Acid Base Balance

Sp Gravity: 1.010-1.030 pH: 4.0-8.0 WBC: negative Albumin: negative

UA Sp Gravity: 1.010-1.030 pH: 4.0-8.0 WBC: negative Albumin: negative

WBC: 5,000-10,000/mm3 Neutrophils: 50-70% Lymphocytes: 20-40% Monocytes: 2-10% Eosinophils: <4% Basophils: <2%

WBC & diff WBC: 5,000-10,000/mm3 Neutrophils: 50-70% Lymphocytes: 20-40% Monocytes: 2-10% Eosinophils: <4% Basophils: <2%

Acidosis: pH below 7.35 Can lead to: 1. Decreased cardiac contractility 2. Decreased vascular response 3. Decreased effect of medications

Acidosis: pH below______ Can lead to:

Make changes to hold the H ion until it can be eliminated from the body 1. Respiratory System: carbonic acid (H2CO3) changes to carbonate (CO2) H2O and CO2 ↔ H2CO3 ↔ H and HCO3 2. monohydrogen-dihydrogen phosphate - Na and other cations and the breakdown is NaCl and NaH2Po4 sodium bi phosphate 3. intracellular and plasma protein Proteins and hemoglobin bind or release H+ -free radicals become CO2 and H -bound radicals become ammonia

Buffering Systems

BUN:10-20 mg/dL Creatinine: 0.2-1.0 mg/dL

Renal BUN:10-20 mg/dL Creatinine: 0.2-1.0 mg/dL

designed for gastric decompression and may be used for feeding and medication administration on a short term basis only. Small bore feeding tubes are preferred for enteral feed administration.

Salem Sump tubes

7.34-7.45

pH:

sea level: 80-100 mmHg mile high: 65 - 75

pO2 sea level mile high

CPAP level →(10cmH2O) • FiO2 →(100%) • SpO2 q5 minutes • Vital Sign q5 minutes • Response to treatment • Any adverse reactions • Justificatio

CPAP Documentation

These patients are often in a state of crisis and respiratory failure. Intubation will be inevitable in some patients regardless of the use of CPAP, and the paramedic must be prepared for rapid intervention by RSI/MAI. Indications to proceed to ET placement are (not all inclusive): • Deterioration of mental status • Increase of the EtCO2 • Decline of SpO2 • Progressive fatigue • Ineffective tidal volume • Respiratory or cardiac arrest

CPAP and Intubation considerations

1. RR & WOB 2: Rate/Rhythm (1 pt.) & Work of Breathing (1 pt.)- Eupnic?- effortless/no sign of accessory muscle hypertrophy? 2. oxygen/RA 3. AP:T Diameter 4. Auscultate breath sounds: A-6/P-6/L-2

RESPIRATORY Assessment

Alkalosis: pH above 7.45 Affects: Tissue oxygenation Neurological functioning Muscle functioning

Alkalosis: pH above Affects

Acid-base status Underlying cause of imbalance (respiratory or metabolic) Body's ability to regulate pH Overall oxygen status

Arterial blood gas (ABG) values provide information about

1. Temperature 2. Pulse: regula, radial/ 30 sec) 3. Respirations 4. Blood Pressure 5. Pulse Oximetry 6. Pain acceptable/unacceptable rating 0/10

Assessment: VITAL SIGNS

35-45 mmHg

pCO2:

Kineys try to hold onto HCO3 or excrete acids HCO3- is a *Base* If pH decreases kidneys will *retain bicarbonate* If pH rises the kidneys will *excrete bicarbonate* Compensation takes *hours-days*

Kidney (HCO3-) Bicarb Buffer Kineys try to hold onto HCO3 or excrete acids HCO3- is a _____ If pH decreases kidneys will _____ If pH decreases kidneys will _____ Compensation takes_____

CO2 is a * 1. volatile acid* 2/. Byproduct of cellular metabolism CO2 + H20= carbonic acid CO2 + H2O <---> H2CO3 <---> HCO3- + H+ Lungs are triggered to increase or decrease resp rate and depth Compensation starts in *1-3* minutes

Maintaining proper pH (Buffering System) Respiratory CO2is a: 2 Lungs are triggered to increase or decrease resp rate and depth Compensation starts in _____ minutes

Total: 6-8 g/dL Albumin: 3.5-5.0 g/dL

Protein Total: 6-8 g/dL Albumin: 3.5-5.0 g/dL

*Chronic* COPD Pneumonia *Acute* Respiratory Failure Pulmonary Edema or Embolus Neuromuscular Diseases Electrolyte Disturbances

RESPIRATORY BUFFER SYSTEM ENEMIES/Primary Diseases of the Lung

CPAP therapy needs to be continuous and should not be removed unless the patient can not tolerate the mask, requires suctioning or airway intervention, experiences continued or worsening respiratory failure, or a pneumothorax is suspected. Intermittent positive pressure ventilation and/or intubation should be considered if patient is removed from CPAP therapy.

