PNL210 - practical nursing lab (week 1-5)

**Describe four other complications of enteral feeding and the nursing interventions to address these.

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**Describe the diagnostic blood screening for surgical clients.

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**Describe the physiological factors that place the older adult at risk during surgery.

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**Describe the procedure for administering medications via an enteral feeding tube

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**Identify goals for pre op teaching.

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**List the equipment required to initiate an enteral feed via a nasogastric and gastrostomy tube.

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**Practice calculations for NG feeds.

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**Why would a gastrostomy tube be used over a nasogastric tube?

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Explain the importance of diffusion, hematocrit and hemoglobin in respiration.

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Explain the terms hypoxemia, hypoxia, and cyanosis and list the signs and symptoms of each.

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List the equipment and describe the procedure for inserting a small-bore nasogastric tube.

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List the procedure for catheter insertion for both male and female catheterization.

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What lifestyle choices may affect a person's respiratory system?

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factors that affect urination

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parts of a tracheostomy?

1) The outer cannula, which includes the neck plate: keeps the stoma open 2) The obturator: guides the outer cannula 3) The inner cannula: fits into the outer cannula

describe nasotracheal suctioning

1) check patients chart for any contraindication 2) attach suction tube to suction machine and increase O2 level to 100% if ordered by physician. 3) suction small amount of NaCL into the catheter (to check if it works) 4) lubricate catheter, client deep breath, then insert into the nasotracheal cavity, & suction. 5) compare and document cardiopulmonary findings before and after procedure and etc.

changing a tracheostomy dressing and changing a disposable in-ner cannula.

1) full respiratory assessment before and after. 2) clean technique: remove dressing & inner cannula 3) sterile technique: insert sterile inner (turning it gentle as you insert). 4) put the tracheotomy tie back on, and apply new dressing. 5) client may cough; suction and wipe mucus

How is tracheostomy care be provided

1) full respiratory assessment before and after. 2) clean technique: remove inner cannula and sock in saline , peroxide solution. 3) sterile technique: scrup outer and inner parts of inner cannula. 4) rince in NAcl & dry with sterile 4/4 and pipe cleaners 5) re-insert clock-wise and clean neck plate and surrounding area. If lungs not clear provide trach suctioning before trach care.

how micturition is controlled

1) stretch receptors ---nerve impulse---> sacral spine 2)detrusor muscle contract & internal urethral sphincter relax 3)bladder ----sensory signals---> micturation center in the pons. If not convinient to urinate ---inhibitory signals---> external sphinter contract. 4)If time appropriate inhibitory signal removed. 5)sacral spine ---nerve impulse ---> bladder contract & sphincter relax

**most common post operative complications

1. Pain 2. Partially Collapsed Lung (Atelectasis) 3. Blood Clots 4. Fatigue and Lack of Energy 5. Muscle Atrophy Infection

Client with an indwelling catheter should drink how much fluid, and why?

3L. Decrease the risk of urine stasis Decrease the risk of sediments building up in the catheter

What is the most common complication of enteral tube feeding and how can it be prevented?

Aspiration Nausa and vomiting Diarrhea Constipation Malabsorption/maldigestion Aspiration

