CH,14, 15, & 16

The six rights of medication administration are:

1 . Right medication 2. Right Dose 3. Right Time 4. Right Route 5. Right Patient 6. Right Documentation

CH 14 NCLEX END OF CH QUESTIONS

1. The LPN/LVN is suctioning a patient through an endotracheal tube. What indicates proper technique? (Select all that apply.): - Preoxygenating the patient before suctioning -Dipping the suction catheter into sterile saline before suctioning 2. A patient's physician told the patient that she was suffering from hypoxia. The patient asks the nurse what that means. Which statement by the nurse is most accurate? -"Hypoxia means that the cells in your body's tissues are not receiving enough oxygen." 3. What is the maximum time suction should be applied during nasotracheal suctioning? -15 seconds 4. If a patient's condition requires a very precise delivery of oxygen concentration, the nurse anticipates that the health care provider will order oxygen to be delivered via which device? -Venturi mask 5. A patient is being discharged to home with an order for oxygen. The order reads, "Continuous O2 at 2 L per N/C." What is the best explanation of this order for the nurse to give the patient? -"You will have oxygen on 24 hours a day at home by use of a nasal cannula, with the flow meter set at 2 liters." 6. The home health nurse is visiting a patient who is on home oxygen therapy. What action by the patient and family members alerts the nurse that further teaching about home oxygen therapy is necessary? (Select all that apply.) -The patient's brother-in-law is in a separate room smoking a cigarette. -The patient states that when shaving an electrical razor is used -The oxygen tubing is coiled and secured with a rubber band to prevent the patient from tripping over the tubing. 7. The nurse encourages the patient to drink an adequate amount of fluids to help with dry mucous membranes and to liquefy secretions. What fluids should the nurse include in this teaching? (Select all that apply.) -water -juice 8. The nurse is reviewing the arterial partial pressure of oxygen (PaO2 ) level on the patient's arterial blood gas report. Which level is most concerning to the nurse? -PaO2 75 mm Hg 9. The home health care nurse is observing the patient while he is filling the humidifier bottle attached to the oxygen tank. Which action by the patient demonstrates knowledge of this procedure? -The patient fills the bottle with distilled water. 10. The nurse observes the student nurse suction the patient with a tracheostomy. Which action by the student nurse requires the nurse to intervene? (Select all that apply.) -The student suctions the patient for 30 seconds during each suctioning attempt -The student uses tap water to clear the catheter tubing between suction attempts. -The student places the thumb over the suction control vent when advancing the catheter into the patient's airway. 11. The health care provider has ordered oxygen at 100% via a nonrebreathing mask. The nurse evaluates that the mask is working properly when making which observation? -The reservoir bag remains nearly full when the patient inhales. 12. The nurse is preparing to perform tracheostomy care and suctioning. What is the best order of actions when performing these two procedures? Place the steps in the correct order. -The nurse performs tracheostomy suctioning. -The nurse changes the tracheostomy ties/strap. - The nurse changes the dressing around the tracheostomy. -The nurse cleans around the tracheostomy with prescribed solution 13. The nurse has just performed oropharyngeal suctioning. Which documentation is the most complete after this procedure? -"Performed oropharyngeal suctioning using Yankaur suction catheter. Moderate amount of thick green, odorless, mucus suctioned. Tolerated procedure well and respirations are nonlabored." 14. The health care provider has ordered a patient diagnosed with pneumonia to have oxygen via a simple face mask. The nurse is aware that the patient will be receiving a FiO2 of what percentage depending on the flowmeter setting? -35%-55% 15. The nurse is assessing a patient who is displaying early signs of hypoxia. What signs and symptoms will the nurse observe? (Select all that apply.) -restlessness -increased pulse rate -irregular apical pulse -dyspnea

Ch.15 Review Questions for the NCLEX ® Examination

1. What would the nurse do to determine the correct distance to insert a nasogastric tube? *Measure from tip of nose to tip of earlobe to the xiphoid process. 2. After inserting a nasogastric tube, the nurse would check for proper placement by which methods? (Select all that apply.) *Gurgling or a swishing sound heard with a stethoscope over the stomach when air is injected into the tube *The ability to aspirate gastric contents with a syringe 3. If the patient is suspected of having a fecal impaction, which type of enema would the nurse anticipate the health care provider to order? *Oil retention enema 4. Bladder training instructions are being given to a patient who has a history of urinary incontinence. The nurse should give the patient which instruction? *"Void every 1.5 to 2 hours while you are awake." 5. A nurse is preparing to insert a nasogastric tube. The nurse should place the patient in which position? *High Fowlers Position 6. A male patient with urinary incontinence has been using an external (condom) catheter. The nurse is evaluating the patient's technique of applying the device. Which finding would indicate that the nurse should give the patient further instructions? (Select all that apply.) *Using elastic tape and wrapping in a spiral pattern to secure the device *Spiraling the tape around the penis to secure the device *Changing the catheter after each time of urination 7. What is considered a noninvasive method of collecting urine for the incontinent patient? *Condom Catheterization 8. A patient with a colostomy continues to worry about odor. Which statement would be appropriate for the nurse to tell the patient about colostomy odor? *"It is caused by certain foods that can be omitted from the diet." 9. The nurse is instructing the patient in performing Kegel exercises. The patient should be instructed to contract the muscles he or she would use to stop the flow of urine. What is the proper technique for performing Kegel exercises? *Contract for 10 seconds and relax for 10 seconds. 10. A bladder retraining program for a patient in an extended-care facility should include which intervention? (Select all that apply.) *Having the patient wear clothing protectors to help decrease embarrassment. *Putting the patient on q 2 hr toilet schedule during the day. 11. The nurse is caring for a patient with a new ostomy. What is the best nursing strategy for encouraging patient self-care of an ostomy? *Encourage the patient to watch the stoma care procedure, gradually encouraging participation. 12. A patient has a nasogastric tube inserted. What type of patient teaching should the nurse give the patient about the NG tube? (Select all that apply.) *"Be careful to not pull on the tube." *"Call the nurse if you feel as if you are going to vomit. *"Let the staff know if the tape holding the tube is irritating your skin." 13. To maintain proper drainage of an indwelling catheter, it is important to perform which action? *Ensure that the collection device is below bladder level. 14. The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause which complication? (Select all that apply.) *Irritation of the stoma *Skin breakdown around the stoma 15. The nurse is administering a cleansing enema. Before administering the enema, the nurse assists the patient into which position? *Left Sims position 16. The nurse caring for a patient with a Foley catheter should perform which actions to lower the risk for infection? (Select all that apply.) *Keep bag below the level of the bed. * Provide perineal care twice a day. * Coil tubing on the bed. * Keep the drainage system closed. 17. The nurse is administering a routine enema to an adult patient. The patient complains of cramping and the urge to defecate. Which nursing intervention is the best to carry out? *Briefly stop the instillation. 18. When providing routine indwelling catheter care, the nurse should be most diligent in cleaning which areas? *The perineal area and 2 inches of the catheter

CH.14 BEFORE THE PROCEDURE DURING THE PROCEDURE AFTER THE PROCEDURE The rationales for these steps are listed in italics in parentheses.

BEFORE THE PROCEDURE 1. Check the health care provider's order. -(Provides basis for care. Many nursing interventions require a health care provider's order. Verification is essential before any procedure is started.) 2. Introduce yourself to the patient; include your name and title or role. -(Decreases patient anxiety and aids in establishing rapport with the patient.) 3. Identify the patient by checking his or her identification bracelet and requesting that the patient state his or her full name or birth date, or both (facility policy will determine the methods for patient identification). -(Ensures that procedure is performed on correct patient.) 4. Explain the procedure and the reason it is to be done in terms that the patient is able to understand. Advise the patient of any unpleasantness that may be involved with the procedure. Give the patient time to ask questions. -(Promotes cooperation, decreases patient's anxiety, and prepares patient.) 5. Determine need for and provide patient education before, during, and after the procedure. -(Promotes patient's independence and compliance.) 6. Evaluate the patient. Each skill box contains an assessment section that includes specific data to evaluate. -(Provides baseline information for later comparisons.) 7. Perform hand hygiene. Don clean or sterile gloves and personal protective equipment as needed according to the procedure, agency policy, and guidelines from the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) (see Chapter 7). -(Reduces the spread of microorganisms and protects the patient and the nurse.) 8. Assemble equipment, and complete necessary charges. Each skill box lists the specific equipment required. -(Organizes procedure so that it will go more smoothly. Some equipment is reusable and is kept at the patient's bedside. Some of the equipment is disposable and charged to the patient when used. Know agency policy.) 9. Prepare the patient for the procedure: a. Close the door or pull the privacy curtain around the patient's bed. -(Provides privacy and promotes patient comfort.) b. Raise the bed to a comfortable working height, and lower the side rail on the side nearest the nurse. --- -(Promotes proper body mechanics by minimizing nurse's muscle strain and preventing injury and fatigue.) c. Position and drape the patient as necessary. Descriptions of specific positions are included in each skill. -(Shows respect for patient's privacy and dignity.) DURING THE PROCEDURE 10. Promote patient involvement as much as possible. - (Participation encourages the patient's cooperation and increases patient's knowledge of condition and care. It also may increase the patient's sense of independence and importance and increase the patient's compliance with treatment.) 11. Determine the patient's tolerance of the procedure, being alert for signs and symptoms of discomfort and fatigue. If the patient cannot tolerate a procedure, describe this inability in the nursing notes. -(Patients' ability to tolerate interventions varies, depending on severity of illness and disability. It is necessary to determine when to provide the patient with an opportunity to rest and when to provide comfort measures.) AFTER THE PROCEDURE 12. Assist the patient to a position of comfort, and place needed items within easy reach. Ensure that the patient has a means to call for help and knows how to use it. -(Promotes comfort and safety. Patients often try to reach items and risk falling or injury.) 13. Raise the side rails, and lower the bed to the lowest position. -(This minimizes the patient's risk in getting out of bed unattended. Use nursing judgment and facility policy to safely allow alert, cooperative patients to have their side rails down.) 14. Remove gloves and all protective barriers such as gown, face shield, and masks. Store appropriately or discard. Remove and dispose of soiled supplies and equipment according to agency policy and guidelines from the CDC and OSHA. -(Reduces spread of microorganisms, maintains cleanliness of environment, and enhances patient comfort and safety.) 15. Perform hand hygiene after removing gloves. -(Wearing gloves does not eliminate the need to perform hand hygiene. Hand hygiene is the most important technique for preventing and controlling the spread of microorganisms.) 16. Document the patient's response to the procedure, expected or unexpected outcomes, and all patient teaching. Specific areas of documentation are indicated in each skill box. -(Timely and accurate documentation is legally required, records patient's progress, and promotes continuity of care.) 17. Report any unexpected outcomes. Specific notes for reporting unexpected outcomes are included in each skill. -(Additional procedures or treatments may be necessary.)