Removal of CPAP

Inspect - Palpation - Percussion - Auscultation

Order for Inspection

Cranial Nerves

Cranial Nerves

Total: <200 mg/dL HDL: >50 mg/dL LDL: <130 mg/dL

Cholesterol Total: <200 mg/dL HDL: >50 mg/dL LDL: <130 mg/dL

sea level > 95% mile high > 90%

SaO2: sea level mile high

1ST NAME: COMPENSATED - pH within the normal range UNCOMPENSATED - pH outside of the normal range LAST NAME: ACIDOSIS - pH < BELOW 7.40 ALKALOSIS - pH > ABOVE 7.40 MIDDLE NAME: LOOK FOR THE PARAMETER THAT RELATES TO THE pH DISTURBANCE. - If the PCO2 is opposite the pH: the middle name or etiology is RESPIRATORY -If the HCO3 is consistent with pH problem: the middle name or etiology is METABOLIC *R*espiratory *O*pposite Alkalosis ↑ pH ↓ PaCO2 Acidosis ↓ pH ↑ PaCO2 *M*etabolic *E*qual Acidosis ↓ pH ↓ HCO3 Alkalosis ↑ pH ↑ HCO3

ABG INTERPRETATION 1ST NAME: COMPENSATED: pH <______> UNCOMPENSATED: pH >_____< LAST NAME: ACIDOSIS - pH <_____ ALKALOSIS - pH > _____ MIDDLE NAME: - etiology is RESPIRATORY If the PCO2 is the ______ pH: -etiology is METABOLIC -If the HCO3 is ______ with pH problem: RO ME

pH: 7.34-7.45 pCO2: 35-45 mmHg HCO3: 22-28 mEq/L pO2: sea level: 80-100 mmHg mile high: 65 - 75 SaO2: sea level > 95% mile high > 90% All the parameters need to be evaluated in relation to the *Hgb level* Only true way to measure hypoxemia= *PaO2*

ABG's pH: pCO2: HCO3: pO2: SaO2: All the parameters need to be evaluated in relation to the: ______ Only true way to measure hypoxemia.

1. *Introduces self professionally* Eye contact; Provide name; Role; Reason for assessment 2. *Provides privacy* Pulls curtain around bed 3.*Washes hands (use hand sanitizer/wash)* 4. *Assess 2 patient identifiers* Wrist band- name/birth date 5. *Question pt. allergies* Medication, food, environmental: iodine/latex 6. *Locked position of bed/safety rails* Upper safety rails up?/down when you are at pt's side, bed locked 7. *Raise/ Lower bed for body mechanics* 8. *Begin and end at lowest setting* 9. *Patient privacy*

Assessment: GENERAL INTRODUCTION/SURVEY

1. Color 2. Scars 3. Lesions 4. Rashes 5. Bruising/trauma 6. Hair distribution 7. Tattoos/ piercings 8. IV sites/ tubing: describe site if present 9. Palpate for: Temperature, moisture, texture, edema, turgor, tenderness

Assessment: Skin

Blood is slightly alkaline at pH 7.35 to 7.45. Perfect homeostasis is between .35 and .45 pH< 6.8 or >7.8 interferes with cellular functioning: poor prognosis

Blood is slightly alkaline at pH: Perfect homeostasis is between: pH< ______ or ______< interferes with cellular functioning: poor prognosis

Hgb: F- 12-16 g/dL M- 14-18 g/dL HCT: F- 35-45 % M- 40-50% RBC: F- 4.0-5.0 m/mm3 M- 4.5-6.0m/mm3 Platelets: 150,000-400,000/mm3 ESR: F-<20 mm/h M- <15 mm/h

CBC Hgb: F- 12-16 g/dL M- 14-18 g/dL HCT: F- 35-45 % M- 40-50% RBC: F- 4.0-5.0 m/mm3 M- 4.5-6.0m/mm3 Platelets: 150,000-400,000/mm3 ESR: F-<20 mm/h M- <15 mm/h