How often should tracheostomy care be provided

At least once a day

**List the common medical conditions that increase the risk of surgery.

Bleeding disorders, Diabetes mellitus, Heart Disease, Obstructive sleep apnea, Upper respiratory infection, Liver disease, Fever, Chronic respiratory disease, Immunoligical disorders, Abuse of street drugs, Chronic pain Type of Condition Reason for Risk Bleeding disorders (thrombocytopenia, hemophilia) Increase risk of hemorrhaging during and after Sx Diabetes mellitus Increases susceptibility to infection and may impair wound healing from altered glucose metabolism and associated circulatory impairment.Stress of surgery may cause increases in blood glucose levels. Heart Disease (recent myocardial infarction, dysrrhythmias, congestive heart failure) and peripheral vascular disease Stress of surgery causes increased demands on myocardium to maintain cardiac output.General anaesthetics depress cardiac function. Obstructive sleep apnea Administration of opioids increases risk of airway obstruction post-operatively.Patients will desaturate - drop in pulse oxymetry reading Upper respiratory infection Increases risk of respiratory complications during anesthesia (pneumonia and laryngeal muscle spasm) Liver disease Alters metabolism and elimination of drugs administered during surgery and impairs wound healing and clotting time because of alterations in protein metabolism Fever Predisposes patient to fluid and electrolyte imbalances and may indicate underlying infection. Chronic respiratory disease (emphysema, bronchitis, asthma) Reduces client`s ability to compensate for acid-base alterations.Anesthetics depress respiratory function and increase risk of hypoventilation. Immunoligical disorders (leukemia, AIDS, immunosupressants, chemo drugs) Increases risk of infection and delayed wound healing after surgery. Abuse of street drugs Individuals may have underlying disease (hepatitis or HIV) which affects healing Chronic pain Regular use of pain medications may result in higher tolerance.Increased doses of analgesic may be required to achieve post-operative pain control. About these ads

Pnea

Breathing

normal breath sounds

Bronchial Sound: full inspiratory and expiratory phase with the inspiratory phase usually being louder Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase.

Types of catheters and uses

Catheters come in many sizes, materials (latex, silicone, Teflon™), and types (Foley, straight, coude tip). • Indwelling or foley catheters - short and long term (inflated balloon makes it stay) : foley catheters • Intermittent or self catheters - short term (quick urine collection, either for testing or to empty bladder) :Nelaton, Robinson or in/out catheters • Coude tip catheter (Curved coude tip makes it easier to navigate catheter past tight spots, strictures, or an enlarged prostate.) : atapered tip, olive tip, and Tiemann tip. • External/condom catheter- short term (can void, but should not or cannot move. should be changed every day) : condom

chest drainage system

Chest drainage therapy is done to relieve pressure on the lungs, and remove fluid that could promote infection. Air or fluid in the plural cavity after ex. heart surgery or chest trauma is drained, leakage is closed.

Type of catheter for a man who has had a prostatectomy and will need an indwelling catheter for a few days

Coude tip

adventitious sounds

Crackles are discontinuous, brief, popping sounds. - obstructed airway Wheezes are continuous, musical sounds, high or low pitched. -When the airways are narrowed -Wheezing may be a symptom of hayfever, COPD, asthma, acute bronchitis, bronchospasm, swelling Stridor is loud, high-pitched sound heard during inspiration but may also occur throughout the respiratory cycle. -Caused by a blockage in the throat or voice box (larynx). Plural rubs are creaking or grating sounds that have been described as being similar to walking on fresh snow. - Inflamed pleural surfaces rub together during respiration. More often heard on inspiration than expiration

Describe the procedure for maintaining a nasogastric tube.

Ensure enough slack, secure tube to patients gown To maintain patency and to avoid harm to the surgical site, do not advance, pull back, or manipulate

Describe care required for a gastrostomy and PEG tube.