Ch.15 Box 15.2 Patient Problem Statements for the Patient With a Gastric Tube

Deficient Nutrition: • Related to insufficient intake Compromised Swallowing Ability: • Related to neuromuscular impairment Potential for Aspiration Into Airway: • Related to inability to swallow effectively Frequent, Loose Stools: • Related to altered intake associated with tube feedings Infrequent or Dif icult Bowel Elimination: • Related to altered intake associated with tube feedings

CH.14 Table 14.1 Oxygen Delivery Devices With Percentage of Oxygen Delivered Terms: PARTIAL REBREATHER MAS NONBREATHER MASK

Delivery Device -Amount of Delivered *Nasal cannula 1-6 L/min = 24%-44% O2 *Simple face mask 5-8 L/min = 35%-55% O2 *Venturi mask 4-10 L/min = 24%-55% O2 *Partial rebreather mask 6-12 L/min = 60%-90% O2 *Nonrebreather mask 6-15 L/min = 70%-100% O2

CH.14 Box 14.3 Identifying Patient Problem Statements to Promote Oxygenation

Inability to Clear Airway • Related to ineffective cough • Related to excessive secretions Inability to Maintain Adequate Breathing Pattern • Related to respiratory muscle weakness • Related to fatigue • Related to abnormal breathing patterns Inability to Tolerate Activity • Related to imbalance between oxygen supply and demand Anxiousness, Fearfulness, or Despair • Related to dyspnea and feelings of suffocation • Related to fear of dying Compromised Verbal Communication • Related to presence of tracheostomy • Related to intubation

CH.15 Gastric Gavage; Term: DUMPING SYDNROME Gastric Lavage Gastric Decompression

Gastric Gavage *When used to deliver fluids or nutrients (gastric gavage), the NG tube can be attached to a feeding pump, or the feeding can be allowed to flow in by gravity via a bag or a syringe. -If a patient is receiving feedings by way of an NG tube, it is essential to keep the head of the bed elevated at least 30 degrees to help prevent aspiration or gastric reflux. *Tube feedings usually are started slowly and gradually increased, or they may be diluted and gradually strengthened, to prevent DUMPING SYNDROME. - Dumping syndrome is caused by too rapid an infusion of highly concentrated feedings. -The symptoms are similar to those of shock and can be very disturbing to the patient. -During tube feedings, the health care provider also may order additional water to be given through the tube. -This helps meet the fluid needs of the patient, keeps the tube patent, and helps dilute the tube feeding. -Before introducing anything into an NG tube, verify placement of the tube to prevent contents from entering the lungs. -Many facilities require injecting air into the tube while listening to the abdomen over the stomach with a stethoscope. If the tube is in the correct place, a swishing or gurgling noise will be heard. -Aspirating gastric contents is also an appropriate way to check NG tube placement. -While the nurse monitors patients receiving nutrients through an NG tube, it is also necessary to check occasionally for residual feeding left in the stomach. -Excess residual formula could indicate a problem with peristalsis, and the health care provider must be notified. It also could cause gastric reflux, aspiration, or both. Each facility and health care provider has a policy for how often to check residual formula and how much is considered excessive. Gastric Lavage *Gastric lavage often is used in cases of poisoning or to stop gastrointestinal bleeding. -It involves instilling room-temperature medications or solutions into the stomach and then suctioning it back out. Iced or cooled solutions should not be used, especially when copious amounts are needed, as with gastrointestinal bleeding, because they may cause hypothermia, impair platelet production, and cause increase in bleeding. -When performing gastric lavage, the health care provider orders the type of solution, as well as the amount, to be instilled. -Usually 500 mL of the solution is administered at a time and then siphoned back out of the stomach. -This process is repeated until the ordered amount of solution has been used or the anticipated results have been achieved. - Every time the solution is removed from the stomach, it must be measured and evaluated and the results documented. -Sometimes the health care provider orders a specimen of the removed solution to be sent to the laboratory for analysis. -Remember that this procedure is emotional and physically challenging for the patient. Provide appropriate support and reassurance. Gastric Decompression *The purpose of gastric decompression is to remove the air and fluids that build up when gastrointestinal motility is slowed. -It is used frequently after surgery to help with the distention that may occur and to prevent nausea and vomiting. -When used for decompression, the NG tube usually is connected to an intermittent gastric suction device, and the nurse must routinely measure and evaluate the contents of the suction canister. -The tubes most commonly used for decompression are the Levin and Salem sump tubes. -The Levin tube has one lumen and several openings near the tip. -The Salem sump tube is a double-lumen tube: one lumen provides an air vent, and the other is for removal of gastric contents -The patient with an NG tube presents several nursing challenges. Maintaining patient comfort is sometimes the biggest challenge. -NG tubes continually irritate the nasal mucosa and can cause trauma to the tissue. -To lessen this discomfort and potential trauma, the tube should be secured to the patient's nose with tape or a nose guard and then secured to the patient's gown with a pin to prevent unnecessary movement (Skill 15.5 and the Patient Teaching box on nasogastric tubes). -Other comfort measures include removing excess secretions from around the nares and then lubricating the nostrils and the tube with a water-soluble lubricant to prevent crusting of secretions. Box 15.2 lists selected patient problem statements for the patient with a gastric tube.

CH.15 NURSING INTERVETIONS #1-12

Nursing interventions for the patient with a urinary drainage system are aimed at early detection and prevention of infection and trauma When caring for urinary drainage systems, take the following actions: 1. Follow aseptic technique when inserting the catheter, and keep the collecting bag off the floor. -This prevents the introduction of microorganisms into the body from the 2. Record fluid intake and urinary output (I&O), and check the drainage system for proper placement and function regularly -For precision monitoring, such as hourly urine output, add a urometer to the drainage system. 3. Encourage the patient to drink plenty of fluids to flush the urinary tract. 4. Do not open the drainage system after it is in place except to irrigate the catheter, and then only with a specific order from the health care provider. It is important to maintain a closed system to prevent urinary infections 5. Perform catheter care twice daily and as needed, according to standard precautions -Inspect insertion site for blood or exudate that could indicate infection or trauma. 6. Check the drainage system daily for leaks. Know facility policy on replacing the system. -Observe characteristics of the urine, noting blood or sediment. Note odor when draining collection bag. 7. Avoid placing the urinary drainage bag above the level of the catheter insertion. -This will cause urine to reenter the drainage system and contaminate the urinary tract (see Fig. 15.4). 8. Secure the catheter to the patient to prevent tension on the system or backflow of urine. 9. Have the patient ambulate, if possible, to facilitate urine flow. -If it is necessary to restrict the patient's activity, turn and reposition patient every 2 hours. 10. Avoid kinks or compression of the drainage tube to prevent pooling of urine within the system. -Gently coil excess tubing and secure to the bottom bed linens with a clamp or pin to avoid dislodging the catheter. Remember to release the tubing before transferring or repositioning the patient. 11. When urine specimens are ordered, collect specimens from the catheter by cleansing the drainage port with alcohol, then withdrawing the urine by using a sterile needle and 10- mL syringe according to standard precautions. 12. Be sensitive to the patient's feelings regarding the catheter and the constant drainage from the system, and answer patient's questions and concerns when presented (see the Lifespan Considerations for older adults box on catheterization and the Home Care Considerations box on urinary catheter care).

Standard Steps in Selected Skills Before the Procedure During the Procedure After the Procedure

Standard Steps in Selected Skills *To ensure patient safety, as well as nurse safety, during nursing procedures involving elimination and gastric intubation, it is important to understand the steps involved in specific skills. Before the Procedure *1. Check the health care provider's order and review facility policy. (Provides basis for care. Many nursing interventions require a health care provider's order. Verification is essential before any procedure is begun.) 2. Introduce yourself to the patient; include your name and title or role. -(Decreases patient anxiety and aids in establishing rapport with the patient.) 3. Identify the patient by checking his or her identification bracelet and requesting that the patient state his or her name or birth date, or both. -(Ensures that procedure is performed on correct patient.) 4. Explain the procedure and the reason it is to be done in terms that the patient is able to understand. Advise the patient of any unpleasantness that may be involved with the procedure. Give the patient time to ask questions. -(Promotes cooperation, decreases patient's anxiety, and prepares patient. Also helps determine whether procedure is still appropriate.) 5. Determine need for and provide patient education before and during procedure. -(Promotes patient's independence and compliance.) 6. Evaluate the patient. Each skill box contains an assessment section that includes specific data to evaluate. -(Provides baseline information for later comparisons.) 7. Perform hand hygiene and don clean gloves according to agency policy and guidelines from the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) . -(Reduces the spread of microorganisms and protects the patient and the nurse.) 8. Assemble equipment, and complete necessary charges. Each skill box lists the specific equipment required. -(Organizes procedure so that it will go more smoothly. Some equipment is reusable and is kept at the patient's bedside. Some of the equipment is disposable and charged to the patient when used. Know agency policy.) 9. Prepare the patient for the procedure: a. Close the door or pull the privacy curtain around the patient's bed. (Provides privacy and promotes patient comfort.) b. Raise the bed to a comfortable working height, and lower the side rail on the side nearest the nurse.(Promotes proper body mechanics by minimizing nurse's muscle strain and preventing injury and fatigue.) c. Position and drape the patient as necessary. Descriptions of specific positions are included in each skill. (Shows respect for patient's privacy and dignity.) During the Procedure 10. Promote patient involvement as much as possible. (Participation encourages the patient's cooperation and increases patient's knowledge of condition and care. It also may increase patient's sense of independence and importance and increase patient's compliance with treatment.) 11. Determine the patient's tolerance of the procedure, being alert for signs and symptoms of discomfort and fatigue. If the patient cannot tolerate a procedure, describe this inability in the nursing notes. -(Patient's ability to tolerate interventions varies, depending on severity of illness and disability. It is necessary to determine when to provide the patient with an opportunity to rest and when to provide comfort measures.) After the Procedure 12. Assist the patient to a position of comfort, and place needed items within easy reach. Ensure that the patient has a means to call for help and knows how to use it -(Promotes comfort and safety. Patients often try to reach items and risk falling or injury.) 13. Raise the side rails, and lower the bed to the lowest position. -(This minimizes the patient's risk in getting out of bed unattended. Use nursing judgment and facility policy to safely allow alert, cooperative patients have their side rails down.) 14. Remove gloves and all protective barriers such as gown, goggles, and masks. Store appropriately or discard. Remove and dispose of soiled supplies and equipment according to agency policy and guidelines from the CDC and OSHA. -(Reduces spread of microorganisms, maintains cleanliness of environment, and enhances patient comfort and safety.) 15. Perform hand hygiene after removing gloves. -(Wearing gloves does not eliminate the need to perform hand hygiene. Hand hygiene is the most important technique for preventing and controlling the spread of microorganisms.) 16. Document the patient's response to the procedure, expected or unexpected outcomes, and all patient teaching. Specific areas of documentation are indicated in each skill box. -(Timely and accurate documentation is legally required, records patient's progress, and promotes continuity of care.)

