Med surg skills test 1

bryant traction

Both lower extremities flexed 90 degree at hips; rarely used because extreme elevation of lower extremities causes decreased peripheral circulation

Drainable pouches

Some drainable pouches can be rinsed and reused. They are recommended for use with an ascending or transverse colostomy, an ileostomy, and a urostomy. Drainable urostomy pouches have a tap instead of a clip

Casting

o Adults and children different Protective shell of fiberglass plastic or plaster o Bandage that molds and protects broken bone/fracture o Do not get wet- some hospitals do use waterproof casts- still will tell you not to get cast wet, it is more expensive

Nursing intervention (NG tube)

o Apply lubricant to nares as needed o Assess color of drainage- report dark, streaky blood or coffee ground o Consider switching to other nare after a while- need order o Rinse mouth use sponge o Lozenges if allowed o Irrigate the tube- unclog blockage- institutional protocol (tap water, feeding) o Change position in case tube is against stomach wall o Verify suction equipment on wall is properly set, somebody can change the suction equipment so always check!

Transverse colon (mid-abdomen) colostomy

§ This location is used for a temporary ostomy, with the stoma constructed as a loop. Output is liquid to semi-formed.

ileostomy drainage

Initial drainage from an ileostomy is typically dark green, loose, and odorless. Drainage gradually thickens and becomes yellow to brown. Instruct patients to empty the pouch when it is one third to one half full, which may require drainage several times a day. Effluent from the ileostomy contains enzymes and bile salts that can irritate the skin. Advise the use of a skin barrier and prompt attention to any signs of pouch leakage.

gastric compression

Patients with suspected gastric or esophageal bleeding should first be examined by upper endoscopy (esophagogastroduodenoscopy or EGD) to control bleeding and treat at the same time. When endoscopic treatment or vasoconstrictor therapy is not immediately available, oro- or nasogastric compression can be used as a temporary measure to control bleeding from esophageal or gastric varices. Inflating a balloon at the end of the tube creates pressure against the injured vessels to slow or stop the bleeding. This temporary intervention is typically used only when endoscopic treatment or vasoconstrictor therapy is unavailable or ineffective. Contraindications for compression include esophageal strictures and recent surgery involving the esophagogastric junction.

gastric lavage positioning

Place the patient in a head-down, left side-lying position with the head of the bed lowered about 15 degrees to reduce the risk of aspiration if the patient vomits

PICC line (peripherally inserted central catheter)

Preferred venous access device for moderate term IV therapy, can remain in place for 6 Months or longer with proper care, it is meant to remain in place for duration of the entire treatment, the catheters designed are highly flexible and there is no need to immobilize the client, movement is encouraged to stimulate blood flow and decrease the risk of phlebitis. PICC lines are inserted at bedside and only local anesthesia is required. · Sterile technique- can only do if you're a certified PICC line nurse

double barrel colostomy

§ With a double-barrel colostomy, two separate stomas are created. Both ends of the bowel are brought through the abdomen to the skin surface as two separate sections. Typically the distal colon is not removed but bypassed. The proximal stoma, which is functional, diverts feces to the abdominal wall. The distal stoma, or mucous fistula, expels mucus from the distal colon

How often to change primary IV tubing

· Go by institution policy · Most institutions 72 hours · Can go up to 96 hours · 72-96 hrs · Will be a test question

Removal of NG tube

· Verify order · Auscultate · Explain · Hand hygiene · Clean gloves · Turn off suction · Disconnect tube from drainage · Irrigate tube with 20ml syringe · Remove tape · Give pt tissues for secretions- or wipe their nares and help them if unable · Kink the tube so secretions don't come out, also they might vomit · Inspect tube- intact, not torn, did a piece stay in · Measure drainage · Give them drink · Back in a comfortable position · Documentation, signature, date and time, VS in EMR

milwaukee brace

- Worn for scoliosis , stabilizes the spine from the neck to the pelvis. It must be removed daily for hygiene care, but that is all. Once the curves has stabilized and spinal growth is nearly complete the ortho surgeon will begin to wean the client out of the brace, but continues to wear it in the evening and at night. The brace will often be worn at night several years after growth is complete to maintain the spinal correction.

