NU 311 Finals

How do you insert and maintain a nasogastric tube for gastric decompression?

(look at check off sheet)

Nasal Cannula

*** Advantages*** -Simple, effective, inexpensive, disposable, and comfortable ***Disadvantages*** -Unable to use with nasal obstruction -Drying of mucous membranes -Can dislodge easily -May cause skin irritation or breakdown -1-6 L/min: 24%-44% -The two tips of the cannula, about 1.5 cm (1/2 inch) long, protrude from the center of a disposable tube and are inserted into the nostrils. -Flow rates less than 4 L/min do NOT require humidification. Those greater than 4 L/min NEED humidification to prevent drying of nasal and oral mucous membranes -An oxygen conserving cannula is indicated for those patients who require higher oxygen concentrations than what can be provided via traditional nasal cannula. *The cannula possess a built-in reservoir that allows for increasing oxygen concentration at a lower flow rate, which can increase patient comfort.

Face Tents

-28%-100% FiO2 -Appropriate for patients with facial trauma/surgery or who cannot tolerate mask. - commonly used in the pediatric setting. -These devices are able to provide high concentrations of humidified oxygen. This is particularly useful in the child with airway inflammation, epiglottitis (croup), or other respiratory tract infections. -not precise on how much O2 the patient is getting

High Flow Nasal Cannula

-Adjustable FiO2 (.21-1.0) with a modifiable flow up to 60 L/min -HFNC has been used in the neonatal population and there is increasing evidence to support its use in adults with acute respiratory failure. *It is used in patients prone to severe oxygen desaturation and is currently recommended for use in critical care settings. *This system can deliver heated and humidified air/oxygen mixture at high flows, up to 60 L/min. *The oxygen gas is then delivered to the patient via wide-bore nasal prongs. ***Disadvantage*** risk for infection

Sodium Restriction

-Allows low levels of sodium and may include a 4g (no added salt), 2g (moderate), 1g (strict), or 500mg (very strict) -ordered for pt's with heart failure, renal failure, cirrhosis, hypertension

What are the best practice measures to prevent catheter related UTI's (CAUTIS)

-Aseptic insertion. -Limit the use of indwelling catheters to essential conditions and removing them as soon as medically indicated. -Use for acute urinary retention, accurate intake and output measurement in critically ill patients, perioperative preparation for select surgeries, healing of open sacral or perineal wounds in incontinent patients, patients requiring prolonged bedrest, and comfort for end-of-life care. -Use the smallest catheter possible. -Daily cleansing of the urethral meatus with soap and water or perineal cleanser. -Maintaining a closed urinary drainage system. -Maintaining a free flow of urine through the catheter. -Avoiding urethral trauma by securing a catheter. -Antiseptics applied to the urinary meatus are NOT effective and should not be applied. -Antiseptic solutions placed in drainage bags and complex urinary drainage systems have NOT been found to be effective.

What are methods to maintain peristomal skin integrity

-Clean peristomal skin gently with warm tap water using washcloth; do not scrub skin. Pat dry. -Pouching peristomal and stomal area.

What are the risk factors for nutritional problems?

-Clear/Full-liquid diets for more than 3 days without or with inappropriate/insufficient nutrient supplementation. -IV feeding (dextrose or saline) or NPO for more than 3 days without supplementation. -Low intakes of prescribed diet/tube feedings. -Weight 20% above or 10% below desirable body weight (accounting for edema). -Pregnancy weight gain deviating from normal patterns. -Diagnoses that increase nutritional needs, decrease nutrient intake, or both: Cancer, malabsorption, diarrhea, hyperthyroidism, excessive- inflammation, postoperative status, hemorrhage, infected/draining wounds, burns, infection, major trauma. -Chronic use of drugs (especially alcohol). -Alterations in chewing, swallowing, appetite, taste, and smell. -Body temperature consistently above 37° C (98.6° F) for more than 2 days. -Hemocrit : <43% in men, <37% in women. -Hemaglobin: <14 g/dL in men, <12 g/dL in women. -Absolute decrease in lymphocyte count ( <1500 cells/mm3). -Elevated (>250 mg/dL)/Decreased ( <130 mg/dL ) total plasma cholesterol. -Serum albumin <3 g/dL in patients without renal or liver disease, generalized dermatitis, overhydration.

How do you give feedings and medications through a feeding tube?

-Continual: uses enteral pump not IV -Intermittent: "Bolus feeding"; administration using a syringe letting gravity help with drip.