CH.14 Transtracheal Oxygen Delivery Term: Endotracheal (ET) tube

* An ENDOTRACHEAL (ET) TUBE is a tube inserted through the patient's mouth and into the upper airway to provide a patent airway. *Oxygen is administered through an ET tube via an oxygen setup or through a ventilator. -Suctioning of secretions also can be performed through an ET tube. -An ET tube typically is used in an emergency situation to establish a patent airway or to provide an airway and oxygenation of a patient undergoing general anesthesia. -ET tubes are used for short-term management of the airway. -Typically an ET tube is replaced by a tracheostomy if an artificial airway is needed for longer than 2 weeks.

Ch.15 Skills for Gastrointestinal Procedures Inserting and Maintaining Nasogastric Tubes Term: NASOGASTRIC (NG) TUBE

** NASOGASTRIC NG TUBE is a flexible, hollow tube that is passed into the stomach via the nasopharynx. -It can be used to remove gas, fluids, or toxic substances from the stomach; to diagnose gastrointestinal problems; to obtain secretions; or to administer fluids and nutrients into the stomach. -It also can help prevent vomiting and abdominal distention and allow the digestive tract to rest and heal. There are various types of NG tubes, including percutaneous endoscopic gastrostomy (PEG), Button, and jejunal tubes. The physician determines which tube is best suited for the patient

Term: BLADDER TRAINING Ch. 15 Removal of Indwelling Catheter

**BLADDER TRAINING g is the achievement of voluntary control over voiding; it often involves developing the use of muscles in the perineum. -When urinary incontinence results from decreased perception of bladder fullness or impaired voluntary motor control, bladder training is often helpful. *Before the removal of a urethral catheter, bladder training may be ordered by the health care provider and involves a clamp-unclamp routine to improve bladder tone. -Kegel exercises also may be used to improve perineal muscle tone and sphincter control as part of a bladder training regimen. -The patient is instructed to perform Kegel exercises by trying to stop the flow of urine during voiding. -Once the patient has identified the correct muscles and the feeling of their contraction, the patient can perform these exercises when not voiding by tightening the muscles of the perineum, holding the tension for 10 seconds, and then relaxing for 10 seconds. -This should be done multiple times, several times a day. Because muscle control develops gradually, it sometimes takes 4 to 6 weeks to slow or stop urinary leakage *Monitor the patient's voiding for a few days to identify patterns, or schedule voiding times to correlate with the patient's activities. -Typical voiding times are upon rising, before each meal, and at bedtime. Assist the patient to void as scheduled, check the patient for wetness periodically, and remind or assist the patient to the toilet as scheduled. -After a few days, evaluate the scheduled voiding pattern by identifying its effectiveness in keeping the patient continent. Then the schedule is modified until continence is established. Fluid intake and medications typically influence voiding patterns. Limiting fluids after the evening meal reduces the need for nighttime voiding and helps keep the patient dry REMOVAL OF AN INDWELLING CATHETER *It is always best to remove an indwelling catheter as soon as possible because its presence increases the risk for urinary tract infection -After surgery, the health care provider usually orders the catheter removed after 8 to 24 hours, depending on the type of surgery. -In some situations, the catheter remains in place for days or even weeks. The longer a catheter has been in place, the greater is the risk that an infection will develop. -Urinary tract infections are one of the most common types of iatrogenic (caused by treatments or diagnostic procedures) infections in health care. -Symptoms of a urinary tract infection may not appear for 2 or more days after the catheter is removed. -That means the patient may already be home before he or she begins displaying symptoms. -For that reason, it is necessary to inform the patient of the risk for infection, how to prevent it, signs and symptoms to watch for, and when to call the health care provide

CH.15 INCONTINENCE & ITS MANAGEMENT Term: INCONTINENCE

**INCONTINENCE —the inability to control urine or bowel elimination— can be a psychologically distressing and socially disruptive problem, especially among older adults. *problem, especially among older adults. Urinary incontinence can occur because pressure in the bladder is too great or because the sphincters are too weak. -It can involve a small leakage of urine when the person laughs, coughs, or lifts something heavy (stress incontinence), or it can be a constant leakage whenever the bladder contains urine (urge incontinence). -Collaborating with other members of the health care team is important to identify the cause and the extent of incontinence and to assist in managing the problem. *Fecal incontinence may result from diarrhea or constipation, muscle damage or weakness, nerve damage, a rectocele, or even inactivity. -Patients with urinary or fecal incontinence may require disposable adult undergarments or underpads to help prevent soiling of clothing and embarrassment. -Use of discreet incontinence products helps promote self-care and self-esteem. *Urine and feces are also very irritating to the skin. Skin that is exposed continuously becomes inflamed and irritated quickly. -To help prevent skin impairment, make sure to change the undergarments or underpads frequently; cleanse the skin thoroughly after each episode of incontinence with warm, soapy water; and dry it completely (Box 15.1). Cleanse the perineum in a professional, caring, and matter-of-fact manner. -The patient must not be reprimanded, scolded, or humiliated for having an "accident.

CH.14 Care of the Tracheostomy Terms: TRACHEOSTOMY APNEA

*A TRACHEOSTOMY is an artificial opening made by a surgical incision into the trachea. -A tracheostomy may be created for patients who are experiencing APNEA (cessation of breathing) or some form of respiratory obstruction. *Many types of tracheostomy tubes are available; the one chosen depends on why it is being used and the condition of the patient. *During a sterile surgical procedure, the health care provider makes an incision into the patient's trachea and inserts a tracheostomy tube into the opening. *The tube then is secured in place by cotton tape or a specifically designed tie/strap wrapped around the patient's neck. -This provides the patient with a patent airway. -Sterile 4 × 4 precut drain gauze is placed around the opening in the neck, under the flange of the outer tube. -This protects the skin during the healing process and decreases the risk for infection. -An endotracheal or a tracheostomy tube provides a direct route for introduction of pathogens into the lower airway, which increases the risk of infection. *The primary nursing responsibilities for maintaining a tracheostomy tube are to keep the airway clear, keep the inner cannula clean, prevent impairment of surrounding tissue, and provide the patient with a means of communication *The nursing interventions that follow enable the nurse to meet those responsibilities and adequately care for a patient with a tracheostomy tube. • Minimize infection risk: • Evaluate the patient for excess secretions and suction as often as necessary. • Provide constant airway humidification. • Change or clean all respiratory therapy equipment every 8 hours. • Remove water that condenses in equipment tubing. • Provide frequent mouth care (apply moisturizing agents to dry, cracked lips). • Maintain nutritional levels: • Patients with ET tubes are allowed nothing by mouth (NPO). It is necessary to provide parenteral or enteral nourishment. • Patients with a tracheostomy may not be limited in regard to drinking fluids and eating once the initial healing phase of the new tracheostomy has passed. -If a patient is able to eat, a cuffless tracheostomy tube is best. Not all patients have cuffless tracheostomy tubes. -The patient may have a tracheostomy tube with a cuff to provide maximum sealing of the airway. -Cuffed tracheostomy tubes generally are used for patients who are at risk for aspiration because of swallowing difficulties or who are receiving mechanical ventilation. -The cuff must be deflated at prescribed intervals to prevent tissue necrosis of the trachea. Noncuffed tracheostomy tubes often are used to maintain the patient's airway when a ventilator is not needed or when the patient is being prepared to have the tracheostomy discontinued. -The physician, often with consultation with the respiratory therapist, chooses the tube based on the patient's condition, neck shape, and size and purpose of the tracheostomy. • Ensure adequate ventilation and oxygenation: • Listen to lung sounds regularly. • Elevate the head of the bed to assist with ventilation. • Turn and reposition the patient every 2 hours for maximal ventilation and lung expansion. • Evaluate the effects of respiratory therapy regularly. • Provide safety and comfort: • Check tube placement at regular intervals; tracheostomy tubes are secured around the neck with tapes or specially designed ties/strap. Make sure they are snug and the tube is securely in the neck stoma. • Change the tapes or ties/strap whenever they are soiled to lessen the chances of skin impairment • Always keep a spare tracheostomy tube at the bedside. • Enhance communication: • Organize questions so that the patient can give simple "yes" or "no" responses by nodding the head or using hand signals. • Assess whether the patient can use an erasable board or notepad to communicate. • Talk to the patient and explain all procedures. • Reorient the patient frequently if necessary. • Encourage family and friends to talk to the patient. • Keep a call light (or tap bell) within patient's reach.

