right knee flexed -place children in the dorsal recumbent position

How long should a patient hold the enema?

Until they feel the need to defecate which is usually 2-5 minutes

How many consecutive enemas can a patient recieve?

Up to 3, no more, more than 3 could cause electrolyte imbalance or fluid overload -for "enemas until clear" order the contents can be tinted but not have any fecal matter

Nasal Cannulas

Up to 6L 24-40% O2 Hi-Flow nasal cannula: -up to 10L, 35-45% O2 Titrate to maintain desired oxygen saturation levels, RR and WOB Humidified and heated oxygen (98.6F or 37C) Prongs should not completely obstruct the nostril HR, RR, and o2 saturation should be monitored continually -up to 60L can deliver 100% O2

orotracheal and nasotracheal suctioning

Used when patient is unable to manage secretions by coughing and does NOT have an artificial airway Nasotracheal preferred to gain a sterile sample because there is fewer bacteria -sterile technique

When is home oxygen indicated?

When O2 sat is 88% or lower on room air at rest, on exertion and with exercise

Do you need to do a bedside report when your patient is on an artificial airway?

YES

Can a NAP give enemas?

YES, but only a RN can give medicated enemas

What are large-bore NG tubes used for?

gastric decompression or removal of gastric secretions

Hyperoxygenation

increasing the oxygen flow before suctioning and between suction attempts to avoid suction-related hypoxemia

fecal effluent

liquid stools that come from a jejunostomy or ostomy higher up in the intestinal track

tracheostomy

long-term, put in after 7-10 days on an endotracheal or nasotracheal tube ventilator if dependent -can be taken out

Oil Retention Enema

lubricate the stool and intestinal mucosa, easing defecation

What are small-bore NG tubes used for?

medication administration and enteral feedings

How many L can you give of home oxygen for patient with COPD or emphysema?

no more than 2 L

Permenant Tracheostomy

obstruction or cancer, disease that permenantely affects the airway

How often do you suction?

on an as needed basis

Temporary tracheostomy

over 7-10 days -for secretions that cannot be cleared routinely

Pursed Lip breathing

prevents alveolar collapse by keeping airways open longer -deep inspiration followed by prolonged expiration through pursed lips for 2x longer than inspiration -helps with anxiety and COPD- relieves shortness of breath -KEEPS AIRWAYS OPEN LONGER to help remove trapped air

Cleansing Enema

promote the complete evacuation of feces from the colon by stimulating peristalsis by large volume or local irritation of intestinal mucosa Different Types: -tap water -normal saline -soap-suds -low volume hypertonic saline

Simple Face Mask

short term 6-12 L or 30-50% O2 Flow rates must be above 5L or patient will be rebreathing exhausted CO2 -assess for skin breakdown under the mask -humidifed

endotracheal intubation

short term mechanical ventilation -hard to wean people off

nasotracheal intubation

short-term mechanical ventilation

tracheal suctioning (also endotracheal)

sterile technique

fecal occult blood test

test to detect occult blood in feces, could indicate colon cancer

Why is it important to do mouth care every 2 hours on an intubated patient?

to prevent hospital acquired pneumonia

Salem sump tube

two lumen NG tube One to pull out contents and then a blue pigtail to ventilate -NEVER PUT ANYTHING INTO THE BLUE PIGTAIL

Can fecal occult blood test be delegated to NAP?

yes, but the nurse is responsible for assessing the significance of the findings, assesses blood in stool