CPAP and Bi-Pap

-Continuous Positive Airway Pressure (CPAP) - can take home -Bi-level Positive Airway Pressure (BiPap) -Cpap provides pressure to keep the alveoli open and decrease the work of breathing. -good for sleep apnea patients -neonatal

Oxygen-conserving cannula (Oxymizer)

-Delivers higher concentrations without mask -8L/min: 34%-60% FiO2 -Patient's breathing pattern may affect % oxygen. -long term O2 use at home ***Disadvantages*** -cannula cannot be cleaned -more expensive

Ventilator Associated Pneumonia (VAP) prevention guidelines

-Good hand hygiene -ETT cuff pressure 25-30 cm H2O every 2 hours -Head of bed elevated 30-45 degrees -DVT Prophylaxis -Peptic Ulcer Prophylaxis -Daily sedation interruptions (sedation vacation) -Oral care with 0.12% chlorhexidine every 12 hours and general oral care every 2 hours -Complete subglottal suctioning to decrease risk of oral fluid aspiration -Accurate and timely documentation -Timely ventilator circuit changes -Turn and reposition every 2 hours

Teaching for CPT

-Ideally treat before breakfast and about 1 hour before bedtime -Frequency depends on need and patient's tolerance and varies from once daily to every 2 to 4 hours in an acute situation. -Instruct patient's family or caregiver in recognizing when patient's respiratory status requires breathing exercises or postural drainage. -In pediatrics, it is usually performed at least twice daily -CPT is not beneficial in the treatment of bronchiolitis in children younger than 2 years of age. -Children with pneumonia, bronchiolitis, and asthma have limited benefits with the administration of CPT.

How do you check for placement of feeding tube before starting feedings?

-Initial x-ray verification. -Re-verify tube position before administering medications or bolus feedings per tube. - Re-verify tube position every 4-6 hours (according to institution policy) during continual feedings. (page 847-851)

Safety Guidelines regarding O2 Therapy

-Know the pt's normal range of vital signs and pulse oximetry values. -Be aware of environmental conditions -Complete an environmental assessment for respiratory hazards in the home -Document a pt's smoking history -Know the pt's most recent hemoglobin values and ABG's -Oxygen is a medication -Provide education to the pt and the family -Have suction equipment available to assist clearing airway secretions -Have self-inflating resuscitation bags available

Performing Percussion and Vibration

-Percussion and vibration can be combined with postural drainage -During postural drainage a nurse, respiratory therapist, or trained family member sometimes uses physical maneuvers such as percussion and vibration on the rib cage over lung tissue. -The clinician uses techniques on specific parts of the rib cage over each affected lung region. -Percussion is the manual external clapping of a patient's chest wall with cupped hands or with a mechanical device in a rhythmic fashion to loosen secretions from the bronchial walls. > You apply vibration to a patient's external chest wall by placing both hands (one over the other) over the areas to be vibrated. >Then you tense and contract the shoulder and arm muscles to create a vibration while the patient exhales to mobilize secretions. -Vibration augments the natural movement of the rib cage during exhalation and helps with secretion clearance. >Never use the clavicles, breast tissue, sternum, spine, waist, and abdomen for percussion and vibration; only perform these maneuvers over the ribs. -High-frequency chest wall compression (HFCWC) consists of an inflatable vest linked to an air-pulse generator. One HFCWC device is the Vest airway clearance system, which assists in loosening and removing secretions from the airways. -HFCWC systems deliver high-frequency, small-volume expiratory pulses to a patient's external chest wall. This mechanical action helps to loosen and mobilize airway secretions. -Patients with sputum production of 25 to 30 mL/day also benefit from this device because HFCWC decreases the viscosity of mucus, making it easier to cough productively. [Demonstrate for students the different motions to produce each type of maneuver.]

How do you apply critical thinking by understanding that nasogastric tubes are placed for different reasons

-Small-bore NG tubes are placed for feeding. -The Levin tube is a single-lumen tube that connects to a drainage bag or an intermittent suction device to drain stomach secretions. -The Salem sump tube is preferred for stomach decompression.

Safety Precautions to take regarding CPT

-Some medications, particularly diuretics and antihypertensives, cause fluid and hemodynamic changes. These changes affect a patient's tolerance of the positional changes. Steroid medications, age, and malnutrition increase a patient's risk for pathological rib fractures and often contraindicate rib shaking. -Know pt's vital signs. Conditions such as atelectasis and pneumonia requiring CPT can affect a patient's vital signs. The degree of change is related to the level of hypoxia, overall cardiopulmonary status, and tolerance of the procedure. -Note previous surgical and medical history.certain conditions such as increased intracranial pressure, spinal cord injury, abdominal aneurysm resection, bone metastases, or severe osteoporosis contraindicate the positional changes of postural drainage. Thoracic trauma contraindicates percussion, vibration, and shaking.] -Note LOC. Alteration in mental status often makes it difficult or impossible for a pt to understand the procedure and participate in coughing. -Always have suction equipment readily available -Note the pt's activity level