Ch.15 Administering an Enema Term; ENEMA, FECAL IMPACTION

*An ENEMA is the instillation of a solution into the colon via the anus. -The primary reason for an enema is promotion of defecation in a patient with constipation. -Enemas can be given for a number of reasons, such as cleansing the colon before a diagnostic procedure or abdominal surgery, management of constipation or fecal impaction, and administration of medication. -The volume and type of enema administered depends on the reason for it and the health care provider's order. -A cleansing enema stimulates peristalsis by introducing large volumes of fluid to distend the bowel. -This type of enema helps empty the colon completely and is used frequently before surgery or a GI diagnostic procedure. *An oil retention enema is used to soften the stool and lubricate the bowel to make defecation easier. It is used when a fecal impaction is suspected. *A FECAL IMPACTION is a collection of feces in the rectum in the form of a mass that becomes so large or hard that the patient is unable to pass it voluntarily. -Medicated enemas can be used for a variety of reasons but are used most frequently to bring down an extremely high potassium level (polystyrene sulfonate [Kayexalate] enema). -No matter what type of enema is used, caution patients to limit the number of enemas they use. -The defecation reflex may become dependent on enemas with repeated use, which can cause constipation. It is better to determine the cause of bowel irregularity or constipation and treat the cause rather than relying on enemas

Box 15.1 Patient Problem Statements for the Patient With a Urinary Tract Disorder

*Functional Inability to Control Urination: • Related to cognitive deficits • Related to mobility deficits • Related to sensory deficits *Potential for Compromised Skin Integrity: • Related to presence of urine on skin *Impaired Self-Esteem due to Current Situation: • Related to inability to control passage of urine *Inability to Control Urination due to Physical Stress: • Related to changes in muscles and structure of urinary system associated with increased age *Inability to Control Urination due to Urgency: • Related to decreased bladder capacity *Potential for Infection: • Related to inadequate personal hygiene • Related to lack of knowledge of care of a urinary stoma

Ch.15 Terms; OSTOMY. ILEOSTOMY, COLOSTOMY, UROSTOMY

*An OSTOMY, by definition, is an artificial opening. -The site of the opening is called a stoma. *OSTOMIES can be created because of trauma to the intestine, severe inflammation, or diseases such as cancer that involve part of the intestine. *They can be temporary or permanent, depending on the reason they are present, and the characteristics of the fecal material vary according to where the OSTOMY is located along the intestine. -Fecal material in the ileum is liquid, and fecal matter in the rectum is solid. -Therefore the closer the OSTOMY is to either end determines what type of stool will be in the OSTOMY. -Material coming out of the stomach contains many enzymes that increase the acidity of the material. -Therefore stool in the ileum, cecum, and ascending colon tends to be more acidic and irritating to the skin surrounding the OSTOMY. -As the material moves through the large intestine, water is removed, and the material becomes more solid and less acidic, causing less irritation to the skin surrounding the stoma. *An ILEOSTOMY is an opening in the ileum (the distal part of the small intestine). -An ILEOSTOMY is needed when the entire colon must be removed or bypassed, as in cases of congenital defects, cancer, inflammatory bowel disease, or bowel trauma. *A COLOSTOMY is the surgical creation of a stoma on the abdominal wall to where the colon is normally attached. -The COLOSTOMY then diverts stool through the stoma. Again, the stool may be liquid, semiformed, or formed, depending on the area of the colon incised. -The procedure is performed for patients with cancer of the colon, intestinal obstructions, intestinal trauma, or inflammatory diseases of the colon. Some colostomies are permanent, and some are temporary measures used until intestinal healing occurs. *A UROSTOMY is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin. -This may be necessary in the presence of a congenital anomaly or when the bladder must be removed because of disease, trauma, or obstruction.

Ch.16 Events Necessitating Cardiopulmonary Resuscitation Terms; Clinical Death, Biological Death & Brain Death

*CPR is indicated when the patient is not responsive and not breathing. *There are two purposes of CPR: 1. To keep the blood circulating and carrying oxygen to the brain, the heart, and other parts of the body 2. To keep the airway open and the lungs supplied with oxygen when breathing has stopped *CLINICAL DEATH means that heartbeat and respiration have stopped. *BIOLOGIC DEATH results from permanent cellular damage caused by lack of oxygen. The brain is the first organ damaged by this lack of oxygen. *If CPR is started within 4 minutes of cardiopulmonary arrest, it may help reverse clinical death. *After 10 minutes without CPR, brain death most likely occurs. -Therefore it is extremely important to begin CPR as quickly as possible. *BRAIN DEATH is an irreversible form of unconsciousness characterized by a complete loss of brain function while the heart continues to beat. -The legal definition of this condition varies from state to state. BRAIN DEATH statutes in the United States differ by state and institution. -Some US state or hospital guidelines require the examiner to have certain expertise . -The usual clinical criteria for brain death include the absence of reflex activity, movements, and respiration. The pupils are dilated and fixed. * Because hypothermia, anesthesia, poisoning, and drug intoxication have the capacity to cause a deep physiologic depression that resembles brain death, a diagnosis of brain death requires that the electrical activity be evaluated and shown to be absent on two electroencephalograms obtained 12 to 24 hours apart. *Cerebral blood flow studies are permitted in some states to evaluate whether brain death has occurred. Brain death also is referred to as irreversible coma. -Statutes in states and even health care facility procedures may vary concerning brain death determination. Refer to your state law and to facility policy and procedure manuals.

Ch.15 Bowel Elimination Term: DEFECTION

*Elimination of bowel wastes (DEFECTION) is a basic human need and is essential for normal body function. -Normal bowel elimination depends on several factors: a balanced diet, including high-fiber foods; a daily fluid intake of 2000 to 3000 mL; and activity to promote muscle tone and peristalsis. -Each patient has an individual pattern of defecation, but every patient should have a bowel movement at least every 1 to 3 days. -This pattern should be determined on hospital admission, and an abdominal evaluation should be completed. -Ask about any alterations in bowel elimination to determine patient problems related to elimination

Ch.15 Term; Flatulence

*FLATULENCE, or the presence of air or gas (flatus) in the intestinal tract, typically occurs when a person consumes gas-producing liquids and foods such as carbonated beverages, cabbage, or beans; swallows excessive amounts of air; or is constipated. -It also can be caused by decreased peristalsis, abdominal surgery, some narcotic medications, and decreased physical activity. -Flatulence may cause distention of the stomach and abdomen and, in some cases, mild to moderate abdominal cramping, which can be painful. -To promote peristalsis and passage of flatus, encourage the patient to ambulate. -If ambulating does not help relieve the flatulence and the possible cause is not found, use of a rectal tube may be necessary. -The presence of the tube in the rectum stimulates peristalsis and the movement of flatus, thus eliminating the discomfort

TERMS: VENTURI MASK SIMPLE FACE MASK; CHAPTER 15

*Face mask: -Depending on patient's respiratory condition, the health care provider may prescribe delivery of oxygen by a mask. -The mask is designed to fit snugly over the patient's nose and mouth. Different types of masks are used according to patient's needs, such as the VENTURI MASK *the partial rebreather mask (Step 8b[5a]), the nonrebreathing mask (Step 8b[5b]), and the SIMPLE FACE MASK

Ch.16 Term; EMERGENCY MEDICAL SERVICES (EMS) & TRIAGE

*First aid includes assessing the victim for life-threatening conditions, performing appropriate interventions to sustain life, and keeping the person in the best possible physical and mental condition until the assistance of EMERGENCY MEDICAL SERVICE (EMS) is obtained *EMS is a national network of services that provides coordinated aid and medical assistance from primary response to definitive care. -First aid does not replace medical care but is used to preserve life until medical help is obtained. - Because permanent disability and injury can occur within minutes, the nurse should be prepared to handle emergency conditions and administer first aid. - In the case of multiple injuries, patients are surveyed quickly for severity of injuries so that health care providers can treat life-threatening problems first. *This process of classifying a group of patients according to the severity of injury and need of care is called TRIAGE. *The TRIAGE process is based on the premise that patients who have a threat to life, vision, or limb should be treated before other patients. In a disaster, triage is a process in which numerous patients are "sorted" so that it is possible to concentrate care and resources on those who are more likely to survive. In this chapter, the rescuer often is referred to as the nurse or you, the reader. *However, any person certified to perform cardiopulmonary resuscitation (CPR) and first aid may assist with these activities.

CH.16 Moral and Legal Responsibilities of the Nurse TERM: GOOD SAMARITAN LAWS

*GOOD SAMARITAN LAWS (legal protection for those who give first aid in an emergency situation) have been enacted in most states to protect health professionals from legal liability when they provide emergency first aid. *If a nurse follows a reasonable and prudent course of action, the chances of resulting legal problems are very small. *Nurses are obliged to obtain permission to treat any conscious patient, even in an emergency situation. Before first aid is administered, verbal permission should be obtained from the victim, because the victim has the right to refuse first aid. -The law assumes consent from an unconscious person. *After the nurse has initiated first aid, there is a moral and legal obligation to continue the aid until someone with comparable or better training is able to care for the victim; for example, an emergency medical technician (EMT), or paramedic, or a health care provider may arrive at the scene and assume first aid care of the victim.

Ch.15 Care of the Patient With Hemorrhoids

*Hemorrhoids are swollen and inflamed veins in the anus and lower rectum. -They may result from straining during bowel movements or from increased pressure during pregnancy or with heavy lifting. *Hemorrhoids can be internal (inside the rectum), or external (around the anus). -They are frequently a source of discomfort and have the capacity to cause an alteration in elimination. *The goal for patients with hemorrhoids is to decrease pain, prevent elimination problems, and prevent damage to the already swollen tissue. - To facilitate these goals, it is necessary for the patient to maintain a proper diet high in fiber, ensure adequate fluid intake, and participate in regular exercise. -If the hemorrhoids are particularly troublesome, localized heat in the form of a sitz bath, or witch hazel pads often provide some relief. *Use extreme caution when inserting rectal suppositories for patients with hemorrhoids. Use a liberal amount of lubricant during insertion to prevent pain or trauma to the rectal tissue. -In such patients, rectal thermometers and rectal tubes should not be used.

CH.14 Care of the Patient With a Tracheostomy Collar and T Piece or T Tube

*In a healthy person, the upper airway normally filters and humidifies air upon inspiration. *The air taken in by a patient with a tracheostomy bypasses the upper airway and is not humidified. *For this reason, patients with artificial airways must have constant humidification. *To humidify the air, or oxygen being given, a T piece (T tube) or a tracheostomy collar is attached to the tracheostomy tube to deliver moisture, oxygen, or both. *The T piece or T tube is a T-shaped device that is connected to large-bore tubing and then can deliver humidification, oxygen, or both *A tracheostomy collar also is designed to supply humidification and humidified oxygen to the lower respiratory tract. *The collar covers the open end of the tracheostomy tube and has an adjustable strap that extends around the patient's neck

CH.15 Urinary Catheters TERMS: IRRIGATION CATHTERIZATION URINARY CATHETER

*Most urinary catheters are made of soft plastic or rubber and can be used for treatment and diagnosis. Urinary catheters are used to maintain urine flow, to divert urine flow to facilitate healing postoperatively, to introduce medications by IRRIGATION, and to dilate or prevent narrowing of some portions of the urinary tract. *Catheters are used for intermittent and continuous urinary drainage. Urinary catheters can be placed in the bladder, the ureter, or the kidney *CATHETERIZATION of the bladder, which is usually the responsibility of the nurse, involves introducing a rubber or plastic tube (a URINARY CATHETER) through the urinary meatus and the urethra into the urinary bladder. *Catheterizing the ureters or kidneys is the responsibility of the health care provider. Catheters are measured by the French (Fr) system and range in size from 14- Fr to 24-Fr for adult patients.