G-Tube: Wash your hands with soap and water. Remove old dressing. Look at the area where the tube enters the skin. Check for redness, swelling, any drainage or excess skin growing around the tube. A small amount of clear tan drainage can be normal. Wash skin around the tube with soap and warm water. Clean around G-tube to remove any drainage and / or crusting. Clean around suture gently. Dry skin thoroughly. Keep this site clean and dry. Use dressing around G-tube site as instructed by your nurse or doctor. Secure the end of the tube by putting a piece of tape around the tube and pinning it to a folded piece of tape on the stomach, diaper or T-shirt. One-piece T-shirt or Onesies protect the tube. Do not use ointments around tube site unless directed by your child's doctor or nurse. How do I care for my PEG tube? Always flush your PEG tube before and after each use. This helps prevent blockage from formula or medicine. Use at least 2 tablespoons (30 milliliters) of water to flush the tube. Follow directions for flushing your PEG tube. If your PEG tube becomes clogged, try to unclog it as soon as you can. Flush your PEG tube with a 60 milliliter (mL) syringe filled with warm water. Never use a wire to unclog the tube. A wire can poke a hole in the tube. Your healthcare provider may have you use a special medicine or a plastic brush to help unclog your tube. Check the PEG tube daily. Check the length of the tube from the end to where it goes into your body. If it gets longer, it may be at risk for coming out. If it gets shorter, let your healthcare provider know right away. Check the bumper (piece that goes around the tube, next to your skin). It should be snug against your skin. Tell your healthcare provider if the bumper seems too tight or too loose. Use an alcohol pad to clean the end of your PEG tube. Do this before you connect tubing or a syringe to your PEG tube and after you remove it. When you disconnect tubing or a syringe from your PEG tube, do not let the end of the PEG tube touch anything. How do I care for the skin around my PEG tube? Do not remove the stitches or medical tape that hold your PEG tube in place when you first get it. Your healthcare provider will take them off once the skin around your tube heals. Leave clean bandages over the tube area for the first 24 hours after the tube is put in. You may not need to use bandages after 24 hours if the skin around the tube looks dry. Ask when you can shower or bathe. Routine skin care: Clean the skin around your tube 1 to 2 times each day. Ask your healthcare provider what you should use to clean your skin. Check for redness and swelling in the area where the tube goes into your body. Check for fluid draining from your stoma (the hole where the tube was put in). Gently turn your tube daily after your stitches come out. This may decrease pressure on your skin under the bumper. It may also help prevent an infection. Keep the skin around your PEG tube dry. This will help prevent skin irritation and infection. Use topical medicines as directed. You may need to put antibiotic cream on the skin around your tube after you are done cleaning it. What else do I need to know about a PEG tube? You may need to keep track of how much formula and other liquids you have each day. You may also need to keep track of how much you urinate and how many times you have a bowel movement each day. Bring this log to your follow-up visits. You may need to check your weight daily or weekly. Keep a record of your weights and bring it to your follow-up visits. Your healthcare provider may need to change your feedings if your weight changes too quickly. Take your medicines as directed. Learn which of your medicines can be crushed, mixed with water, and given through the PEG tube. Certain medicines should not be crushed or may clog the PEG tube. Go to all follow-up appointments. You may need to have blood tests and other tests when you see your healthcare provider. When should I contact my healthcare provider? You have nausea, diarrhea, or abdominal bloating or discomfort. You have stomach pain after each feeding or when you move around. You have discomfort or pain around your PEG tube site. The skin around your PEG tube is red, swollen, or draining pus. You weigh less than your healthcare provider says you should. Your PEG tube is longer than it was when it was put in. You have questions or concerns about your condition or care. When should I seek immediate care or call 911? You start coughing or vomiting during or after a feeding. You have severe abdominal pain. Blood or tube feeding fluid leaks from the PEG tube site. Your PEG tube is shorter than it was when it was put in. Your PEG tube comes out. Your mouth feels dry, your heart feels like it is beating too fast, or you feel weak. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you. Google Facebook Twitter Print Email © 2014 Truven Health Analytics Inc. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics. 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risks of urinary incontinence

Gender. Women are more likely to have stress incontinence. Pregnancy, childbirth, menopause and normal female anatomy account for this difference. However, men with prostate gland problems are at increased risk of urge and overflow incontinence. Age. As you get older, the muscles in your bladder and urethra lose some of their strength. Changes with age reduce how much your bladder can hold and increase the chances of involuntary urine release. Being overweight. Extra weight increases pressure on your bladder and surrounding muscles, which weakens them and allows urine to leak out when you cough or sneeze. Other diseases. Neurological disease or diabetes may increase your risk of incontinence.

assessment prior to performing oropharyngeal suctioning

Gurgling sound during respiration. adventitious breath sounds when auscultated Rate and pattern of respiration decreased O2 sat. pulse rate and rhythm

complications of nasotracheal suctioning. (3)

Hypoxemia, trauma to the airway, nosocomial infection

indications for short-term, long-term and intermittent catheterization.