Use of Peak Flowmeter

-The peak expiratory flow rate (PEFR) measurement is the maximum flow that a patient forces out during one quick, forced expiration, measured in liters -Use these measurements as an objective indicator of a patient's current status or the effectiveness of treatment. -Normal peak expiratory flow rate (PEFR) values vary according to a person's age, gender, and size. -Decreased PEFR may indicate the need for further interventions such as increased doses of bronchodilators or anti-inflammatory medications. -Patients with asthma perform PEFR measures in the home to monitor the status of their airways. -Health care providers usually recommend that patients measure their PEFR during the following times: every morning, before taking asthma medicines, during asthma symptoms or an asthma attack, after taking medicine for an asthma attack, and at other times recommended by their health care provider. *Pt's with asthma should measure PERF at the same time each day -Green indicates 80-100%, Yellow indicates 50-90%, Red indicates < 50%

Using an Incentive Spirometry

-The use of an incentive spirometer (IS) alone is not recommended in order to prevent postoperative pulmonary complications. It should be used in combination with other pulmonary maneuvers such as deep breathing and coughing, early mobilization of the patient, and directed coughing. -Studies demonstrate that use of an IS in combination with coughing and other methods of lung expansion lowers rates of postoperative pneumonia -two types

Chest Physiotherapy

-Used to mobilize pulmonary secretions -Includes physical chest wall maneuvers > Percussion >Vibration >Shaking >Postural drainage -Early CPT for intubated patients improves airway patency, secretion clearance, and oxygen delivery to tissues -aimed to remove secretions that accumulate in the airways of patients with cystic fibrosis -often combined with other therapies

High-Flow devices

-Ventri mask -Oxygen hood -Face tent -Large volume nebulizer -Blender mask

Peforming Oropharyneal suctioning

-Yankauer suction catheter or tonsillar tip, suction device is used for oropharyngeal suctioning (i.e., the removal of pharyngeal secretions through the mouth). -The tip of this suction catheter usually has one large and several small openings through which the mucus enters with application of negative pressure. -The Yankauer suction catheter is angled to facilitate removal of secretions through a patient's mouth. It handles large volumes of secretions better than a standard suction catheter. - It is not used to suction the nares or trachea because of its size. -Patients with artificial airways and impaired swallowing require use of the Yankauer suction device to provide oral hygiene. >Rigid, minimally flexible plastic >multiple openings > used when secretions are copious and thick

Ventri Mask

-a cone-shaped, high-flow device with entrainment ports of various sizes at the base of the mask. -The entrainment ports adjust to permit regulation of FiO2 from 24% to 50%. -More precise delivery of FiO2 % -good for COPD patients

Know the types of therapeutic diets

-clear diet -full liquid -pureed -mechanical/dental soft -soft/low residue; low fiber -high fiber -regular

Acapella Device

-designed to aid sputum clearance -handheld -provides positive expiratory pressure and vibration -During exhalation pressure from the airways is transmitted to the Acapella device, which helps mucus dislodge from the airway walls and as a result prevents airway collapse, accelerates expiratory flow, and moves mucus toward the trachea. -Some patients with cystic fibrosis may have greater benefit from this device versus standard chest physiotherapy. -two types

Describe how to obtain a mid-stream catch urine specimen

-have pt independently clean perineum area and collect specimen. Help bedridden patients onto bed pan to facilitate access to perineum ***Males: *** 1. Hold penis with one hand; using circular motion and antiseptic towelette, clean meatus, moving from center to outside 3 times with different towelettes. 2. Have uncircumcised male pt retract foreskin for effective cleaning of urinary meatus and keep retracted during voiding. 3. Return foreskin when done. 4. Rinse area with sterile water and dry with cotton balls or gauze pad. 5. After pt initiates urine stream into toilet or bedpan, have him pass urine specimen container into stream and collect 90-120 mL of urine ***Females:*** 1. Either nurse or pt spreads labia minora with fingers of nondominant hand. 2. With dominant hand clean urethral area with antiseptic swab. Move from front (above urethral orifice) to back (toward anus). > Use fresh swab each time; clean 3 times; begin with labial fold farthest from you, then labial fold closest, and then down center. 3. Rinse area with sterile water and dry with cotton ball. 4. While continuing to hold labia apart, pt initiates urine stream into toilet or bedpan; after stream is achieved, pass specimen container into stream and collect 90-120 mL of urine. 5. Remove specimen container before flow of urine stops and before releasing labia or penis; allow pt to finish voiding into bedpan or toilet. Offer to help with personal hygiene as appropriate.