IV push

- you better know what you're pushing and how fast you can push it o Cant push K o If you push Benadryl too fast they will be mad at you o Some meds are better to be infused

removal of NG tube

Provide a "trial run" to determine how the patient will fare without the tube. Intermittently clamp the tube for several hours to make sure the patient does not develop nausea, vomiting, or distention. If the patient is uncomfortable with the tube clamped, consult the provider about the advisability of removing the tube at this time. Wear gloves when handling the tube to prevent contact with bodily fluids. Prior to removal, be sure to inject 10 mL of air to clear the tube of fluid and ensure that is it free of debris and loose from the gastric mucosa. Remove the tape from the patient's nose and release the tube from its anchoring device. Place a towel or a disposable pad over the patient's chest to protect clothing and linen. Provide an emesis basin and facial tissues for the patient. With the patient holding her breath, pinch off the tube at the naris and withdraw 15 to 20 centimeters of the tube's length slowly until its tip reaches the esophagus. Withdraw the remainder quickly from the nostril. If the tube does not come out easily, do not use force; report the problem to the provider. As you withdraw the tube, wrap it end over end to keep secretions away from the patient. Dispose of the equipment and your gloves in the appropriate receptacle. Use hand hygiene, apply clean gloves, and provide mouth care for the patient. Document tube removal and the patient's response to the procedure

midline catheter

3-8 inches long, double or single lumen; inserted through veins of antecubital fossa most commonly used (basilica vein is preferred over cephalic due to larger diameter and straighter path); used for therapies lasting 1-4 weeks but no recommended optimal dwell time (fluid hydration, long-term antibiotics, heparin infusions for DVT, bronchodilators, steroids); should not be used for infusion of vesicant medications; NO osmolality >600 mOsm/L, all parenteral nutrition, no blood draw

Kock's pouch

A continent internal ileal reservoir or continent ileal bladder conduit (Kock's pouch) is created the same way as an ileal conduit is, except that nipple valves are formed by intussuscepting tissue backward into the reservoir; the pouch is connected to the skin and the ureters are connected to the pouch. Filling pressure closes the valves, thereby preventing leakage and reflux. An external drainage collection device is not necessary because the patient self-catheterizes about every 4 hours.

Two-piece systems

A two-piece system permits frequent pouch changes and also minimizes skin breakdown. The pouch and skin barrier are connected with a flange mechanism. With a two-piece system, the pouch may be disposable or reusable, and it may have a filter for gas release. Choosing a well-fitted pouching system is essential for preventing irritating stool, urine, or mucus from contacting the surface of the skin. To help maintain the best fit, be sure to determine the size and shape of the stoma using a measuring guide.

urostomy

A urostomy is a urinary diversion that allows urine to exit the body after removal of a diseased or damaged section of the urinary tract. When the entire bladder must be removed, an ileal conduit can be created. For this type of surgery, a loop of intestinal ileum is separated and used as a conduit for urine. The ureters are attached to the ileal conduit, and the open end is brought out through the abdominal wall to form a stoma. The remaining ileum is reconnected to the rest of the digestive tract. This is the most common type of urinary diversion.

securing NG tube

After confirming the tube's placement in the stomach, apply a skin barrier and then secure the tube by taping it to the bridge of the patient's nose or by using a tube attachment device. Anchor the tube to the patient's gown. Clamp the end of the tube or attach it to suction, as prescribed. If the tube has multiple lumens, be sure to label each lumen appropriately according to its intended use. Discard any waste in the appropriate receptacle. Ensure that the patient is comfortable and then document the procedure

indiana continent urinary reservoir

An Indiana continent urinary reservoir is formed from the cecum and a portion of the ileum. The created stoma is continent and flush with the skin. The patient self-catheterizes to empty the reservoir

Kock's continent ileostomy

An alternative to the standard ileostomy is Kock's continent ileostomy. During the procedure, an internal pouch is created from the distal segment of the ileum, which serves as a reservoir for stool. During surgery, a one-way nipple valve is constructed through the stomal opening so that eventually the patient can insert a catheter through the stoma and through the one-way valve to drain the fecal contents of the internal pouch. This type of ostomy is occasionally created to treat ulcerative colitis and may be an option for patients who do not wish to wear an external pouch over the stoma. However, the complication rate associated with a continent ileostomy is usually higher than with a traditional ileostomy. The patient empties the pouch several times a day and the stoma is covered with a protective dressing or a stoma cap.