COMPENSATION BY THE RESPIRATORY OR THE RENAL SYSTEM IS ACHIEVED WHEN THE ph REMAINS OR RETURNS WITHIN THE NORMAL RANGE

COMPENSATION BY THE RESPIRATORY OR THE RENAL SYSTEM IS ACHIEVED WHEN ______

This procedure is specific to the Emergent PortO2Vent CPAP device. When another device is used, and there is a conflict with this procedure and the devices recommended guidelines use the manufacturers recommended guidelines when they will not result in a detriment to patient care. 2. Advise receiving hospital as soon as possible so they can prepare for the patient's arrival. 3. Do not remove CPAP until hospital therapy is ready to be placed on the patient 4. Once CPAP headset is in place, consider early administration of nitro-paste, as nitro spray may be impractical to use in CHF patients. 5. Success is highly dependent upon patient tolerance, and EMT-P ability to coach the patient. a. Instruct patient to breath in through nose and exhale through mouth as long as possible 6. Monitor closely for development of pneumothorax and or hypotension 7. Monitor patients closely for vomiting and or gastric distention 8. Most patients will improve in 5-10 minutes. If no improvement within this time, assess for other causes and problems. Re-evaluate for intermittent positive pressure ventilation or Intubation 9. CPAP is an acceptable treatment option for a patient with a DNR/DNI order who is in respiratory failure

CPAP Notes

1. *Precordium*: pulsations, heaves, lifts at (eye level), 2. *UE's/edema*: Presence of varicosities/spider nevi/etc. and edema (present, 1+) 3. *Palpate radial pulses*: describe strength on 0/3+ scale 4. *Palpate CRT*: CRT= Capillary refill time, state less than ? seconds 5.*Inspect vascularity of LE's/edema*: Presence of varicosities/spider nevi/etc. and edema (present, 1+) 6. *Palpate dorsalis pedis & posterior tibial pulses*: 7.* Auscultate 4 cardiac*: note rate and rhythm --use diaphragm and bell

Cardiac Assessment

1. Neutralize the acid before its entry into the serum or 2. Hide / excrete the ingredients or 3. Make more of compensating substances

Cellular metabolism results in acid production. The body must compensate by:

BT: 3.0-9.5 min. INR: 1 PT: 10-15 sec. PTT: 60-70 sec. aPTT: 30-40 sec

Coagulation BT: 3.0-9.5 min. INR: 1 PT: 10-15 sec. PTT: 60-70 sec. aPTT: 30-40 sec

Prothrombin Time (PT):11-14 seconds Partial Thromboplastin Time (PTT):25-35 seconds International Normalized Ration (INR):0.8-1.2 Activated Partial Thromboplastin Time (aPTT):1.5-2.5 Fibrinogen: 203-377 mg/dL Bleeding time: 1-6 mins

Coagulation Studies Prothrombin Time (PT):11-14 seconds Partial Thromboplastin Time (PTT):25-35 seconds International Normalized Ration (INR):0.8-1.2 Activated Partial Thromboplastin Time (aPTT):1.5-2.5 Fibrinogen: 203-377 mg/dL Bleeding time: 1-6 mins

1. Complete order for x-ray to confirm initial NG tube placement. Requisition MUST indicate reason for X-ray i.e.'Chest x-ray for confirmation of gastric tube placement' 2. Initial placement: MRP or designate MUST check placement by reviewing xray with Attending Radiologist, Radiologist Resident, or credentialed non radiologist. Order MUST be written into Practitioners orders stating "Tube placement verified by x-ray and may be used" 3. Assess for correct placement of feeding tube prior to each intermittent feed, medication administration and at least every 4 hours when patient is receiving a continuous feed. 4. See procedure for methods

Confirm Correct placement of Feeding Tube

Do not aspirate, check patient for abdominal distension and vent tube prn.

Enteral tube feeding Assessing Tolerance of Tube Feed for Buttons:

Do not aspirate as cannot obtain gastic residuals, instead check patient for abdominal distension