Plastic Face Mask with reservoir bag (Partial nonrebreather )

-higher concentrations of O2 -When used as a nonrebreather, the plastic face mask with a reservoir bag delivers 60% to 90% oxygen at 10-15min rates. -doesn't dry out membranes -Breathing in O2 that is in the bag ONLY -Last resort before ventilation -bag must be inflated before placing on patient -Frequently inspect the bag to make sure that it is fully inflated. If it is not fully inflated, the patient may breathe in large amounts of exhaled carbon dioxide. ***Disadvantages*** -hot and confining -may irritate skin -bag may twist and deflate itself

Administering O2 therapy to a patient with an artificial airway

-humidification is required parts include: -T tube: The T tube, also called a Briggs adaptor, is a T-shaped device with a 15-mm connection that connects an oxygen source to an artificial airway such as an endotracheal (ET) tube or tracheostomy -Trach collar: a curved device with an adjustable strap that fits around a patient's neck. collects sputum. Always document with O2 %

Fat modified

-low total and saturated fat and low cholesterol intake limited to < 300mg daily, and fat intake 30% to 35% -eliminates/reduces fatty foods for hypercholesterolemia, malabsorption disorders, diarrhea

Low flow devices

-nasal cannula -simple nonrebreather mask -partial rebreather

Pulse Oximetry

-the noninvasive measurement of arterial blood oxygen saturation, the percent to which hemoglobin is filled with oxygen. - The more hemoglobin saturated by oxygen, the higher the oxygen saturation. -Normally oxygen saturation (SpO2) is greater than 95%. -A saturation less than 90% is a clinical emergency -Pulse oximetry measurement of SpO2 is simple and painless and has few of the risks associated with more invasive measurements of oxygen saturation such as arterial blood gas sampling.

Simple Face Masks

-used for short-term oxygen therapy -fits loosely and delivers oxygen concentrations from 35% to 50%. 6-12 L/min ***Advantages*** 50% Useful for short periods of time such as patient transportation ***Disadvantages*** Contraindicated for patients who retain CO2 -May induce feelings of claustrophobia -Therapy interrupted with eating or drinking -Increased risk for aspiration

Know how to obtain urine specimen from a closed system

1. Explain that you will use syringe without need to remove urine through catheter port and that pt will not experience any discomfort. 2. Explain that you will need to clamp catheter for 10-15 min before obtaining urine specimen and that urine cannot be obtained from drainage bag. 3. Clamp drainage tubing with clamp or rubber band for as long as 15 min below site chosen for withdrawal. 4. After 15 min, position pt so catheter sampling port is easily accessible. 5. Clean port for 15 sec with disinfectant swab and allow it to dry. 6. Attach needleless Luer-Lok syringe to built-in catheter sampling port. 7. Withdraw 3 mL for culture or 20 mL for routine urinalysis. 8. Transfer urine from syringe into clean urine container for routine urinalysis or into sterile urine container for culture. 9. Place lid tightly on container and unclamp catheter to allow urine to flow into drainage bag; ensure that urine flows freely. 10. Open specimen container, maintaining sterility of inside specimen container, and place cap with sterile inside up. Do not touch inside of cap or container. 11. Replace cap securely on specimen container, touching ONLY the outside. 12. Clean urine from exterior surface of the container. 13. Securely attach label to container, not lid. 14. In patient's presence, confirm label identifiers > If patient is female, indicate if she is menstruating. 15. Send specimen and completed requisition to lab within 20 min; refrigerate specimen if delay cannot be avoided

How to place a patient on a bedpan

1. Have pt assume supine position. 2. Place pt who can help on a bedpan: 3. Don clean gloves. 4. Raise head of bed 30-60 degrees 5. Remove upper bed linens, do NOT expose the pt. 6. Place hand, closest to pt's head, palm facing up under pt's sacrum to help lift; ask pt to lift hips upward. 7. As pt raises hips, use other hand to slide bedpan under them. Keep pt's knees bent. Be sure that open rim of bedpan is facing toward foot of bed 8. Position pt on one side and place bedpan firmly against buttocks. 9. Push bedpan down and toward pt. 10. Keep one hand against pt, place other around far hip; ask pt to roll back on bedpan, flat in bed. 11. Raise pt's head 30 degrees and have them bend their knees. 12 Maintain pt's comfort and safety; cover pt for warmth. 13. Have call bell and toilet tissue within reach; ensure that bed is in lowest position and raise side rails. 14. Remove and discard gloves and perform hand hygiene. 15. Allow pt privacy but monitor status and respond promptly.