ileostomy

An ileostomy is a surgical opening created in the ileum to bypass the entire large intestine. A procedure used to treat colon cancer and ulcerative colitis, total proctocolectomy, involves surgical removal of the entire colon, rectum, and anus, with closure of the anus, resulting in the need for stool diversion. After this type of ileostomy surgery, the patient has no voluntary control of bowel movements. The stoma of an ileostomy is typically located in the right lower quadrant. A restorative proctocolectomy with IPAA (ileal pouch anal anastomosis) involves connecting the ileum to a "new" rectum (or anal pouch), also made out of a portion of ileum; it is the procedure of choice in cases where the rectum can be preserved, allowing the patient to retain anal sphincter control of bowel movements

ostomy

An ostomy is an opening surgically created in the abdominal wall to allow for the elimination of urine or feces. Ostomy surgery is performed when a disorder or an injury keeps the urinary or gastrointestinal system from functioning properly.

ileostomy complications

Because the ileum contains digestive enzymes and acids that cause skin irritation, extra care is required to keep waste materials from contacting the abdominal surface. Initially, stool output may be as high as 1,000 to 2,000 mL per day, putting some patients at risk for dehydration.

Closed-end pouches

Closed-end pouches are designed for one-time use and may meet the needs of a patient who irrigates. Some closed-end pouches come with a filter designed to reduce odor and gas buildup. This type of pouch has no drain or clip, and it is recommended for use with sigmoid colostomies. When the pouch is full, it is removed from the skin barrier and discarded in an appropriate receptacle.

electrolyte imbalances (ileostomy)

High-volume ileostomy output can put patients at risk for fluid and electrolyte imbalances. They need to recognize the signs and symptoms of dehydration or electrolyte imbalance, including: § extreme thirst § dry skin and oral mucous membranes § decreased urine output § weakness, fatigue § headache, dizziness § muscle cramps § abdominal cramps, nausea, vomiting § shortness of breath § orthostatic hypotension

10% dextrose D10W, 3.5% Nacl

Hypertonic

0.45 Nacl, 0.33 Nacl (pediatric)

Hypotonic

indications for ostomy

Indications for ostomy surgery include: § congenital anomalies § bladder, colon, and rectal cancer § inflammatory bowel diseases (Crohn's disease, ulcerative colitis) § inherited disorders such as familial adenomatous polyposis § obstruction of the ureter stab or gunshot wounds to the abdomen

5% dextrose in water D5W same concentration, NS (0.9% NaCl)

Isotonic

inserting the NG tube

Lubricate the tip of the tube with water-soluble lubricant. Encourage the patient to breathe deeply through her mouth. Gently insert the tube into the nostril and advance it toward the posterior pharynx. Have her tilt her head forward and encourage her to drink water slowly. Advance the tube without using force as the patient swallows until the desired tube length is inserted. If, at any time, the patient experiences respiratory distress, is unable to speak, or has significant nasal bleeding or if the tube meets resistance, stop advancing the tube and withdraw it.

peristomal cleansing

Make sure they understand the type of cleansing agent to use on the peristomal skin, typically a mild, pH-balanced soap or no soap at all and just water. Using other products such as alcohol, povidone-iodine (Betadine), or oil-based soap can interfere with the adhesion of the skin barrier and could promote skin breakdown.

Needed for NG intubation

NG tube, water, tape, adhesive, lube, stethoscope

One-piece systems

One-piece systems with an attached skin barrier are available. They are available in cut-to-fit and pre-cut types.

ostomy care

Ostomy care · Self esteem issues, especially if new, show empathy and compassion · Surgically created opening from urinary tract or intestines where fecal or urine or mucous is rerouted to a stoma (surgery · Stoma protrudes above skin, can be pink or red in color, moist · No nerve sensation- when you wipe it doesn't hurt patient · Bowel or urinary system is diseased · Effluent **** - stuff that comes out? · Ostomy named after part of intestine · Surgeries perfomed on pt such as cancer of bowel or bladder, crohns, colitis · Permanent or temporary depending on surgery · Double barel ostomy, loop ostomy

Exercise with ostomy

Ostomy patients should be advised to remain vigilant of their hydration status during strenuous physical activity. Patients should engage in a regular exercise routine that includes activities that promote cardiovascular and musculoskeletal fitness.

distal bowel in double barrel and loop colostomies

Patients with a double-barrel or loop colostomy should be aware that the distal bowel carries no fecal contents and does not need irrigation. If they use irrigation at all, they should irrigate the proximal stoma only.