Long-term catheterization -Bladder outlet obstruction not correctable medically or surgically -Intractable skin breakdown caused or exacerbated by incontinence -Some patients with neurogenic bladder and retention -Palliative care for terminally ill or severely impaired ------incontinent patients for whom bed and clothing changes are uncomfortable -Preference of a patient who has not responded to specific incontinence treatments Short-term catheterization -Urologic surgery -Surgery on contiguous structures -Critically ill patients requiring accurate measure of urinary output -Acute urinary retention intermittent/self catheterization: Neurogenic bladder caused by neurogenic damage

**Describe the unexpected outcomes for insertion of an NG tube and the relevant nursing interventions.

Most complications are related to tube misplacement; aspiration and tissue trauma.

difference between a nasogastric, nasointestinal, gastrostomy, jejunostomy, and (PEG) percutaneous endoscopic gastrostomy tube.

Nasogastric tube insertion is the placement of a soft plastic or vinyl tube through the nose, down the esophagus, and into the stomach. It is also called nasogastric intubation. In nasointestinal tube insertion, the tube extends past the stomach and into the small intestine. jejunostomy: the surgical formation of an opening through the abdominal wall into the jejunum Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation).

Type of catheter for a man who will have intermittent catheterization.

Nelaton, Robinson or in/out catheters

procedure for pulse oximetry

No nail polish, or thick nail Avoid using lower extremities that may have compromised circulation, or extremities receiving infusions or other invasive monitoring.

**nurse's role in administering CPAP

Patient Safety: * At the beginning of the shift, the nurse should check the CPAP circuit for proper functioning: that is: absence of circuit leaks; maintenance of positive pressure; adequate inspiratory air flow and prescribed FIO2. * At no time, should the patient receiving CPAP be left without the direct supervision of a "responsible" nurse. * The principles of "Universal Precautions" are to be adhered to at all times. In particular, no piece of equipment is to be shared between patients, without having been first been cleaned according to the policy / procedure "Ventilatory Circuit Changes and Setups". Required Observations: * Every 30 minutes: visual check. Note respiratory rate and effort; SpO2; nausea and vomiting. * Hourly: pulse rate and rhythm; blood pressure; peripheral circulation and proper functioning of humidification system. * Every two hours: condition of skin around and under mask and rubber securing band. Document condition and interventions; condition of conjunctivae. * Every four hours: palpate abdomen for distension and assess need for stomach decompression. Auscultate lungs for equal air entry. * Every four hours: palpate abdomen for distension and assess need for stomach decompression. Auscultate lungs for equal air entry.

What assessment should the nurse perform prior to insertion of an indwelling catheter?

Pattern of voiding Amount of voiding Examine penis for swelling or excoriation that would contraindication the use of condom catherter

List the different equipment used for oxygen supplementation.

Portable oxygen concentrators: -is a device which concentrates the oxygen from a gas supply (typically ambient air) to supply an oxygen enriched gas mixture. CPAP machines and accessories: -Continuous positive airway pressure therapy (CPAP camera.gif) uses a machine to help a person who has obstructive sleep apnea (OSA) breathe more easily during sleep. A CPAP machine increases air pressure in your throat so that your airway doesn't collapse when you breathe in. pulse oximeters, and nebulizers: To convert liquid medication into to a fine spray to be delivered directly to the lungs. -different from inhalers (ie. puffers) b/c inhalers are potable etc.

How can a nurse promote oxygenation in a client?

Positioning the client to allow for maximum chest expansion Encouraging or providing frequent changes in position Encouraging ambulation Incentive Spirometry Implementing measures that promote comfort, such as giving painmedications Deep Breathing and Coughing Hydration

Explain care for the client in the post operative period.

Postoperative care begins in the recovery room and continues throughout the recovery period. Critical concerns are airway clearance, pain control, mental status, and wound healing. Other important concerns are preventing urinary retention, constipation, deep venous thrombosis, and BP variability (high or low). For patients with diabetes, plasma glucose levels are monitored closely by fingerstick testing every 1 to 4 h until patients are awake and eating because better glycemic control improves outcome.

Laboratory findings would indicate possible infection in a patient with an indwelling catheter

Presence of bacteria and white blood cells that is higher then normal in a symptomatic patient.