CH.15 ROUTINE CATHETER CARE

*Patients should receive routine catheter care and perineal hygiene at least every 8 hours to prevent urinary tract infections *During catheter care, cleanse the first 2 inches of the catheter to remove any secretions or encrustations from the catheter. *Look for inflammation at and around the urethral meatus and check for swelling or discharge from the urethra. -Some facilities discourage the use of powders and lotions in the perineal area of patients with catheters because these can lead to the growth of microorganisms that could enter the urinary tract and cause urinary tract infections. -Perform perineal and catheter care after bowel movements, especially if the patient is incontinent of stool.

CH.15 SEL-CATHETERIZATION

*Self-catheterization is a potential option for the patient who has had a spinal cord injury or other neurologic disorders that interfere with urinary elimination. **Intermittent self-catheterization promotes independence for the patient and eliminates the need for an indwelling urinary drainage system -. In the home, there are fewer foreign microorganisms and therefore less risk of cross contamination. For this reason, it is possible to perform the catheterization procedure with clean technique rather than sterile technique. **It is necessary to instruct the patient to be alert for signs of infection, and the patient should be encouraged to have periodic evaluations by the health care provider.

CH.14 SKILLS FOR RESPIRATORY DISORDERS OXYGEN TERMS: Fraction of Inspired (FiO2) -Flowmeter -nasal cannulla

*The flow rate of oxygen is ordered in liters per minute (L/min). This determines how much oxygen the patient will receive; however, these numbers do not correlate directly with the percentage of oxygen delivered. *The percentage or concentration of oxygen delivered is called the FRACTION INSPIRED (FiO2) *The amount of oxygen delivered will depend on the type of device used *An oxygen FLOWMETER (Fig. 14.1) is the device used to set the prescribed rate of oxygen. *There are many safety issues involved in the administration of oxygen. *It is a colorless, odorless, and tasteless gas that does not burn or explode, but it does support combustion; that is, if it is combined with other factors, such as an electrical spark or fire, oxygen enables combustion, and nearby objects ignite *Therefore smoking, wool blankets, and friction toys should be avoided when oxygen is administered. * Its the nurses job to observe all safety precautions (14.1) *It also can be very drying to mucous membranes, which increases the risk of tissue cracking and opening, leaving the patient at risk for infection; humidification may be necessary. *In addition, oxygen toxicity can cause scarring of the respiratory tract tissue and blindness. *Oxygen therapy may be initiated by a respiratory therapist, a nurse, an emergency medical technician (EMT), or any other licensed health care provider with an appropriate order for the oxygen. *In some facilities, there is a respiratory care department, staffed by respiratory therapists who assume the responsibility of administering oxygen and delivering treatments that will improve a patient's ventilation and oxygenation. *In caring for a patient having difficulty breathing or exhibiting any symptoms of HYPOXIA, the nurse must recognize the symptoms quickly and administer the oxygen via the appropriate mechanism as soon as possible. *There are several ways to deliver oxygen. Delivering through a NASAL CANNULA (device consisting of small tubes inserted into the nares) is the most common way to administer oxygen, but it also can be delivered by a Venturi mask by an oxygen hood or halo, or by an oxygen tent *Many elderly patients and patients with chronic lung disease require oxygen in the home setting

Ch.16 Obtaining Medical Emergency Aid Terms; cardiopulmonary resuscitation (CPR)

*The nurse's ability to recognize the need for medical assistance and understanding of how to obtain medical emergency aid can sometimes mean the difference between life and death to an injured or ill person. -It is important for the nurse to know the right phone number to call in the community and in the institutional setting. In most communities, the emergency medical number is 911. -However, in some areas and in some situations, it may be best to call the number for the fire department, police department, or local hospital. *Box 16.1 provides information to convey when calling in a medical emergency from the community *Health care providers must be prepared to provide CARDIOPULMONARY RESUSCITATION (CPR) (basic emergency procedure for life support) if needed until emergency medical assistance arrives. *All health care providers should maintain CPR certification. Most health care institutions provide training. *CPR certification is also available from local fire departments and local chapters of the American Red Cross and the American Heart Association

CH.15 TYPES OF CATHETERS

*The type and size of urinary catheter used are determined by the location being catheterized and the cause of the urinary tract problem *The coudé catheter has a tapered tip and is used when enlargement of the prostate gland is suspected. *The curved stylet of the coudé catheter is used to assist the health care provider in the insertion of a urethral catheter in a male patient with prostate enlargement. *The Foley catheter has a balloon near its tip that is inflated after insertion to hold the catheter in the urinary bladder for continuous drainage. *Malecot and de Pezzer (mushroom) catheters are used to drain urine from the renal pelvis of the kidney, and the Robinson catheter has multiple openings in its tip to facilitate intermittent drainage. *Catheters designed to be inserted into the ureters are long and slender to pass into the ureters more easily. In patients with blood in their urine, a whistle-tip catheter may be used because it has a slanted, larger orifice at its tip. *The cystostomy, the vesicostomy, or the suprapubic catheter is inserted through the abdominal wall above the symphysis pubis to create a urinary diversion in cases of obstruction, strictures, or injury to the bony pelvis, the urinary tract, or surrounding organs. -The catheter is inserted surgically, is connected to a sterile closed drainage system, and is secured to avoid accidental removal; the wound is covered with a sterile dressing. When the lower urinary tract has healed, the patient's ability to void is tested, and when the patient's residual urine is low enough, according to the health care provider, the catheter can be removed. Sometimes, the problem causing the need for a suprapubic catheter is permanent, and the catheter is left in place. *Another form of urinary drainage system that many refer to as a catheter is the condom, or Texas, catheter. This device is not a catheter but rather a drainage system connected to the external male genitalia *Use of the external condom catheter allows for a more normal lifestyle for the patient and limits the risk for infection that an indwelling catheter may cause.

Ch.16 CABs of Cardiopulmonary Resuscitation Term; CAB Circulation Airway Breathing

*To remember the steps of one-rescuer or two-rescuer CPR, remember to spell CAB, a mnemonic for assessing the status of patients in an emergency: Circulation Airway Breathing *CPR performed by the health care provider differs slightly from that performed by the layperson. -The health care provider and layperson verify unresponsiveness, activate the EMS, and retrieve an AED. -Both determine whether there is no breathing or abnormal breathing. *Only the health care provider assesses for a carotid pulse, taking no more than 10 seconds to palpate for the pulse. The layperson does not assess for a carotid pulse. CIRCULATION *Respiratory arrest is possible without cardiac arrest. Once the nurse has determined that the victim is not breathing, the nurse should assess the person's pulse. -Pulselessness (cardiac arrest) indicates the need for external cardiac compressions. -Performing external cardiac compressions on a victim with a pulse, however, has the potential to result in injury to the victim. *To determine pulselessness, the carotid pulse is the most reliable and accessible to the nurse. *Maintain the head tilt with one hand resting on the victim's forehead while assessing for the presence of a pulse. -With two or three fingers of the other hand, locate the victim's thyroid cartilage. -Then gently slide the fingers into the groove between the trachea and the muscles on the side of the neck until the carotid pulse is felt. -Palpate the pulse gently only on one side so as not to obliterate arterial blood flow to the brain (Fig. 16.2). - The absence of a pulse confirms the diagnosis of CARDIAC ARREST (sudden cessation of functional circulation). *Performing external cardiac compressions helps blood circulate to the heart, the lungs, the brain, and the rest of the body. * If external cardiac compressions are performed properly, it is possible to maintain 20% to 50% of the normal output of the heart. This provides enough oxygen to the body to sustain life. Proper hand position enables as much blood to be circulated as possible.

CH.15 Skills for Urinary Tract Procedures Urinary Elimination

*Urinary elimination is a natural process that clears the body of waste material and helps maintain electrolyte balance. *Therefore conditions that interfere with urinary function have the potential to create a health crisis. *The urinary tract can be affected by a problem with the kidneys, the ureters, the bladder, the urethra, or surrounding organs. *It is also very susceptible to infection. Neurologic deficits also may lead to problems with the urinary system. *Patients at risk for problems with urine elimination include those who have undergone surgical procedures of the bladder, the prostate, or the vagina; patients with primary urologic problems, such as urethral stricture or tumor; neurologic trauma; and those who are critically ill with multisystem problems. *When there is a problem with the urinary system, the health care provider often orders a urinary catheter to be inserted to monitor urinary output and the urinary system.

CH.14 HYPOXIA ( look at box #8)

*When hypoxia (reduced oxygen content in tissue and cells) occurs, cell metabolism slows down, and cells begin to die. *Oxygen therapy is one method of preventing or relieving tissue hypoxia. *Oxygen therapy must be ordered by a health care provider and closely monitored by the nurse to ensure proper administration *Oxygen is treated as a drug; therefore it is important to follow the six rights of drug administration when administering oxygen (6 rights of drug administration when administering oxygen is up on top of page 1st term)

Box 16.1 Information to Convey in a Medical Emergency

1. Name of the person making the call 2. Location of the emergency 3. What has happened (either by direct observation or by gathering data from other people) 4. Whether an immediate threat, such as fire or flood, or physical threat by someone, such as use of a gun or knife, still exists 5. Number of people who need assistance 6. Every victim's name and age 7. Obvious injuries and every victim's apparent condition 8. First aid measures that have already been administered 9. Presence of medical-alert bracelet or any known history 10. The physical characteristics of the scene of the rescue (stairs, elevators) NOTE: Only hang up when instructed to do so by the emergency services operator.