NG tube skills checklist

Skills checklist · Make sure you ID pt with 2 identifiers according to policy · Verify order to place NG tube has been confirmed with suction and drainage · hand hygiene · get Hx on patient with nasal surgery, congestion, allergies · do they have deviated nasal septum · auscultate and assess abdomen, respiratory assessment (O2 monitor)- if they aspirate and you hear an abnormal breath sound you need to know if it changed · bowel sound, abdomen, auscultate a MINUTE in each quadrant · assess loc · determine if they had previous NG tube · assess caregivers knowledge and health literacy- make sure they understand what is about to happen

signs and symptoms of food blockage (ileostomy)

Teach patients to recognize the signs and symptoms of food blockage and to know when to contact their provider. Common manifestations are abdominal cramping, nausea, vomiting, swelling of the stoma, and no ileostomy output for at least 6 hours. When these develop, patients should place moist towels on the abdomen, drink hot tea, lie down and assume a knee-chest position to relieve intra-abdominal pressure, and/or massage the abdominal area to promote peristalsis and fecal elimination. Also, if the stoma is swollen, they might have to replace the pouch with one that has a larger opening to avoid mechanical obstruction.

confirming NG tube placement

Temporarily tape the tube to the patient's nose, then assess the tube's placement either radiographically, magnetically, with pH testing, or with capnography, depending on your facility's protocol. The gold standard for ascertaining accurate placement of the tube is radiographic confirmation. Also, determine placement by aspirating fluid from the tube at the time of the insertion and testing its pH. If the pH is 0 to 5, the tube is most likely in the stomach. Do not auscultate over the stomach while air is irrigated through the nasogastric tube because it is not a reliable method of assessing placement. You can also hear air over the stomach if the tube has been inserted in the lung. If fluid is to be administered though the tube, radiographic confirmation is strongly recommended.

Sengstaken-Blakemore tube

The Sengstaken-Blakemore tube is a three-lumen tube used to treat upper gastrointestinal bleeding from esophageal varices when endoscopy is not available. It is made of rubber and has two lumens used to inflate the gastric and esophageal balloons, with one tube reserved for gastric suction or drainage. It can be inserted orally or nasally, and endotracheal intubation is strongly advised to secure the airway before insertion. The distal balloon is inflated in the stomach and the proximal balloon is inflated to compress esophageal varices or to reduce gastrointestinal hemorrhage. The Sengstaken-Blakemore tube is a temporary measure for treating upper gastrointestinal bleeding and is reserved for emergency settings only when endoscopy is not immediately available.

salem pump (NG tube)

The most common nasogastric tube is the double-lumen (two-channeled) gastric (Salem) sump tube made of clear plastic and sized according to the French method. This type of tube is useful for irrigating the stomach but is most often used for drawing out fluid and gas from the stomach. In fact, it is the preferred tube for gastric decompression. A major advantage of the gastric sump tube is that it can be used for continuous suction. Sizes 14 to 18 French with a length of 120 centimeters (48 inches) are typical adult sizes. When using this type of tube, connect the larger lumen to suction and collect the aspirated gastric contents in a drainage container

Descending colon (left upper abdomen)

The output is semi-formed because more water is absorbed while fecal material is in the ascending and transverse colon.

Ascending colon (right abdomen) colostomy

The output is typically liquid to semi-liquid and is very irritating to the surrounding skin.

Levin NG tube

The single-lumen (Levin) tube, which is also a nasogastric tube, ranges from 14 to 18 French in size. It is made of plastic or rubber with several drainage holes near the gastric end of the tube. It is 125 centimeters (50 inches) long with circular markings at specific points on the tube for monitoring insertion. This tube is useful for decompressing the stomach, withdrawing specimens for diagnostic analysis, washing the stomach free of toxic substances other than poison, and for irrigating the stomach to diagnose and treat upper gastrointestinal bleeding during emergencies when endoscopy is not immediately available. It can also be used to administer feedings and/or medications. The Levin tube is connected to low intermittent suction (25 mm Hg) to avoid erosion or tearing of the stomach lining, which can result from constant adherence of the tube's lumen to the mucosal lining of the stomach