Why might a client require enteral tube feeding

Prolonged anorexia Severe protein-energy undernutrition Coma or depressed sensorium Liver failure Inability to take oral feedings due to head or neck trauma Critical illnesses (eg, burns) causing metabolic stress

causes that affect the colour of urine

Red/Pink: blood Dark yellow: dehydration Orange: medication Dark brown: food,medication Blue and green: dye, food, medition Red/Pink Red or pinkish urine could be caused by blood. Blood in the urine may come from an infection, kidney disease, cancer, or an enlarged prostate in men. Certain foods like blackberries, beets, and rhubarb may turn your urine a pink or red color. The antibiotic rifampin, pyridium (a drug for urinary tract discomfort), and laxatives with the ingredient senna can all turn urine pink to red. Poisoning from lead or mercury can also make your urine red. Orange Orange urine is commonly caused by medications. These include rifampin, pyridium, laxatives, sulfasalazine (an anti-inflammatory), and some chemotherapy drugs. Medical conditions can also result in your urine being orange. It can be a problem with your bile duct or liver, especially if your stool is also light in color. If you are dehydrated, your urine can be an orange color because it's too concentrated. Blue/Green Food dyes may turn your urine blue or green. Dyes that are used in certain kidney and bladder tests can also result in blue and green urine. Some medications can produce these colors as well; these include indomethacin, amitriptyline, and propofol. This is also true of some multivitamins. Less commonly, green urine may be caused by an infection in the urinary tract cause by the bacteria pseudomonas. The rare, hereditary disease hypercalcemia (having too much calcium in your blood) causes blue urine. Dark Brown Eating a lot of fava beans, aloe, or rhubarb can make your urine dark brown. Medications for malaria such as primaquine and chloroquine and the antibiotics nitrofurantoin and metronidazole can also turn urine dark brown. Methocarbamol, a muscle relaxant, and laxatives with cascara or senna, can also give your urine a brownish color. Some urinary tract infections and disorders of the liver or kidneys can also result in brown urine. Dark Yellow If your urine just appears darker than normal, you are probably dehydrated. The resulting concentration of the compounds in your urine make it appear dark. When to Seek Medical Help You should see your doctor if you cannot explain the unusual color of your urine as resulting from a food, as a side effect of a medication, or from being dehydrated. Some of the underlying causes of abnormal or dark urine can be very serious illnesses that need to be treated. It is especially important to see your doctor if you think there is blood in your urine. Dark brown urine along with pale-colored stools or a yellowish tinge to your skin and eyes is another reason for a trip to the doctor.

signs and symptoms of a urinary tract infection

Strong-smelling urine Pain or a burning feeling during urination A feeling of urgency, or feeling the need to urinate frequently. An altered appearance of the urine, either bloody (red) or cloudy (containing pus)

Phagia

Swallowing

Cuffed and Cuffless Tracheostomy Tubes

The cuff blocks any air from flowing around the tube and assures that the patient is well oxygenated. Cuffless tubes are usually worn over a long period of time so require a very accurate fit in order to prevent pressure sores in the trachea or at the tracheal stoma. it allows air to pass into the upper trachea and larynx so the patient speck.

**Describe the procedure for verifying tube placement prior to enteral feeding with a nasogastric tube.

These steps will help you check the correct placement of the tube. • Wash your hands well with an antibacterial soap (any soap that says deodorant or antimicrobial). See "GREAT information...Clean hands" for guidelines. • Pull back the plunger of a syringe to the 10ml or 15ml mark. You should have nothing but air in the syringe at this point. • Connect the syringe to the NG tube. Place the flat side of a stethoscope over your child's stomach. While you listen through the stethoscope, slowly push the air into the NG tube. If the tube is in the right place, you will hear the air as it passes into the stomach (it sounds like a "burp"). Another way for you to check for tube placement is to pull back on the plunger of the syringe. If stomach contents come back into the NG tube, the placement is correct.

ventilation, eupnea, bradypnea, tachypnea, hyperventilation, hypoventilation and apnea.

Ventilation: The exchange of air between the lungs and the atmosphere so that oxygen can be exchanged for carbon dioxide in the alveoli eupnea: normal, good, unlabored ventilation, sometimes known as quiet breathing or resting heart rate. bradypnea: abnormally slow breathing rate. tachypnea: abnormally rapid breathing. Hyperventilation: suddenly start to breathe very quickly. apnea: temporary cessation of breathing, especially during sleep.