Enteral tube feeding Assessing Tolerance of Tube Feed for Nasoduodenal (ND), Nasojejunal (NJ), Jejunostomy (J-tube) and Percutaneous Gastro-jejunostomy (PGJ) Feeding Tubes:

a non-invasive method to provide respiratory support to certain patients. CPAP has been shown to rapidly improve vital signs, gas exchange, work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in the patients who suffer from shortness of breath from congestive heart failure (CHF), acute pulmonary edema (APE), and COPD. *Mechanism of Action* CPAP works by providing increased continuous gas pressures at the level of the lower airway structures, improving gas exchange in the alveoli. In patients with CHF, CPAP improves hemodynamics by reducing preload and after load * Indications:*: moderate to severe respiratory distress secondary to asthma/reactive airway disease, near drowning, COPD, CHF, acute pulmonary edema (cardiogenic and non cardiogenic), or pneumonia who present with any of the following: • Pulse oximetry < 88% not improving with standard therapy • ETCO2 > 50mmHg • Accessory muscle use / retractions • Respiratory rate > 25 • Wheezes, rales, rhonchi • Signs of respiratory fatigue or failure *Contraindications* Physiologic • Unconscious, Unresponsive, or inability to protect airway. • Inability to sit up • Respiratory arrest or agonal respirations (Consider Intubation) • Persistent nausea/vomiting • Systolic Blood Pressure less than 90 mmHg • Inability to obtain a good mask seal Pathologic • Suspected Pneumothorax • Shock associated with cardiac insufficiency • Penetrating chest trauma • Facial anomalies / facial trauma • Has active upper GI bleeding or history of recent gastric surgery

Continuous Positive Airway Pressure (CPAP) Mechanism of Action Indications: Contraindications (Physiologic & Pathophysiologic)

1. Place patient in a sitting position or similar position of comfort 2. Assess and monitor the patient • Vital signs q5 min • Lung sounds before and after CPAP, and as feasible thereafter. • Attach ECG and pulse oximeter • Medical Control Contact: If BP <90 systolic contact Medical Control prior to beginning CPAP 3. Explain the procedure to the patient 4. Anticipate and control anxiety • The CPAP may produce anxiety in some patients. Verbal coaching is often very effective in reducing this • Verbally coach breathing as needed • In some patients, low dose benzodiazepines may be needed. See Adult Sedation for Painful Procedures (M-15) 5. Assemble CPAP. Attach CPAP to O2 source and adjust starting CPAP pressure: • Begin at 5 cmH2O • Consider use of nebulized medications as indicated by patients clinical presentation and suspected etiology • Progressively increase the pressure desired cmH2O There is better tolerance with gradual progression of pressure • MAX CPAP PRESSURE: i. CHF: 10 cmH2O ii. All other respiratory conditions: 5 cmH2O Apply mask. • Check for air leaks • Consider having the patient hold the mask in place for a minute or so to reduce anxiety. As an option the medic may hold it in place to ensure a good seal is obtained • Using the head Straps: The use of the head straps is at the medics discretion based on ability to keep a continuous face mask seal weighed against the increased anxiety the head straps may cause o Place head strap over occipitoparietal area o Gently hold the delivery device to the patient's mouth and nose o Attach the straps, loosely at first, gradually tightening as the patient tolerates. Proceed with tightening the straps until air leaks are eliminated • Continue to coach patient to keep mask in place and readjust as needed 7. An in line nebulizer may be run simultaneously with the CPAP. 8. Treatment should be given continuously throughout transport to ED.

Continuous Positive Airway Pressure (CPAP) Procedure:

When a resident is involved, review the Advance Directives to ensure that s/he wants to be resuscitated. If s/he wants to be resuscitated, proceed with the CODE BLUE procedure. When an individual's wishes are unknown (resident, outpatient, staff or visitor), proceed with the CODE BLUE procedure. Please Note: It is acceptable NOT to initate CPR in any case where the cardiac arrest was unwitnessed and the affected individual exhibits obvious signs of death (i.e. vital signs absent with the presence of rigor mortis and/or tissue decay, etc.).

Determine whether or not to initiate a CODE BLUE.

Diabetes Hypertention Kidney Disease- pre, intra, or post renal Nephrotoxic drugs Congenital renal diseases

Diseases that oppose Renal Buffer System

1. Pharmacy will be notified that an order to give medications through tube (include type of tube inserted) has been obtained and suspensions for medications will be supplied when possible. 2. When a liquid suspension is not available medications should be crushed and mixed with sterile water 3. All oral medication suspensions will be prepared in, delivered and administered in a labeled oral syringe. Oral medications will not be prepared in syringes usually used for injections. 4. Do not give any sublingual, enteric coated or sustained release medication through the feeding tube. 5. Contact Pharmacy for reconstitution of Hazardous medications as per policy: Hazardous Drugs (non-Chemo) Administration & Precautions #1044 6. Medications will be given one at a time. 7. Flush with 15mL sterile water before and after each medication 8. If the patient requires a fluid restriction, notify pharmacy (to concentrate medications) if applicable.