3 main types of ostomy surgery

The three primary types of ostomy surgery are: § colostomy § ileostomy § urostomy

Miller Abbott tube

There are several dual-purpose nasoenteric (Keofeed, Moss, Dobbhoff) and nasojejunal (Miller-Abbott) tubes that can provide simultaneous gastric suction and enteral feeding. They are inserted nasally and extend into the duodenum or jejunum. These tube systems allow for removal of excess feeding formula from the stomach, thereby reducing reflux. These tubes are used short-term and are used primarily for patients undergoing surgery

Sigmoid colon (left lower abdomen) colostomy

This is the location for a permanent colostomy, particularly for cancer of the rectum. The stoma is typically located on the lower left quadrant of the abdomen, and the output is formed.

NG intubation reasons

To decompress air or stomach contents, feeding, oral med or supplements, infuse material like charcoal for overdose, abdominal surgery, relieve some of the content (bleeding), or you want to test whats in stomach (pH strip), to lavage the stomach (ingestion, bleeding), to apply pressure thru NG tube to prevent hemorrhaging

normal stoma after surgery

Typically, a stoma is pink to red. Report any stoma that turns pale, dark red, purple, brown, or black to the surgeon immediately as its blood supply may be compromised. The swelling subsides with time, gradually shrinking over the first few months. It is important to measure the stoma periodically to ensure that the size of the pouching system is appropriate. Once the stoma has a consistent size and shape, less frequent measurement is indicated.

vascular access devices

Vascular access device · Catheter, cannula, infusion ports, venipuncture

saphenous vein

Veins that run on ankle- good for neonate IV access

dorsal venous arch

Venous return that drains the top of the foot

end colostomy

With an end colostomy, the damaged section of the bowel is removed and the working end is brought through the abdomen to the skin surface. When a colostomy is intended to be permanent, an end stoma is typically created. A temporary colostomy may be performed to allow bowel rest or healing, such as following tumor resection. A common temporary colostomy surgery involves leaving the distal portion of the colon in place, which is oversewn for closure to create what is known as a Hartmann's pouch. Anastomosis of the severed portions of the colon may be delayed for several reasons, including bowel inflammation or tumor location

Placement of NG tube

aspirate to collect gastric contents, acidic, pH of 4 or less o Check odor, color, consistency o Confirmation with XR (dr)- not always required o Another RN auscultate and see if they hear gurgling to confirm- not always required

Evaluation (NG tube)

assessment- goal- positive outcomes o No more distention o Nausea- provide antiemetic like Zofran, § Relieved if they vomit? o Nutrition or NPO o Evaluate for active bleeding, what they may have ingested, what gets washed up from stomach o Did the hemorrhaging cease or is somewhat controlled if they had it o Comfort o Proper functioning of tube o DOCUMENT anything you do o Reassess

Before nasogastric tube insertion

check the provider's orders and the patient's care plan. Assess relevant diagnostic data such as coagulation studies and verify the patient's history. Patients at high risk for complications, such as those with a history of craniofacial surgery or trauma, may require special insertion techniques or equipment (fluoroscopy). Be sure to discuss any contraindications with the provider. Explain the purpose of the tube to the patient and let her know that discomfort is likely as the tube passes. Agree on a signal the patient can use if she wants you to stop briefly during the procedure

Colostomy

colon

Fiberglass cast

durability of plaster, lighter, hardens within minutes, porous (less skin problems). Do not get it soft by getting it wet, use hairdryer on cool setting if cast starts to itch, don't hit it on stick things in

extravasation

escape of blood from the blood vessel into the tissue

External fixation

go on outside, lower extremity, wrist, can actually see device outside of skin, stabilizes bone fractures

Induration

hardening or lump, such as what forms in lump from tuberculin skin test

dunlops traction

horizontal traction is used to align fractures of the humerus; vertical traction maintains the forearm in proper alignment

Contraindications for gastric lavage

include ingestion of poison, ingestion of hydrocarbon with a high aspiration potential, ingestion of a corrosive substance such as a strong acid or alkali, or absent airway protective reflexes unless the patient is intubated. Assess relevant diagnostic data such as coagulation studies and verify the patient's history. Patients at high risk for complications with nasogastric intubation, such as those with a past history of craniofacial surgery or trauma, may require special insertion techniques or equipment (fluoroscopy). Be sure to discuss any contraindications with the provider