Box 15.3 Patient Problem Statements for the Patient With Altered Bowel Elimination

Anxiousness: • Related to bowel function • Related to rejection by friends Distorted Body Image: • Related to presence of ostomy Impaired Coping: • Related to daily ostomy care requirements Infrequent or Difficult Bowel Elimination: • Related to decreased activity • Related to decreased peristalsis • Related to dehydration • Related to inadequate dietary fiber Insuficient Knowledge Regarding Condition, Treatment Program, and Self-Care: • Related to lack of exposure and information • Related to misinterpretation of information • Related to unfamiliarity with information Potential for Compromised Skin Integrity: • Related to irritation of skin around stoma Recent Onset of Pain: • Related to bowel distention

CH.16 Assessment of the Emergency Situation

Assessment of life-threatening problems is the priority in an emergency situation. Assess the scene for potential safety hazards. Sometimes you will need the aid of another person, whether to help care for victims with some injuries or illnesses or to call EMS. If necessary, shout to get someone's attention or request that someone call 911 or another emergency number. While seeking help, continue the primary survey by assessing the patient's circulation, airway, and breathing (CAB). An immediate life-threatening situation of highest priority is abnormal circulation; an absent or abnormal pulse is a life-threatening situation. Assess the rate, rhythm, and strength of the carotid pulse for no longer than 10 seconds. Monitor the victim for signs of external bleeding and internal bleeding, which may lead to shock. Additional assessment includes the person's skin color, temperature, pupil reaction, pulse, and respiration. Poisonings also may be life threatening. Observe for burns or stains in and around the person's mouth or hands. Depressed respirations and circulatory collapse are other possible results of poisoning. Ensure that the victim's airway is open. The airway is opened with a head-tilt/chin-lift maneuver unless a neck injury is suspected. If a cervical spine injury is suspected, use a jaw-thrust maneuver without tilting the head to open the airway. Use caution not to move the neck out of proper alignment. Because of the potential for causing or exacerbating a cervical spine injury, do not hyperextend the patient's neck to establish an airway. Assess the victim's ability to breathe by determining whether the chest is rising, listen for breath sounds, and place your cheek near the victim's mouth to feel the passage of air from the victim's breathing. Assess rhythm, depth, and rate of respirations. The following clinical manifestations indicate that the victim is having trouble breathing: cyanosis, gasping, wheezing, stridor, and snoring. After the initial assessment for life-threatening problems, assess the victim for indications of skull injury and brain or spinal cord damage, which necessitate immediate interventions. A decreasing level of consciousness, abnormal pupil reaction, and lack of movement in the arms or the legs are indicative of a possible injury to the head or spinal cord. Focus on the victim's fractures, dislocations, and superficial ecchymoses or wounds only after treating the more serious conditions.Ch.16

Ch.16 Cardiopulmonary Resuscitation (CPR) Ethical Implications

Reasons that individuals choose not to become involved in performing CPR include feeling panicked, fear of incorrectly administering CPR, and fear of hurting the patient. However, once the nurse or anyone starts CPR, it should not be discontinued except for the following reasons: • The victim recovers. • An automated external defibrillator (AED) is available and CPR is discontinued before the equipment is applied. • The scene becomes unsafe and evacuation of the victim is necessary. • The rescuer is exhausted and is not able to continue CPR. • Trained medical personnel arrive on the scene and take over CPR. • A licensed health care provider arrives on the scene, has the authority to pronounce the victim dead, and orders CPR to be discontinued. -When a licensed practical nurse/licensed vocational nurse (LPN/LVN) is providing emergency care to a patient, this nurse should stay with the patient until care is taken over by a registered nurse (RN), a health care provider, or emergency medical personnel.

Ch.15 Colostomy Care Colostomy Irrigation

To be able to provide the patient with optimal colostomy care, it is important for the nurse to know the correct use of various products used for colostomy care and to educate the patient about appropriate care and use of these products. There are various types of pouching systems and skin barriers available to patients. Onepouch systems have a skin barrier (wafer) that is preattached to the pouch; two-piece systems have a pouch that is separate from the wafer. Some skin barriers are precut, whereas others must be cut to fit the stoma. When skin barriers are cut to fit the stoma, ensure the ostomy appliance opening is small enough to form a proper seal, inch larger than the stoma. COLOSTOMY IRRIGATION *Colostomy irrigation sometimes is used to maintain a regular elimination pattern. -It is used less frequently now than in the past: many patients have regular bowel movements without irrigation. -If the patient desires irrigation, the patient must be prepared to devote 60 to 90 minutes per day in the bathroom for the procedure. -Colostomy irrigation requires special equipment and is not without complications. -The patient needs a cone-tipped irrigation device (see Step 7 of Skill 15.12), an irrigation sleeve, and irrigation solution or access to tap water. -The patient places the cone-tipped irrigation device in the stoma through the sleeve. -The sleeve is used to contain the drainage from the stoma as it passes into the commode. -Approximately 500 to 1000 mL is instilled slowly into the stoma, and the patient must sit on the commode while it drains out (approximately 30 minutes). -Complications associated with colostomy irrigation include damage or perforation of the bowel, which can lead to peritonitis. -Other complications range from tissue damage as a result of the temperature of the irrigating solution to fluid and electrolyte imbalances if too much tap water is used.

CH.15 Lifespan Considerations Older Adults Catheterization

• A patient with a catheter is especially vulnerable to urinary tract infections. -Older adult patients who are physically compromised run the additional risk of developing septicemia, a potentially life-threatening infection that has spread to the blood. Therefore do not routinely catheterize an older patient who is incontinent. • Encourage adequate oral fluid intake of at least 2000 mL/day, and assist the older adult to the bathroom on a regular, timed basis. -This will help with bladder retraining and may prevent the need for excessive catheterization. • When catheters are required, an older adult may be more cautious when ambulating. Encourage as much ambulation as tolerated, and remove the urinary drainage device as soon as possible. • Suggest to patients who are at home or in long-term care that they use a leg bag during the day and switch to a large-volume bag at night so that sleep is not interrupted. • Intermittent self-catheterization may be an option for some patients at home or in long-term care facilities. -Discuss this option with the health care provider. Self-catheterization can be successful in maintaining continence and may enable more independence. • External catheters may work well for patients with prostatic obstruction. -An internal catheter may cause prostate trauma if insertion is attempted. • Carefully evaluate patients with neuropathy before application of an external catheter; such patients may require more frequent monitoring related to the tissue damage that could occur. • If a condom catheter is used on an older person, close monitoring is necessary. -The skin of an older patient is frail and delicate, and the adhesive used on the condom catheter could damage the skin. *If the patient complains of urinary retention, try stimulating urination by running water, placing the patient's hands in warm water, or pouring warm water over the perineum. *Female patients should be encouraged to sit on a bathroom stool or commode and male patients to stand to void. *. Some patients may experience some dribbling of urine after voiding as a result of dilation of the sphincter from the catheter. *Such patients should be reassured that this is normal and should improve as sphincter tone improves. *Record the time of urination, the amount of urine output, and the color of the urine.

Box 16.2 Events Necessitating Cardiopulmonary Resuscitation

• Anaphylactic reaction: Exposure to a known allergen (e.g., food, poisons, and drugs) or an insect bite has the capacity to produce the severe allergic reaction known as anaphylaxis. -This reaction often causes spasms or edema of the upper airway and, in some cases, progresses to cardiovascular collapse. It is necessary to initiate cardiopulmonary resuscitation (CPR) immediately, as with any other emergency situation. • Asphyxiation: Asphyxiation or suffocation caused by inhaling a gas other than oxygen is possible as a result of fires, chemical spills, or gas leaks. -In addition, children and adults sometimes suffer respiratory arrest and ultimately cardiac arrest from choking on food or small objects that are placed in the mouth. -Abdominal thrusts and CPR are performed in this instance. • Cardiac arrest: The most common cause of cardiac arrest is myocardial infarction (MI). In addition, shock from hemorrhage, trauma to the heart, respiratory arrest, and drugs have the potential to precipitate a cardiac arrest. • Drowning: Children are common victims of drowning and boating accidents. People using alcohol or other drugs near bodies of water are often victims of drowning. -It is important to note that near-drowning victims sometimes recover completely after long periods of submersion. -The low water temperature that produces hypothermia reduces the metabolic rate and decreases oxygen demands. -Because of this, it is necessary to initiate CPR even when 4 to 6 minutes of cardiac or respiratory arrest is known to have elapsed. • Drug overdose: Intentional or accidental abuse of alcohol and drugs poses a risk for respiratory and cardiac arrest. Besides treating this as a poisoning emergency, perform CPR as necessary. • Electrical shock: People who come near sources of high-voltage electricity run the risk of accidental electrocution. -Electrical shock sometimes paralyzes the breathing muscles and causes cardiac arrest by interfering with the normal rhythm of the heart. -It is essential for the rescuer who is initiating CPR to be careful not to inadvertently come into contact with the electric current. -The rescuer must ensure that the current is deenergized before beginning CPR. • Sudden infant death syndrome (SIDS): SIDS is the unexpected and sudden death of an apparently normal and healthy infant that occurs during sleep and with no evidence of disease on physical examination or autopsy. -Aspects of prevention include readiness to perform early CPR and home monitoring systems

CH.14 Box 14.2 Signs and Symptoms of Hypoxia

• Apprehension, anxiety, restlessness • Behavioral changes • Cardiac dysrhythmias • Cyanosis • Decreased ability to concentrate • Decreased level of consciousness • Digital clubbing (with chronic hypoxia) • Dyspnea • Elevated blood pressure • Increased fatigue • Increased pulse rate: As hypoxia advances, bradycardia results, which in turn results in decreased oxygen saturation • Increased rate and depth of respiration: As hypoxia progresses, respirations become shallow and slower, and apnea develops • Pallor • Vertigo

Ch.15 Key Points

• Closed bladder drainage systems necessitate the use of aseptic technique during care. • Intermittent urinary catheterization has a lower risk of infection than indwelling urinary catheterization because of the relatively shorter time the intermittent catheter remains in the bladder. • Strict asepsis is necessary in caring for a closed urinary drainage system. • It is possible to use closed urinary drainage systems for instillation of sterile solutions or medications into the bladder. • When a nasogastric tube is to be inserted, it is necessary to lubricate the tube well with a water-soluble lubricant to prevent trauma to the mucous membranes. • It is imperative for the nurse to check for proper nasogastric tube placement before an irrigation or a tube feeding. • Proper administration of an enema consists of the slow instillation of the correct volume of a warm solution. • Emotional support of the patient with an ostomy is important to foster eventual acceptance of the change in body image. • Consistency of the feces is affected directly by which portion of the colon is brought out to the stoma. • Even when an ostomy pouch is adhering well, it is best to change it at least every 3 to 5 days or according to pouch recommendations to allow for observation of the stoma and the skin around the stoma. • Patients with urostomies are at high risk for skin impairment at the site because of the nearly continuous urine drainage. • Irrigation of an ostomy follows the same principles as an enema administration, except that a special irrigating tube is needed and the patient is not able to control the passage of feces. • Skin impairment is possible after repeated exposure to liquid stool. This is especially true in patients who have a stoma