ENTERAL TUBE FEEDING Medication Administration

Continuous: feeding for 24 hours continuously either by gravity drip or feeding pump • Bolus: feeding is infused over a short time period at specified intervals (less than or equal to 15 minutes) • Intermittent: similar technique to that of bolus feeding, but it is infused over a longer duration (greater than or equal to 30-120 minutes) • Cyclic: continuous feeding over a specified period (e.g. 8-20 hours per day, i.e. night time feeds)) administration set must be labeled with patient's name, formula type, rate, and date.

ENTERAL TUBE FEEDING Method of Administration Continuous: Bolus: Intermittent: Cyclic:

1. Check gastric residual volumes every 4hrs X 48hrs post initiation of new continuous feed. 2. If the residual is less than or equal to 350mL, refeed the aspirated volume and continue feeding as before. 3. If the residual is greater than or equal to 350mLs, refeed 350mLs, discard remaining aspirated volume, and hold feed x 4 hours. Restart the feed at 10mL/hr and increase by 10mL/hr q1h back to the previous tolerated rate. 4. If the residual is greater than or equal to 350mLs a second time, refeed 350mLs, discard remaining aspirated volume, and hold feed x 6 hours. Consider a promotility agent in adult patients. Re-check residuals after 6 hours and if less than 350mLs, restart feed as above. 5. If intolerance (residual greater than or equal to 350mLs) occurs a third time, consider a small bowel feeding tube. At RUH, consult the NSS. 6. For established gastric feeds (greater than 48 hours), check residual when patient exhibits signs of gastric intolerance (abdominal distension, nausea, and vomiting).Diarrhea could indicate formula is being administered too rapidly. 7. Critically ill patients require continuous monitoring of gastric residual volumes q4h.

Enteral tube feeding Assessing Tolerance of Tube Feed for Nasogastric(NG) or Orogastric(OG) Feeding Tubes

1. Notify practitioner 2. Obtain order for X-ray for tube placement check. MRP or designate MUST confirm placement with Attending Radiologist, 3. Radiology Resident or credentialed non radiologist. The confirmation order MUST be written into the practitioners orders stating "tube placement verified by X-ray and may be used"

Enteral tube feeding Displaced Tubes: methods of checking placement forSmall Bore Feeding Tubes:

Notify practitioner if the button is not useable because of a broken balloon

Enteral tube feeding Displaced Tubes: methods of cheking placement for Button feeding

1. For PG and PGJ notify practitioner or NSS at RUH. Radiology will need to be consulted for tube reinsertion. It is recommended that Radiology is notified as soon as possible. 2. For PEG consult NSS (at RUH) or Surgeon (at SPH) for reinsertion. 3. Cover site with a sterile dressing. 4. Practitioner may consider insertion of Foley catheter to maintain a tract for a short period of time. An individualized care plan for the patient must be developed and all other options considered prior to use of a Foley Catheter as a replacement device. Foley is Not intended for feeding

Enteral tube feeding Displaced Tubes: methods of cheking placement for Gastrostomy (PEG/PG)/Jejunostomy (PGJ):

1. Notify practitioner 2. Reinsert if ordered 3. X-ray for gastric tube placement will be done and MRP or designate MUST confirm placement with the Attending Radiologist, Radiology Resident or credentialed non radiologist prior to use. Order must be written by MRP or designated physican that "tube placement verified by x-ray and may be used"

Enteral tube feeding Displaced Tubes: methods of cheking placement for Nasogastric (NG) or Orogastric (OG)

Check balloon volume per unit specific protocol and /or manufacturers recommendations

Enteral tube feeding PROCEDURE: methods of cheking placement for Button feeding tubes

1. Confirm correct placement by ensuring gastrostomy flange is flush to the skin. 2 PEG: compare the level of which the flange is placed (cm markings on the tubing) to that recorded in the nursing care plan at the time of PEG insertion 3. PG: check for discoloration of the tube shaft; this indicates that the tube may have been pulled out. Tubing that has been exposed to gastric contents will be brown in color in comparison to the usual cream color of the tube. If the discoloration measures less than 7.5 cm (3 inches) in length an x-ray should be done to confirm placement. If discoloration of the tube measures greater than 7.5 cm (3 inches), consult intervention

Enteral tube feeding PROCEDURE: methods of cheking placement for Gastrostomy Tubes (PG,PEG)

1. Confirm correct placement by measuring external length of tube and compare to length documented in the nursing care plan. 2. Check for discoloration of the tube shaft. Tubing that has been exposed to gastric contents will be brown in color in comparison to the usual cream color of the tube. If the discoloration is less than 7.5 cm (3 inches)in length and xray should be done to confirm placement. If discoloration of the tube is greater than 7.5 cm (3 inches), consult interventional radiology for a tube check. Hold feed until placement is confirmed