How to remove an impaction

1. Lower side rail on pt's RIGHT side. 2. Help pt roll to left side with knees flexed and back. 3. Drape pt's trunk and lower extremities with bath blanket and place waterproof pad under pt's buttocks. 4. Place bedpan next to pt. 5. Perform hand hygiene and apply clean gloves; lubricate gloved index finger and middle finger with dominant hand with anesthetic lube. 6. Instruct pt to take slow deep breaths during procedure. Gradually and gently insert gloved index finger and feel anus relax around finger; insert middle finger. 7. Gradually advance fingers slowly along rectal wall toward umbilicus. 8.. Gently loosen fecal mass by moving fingers in scissors motion to fragment fecal mass. 9. Work stool downward toward end of rectum; remove small sections of feces and discard into bedpan. 10. Observe pt's response and periodically assess heart rate and look for signs of fatigue. > STOP procedure if HR drops/rhythm changes from baseline OR if pt has dyspnea/complains of palpations. 11. Continue to clear rectum of feces and allow pt to rest at intervals. 12. After removal of impaction, perform perineal hygiene. 13. Remove bedpan and inspect feces for color and consistency; dispose of feces in toilet.

How do you apply a urinary pouch?

1. Place towel under and across pt's lower abdomen. 2.Remove used pouch and skin barrier. If stents are present, pull pouch gently around them and lay towel underneath. 3. Empty pouch and measure output. Dispose of pouch in appropriate receptacle. 4. Place rolled gauze at stoma opening. Maintain gauze at stoma opening continuously during pouch measurement and change. 5. While keeping rolled gauze in contact with the stoma, cleanse peristomal skin gently with warm tap water using washcloth but do not scrub skin. > If you touch stoma, minor bleeding is normal. Pat skin dry. 6. Measure stoma; be sure that opening is at least 1/8 in larger than stoma to avoid pressure on stoma. > Expect size of stoma to change for first 4-6 weeks after surgery. 7. Trace pattern on pouch backing/skin barrier. 8. Cut opening in pouch. 9. Remove protective backing from adhesive surface; remove rolled gauze from stoma. 10. Apply pouch. Press adhesive barrier firmly into area around stoma and outside edges; have pt hold hand over pouch 1-2 min to apply heat to secure seal. 11. Use adapter provided with pouches to connect pouch to bedside urinary bag. Keep tubing BELOW level of bag.

How do you insert and check the placement of nasogastric tube?

1. Position patient upright in high Fowler's position unless contraindicated. a. If patient is comatose, raise head of bed as tolerated in semi-Fowler's position with head tipped forward, chin to chest. b. If patient is forced to lie supine, place in reverse Trendelenburg's position. 2. Determine length of tube to be inserted and mark location with tape or indelible ink. a. Measure distance from tip of nose to earlobe to xyphoid process of sternum. 3. Prepare NG for intubation. a. Inject 10 mL of water from 30- to 60-mL Luer-Lok or catheter-tip syringe into the tube. b.Dip tube with surface lubricant into glass of room-temperature water or apply water-soluble lubricant. 4.Explain the step and gently insert tube through nostril to back of throat (posterior nasopharynx). This may cause patient to gag. Aim back and down toward ear. Advance tube as patient swallows 5. When tip of tube reaches carina (approximately 25-30 cm./10-12 in. in an adult), stop and listen for air exchange from distal portion of tube. 6.. Check for position of tube in back of throat with penlight and tongue blade. 7. Keep tube secure and check placement of tube by aspirating stomach contents to measure gastric pH. (should be 5.0 or less) 8. Fasten end of NG tube to patient's gown using clip or piece of tape. Do not use safety pins to secure tube to gown. 9. Obtain x-ray 10. perform oral hygiene (Read check off)

How to assist with feeding patients

1. Prepare patient's room for mealtime. a. Perform hand hygiene. Clear over-bed table. b. Help patient to comfortable sitting position in chair or place bed in high-Fowler's position. If patient is unable to sit, turn him or her on side with head of bed elevated. 2. Prepare patient for meal. a. Help patient with pain relief and elimination needs and help him or her perform hand hygiene before meals. b. Help patient put in dentures and put on eyeglasses or insert contact lenses if used. 3. Ask in which order patient would like to eat his or her meal. Ask about desired seasonings. Help patient to cut food in bite size pieces if unable to do independently. 4. Use adaptive eating and drinking aids as needed according to your assessment (e.g.,two-handled cup with lid, plate with plate guard, utensils with splints, utensils with enlarged handles) 5. Identify food placement for disoriented, visually impaired, or easily fatigued patients by locating on plate as if plate were a clock. 6. Feed patient in manner that facilitates chewing and swallowing. a. Older adult: Feed small amounts at a time, observing biting, chewing, swallowing, and fatigue between bites; be sure that patient has swallowed food. 7.Watch patient successfully swallow first few bites of food and drink. If the patient is able to do so on there on stop here and return back to the room 15-20 minutes later. If patient is at risk to aspirate then stay at bedside.