Ch.15 Home Care Considerations Ostomy Care

• Consult with the health care provider to obtain a referral to a home health agency or a visiting nurse before patient's hospital discharge. • Pouches that wear well in the hospital will not necessarily wear well when the patient resumes a normal routine. • If an irrigation routine is required, assist the patient to adapt the procedure to the home setting. -Suggest hanging the irrigation solution container from a hook on the wall or from a shower curtain rod instead of an intravenous (IV) pole. • Urostomy, colostomy, and ileostomy products are usually available for purchase at local pharmacies. • Encourage the patient to become involved with local ostomy organizations. • Teach the patient and caregivers to routinely inspect the stoma and the surrounding skin. -The proper appearance of the stoma is moist, shiny, and dark pink to red, with minimal if any bleeding around it. -Teach the patient and caregivers to report excessive bleeding, abnormal color, or swelling to the nurse or the health care provider. • Teach the patient and caregivers to avoid using alcohol around the stoma, because alcohol dilates capillaries, causing bleeding, and may dry the skin excessively. • Teach the patient and caregivers not to use lotions or creams around the stoma, because they may prevent pouches from adhering. • Teach the patient and caregivers not to use peroxide on or around the stoma, because it may irritate the tissue. • Instruct the patient and caregivers to wash the skin around the stoma with mild soap and water and rinse thoroughly. -Soap is often irritating to the skin. Pat or blot the skin dry. • Evaluate the patient's home toileting facilities for the following: • The presence of adequate functioning and accessible toileting facilities • Number and location of toileting facilities • Number of other people living in the home who have to share the toileting facilities • The pattern of use of the toileting facilities by the other people living in the home (time of day and amount of time spent in bathroom) • Evaluate the patient's ostomy routine in relation to his or her usual lifestyle after discharge. • Caution the patient not to flush ostomy pouches and barriers down the toilet; they clog the pipes. -Dispose of used ostomy pouches according to local sanitation regulations. • Make sure the patient understands that it is not necessary to use sterile gauze to cleanse the stoma. Using a washcloth made of any soft material is fine. • Review the patient's dietary pattern. -Help patient and family members learn the types of foods to avoid to prevent problems with stoma drainage or odor. • Teach patients that if water is not drinkable, they should not use it for irrigations (e.g., as in another country).

CH.15 Home Care Considerations Urinary Catheter Care

• Determine patient and primary caregiver's ability and motivation to perform the following actions: • Maintain accurate records of intake and output (I&O) • Participate in routine catheter care • Perform catheter irrigation when necessary • Demonstrate proper method for measuring I&O, and provide appropriate receptacles for measuring urinary output if needed. Allow for questions and return demonstrations. • Instruct on appropriate catheter care (see Skill 15.2). • Teach signs and symptoms of urinary tract infection: • Urgency • Frequency • Hesitancy • Burning sensation • Bladder spasms • Disposable supplies are best. If it is necessary to reuse catheters, teach patient and primary caregiver to boil rubber catheters 20 minutes and wrap in clean cloth. • Teach catheterization techniques if necessary (see Skill 15.1). • Evaluate patient's environment for appropriate space to store required materials and to perform procedure. • Consult with health care provider for a home care agency referral for follow-up and to reinforce teaching concepts.

Ch,15 Lifespan Considerations Older Adults Ostomy Considerations

• Evaluate the older adult's cognitive status and capacity to understand ostomy self-care instructions. • Evaluate the older adult's motor and visual ability to prepare ostomy equipment. • For patients who are unable to custom-cut the size of their skin barriers, consider having barriers precut by the ostomy equipment supplier or using a precut two-piece system. • Avoid hot water and harsh soaps when washing the skin around the ostomy. • Teach patients about the change in the number of bowel movements that may occur on a daily basis. -With some irrigation routines, irrigation is not performed daily; therefore the patient may not have a daily bowel movement. • The cost of ostomy supplies and reimbursement are often an important concern for older patients on limited incomes; referral to community resources may be necessary.

Ch.15 Patient Teaching Nasogastric Tube

• Explain the need for a nasogastric tube. • Explain how the tube will prevent nausea, vomiting, and abdominal distention. • Teach patient and family how to care for the nasogastric tube at home, if this is appropriate. • Explain the need to maintain moistness of mucous membranes with special mouth care. • Explain to patient how to relax and communicate during tube insertion. • Before insertion, explain the technique and sensations that the patient may feel. • Allow time for, and address, patient's questions and concerns. • Ensure adequate lubrication of the tube to decrease discomfort, especially with older adults.

CH.15 Patient Teaching Indwelling Urinary Drainage System Care

• Explain the procedure and expected sensations associated with the procedure to the patient before you insert the catheter. • Answer the patient's questions about the procedures. • Explain the need for the patient to drink fluids to flush the urinary system. • Instruct the patient about proper transfer from a bed, chair, or stretcher. • Teach the principles of, and need for, catheter and perineal care. • Instruct the patient how to perform Kegel exercises. • Teach the patient the side effects that are possible with an indwelling catheter and symptoms of an infection. Encourage the patient to report symptoms immediately. • Caution the patient not to lie on tubing and to keep the drainage bag below the level of the bladder. • Discourage the use of lotions or powder during perineal care. • Encourage using a leg bag during the day and a bedside drainage bag at night. • Instruct patient to wear loose-fitting clothing to promote adequate drainage.

CH.14 Home Care Considerations Oxygen Therapy

• If oxygen is used at home, instruct the patient's family to post a "No Smoking" sign on all entry doors of the house. • When oxygen cylinders are used, it is necessary to secure them so that they will not fall over. Oxygen cylinders are stored upright, chained on appropriate holders. • In home settings, oxygen tubing is sometimes as long as 50 feet (15.2 m), which presents a tripping hazard. Instruct patient on risks for falling that are associated with this length of tubing. • Instruct patient's family on safety measures of oxygen therapy (see Box 14.1). • Teach patient and family members how to use home equipment. • Instruct patient and family members to observe level of oxygen in canister tanks and to use portable tanks when patient is not at home. • Instruct patient and family members to fill plastic humidifier bottle with distilled water every 24 hours. Instruct patient and family members to use only distilled water, not tap water. • Provide two complete sets of tubing so that one set of equipment is available for use while the other is being cleaned or repaired. • Evaluate home for availability of a three-pronged outlet for the compressor, to prevent electric shock. • Teach patient to maintain constant flow rate and to change flow rate only with the health care provider's knowledge and advice. • Evaluate home for appropriate storage of equipment. • Evaluate family's willingness to assist patient with home delivery system. • Teach patient and family deep breathing and coughing exercises. • Teach patient and family adequate nutritional and hydration needs based on the patient's diagnosis and current condition.

Patient Teaching Ostomy Care

• Include family members or significant others in teaching; this tends to facilitate the patient's readiness to learn. • Use every pouch change as an opportunity to teach even if the patient does not appear interested. -Do not force the patient to look at the stoma; allow for a period of adjustment. • Reinforce positive performance. - Some patients are not willing to learn ostomy care for a period of time after receiving one. -The patient may refuse to look at or touch the stoma and may not participate in ostomy care until he or she has accepted the ostomy. • Many nurses are able to judge a patient's readiness to learn by the patient's willingness to look at the stoma and by the patient's asking questions. -If the patient is apprehensive about touching or looking at stoma, have the patient hold a gauze pad over the stoma and clean around the stoma. • Some patients acknowledge a stoma with minimal emotional difficulty; some never completely adjust to it. Individualize care according to the patient's situation and circumstances. • Teach the patient to avoid constipation by eating a balanced diet or using a daily stool softener. • If the patient has limitations affecting dexterity, select a pouching system that can be most easily managed. • A teaching manual with clearly stated steps or audiotaped instructions may be helpful for the patient. Patients with a learning disability may benefit from a picture book of the steps involved in ostomy care. • Give the patient a list of equipment and the name, address, and phone number of a supplier in the patient's community. • In most cases, patients are able to wear their normal clothes; snug clothing does not interfere with ostomy function. • Instruct patients not to leave pouches in extremely hot or cold locations because temperature has the potential to affect the barrier and adhesive materials.

Ch.15 Patient Teaching Removing Urinary Catheter

• Instruct the patient that it will take time for the urinary bladder to reestablish voluntary control of urine. • Explain the need for collecting and measuring urine output, and teach the patient how to do so. • Explain the need to drink at least 2 L (eight 8-oz glasses/cups) of fluid per day (to reduce risk of infection) unless this is contraindicated by the patient's condition. • Explain that it is common to feel some burning sensation or discomfort when first voiding. • Identify the side effects that are possible, and explain the need to report them immediately. • Instruct patients that the use of over-the-counter medications, such as nasal decongestants and anticholinergic medications (e.g., diphenhydramine, acetaminophen PM), have the potential to cause urinary retention and that their use should be limited.