Enteral tube feeding PROCEDURE: methods of cheking placement for Jejunosotomy (Surgical J-tubes, PGJ)

1. Check external length of feeding tube (tube must be marked with permanent marker or tape at insertion site) and compare to length documented on nursing care plan. 2. Aspirate and visualize gastric contents. Gastric aspirates often grassy green or colorless with sediment. Intestinal aspirates often yellow or bile stained and either clear or cloudy. 3. Test pH of gastric contents (pH of 5.5 or below indicates correct placement in most patients). Note: patients taking acid reducing drugs (e.g. Pantoprazole, Ranitidine) may have an altered pH. PH testing is of minimal value for continuous feeds. 54. Assess patient for signs & symptoms of inadvertent respiratory migration of tube: coughing, choking or cyanosis. 6. Assess for coiling of tube in back of throat with a flashlight and tongue depressor.

Enteral tube feeding PROCEDURE: methods of cheking placement for Nasogastric (NG) or Orogastric(OG) Tubes: Methods to check feeding tube placement: X-ray will be ordered to confirm initial tube placement prior to use

1. Confirm correct placement by measuring external length of tube and compare to length documented in nursing care plan. 2. Small bore soft lumen tubes should be carefully assessed in unconscious or disoriented patients since it is difficult to aspirate stomach contents to confirm placement. 3. Assess for coiling of tube in back of throat with a flashlight and tongue depressor.

Enteral tube feeding PROCEDURE: methods of cheking placement for Small Bore Feeding Tubes

1. type of feeding tube being utilized 2. initial external length of feeding tube in nursing care plan. 3. If feeding tube requires rotation document time and date rotated. 4. Record formula type, hourly intake, flush volume, aspirate volume 5. Symptoms of feeding intolerance: vomiting, diarrhea, abdominal distension and/or pain, large residual volume. 6. Document insertion site assessment and care. 7. Document feeding system changes.

Enteral tube feeding Documentation

1. All types (NG,OG, ND,NJ, PGJ, PEG, J-tube, Buttons) [Flushes are provided to maintain tube patency, before and after gastric residual volume checks, before and after medication administration, before and after intermittent and bolus feeds and when providing additional free water.](See Infection Control section for appropriate water type) 2. Flush with a pause/push technique to decrease clogging of tube. 3. Use 60 mL syringe to avoid high pressures. 4. Flush with 30mLs water every 4 hours (continuous feed) to maintain patency of feeding tube unless otherwise ordered. 4. Flush with 30mLs water before and after each feed (intermittent) to maintain patency of feeding tube unless otherwise ordered. 5. Flush with 30mLs water before and after checking residuals to maintain patency of feeding tube unless otherwise ordered. 6. Flush with 15mL water before and after each medication 7. If the patient requires a fluid restriction, notify the dietitian (to review concentration of formula and/or decrease water flushes) and pharmacy (to concentrate medications). 8. Flush unused tube with 30 mLs water BID. 9. Regular flushing can be programmed into the Kangaroo pump

Flushing of Feeding Tubes

1. voiding: regularly, amount 2. Inquire on description of urine: Color, Smell 3. Inquire if voiding is asymptomatic (Burning, itching, etc)

GENITOURINARY Assessment

1. *Inspect contour/symmetry*: abdomen 2.*Auscultate bowel sounds*: 4 quads w/ diaphragm. 3. *Auscultate*: aorta for bruit w/bell 4. *Percuss* abdomen for tympany/dullness. 5. *Palpate abdomen* (light only) 6. Inquire of last BM/flatus 7. Inquire on color/consistency/NML frequency

GI Assessment

HBA1C: 4.0-7.0% FBS: 70-110 mg/dL

Glucose HBA1C: 4.0-7.0% FBS: 70-110 mg/dL

22-28 mEq/L

HCO3:

Diabetes mellitus Vomiting and diarrhea Respiratory conditions

Health Problems that lead to Acid Base Imbalance

ALT (SGPT): 4-36 u/L AST (SGOT (F): 9-25 u/L (M): 10-40 u/L Bilirubin (total): 0.2-1.3 mg/dL Ammonia: 30-70 mcg/dL

Hepatic ALT (SGPT): 4-36 u/L AST (SGOT (F): 9-25 u/L (M): 10-40 u/L Bilirubin (total): 0.2-1.3 mg/dL Ammonia: 30-70 mcg/dL

RED ± Fire BLUE ± Cardiac / Respiratory Arrest PINK ± Infant / Child Abduction BLACK - Bomb ORANGE - Hazmat / Bioterrorism GREY - Violence/Security Alert WHITE - Hostage YELLOW - Lockdown GREEN - Mass Casualty / Disaster BROWN - Severe Weather

Hopsital Codes

1.