Contraindications to nasogastric tube placement

include severe midface trauma, recent nasal surgery, and esophageal perforation. Patients with recent head trauma or brain surgery, deviated septum, esophageal varices or strictures, recent banding or cautery of esophageal varices, coagulation abnormalities, alkaline ingestion, or nasal polyps are at higher risk for complications. The provider must consider the various options carefully for patients who have these conditions

Plaster cast

inexpensive, heavy, set between 3-15 min, 24-72h to dry, messy, more support for bad fractures

Fixation

injury is rendered immobile, internal or external fixation

Casting or traction

internal or external fixation- rods and screws, requires surgical procedures, sometimes left in place, sometimes after a while are removed § Mechanical devices, pins rods wires screws

Lidocaine gel

is often used to eliminate sensation in the nasal mucosa during NG intubation

Gastric lavage (NG tube)

is the irrigation of the stomach. This is typically performed in acute-care settings, especially in cases of drug overdose for which swift removal of stomach contents is required. In that situation, an orogastric or nasogastric tube is inserted to aspirate gastric contents or to administer activated charcoal. Patients who have active gastric bleeding were, at one time, treated with gastric lavage to empty the stomach of blood and slow bleeding. However, this is no longer accepted practice except during emergencies when endoscopy is not available and the patient's life it at risk. Lavage may also be used as a therapy for hyper- or hypothermia to help stabilize the body temperature

Nursing care (of cast, traction etc)

maintain integrity of device, assess skin, assess muscle function, q4h check on things, perfusion, sensation, touch pain § Make sure pt is able to move to the right and left, monitor pin sites according to hospital policy for redness edema or drainage

Preventing IV complications

make sure IV are secured properly, infusing into the vein correctly etc Don't ever use IV bag that is uncovered, you have no idea who has tampered with it Start low, go slow- medication administration, know if they will have a reaction or not

traction

make sure we apply specific force (weights) to lower extremity in trying to align the bones o Tibia or fibula requires alignment, weights pulling it, mechanism to straighten broken bones or relieve pressure in spine- minimize spasms, reduce alignment and immobilize fractures, reduce deformity o Skin traction- direct application or force, as a temporary measure o Skeletal traction- attached directly to the bone could be used for long periods of time o Calipers on top of pt skull, apply weight which is pulling- help spinal traction o Bucks traction- involves skin traction, used in femoral fracture, slow back pain, hip pain o Dunlops traction- used when a patient (child) has humerus fracture o Milwalkee o Bryce traction

Gastric lavage indications (NG tube)

may be performed for diagnostic purposes, such as in preparation for an endoscopic examination, for treatment following ingestion of a toxic substance other than poison, for treating drug overdose, or to identify or treat gastric hemorrhage, in emergency situations when endoscopy is not available. It can be applied continuously or intermittently and is typically performed in an emergency department

Traction

mechanism to straighten broken bones

Maintaining NG tube

o Measure output o How comfortable is pt, pain? o Oral hygiene o Abdominal assessment again

traction nursing management

o Nursing magament § Continue to assess for any alteration in peripheral tissue, perfusion § Make sure no compromise with circulation § Circulatory care- better to apply traction with fracture to certain extent § Stockings, deep breathing, cough, etc to prevent DVT Teach them about anticoagulants- may be put on

Assess size of nares (NG tube insertion)

one larger than another, assess patency and tell to breathe and see how much flow is there, feels better to breathe left or right- know what size going to

Colloid

plasma expander

Cast

protective shell molded to protect broken limb

Ileostomy

sm bowel

gastric decompression (NG tube)

stomach contents are removed to relieve the stomach and intestines of pressure caused by the accumulation of gastrointestinal air and fluid. The nasogastric tube is connected to suction to facilitate decompression by removing stomach contents. Gastric decompression is indicated for bowel obstruction and paralytic ileus and when surgery is performed on the stomach or intestine. The tube usually remains in place until normal bowel function resumes, as evidenced by active bowel sounds on auscultation and/or when the patient is able to pass flatus. For some patients, a gastrostomy tube is placed during surgery and used postoperatively for gastric decompression. This is usually reserved for patients who undergo extensive surgery or who are at high risk for prolonged postoperative ileus

stoma

surgically-created opening in the skin of the abdomen is called a stoma. A stoma is the communicating end of the bladder or bowel that is brought to the surface of the abdomen. The location of the stoma depends upon the location of the patient's beltline, the location of any scars and skin folds, where the damage is, and the type of ostomy surgery performed. The stoma should be shiny, wet, and red in color, similar to the mucous membranes of the mouth. A stoma can be round, oval, or irregular in shape, and either protruding, flush with the skin, or retracted