**Your client has difficulty with dribbling and incontinence after removal of an indwelling catheter. Review the steps you will take to retrain the bladder before and after catheter removal?

Void according to a timetable not urge: every 2 to 3 hours, then every 4 to 6. With habit training client does not need to learn to control urge to void by deep slow breathing. Pelvic floor/kegal exercise exercise to reduce episodes of incontinence.

normal range of respirations for an adult, elderly person and a newborn

adult: 12 to 16 breaths per minute. elderly: 16-35 newborn: 30-60 breaths per minute

When would a client require nasopharyngeal or nasotracheal suctioning

air passage filled with secretion

Type of catheter for a child who needs an indwelling catheter for a for three days. He has a latex allergy.

all-silicon foley catheter

hemothorax

an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae, usually as the result of trauma

purpose of continuous bladder irrigation (CBI)

cleansing of blood and other sediments after an operation/surgical procedure.

pneumothorax

collection of air in the pleura space pneumothorax (noo-mo-THOR-acks) is a collapsed lung. -Pneumothorax occurs when air leaks into the space between your lungs and chest wall.

assessment of a client with a tracheostomy prior to suctioning.

congestion of the thorax on auscultation. is client able to cough out secretion?

non-fenestrated vs. fenestrated tracheostomy tube?

fenestrated tube has a hole above the curviture of the treacheotomy tube and inner cannula. Tracheostomy patients can communicate without a fenestrated tracheostomy tube. However, speech is forced and limited.

Type of catheter for a small female who will need an indwelling catheter for up to three months.

foley

questions/history taking the nurse should ask in order to identify a urinary alteration

oliguria, anuria, polyuria, hematuria, proteinuria, dysuria, and nocturia

assessment of a client with a chest tube

patency of chest tubes, presence of drainage, presence of fluctuations, patient's vital signs, chest dressing status, type of suction, and level of comfort. a. Assess patient for respiratory distress and chest pain, breath sounds over affected lung area, and stable vital signs b. Observe for increase respiratory distress c. Observe the following: (1) Chest tube dressing, ensure tubing is patent (2) Tubing kinks, dependent loops or clots (3) Chest drainage system, which should be upright and below level of tube insertion d. Provide two shodded hemostats for each chest tube, attached to top of patient's bed with adhesive tape. Chest tubes are only clamped under specific circumstances: (1) To assess air leak

**Describe nursing interventions for dyspnea management and airway maintenance.

positioning (upright), a fan blowing air, and cool foods and a cool environment can also be helpful. Decreasing the total body fluid burden, diuretics q Administration of bronchodilators, of oxygen therapy Offering fluids and using humidifier loosen mucus, coughing easier

purpose of catheter irrigation

to remove obstruction such as a blood clot that develops after bladder, kidney, or prostate surgery.

equipment required for oropharyngeal suctioning

wall or portable suction machine suction catheter kit sterile NaCl clean and sterile gloves towel moisture resistant disposable bag.

difference between a water-seal and a waterless chest drainage system

water-seal: simple means of draining air in body cavity out of the client without it returning waterless: simple means of draining fluid in body cavity out of the client without it returning

Explain the difference between a bolus and continuous enteral feed and why they might be used.

with continuous feeding, you will slowly be fed throughout the day. Bolus tube feeding is a method of tube feeding characterized by giving a patient a certain amount of formula three or more times (6 times) a day. -A feeding tube will be used to give you nutrients while you cannot eat, swallow .... meaning that the medication is released over time rather than all at once. Continuous Feedings Better tolerated than intermittent or bolus delivery particularly in patients with limited absorptive surface area results in less reflux, dumping and diarrhea. Better tolerated in critically ill children. In the PICU, best to start with a continuous schedule and to progress to intermittent schedule once clinical status is improved. Recommended for delivery of nutrients directly into the small bowel. Recommended for preterm or term infants with persistent feeding intolerance, significant respiratory instability or significant gut resection. Useful for overnight nasogastric for children with chronic diseases i.e. renal disease, CF, CHD.