How do you care for a gastrotomy or jejunostomy tube?

1.Exit site may have a dressing or be open to air (confirm order). 2.Assess site for excoriation, drainage, signs of infection, or bleeding (q 4-6 hours depending on institution). 3. Cleanse around site with warm water and mild soap (or according to institution policy) using clean gloves (frequency varies with institution). 4. Replace dressing if indicated (date, time, and initial). 5.Document appearance of site, drainage noted, and application of dressing.

What is the purpose of the blue pigtail on a salem sump?

A "blue pigtail" is an air vent that connects with the second lumen on the salem sump. When the main lumen of the sump tube is connected to suction, the air vent permits free, continuous drainage of secretions.

When receiving report at change of shift, the nurse is informed that her 65-year-old male patient has intermittent episodes of bronchospasm. What symptom(s) will the nurse expect to see when the patient is experiencing bronchospasm? (Select all that apply.) A. Wheezing B. Dyspnea C. Bradycardia D. Hyperthermia

A & B. Bronchospasm is the constriction of bronchi and bronchioles. It is a normal physiological reaction to alveolar hyperventilation. Symptoms include wheezing, dyspnea, difficulty breathing, and coughing.

What is a bladder scan machine and how is it used for determining residual urine?

A bladder scanner is a noninvasive device that creates an ultrasound image of the bladder for measuring the volume of urine in the bladder. The device makes calculations to report accurate urine volumes (especially lower volumes). Use a bladder scanner to assess bladder volume whenever inadequate bladder emptying is suspected such as after the removal of indwelling urinary catheters, in the evaluation of new-onset incontinence, and after urologic surgery. The most common use for the bladder scan is to measure postvoid residual (PVR), the volume of urine in the bladder after a normal voiding. To obtain the most reliable reading, measure PVR within 10 minutes of voiding. A volume <50 mL is considered normal. Two or more PVR measurements >100 mL require further investigation.

What is a Suprapubic Catheter?

A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. The catheter may be sutured to the skin, secured with an adhesive material, or retained in the bladder with a fluid-filled balloon (similar to an indwelling catheter). Suprapubic catheters are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urologic surgery) and in situations when a long-term urethral catheter causes irritation or discomfort or interferes with sexual functioning.

Ostomy

A surgical procedure in which the elimination of stool or urine is rerouted from the usual exiting part of the pt. Instead, the stool or urine exits the body through a surgically created opening called a stoma. *Pt has no sensation or control over the time or frequency of the output and must wear a pouch to collect the effluent.

High Fiber

Addition of fresh uncooked fruits, steamed veggies, bran, oatmeal and dried fruits; includes sufficient amounts of ingestible carbohydrates to relieve constipation, increase GI motility, and increase stool weight

Soft/ low residue; low fiber

Addition of low fiber, easily digested foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and veggies; includes foods that are easy to chew and simply cooked. Does NOT permit fatty, rich, and fried foods

Precautions with aspirations

Almost any condition that produces general muscle weakness or any condition associated with neurologic impairment of the swallowing mechanism and altered mental status places patients at risk for dysphagia/aspirations (e.g., brain injury, stroke). Be aware that patients without primary neurologic diagnoses such as myocardial infarction (heart attack), pneumonia, and chronic obstructive pulmonary disease are also at risk for dysphagia/aspirations. (read page 832 in skills book)

How do you check residual? What to do with aspirant?

Assess residual (tolerance of feedings) by performing syringe aspiration (q4-6 hr; see if pt is tolerating it); usually stop feedings if gastric residual is more than 500 mL or 250 mL when 2 measurements are taken 1 hour apart.

How do you assess a stoma?

Assess type, location, color, swelling, presence of sutures, trauma, and healing/irritation of peristomal skin. Color/moisture: Red or pink and moist. Report a gray, purple, or black stoma to the charge nurse or health care provider. Size: In the 4-6 weeks after surgery, the stoma will likely decrease in size. Measure with each pouch change. Peristomal skin normally is intact with some reddening. Presence of blisters, a rash, or raw-like appearance is abnormal.