Pouching

system changing, ostomy appliances o Barrier gets attached to actual pouch o One piece or 2 o Flange - skin barrier, sits against skin

measure tube length (NG tube)

there are 2 ways o some people measure from nare to earlobe and go down to to xiphoid process (below sternum), if they measure that way they should add a few inches (4-6in) o if they measure from nare and go around ear down to xiphoid process, there is no need to add extra length § once you get down to measurement, you will decide how to measure- sharpie, strip of tape to tell you, BOTH ways are correct

Plaster care

uncomfortable cast, plaster can cause indentation if form it or leaning, can cause pressure spots in skin when it finally dries § If you put palm on it, it can shape palm on hand § Don't rest on hard surface or sharp edges

Urioscopy

ureter sewn through intestine, brought out

Bifurcation

where 2 veins meet, sometimes has a little valve, if you are trying to get an IV access through bifurcation, you either get it or blow the vein · Shouldn't be going through that area · Sometimes you have no choice- elderly pt or pediatric patient with delicate frail veins and you don't see anything else

loop colostomy

§ With a loop colostomy, a loop of the bowel is brought through the abdomen to the skin surface and temporarily supported by a plastic bridge or rod. A transverse loop colostomy is typically created as an emergency procedure to relieve an intestinal obstruction or perforation. A communicating wall remains between the proximal and the distal bowel. It has two openings through the one stoma - the proximal end drains stool while the distal portion drains mucus. The bridge can be removed in 7 to 10 days. Transverse loop colostomies are typically temporary.

Instruct patients to notify their clinician for any of the following (ostomy)

§ increased pain in the abdomen or the incision; fever, redness, or drainage of the incision; or irritation, redness, or breakdown of the peristomal skin § change in bowel habits, such as diarrhea or constipation § skin irritation unrelieved by a properly fitting pouching system § problems obtaining a good seal of the wafer or skin barrier § a hernia or bulge around the stoma § narrowing of the stoma lumen § separation of the stoma from the abdominal surface § lacerations or cuts in the stoma

Tips for documentation

· Always document response example= "pt tolerated well" · Document when iv infusion starts, when it ends · Inserting IV catheter, date time and size IV catheter is used, initials with RN at end · Document type of dressing etc · What you used to stabilize the IV · Patients status- awake alert sleeping etc · Taking out peripheral IV solution- date and time · How area looks- swelling etc

complications (NG tube)

· Complication o Excoriation of nares and stomach o Bleeding o Discomfort o Occlusion of NG tube that can lead to distention o Tube is displaced o Patient pulled the tube out

During NG tube insertion

· During: abdominal assessment, respiratory assessment (auscultate, breathing), raise HOB to comfortable working position and for pt, High fowlers usually (45-90 degrees) -assess size of nares -Placement -Maintaining -evaluate

Education (NG Tube)

· Education: o Explain procedure BEFORE it starts o Communicate with client during procedure o Explain whats happening o Evaluate pt ability to assist or cooperate o Establish means to signal distress (raising hand- pain with procedure- stop and let them relax and then continue with procedure) o Difficulty in pt with ingestion, sedated state, combative patient, geriatric age and does not understand, pediatric patient Assess clients education level

Basic steps of ostomy

· Hand hygiene · Gather supplies · ID pt. review procedure · Check order · Encourage pt to be part of care if possible · Give patient privacy, pull the curtain, be careful if another person in room · Waterproof pad for leakage · Gloves · Remove ostomy bag, place in garbage if throwing away, if draining it put it down the drain and just put warm water · Remove flange by moving towards the stoma · Cleans with adhesive remover wipe to remove flange · Clean gently, no nerve sensation but use nice soft wiping with warm water · DO NOT use soap · Assess the stoma and skin around in · Make sure it's pink/red, should be raised, above the skin level and moist · When you wipe stoma, there might be a little bleeding · Opening is 2mm larger then the actual stoma barrier guide- should fit nice and tight · Measure stoma with measuring guide in packet · Trace diameter into flange and cut the flange, use curved scissors · Prepare skin and apply barrier products according to agency policy · Remove any inner backing of flange, leave on skin and press for 1 minute, warm of hand will create a nice tight sealed barrier after you put on new one · Then apply ostomy bag if it's a 2 step process · Apply clip if it comes with bag · 1-2 min, continue applying pressure nice seal · Clean up area · Throw away · Hand hygiene · Document