IV Therapy Calculating Maintenance Fluids. Checking Fluid Infusing. Calculating / Administering Replacement Fluids. Maintaining Site. Priming Tubing / Changing Tubing. Administering Electrolyte Infusions (K+) Heparin Locks. Monitoring and Charting Infusions.

1. Wipe top of formula can with alcohol swab before opening. 2. Cover, label (with patient name date and time opened) and refrigerate remaining formula and use within 24hrs. 3. Wash hands and wear non-sterile gloves when accessing formula and feeding tube. 4. Maintain clean technique when accessing. 5. Clean each enteral tubing connection with an alcohol swab when accessing. 6. Formula will be suspended for no longer than 4 hours if reconstituted or premixed by Dietary. Formula that is sterile (e.g. canned formula) may be hung for no longer than 8 hours. 7. Do not add new formula to that remaining in administration bag. Before adding new formula, rinse bag with sterile water. 8. Change administration sets and additional medication and any additional administration supplies every 24 hours.

Infection Control

PG, PGJ, PEG, J- tube, Button • Follow post insertion orders. • Check security of PGJ/PEG anchoring device frequently to prevent dislodging. • Observe & assess PG, PGJ/PEG/Button insertion site every shift - assess skin condition, notify Practitioner of redness greater than 1 cm, swelling, drainage or leaking of gastric contents or tube feed. • Clean insertion site q12 hours and prn with saline. Apply gauze dressing if required (change dressing prn). • Rotate Buttons and PEG 360 degrees once daily. Button should turn freely. • For PEG-Avoid a dressing if possible. If there is drainage or the bolster is 'digging' into the skin in one area the thickness of the dressing should be limited to one layer of a drain dressing. Excessive layers of dressing under the bolster can result in the internal bolster eroding into the stomach wall. The PEG should also be secured to the abdominal wall rather than left to 'hang' freely. If the tube is not secured the entry point into the skin will begin to enlarge/stretch increasing the potential for drainage at the site of entry. NG, OG, Small Bore NG • Observe skin at nares, lips and oral mucosa for any redness or breakdown every shift. • Alternate nares with re-insertion of nasal tube if possible.

Insertion Site Care

HCO3 loss, acid retention (increased carbonic acid: *decreased pH* Caused By 1. Either deficit of base (Diarrhea, high K. Exchances H for K) OR 2. Increased acid other than CO2 (Renal failure, DKA, starvation, anaerobic metabolism, antifreeze, ASA overdose) Compensation 1. Lungs eliminate CO2; kidneys conserve HCO3 2. Urine pH decreased PaCO2 decreases when compensation is occurring *Signs and symptoms*: Neurological : headache, confusion (decreased muscle tone/reflexes) , restless, coma Cardiovascular (vasdilation): warm, flushed skin, dysrhythmias, Hypotension Pulmonary: Kussmaul's Respirations (compensatory hyperventilation) Gastrointestinal: nausea and vomiting *Nursing Management* Act quickly 1. Correct the underlying condition 2. Respiratory compensation 3. I & O 4. Insulin for DKA via iv 5. Keep your eye on the K+ 5. Pump up the Bicarb 6. Monitor VS 7. Monitor ABG and electrolytes

Metabolic Acidosis HCO3 loss, acid retention (increased carbonic acid): Decreased ______ Caused By Compensation Signs and symptoms Neurological : Cardiovascular Pulmonary: Gastrointestinal: Nursing Management

The underlying mechanisms include: *loss of H+ (acid), gain in bicarb, or both* Decreased acid other than CO2 Vomiting, gastric suction, hypochloremia, diuretics (excessive) Either excess of base OR Antacids, bicarbonate, dialysis *Compensation*: -↓ respiratory rate (↑CO2) and renal excretion of bicarb -Lungs retain CO2; kidneys conserve H+ and excrete HCO3 -PaCO2 increases w/ compensation -Urine pH increases *Ssx* Neurological: dizzy, lethargic, seizure, coma, confusion (r/t Pa02) Cardiovascular: Dysrhythmia/Tachycardia, hypokalemia Musculoskeletal: weakness, tetany/ cramps/twitching, hypertonic muscles Pulmonary: Respiratory depression (hypoventilation) GI: N/V *Nursing Management* 1. Improve ventilation and lower PaO2 2. Correct the underlying condition 3. Bronchodilators 4. Supp O2 5. Semi-Fowlers-Fowlers 6. Meds 7. Treat hyperkalemia 8. Chest PT breakup flem 9. Monitor VS- Apical 10. Monitor ABG and electrolytes