Which of the following patient statements indicates to the nurse that there is a need for additional teaching related to the patient's use of a peak flowmeter? A. "I prefer to stand when using the meter." B. "I record the third reading in my diary." C. "I make a firm seal on the mouthpiece with my lips." D. "I blow out as hard as possible."

B. The patient will perform three measurements. The highest number is what is to be recorded in the chart or the patient's diary. This reading is the peak expiratory flow (PEF).

A 52-year-old man with a history of hypertension was diagnosed with sleep apnea. Which oxygen therapy delivery method would benefit this patient? A. Nonrebreather mask B. Incentive spirometry C. Continuous positive airway pressure D. Oxymizer

C. Continuous positive airway pressure (CPAP) keeps the terminal airways (alveoli) partially inflated, reducing the risk for atelectasis; if atelectasis has occurred, positive pressure assists in reinflation. This is very beneficial in patients who retain carbon dioxide, such as those with obstructive sleep apnea (OSA) or acute exacerbations of COPD. CPAP keeps the airway open and prevents upper airway collapse. As a result of CPAP therapy, the patient breathes more normally, sleeps better, and has markedly reduced snoring.

When performing rib shaking on a 78-year-old woman who is malnourished, what potential complication will the nurse be watching for? A. Vomiting B. Fever C. Rib fracture D. Apnea

C. Malnutrition increases a patient's risk for pathologic rib fractures and often contraindicates rib shaking. The force and motion required for the therapy pose a risk for this patient.

What patients should not use Chest Physiotherapy

CPT not recommended for pneumonia; ACT not recommended for COPD (unless secretion retention is present)

Mechanical/ Dental Soft

Consists of all previous diets plus addition of lightly seasoned ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, peanut butter; AVOID tough meats, nuts, bacon, and fruits with tough skin or membranes

Which of the following conditions is a contraindication for postural drainage? A.Stabilized head injury B.Tracheobronchial secretions C. Chronic pulmonary disease D. Pulmonary embolism

D. Chest physiotherapy (CPT) consists of physical chest wall maneuvers such as percussion, vibration, and shaking, postural drainage (PD), and cough. CPT can dislodge an embolism, which could be fatal for the patient.

Once a patient with cystic fibrosis reaches the age of 25 years, he can safely reduce the number of times he has chest PT to twice daily. True or False?

False. When dealing with patients who have cystic fibrosis, skipping CPT maneuvers is not an option. Often these patients get tired of the daily routine and need assistance in designing an individualized plan for airway clearance. Chest physical therapy for cystic fibrosis should be done 3 to 4 times each day.

What is the color and consistency of an Ileostomy?

Fecal effluent will be watery-to-thick liquid and contain some digestive enzymes

Nasogastric/nasointestinal tube for feeding

Feeding: -Administration of nutrition into the gastrointestinal (GI) tract when a patient cannot ingest, chew, or swallow solid food but can digest and absorb nutrients. -Uses a small-bore, flexible feeding tube

Clear Liquid Diet

Foods that are clear and liquid at room or body temperature that leave little residue and are easily absorbed; commonly ordered for short-term use (24 to 48 hours) after surgery, before diagnostic tests, and after episodes of diarrhea and vomiting. Examples: water, apple/cranberry juice, gelatin, popsicles

Flow-oriented Incentive Spirometry

Have one or more plastic chambers with freely movable, colored balls. As a patient inhales slowly, the balls are elevated to a premarked area.

Pureed

Includes foods on clear- and full-liquid diet plus easily swallowed foods that do not require chewing (scrambled eggs, pureed meats, vegetables and fruits, mashed potatoes); ordered for patients with head and neck abnormalities or who have had oral surgery; can be modified for low sodium, fat, or calorie count.

Full Liquid Diet

Includes foods on clear-liquid diet plus addition of smooth-textured dairy products like milk and ice cream, strained soups, custard, refined cooked cereals, vegetable juice, and pureed vegetables; commonly ordered before or after surgery for patients who are acutely ill from infection or for patients who cannot chew or tolerate solid foods.

What is the difference between a straight and indwelling catheter?

Indwelling catheter: remains in the bladder after urination Straight catheter: removed from the bladder after urination (one time use)

Regular Diet

NO dietary restrictions

Can removing an impaction be delegated to a NAP?

No

Can the skill of inserting and maintaining an NG tube be delegated to a NAP?

No

Can the task of administering oxygen therapy to a patient with an artificial airway be delegated to NAP?

No

Can the task of caring for a patient receiving noninvasive ventilation be delegated to NAP?

No

Can the assessment of a patient's risk to aspirate be delegated to a NAP?

No; However, NAP may feed patients after receiving instruction on aspiration precautions.

Can the initial assessment of a pt's condition be delegated?