Saline Lock

· IV catheter inserted into vein · Flushed with NS · Can be just left without being connected to primary IV tubing o Labeling medication o Date o Time o Initials, RN

Ostomy pouch

· No control or sensation of output out of the stoma- they don't know when they're going it just flows out · Must wear a pouching system to collect this matter · Assess patients skin for breakdown · Completely sealed to prevent leakage · Ask for allergies · Make sure its leak proof · Drain o Some roll up and snap Velcro o Some have a plastic clip o If 2 piece you might have to cut out flange depending on size of stoma

pre NG tube insertion

· Pre: Review prescription, hand hygiene, equipment, privacy, educate patient, evaluate the patient's understanding of the procedure, talk to them and educate family member too (PRE)

ostomy safety

· Safety o Priority o Acute care setting- 4-7 days need to change o At home- educating on change 3-5 days need to change o Empty when it's 1/3 full, ask when they last ate, usual time to feed o Change in AM before breakfast o Consult wound care specialist if wound care breakdown o Patient should participate and family member o Encourage the patient to empty the pouch- 1/3 or ½ way full § Different products, different pouches based on needs of patient or doctors preference o Medications might need to be used o Special diet o Ostomy belt- hold pouch in place o Sweating, high heat, moisture, oily skin, exercise might affect the intactness of the pouches Treat minor skin irritation right away to prevent sores and further leakage

Drip chamber on tubing

· Squeeze chamber gently once or twice, get it to the MIDDLE of the plastic chamber, don't fill it up too much or you will have to take off hook and invert the bag and squeeze the chamber

Central venous catheter

· Subclavian and clavular veins, going to superior vena cava · Some go to the heart · Extremely important sterile technique is used · Change dressing- sterile technique · Could lead to death of pt if infection occurs!

Transparent dressing

· Tegaderm · Secure catheter and access and protect from infection

Special considerations (ostomy care)

· When theyre about to leave hospital or center, make sure you have provided or referred anyone who needs help · Will be able to access equipment at home · Proper training, care, comfortable

Understand physical and emotional assessment (ostomy)

· be empathetic and compassionate o May have comorbidities, may not have ability to manage ostomy care themselves o Arthritis, vision, parkinsons, stroke, keep them from taking care of themselves o Have family member help if possible · Self esteem, body image, quality of life, ability to be intimate o Very common struggle · Make sure they have appropriate information and help- support group, social worker, ostomy nurse to help them with the care · Use nonverbal cues- don't demonstrate disgust when performing ostomy care o Can have odor to it o Alcohol in mask to hide smell o Destroy their self esteem! Don't make comments or grimace!

Planning (NG tube)

· expect there will be some outcomes · abdomen is now soft nontender, nares and mucosa intact, level of comfort improved, gave privacy by pulling curtain, performed hand hygiene, cleaned bedside, informed on procedure, you have done your assessments, have everything ready

Implementation (NG tube)

· high fowler 45-90 degrees, depending on pt orders or contraindications (maybe Dr doesn't want to go over 45) · check facial tissue- no swelling, patency of nares · if right handed- stand on pt right side, if left handed stay on pts left side · lower the rails · pt takes deep breath to show clear lungs and patency measure tube length · wash hands, clean gloves · NOT A STERILE PROCEDURE. Don't need sterile gloves · Put patient on pulse oximeter- document lung sounds equal bilaterally, continue to monitor as procedure goes (does not have to do) · Option- dip tip of tube in lubricant or you grab it · Need to do- give pt a cup of water, they may not be able to know they need to drink and swallow when you tell them to o Swallowing helps you put the tube down · DO not push through if they're coughing, could get dislodged and go into wrong place · Skin adhesive, slits of 1/3,2/3 length of tape over bridge of nose to keep in place · Make sure HOB is elevated afterwards most say keep at 45 degree, 3-45 · Hand hygiene · Document- measurement, gastric content, how pt tolerated · Attach to suction on wall according to doctor orders