Ch.15 Lifespan Considerations Older Adults Altered Bowel Elimination

• Many older adult patients are especially prone to dysrhythmias and other problems related to vagal stimulation associated with defecation. Therefore it is important to monitor heart rate and rhythm closely. • In many older adults, constipation results from insufficient dietary bulk, inadequate fluid intake, laxative abuse, diminished muscle tone and motor function, decreased defecation reflex, mental or physical illness, and the presence of tumors or strictures. • For an older adult, a diet containing at least 6 to 10 g of dietary fiber per day adds bulk, weight, and form to stool and improves defecation. • Older adults should develop a regular toileting routine in response to the urge to defecate. • The older adult patient or a family member should keep a week's diary of meals and fluid intake. The nurse should determine whether dietary pattern contributes to constipation. The nurse should recommend an increase in fiber if it is needed. • The nurse should encourage as much activity as tolerated to maintain peristalsis and decrease the risk for constipation

CH.14 Lifespan Considerations Older Adults Oxygen Therapy Term: ARTERIAL PARTIAL PRESSURE OXYGEN (PaO2) level

• Normal arterial oxygen levels sometimes decrease with age but not usually low enough to fall outside the normal range. *It may be possible for a 70-year-old person to have an ARTERIAL PRESSURE OXYGEN (PaO2) level (the amount of oxygen found in the arterial circulation) between 80 and 85 mm Hg (normal range is 80 to 100 mm Hg) without experiencing significant alterations in health. *• The respiratory drive normally is initiated by arterial carbon dioxide (PaCO2 ) levels rising, but in patients with chronic obstructive pulmonary disease (COPD), hypoxia tends to be the driving force behind respiratory effort (hypoxic drive). -If the hypoxia is corrected in a patient with COPD, then the respiratory drive is reduced, and respiratory difficulty will occur. For this reason, oxygen flow rates greater than 2 L/min are to be given with great caution in these individuals. -Flow rates higher than 2 L/min could eliminate the respiratory drive, and breathing may stop. • The older adult is often at increased risk for skin impairment. -Therefore frequent monitoring for erythema and skin breakdown over the ears is necessary when a nasal cannula is being used for oxygen delivery. -Early interventions such as loosening the straps, repositioning the tubing, or adding padding over the ears often prevent impairment.

CH.14 Coordinated Care Collaboration Oxygen Administration

• Oxygen administration requires the critical thinking skills of a nurse. -The nurse is responsible for ensuring that the oxygen is administered in the correct manner, adjusting oxygen flow rate and evaluating the patient's response to oxygen therapy. • Correct placement and adjustment of oxygen devices may be delegated to unlicensed assistive personnel (UAP) after the care provider is instructed about the possible complications and outcomes associated with oxygen delivery and the need to report these to the nurse immediately if they occur. -Adjustment of the oxygen flow rate is not delegated to UAP.

CH.14 Key Points

• Oxygen therapy improves tissue oxygenation. Delivery devices include, but are not limited to, nasal cannulas, nasal catheter, and various types of oxygen masks. • Teaching the patient effective coughing techniques and the implementation of suctioning will help keep the patient's airway patent. • The Venturi mask offers a precise concentration of oxygen and is used for patients requiring a more controlled concentration of oxygen. • Safety precautions must be followed in the clinical setting and in the home setting. • Hypoxia signs and symptoms include neurologic changes, changes in vital signs, cardiac dysrhythmias, and changes in the color of the mucous membranes. Early and later signs of hypoxia differ. • COPD patients require a lower concentration of oxygen therapy to not suppress their respiratory center. • Endotracheal tubes are used for short-term airway maintenance. • Tracheostomy is used for long-term airway maintenance. • Tracheostomy tubes may be cuffed or noncuffed, depending on the patient's need. • Tracheostomy care and suctioning can be performed by the nurse, or by the patient or caregivers. • Tracheostomy care and suctioning requires sterile technique. • The tracheostomy collar is used to supply oxygen to a patient with a tracheostomy. • The Yankaur suction catheter is used to perform oropharyngeal suctioning.

CH.14 Box 14.1 Safety Precautions During Oxygen Use

• Place "No Smoking" or "Oxygen in Use" signs, or both, in the patient's room and where easily seen. • Instruct the patient, the family, and visitors that smoking is not permitted because oxygen supports combustion (burning). • Avoid the use of electrical appliances, such as razors, blankets, and heating pads while oxygen is administered. • Avoid use of petrolatum products such as petroleum jelly when oxygen is administered because of the combustibility of oxygen. • Secure portable oxygen delivery systems, such as cylinders or portable tanks, into proper portable oxygen carrying equipment to prevent falling or tipping because these delivery devices can become projectiles. • Avoid placing oxygen cylinders near sources of heat, such as lamps or radiators. • Avoid clothing that is not fire resistant. • Ensure that all electrical equipment is functioning appropriately and is well grounded (three-prong plug). Avoid frayed, tangled, or cluttered cords, and do not overload circuits. • Know the facility's fire procedure and the locations of fire extinguishers. • Administer oxygen by the method and rate ordered by the health care provider. • Ensure that the patient is aware if extension tubing is in use to prevent falls from tripping over the tubing.

CH.14 Home Care Considerations Tracheostomy Care

• Some patients with an artificial airway who are at home have a permanent tracheostomy, as well as a T piece or T tube or tracheostomy collar • Determine patient's ability to perform tracheostomy care and suctioning techniques. • Evaluate patient's home environment for presence of respiratory irritants, cleanliness, and location in which to clean suctioning equipment and hang it up to drain. • Ensure that a humidifier is present: added moisture is important.

CH.14 PATIENT TEACHING OXYGEN THERAPY

• Teach patient how to apply the oxygen equipment, such as the nasal cannula or oxygen mask, appropriately. • Discuss safety precautions for oxygen use (see Box 14.1). • Stress the dangers of adjusting the oxygen flow rate without notifying the health care provider. -Emphasize that it is possible for the patient to be short of breath because of reasons other than hypoxia and to contact the health care provider if shortness of breath increases. • Instruct patient to ambulate or change positions frequently to mobilize secretions. • Teach the patient to cough and practice deep breathing, and encourage practicing these techniques frequently, as directed by the patient condition or provider's orders, to facilitate air exchange. • Teach the patient to maintain adequate fluid intake to help liquefy secretions. -Recommend fluids that are free of caffeine and sugar because drinks high in caffeine and sugar sometimes cause dehydration. -Teach the patient to avoid dairy products, which tend to thicken secretions. • Teach the rationale for prescribed medications, as well as side effects. -This helps increase compliance. • Teach that performing oral hygiene at regular intervals helps rid the mouth of any bad taste from secretions coughed up or expectorated.

Ch.15 Patient Teaching Urostomy Care

• Teach the patient and caregivers to avoid touching the stoma with adhesive solvents to prevent irritating the stoma. • Teach the patient and caregivers to wick the urine with an absorbent, lint-free material to prevent a constant flow of urine while they change the appliance. • Teach the patient and caregivers to remove hair from the stoma area with scissors or an electric razor to prevent hair follicles from becoming irritated when the pouch is removed. • Teach the patient and caregivers that the appliance should be able to remain in place 3 to 5 days. • Teach the patient and caregivers to empty appliance through the drain valve when it is one third to one half full to prevent the weight of the urine from loosening the seal around the stoma. • Teach the patient and caregivers to connect the appliance to a urine-collection container at night to prevent urine from stagnating in the appliance. • Teach sanitary and dietary measures that will protect the skin around the ostomy and control odor. • Offer positive reinforcement and written instructions or videos.

Ch.15 Coordinated Care Collaboration Ostomy Care

• The skill of applying a pouch to a fresh stoma requires the critical thinking and knowledge of a nurse. -Some facilities permit delegation of the task of pouching of an established ostomy. -Instruct the care provider about the expected amount, color, and consistency of drainage from the ostomy. -In addition, teach the care provider to report changes in the stoma and surrounding skin integrity. • The skill of applying a pouch to an incontinent urinary diversion requires the critical thinking and knowledge of a nurse. -In some facilities, a stoma nurse specialist is available to provide this care. -Unlicensed assistive personnel (UAP) who provide personal care are instructed to report any leakage of urine and breakdown of skin to the nurse. • The skill of irrigating a newly established colostomy requires the critical thinking and knowledge of a nurse. -In some settings, UAP are trained to perform irrigations on established ostomies. Review facility policy.

Ch.15 Coordinated Care Collaboration Nasogastric Tube

• The skill of inserting a nasogastric tube requires the critical thinking and knowledge of a nurse. -Unlicensed assistive personnel (UAP) are permitted to measure and record the drainage from the NG tube and provide oral and nasal hygiene. Teach UAP how to properly secure the NG tube. • The skill of irrigating an NG tube requires the critical thinking and knowledge of a nurse; this task should not be delegated to UAP. • The skill of removing an NG tube requires the critical thinking and knowledge of a nurse; this task should not be delegated to UAP.

CH.14 Coordinated Care Collaboration Suctioning a Tracheostomy TERM; PATENCY

• The skill of suctioning, other than oropharyngeal suctioning, requires the critical thinking and knowledge of a nurse or other licensed health care professional. • The task of oropharyngeal suctioning can be delegated to unlicensed assistive personnel (UAP), including the patient and family when appropriate. Check facility policy. • In special situations, the task of performing a permanent tracheostomy tube suctioning can be delegated to UAP. -These situations include those in which stable patients have a wellestablished permanent tracheostomy tube and patients are receiving mechanical ventilation at home. • The nurse is responsible for evaluating the patient's airway PATENCY (openness) and response to airway suctioning.

CH.14 Care of the Tracheostomy Cont.

• To prevent depression of the respiratory center, it is advisable to give analgesics and sedatives with caution. • Suction is performed as often as necessary, possibly every 5 minutes during the first few postoperative hours. (Whenever respirations are noisy and the pulse and respiratory rates are increased, the patient needs suctioning.) • Patients who are conscious are usually able to indicate when they need suctioning. • A patient who is able to expectorate secretions requires less suctioning. • The amount of mucus decreases gradually, and the nurse performs suctioning less frequently. - A patient who remains apprehensive may require constant attendance and reassurance.

CH.15 Coordinated Care Delegation Urinary Catheterization

• Urinary catheterization is a task that can be delegated to unlicensed assistive personnel (UAP) in some settings (check facility policy). In some facilities, first-time catheterization, catheterization of patients in an acute care setting, or catheterization of patients with urethral trauma requires the critical thinking and knowledge of a nurse, and delegation of this task to UAP is inappropriate. • The task of removing a urinary catheter can be delegated to UAP in some facilities; however, patient evaluation and teaching must be performed by the nurse. After removal of the catheter, instruct UAP to measure amount of urine in patient's first voiding and to report time and amount to the nurse. • It is acceptable to delegate the task of obtaining urine specimens from a catheter to UAP in some settings (check facility policy). Initial patient evaluation and coordination of repeated specimens require the knowledge of a nurse, and delegation of this task to UAP is inappropriate. • The skill of catheter irrigation requires knowledge of a nurse. Delegation of this task to UAP is inappropriate. • The skill of caring for a newly established suprapubic catheter requires the knowledge of a nurse. Delegation of this task to UAP is inappropriate.