No; however, the skill of follow-up PERF measurements can be

Can feeding tube insertion be delegated to a NAP?

No; however, they can help with patient positioning and comfort measures during insertion

Oxygen Hood

Oxygen hoods and tents provide an oxygen-rich environment to patients needing supplementation. The pictures above are "hoods" and are used with newborns. They are usually attached to "blenders" so the percentage of oxygen delivered to the infants can be adjusted. They also provide a humidified environment. Clear plastic oxygen tents are also used for older children.

Non continent (Incontinent) Ostomy/Diversion

Results from a surgical procedure that leaves a pt with an external stoma through which either stool or urine drains. It is noncontinent/incontinent because the effluent drains spontaneously from the stoma and the pt must continuously wear an external ostomy pouch over the stoma.

What should you do if you are feeding your patient and they begin to aspirate?

STOP FEEDING IMMEDIATELY and suction their airway

Why should a catheter be secured to the patients leg?

Securing catheter reduces risk of urethral erosion, CAUTI, or accidental catheter removal; attachment of securement device at catheter bifurcation prevents occlusion of catheter.

Nasogastric/nasointestinal tube used for suctioning

Suctioning: -Following major surgery. - Conditions affecting GI tract altering normal peristalsis. -Keeps stomach empty until normal peristalsis returns.

Colostomy

Surgical formation of an opening of the colon or large intestine onto the surface of the abdomen through which fecal matter is emptied.

Ileostomy

Surgical formation of an opening of the ileum onto the surface of the abdomen through which fecal matter is emptied.

Volume-oriented Incentive Spirometry

Use a bellows that a patient must raise to a predetermined volume by inhaling slowly. The advantage of the volume-oriented is that a patient can achieve a known inspiratory volume and measure it with each breath

Can the task of applying a nasal cannula or oxygen mask be delegated to nursing assistive personnel?

Yes

Can the task of assisting a patient to use incentive spirometry (IS) be delegated to NAP?

Yes

Can the task of performing oropharyngeal (Yankauer) suctioning be delegated to nursing assistive personnel (NAP)?

Yes

Can the task of performing percussion and vibration be delegated to NAP?

Yes

Can the task of postural drainage be delegated to nursing assistive personnel (NAP)?

Yes

Can the task of using an acapella device be delegated?

Yes

How to remove a bedpan

a. Place pt's bedside chair close to working site of bed. b. Maintain privacy; determine if pt is able to wipe. c. Deposit contaminated tissue in bedpan if no specimen/intake and output (I&O) is needed. ***MOBILE PT:*** > Ask pt to flex knees and upper torso; lift buttocks up from bedpan. > At the same time, place hand (farthest from pt) on side of bedpan to support it and place other hand (closest to pt) under sacrum to help lift. > Have pt lift and remove bedpan. > Place bedpan on draped bedside chair and cover. ***IMMOBILE PT:*** > Lower head of bed and help pt roll onto side AWAY from you and off bedpan. > Hold bedpan flat and steady while pt rolls off. > Place bedpan in draped bedside chair and cover. 13. Allow pt to perform hand hygiene. 14. Change soiled linens, remove and dispose of clean gloves and return pt to comfortable position. 15. Place bed in lowest position and ensure that call bell, phone, water, and desired personal items are within easy access. 16. Perform hand hygiene.

Diabetic

allows for patients to select amount of food from basic food groups

The color and ph of intestinal contents

color: clear, clear and dingy yellow, clear brown ph: >6.0

The color and ph of pulmonary contents

color: cloudy yellow ph: > 6.0

The color and ph of gastric contents

color: dark green, cloudy, dingy yellow and clear, dark brown ph: < 5.0

What is the color and consistency of a descending/sigmoid colon?

effluent similar to that normally passed through the rectum

What is the color and consistency of an ascending/transverse colon?

effluent varies from thick liquid to semi-formed stool

Green device (Acapella)

for patients who can maintain expiratory flow above or equal to 15 L/min for at least 3 seconds

Blue device (Acapella)

is for patients who cannot maintain their expiratory flow above 15 L/min for greater than 3 seconds

What best determines the type of fecal effluent from an ostomy?

location

What causes constipation?

may be a side effect of opioid use, decreased mobility, and change in fluid and diet intake ( view table 35.1 on pg 906)

Restricted Fluids

required in severe heart failure or kidney failure

Postural Drainage

use positioning techniques to drain secretions from segments of the lung and bronchi

Why does it take an older adult longer to achieve target volume when using an incentive spirometer?

weakened respiratory muscles and decreased elastic recoil properties of the lungs affect a patient's ability to cough and deep-breathe.