Metabolic Alkalosis The underlying mechanisms include: Compensation: Signs and symptoms Neurological : Cardiovascular Pulmonary: Gastrointestinal: Nursing Management

1. LOC x 4 4 Person, place, time, purpose 2. Extremity strength/symmetry: 5+/5+ 3. and symmetrical- arms & legs 4. Speech : Clear, articulate? 5. PERLA 6. CN VII: smile showing teeth, frown, raise eyebrows, resist during closing, puff out cheeks 7. Inspect mouth & describe 8. JVD: disappears at X°(if pillow present -.5 pt.) 9. Assess gait: Steady/coordinated; provide/apply

Neuro/head & Neck Assessment

1. Note: if tube occlusion occurs do not force irrigation. 2. Do not use carbonated beverages to attempt to clear occlusion 3. Attempt to irrigate with 50mLs warm sterile water using a gentle back and forth motion. 4. If above is unsuccessful, obtain order for pancreatic enzyme mixture: Recommended mixture: 1 tab of Pancrelipase (Cotazyme or Viokase-8) and 1 tab of sodium bicarbonate (325mg) with 5-10 mLs sterile water. (Note: for safety reasons wear gown and mask when preparing and administering this mixture) 2. Infuse gently into feeding tube and leave for 5 minutes. 3. Attempt to irrigate with warm sterile water. If still occluded repeat pancreatic enzyme and sodium bicarbonate solution as above. Attempt to flush. 4. Notify practitioner if occlusion persists.

Occlusion of Feeding Tube

Caused By Blows off CO2 (↓pCO2) which ↓ carbonic acid and ↑ pH Hyperventilation—MAIN CAUSE! Due to Fear, pain, fever, medications or drugs that are respiratory stimulants, CNS lesion Compensation 1. Kidneys conserve H+ and excrete HCO3 2. Low HCO3 indicates body is trying to compensate Signs and symptoms Neurological : Anxiety, lightheaded, Parasthesias (numbness), confusion, blurred vision Cardiovascular: palpitations, dysrhythmias, diaphoresis Systemic: dry mouth, tetany (twitching) of arms and legs Respiratory : Rapid, deep respirations (Kussmals) respiratory failure due to fatigue Nursing Management Correct underlying disorder Supp O2 Reduce fever Eliminate source of sepsis Reduce anxiety Protect from injury Paper bag Monitor VS Monitor ABG and electrolytes

Respiratory Alkalosis Caused By Blows off CO2 (↓pCO2) which ↓ carbonic acid and ↑ pH Hyperventilation—MAIN CAUSE! Due to Fear, pain, fever, medications or drugs that are respiratory stimulants, CNS lesion Compensation Signs and symptoms Neurological : Cardiovascular Systemic: Respiratory: Nursing Management

Airway obstruction Decreased respiratory effort Respiratory muscle weakness

Respiratory arrest (and impaired respiration that can progress to respiratory arrest) can be caused by

Lithium: 0.5-1.5 mEq/L (toxic >2) Digoxin: 0.5-2.0 ng/mL (toxic >2) Theophyllin: 10-20 mcg/mL (toxic) >20 INR: 2-3

Therapeutic Levels

1. Use sterile water in Acute Care for ALL patients of ALL age groups for ALL purposes (drug preparation/administration, reconstituting formula and water flushes). 2. Use sterile water (or boiled tap water (NOT from the bathroom) in the community setting or LTC for drug preparation and before and after medication administration for ALL patients of ALL age groups. 3. Use sterile water (or boiled tap water (NOT from the bathroom) in the community setting or LTC) for reconstituting formula or for water flushes in high risk groups of All ages (including immunocompromised, those critically ill, and ALL neonates/infants). 4. Use tap water (NOT from the bathroom) or bottled water for reconstituting formula or for water flushes in the home or clinic (or LTC) if municipal water is safe for All ages, EXCEPT immunocompromised, those critically ill, and ALL neonates/infants who will still need sterile water (or boiled tap water (NOT from the bathroom) in the community setting or LTC)

Types of water to be used: