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foundations, test 2 review

by: Brenna Notetaker

foundations, test 2 review nurs 3370

Marketplace > East Carolina University > nurs 3370 > foundations test 2 review
Brenna Notetaker
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test 2
Dr. Cherry
Study Guide
nursing foundations, Test 2 review
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This 27 page Study Guide was uploaded by Brenna Notetaker on Wednesday February 3, 2016. The Study Guide belongs to nurs 3370 at East Carolina University taught by Dr. Cherry in Spring 2015. Since its upload, it has received 114 views.


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Date Created: 02/03/16
 Nasogastric tubes o Used for the management of patients who require decompression (removal of stomach contents for prevention of N/V and gastric distention when motility is slow of absent by way of suction) of the GI tract, intestinal obstruction, post of ileus, gastric or intestinal surgery, pancreatitis, diagnosis and assessment, nutritional support, and medication administration o Gavage: giving food or meds through the tube when the patient cannot swallow but has normal bowel function o Lavage: the washing of stomach contents (think lava soap or laundry. Repeated washing with NS) o Decompression: the removal of gas or air or other substances from the stomach (usually with suction) o Compression: pressure applied to stop bleeding, done with NG tube and inflated balloon, used in bleeding varicies and ulcers, iced saline is used often, pressure is applied with manometer o Normal saline: .9% NS, compatible with blood o Everyone with a tube in for decompression must have an IV (most will have some kind of dextrose solution because they need calories/nutrients) o French: system used to indicate the outer diameter of catheters, each unit is approximately 1/3mm, normal for NG tubes is 12-20 Fr o Large/small bore: inner diameter of the catheter or tube, G-tubes and decompression tubes are large bored while J-tubes and feeding tubes are small bores  Small bores clog easier (flush with warm water)  Large bores are for shorter term and may cause irritation to the nose, mouth, throat, and esophagus o Ways to assess NG tube placement at the bedside  Observing for cough and choking  Auscultation of air insufflated through tube  Not a reliable method  Aspiration of fluid  Small bowel aspirates are golden yellow or greenish brown  Gastric aspirates are grassy green, off white, or tan  Respiratory secretions can be white, yellow, straw-colored, or clear  Visual inspection of aspirates  Not a reliable method  Can not be used solely to determine feeding tube location as the color, clarity, and consistency could be changed as a result of enteral feedings, bleeding, or obstruction of the GI tract  Testing of aspirates for pH or concentrations of bilirubin, pepsin, or trypsin  pH of 1-4 (the book says 5) determines the correct tube placement  pH >5 is respiratory  Bilirubin <5 mg/dl indicated respiratory placement  pH can be altered by medications (acid reducers for ulcers) or feedings  Respiratory secretions can be acidic in patients with esophageal rupture, acid reflux, or a pleural infection  This is the second most accurate way to test placement  Wait at least one hour after feeding or giving meds to test pH (feedings may increase pH)  Observing for bubbling when the tip of the tube is held under water  Testing the ability to speak  Magnetic detection  Reliable, but unable to determine exact location of tube in GI tract  Spring gauge pressure manometer  Capnograohy  Effective method in differentiating between respiratory and GI tube placement in adult patients  Colorimetric capnometry  Effective method in differentiating between respiratory and GI tube placement in adult patients  Radiography  Most accurate way to verify placement is with x-ray  The tube must follow a straight course down the midline of the chest to a point below the diaphragm without coils anywhere in the chest and without following the path of the bronchi  Radio opaque line in tube so that x-ray can show tube in stomach o o Risk factors for incorrect feeding tube placement  Patients at greatest risk for misplacement are those with diminished mental status and decreased cough or gag reflexes  Critically ill, obtunded, uncooperative, debilitated patients and those with maxillofacial or craniofacial surgery are at greater risk for misplacement  An endotracheal or tracheal tube cuff does not provide protection from feeding tube misplacement  Regularly assess the external length of the tubing to detect changes or movement o Types of tubes  NG tube: can be a feeding tube or used just for suction  Levin tube o Not vented o Not used for gastric decompression o Rubber or plastic o Used for suction o Single lumen  Salem Sump o Used for suction- used for stomach decompression o Keep above midline to prevent leakage of stomach contents o Never irrigate o Don’t put anything through it o 5-in-1 connector used to connect suction to tube (typical suction range is 80-120, intermittent suction is lower), more than 80-120 may cause bleeding o Double Lumen- one for removal of gastric contents and one to provide an air vent  Blue tip (pigtail) at end is to vent air and reduces pressure in stomach (prevents erosions in gastric mucosa)  Do not clamp, do not connect to suctions, and do not irrigate pigtail  Needs to be at shoulder level  Dobhoff o Most often for feeding o Radiopaque stylet o Tungsten weighted end for easier mobility o Goes into small intestine  Ewald o 26-30 Fr o Used for patients who have ingested poison o Inserted through mouth  Miller-Abbott o Long, double lumen o Balloon end with Hg, air, or fluid o Rubber o Used for suction and irrigation  Sengstaken-Blakemore o Triple lumen o Esophageal tampenade o Balloon in stomach and esophagus  Non-NG tubes  Gastrostomy o Tube going directly through skin into the stomach o Used for feeding o When endoscopy is used, its called a PEG (long-term feeding)  Jejunostomy o A tube going directly through the skin into the jejunum, bypassing the stomach o Used if patient has GERD, risk for aspiration, or gastritis o Used for long term feeding o Putting an NG tube in  NEX- measure from nose (N) to earlobe (E) and down to xyphoid (X)  Check coagulation studies because anticoagulation and bleeding disorders pose a risk for epistaxis during nasal tube placement  Place bed un high fowlers (60-90 degrees), at least 30 degrees if unconscious  Use water soluble jelly (oil based can harm lung tissue) to put tube in  Discuss spraying lidocaine into the nose  Use splash shield (incase patient vomits) and gown  Ask patient to give sign if they need a break (raise hand)  Ask patient to hyperextend neck or keep it straight up, then once you hit gag reflex ask them to tuck chin to chest  Ask “have you ever had a broke nose?” and do the sniff test  Put tube on the nostril that air flows out best (most patent)  Ask patient to start swallowing water when they start gagging  You can take tube out when bowel sounds return and patient is passing gas  Always listen for bowel sounds before inserting and NG tube and listen to lung sounds once a shift  Check placement every 4-6 hours and before feeding or giving medications (monitor external length, check pH, x-ray)  Always keep HOB up 30 degrees when tube is in to prevent aspiration  Document reason for insertion, kind of tube, placement check, patients response, drainage o Removal of NG tube  Wear gloves  Listen for bowel sounds  TURN OFF SUCTION  Irrigate tube with NS then air to displace contents  Tell patient to hold breath to protect airway  Pull tube out and wrap in a towel  Provide mouth care  Document bowel sounds, procedure, patient response o Irrigation of NG tube  At least once a shift and prn  Turn off suction and use 30-60 cc NS (water can be used for healthy patients)  Irrigate if tube is no longer draining or gastric distension occurs  Patient may complain of nausea if tube is not patent  Change irrigation bottle every 24 hours o Feeding through NG tube  Feeding through NG tube is preferred over perenteral nutrition because it improved utilization of nutrients, is generally safer, maintains structure and function of gut, and is less expensive  GI feedings don’t require consent form  Who should be fed with NG tube?  Clients who cannot eat (comatose, with a functional gastrointestinal system, clients receiving mechanical ventilation, or clients recovering from oral, head, and neck surgeries)  Clients who will not eat (older adults or confused clients)  Clients who cannot maintain adequate nutrition (cancer, sepsis, infection, trauma,  head injury)  For many clients, the psychological component that often accompanies tube feedings is  depression  Also, altered body image, sense of loss of control  Always use a lareg syringe (60 cc) for less pressure on tube  If client is being fed for weight gain and good outcome is 1lb per week  Best assessment for aspiration is breath sounds and vitals  Pt. may not be interested in regular food since he has not been tasting food in a while  Irrigate feeding tube every four hours and after feeds to keep tube from clotting  Only pour enough food to last 4 hours so that it does not go bad in tube  Feed with food at room temperature to prevent cramping and discomfort  Have patient in high fowlers positions or elevate bed at least 30 degrees to prevent aspiration  Flush tubes with platonics to prevent ulcerations  Use sterile water for patients with HIV or cancer  Saline flush is used for patient with low serum sodium levels and head trauma patients  Check residual: if less than 150 cc, re-feed and start tube feeding. If more than 150 cc (book says 250-500 cc), re-feed, hold the feeding and call MD  Withhold feedings if residuals are 250-500 (check residual by turning them on right side, turn off feeding pump)  If residual is over 100 cc, turn patient on right side, raise HOB  High gastric residuals are normally because of low gastric motility  To keep gastric residuals low: turn every 2 hours, ambulate, sit up in chair, give water between feedings. Is those don’t work, give reglan to increase gastric motility  You don’t need to check residuals if patient is stable  Feed the most intact formula that the patient will tolerate  Intact nutrition, general purpose formulas are least expensive and may be more physiological  Change feeding tubing and bottle every 24 hours  Bolus- small feedings that are usually given around the clock or during daytime hours  Intermittent- usually given slowly during the evening or night hours for clients who cant eat enough  Continuous- around the clock, most common in hospitals  If client starts coughing, gagging or breath sounds have crackles, gurgles or diminished,  stop feeding immediately and notify MD  Enteral food selection  Proteins break down in stomach, carbs break down in duodenum, fats break down in ilium (so if any parts of these are removed, the pt will get a decreased absorption of these elements)  Blenderized (complete or homemade (caution))  Standard isotonic (osmolite, nutren, isosourse)  Added fiber (Jevity, impact with fiber, nutren with fiber, fibersource)  Extra calories/volume restricted (osmolite, twocal, novasource, nutren, peptamen, jevity)  High nitrogen (osmolite, twocal, fibrosourse, peptamen, isosource)  Disease specific o Diabetes: resourse diabetic, diabetisource, glucerna o Pulmonary: nutren pulmonary, pulmocare, novasource pulmonary, oxepa o Renal: novasource renal, nepro, suplena, nutren renal o Liver: nutrihep o Cancer: prosure  Trauma/critical care: traumacal, perative, impact, alitraq, oxepa, promote, pivot  Wound healing: isosource VHN, replete, promote, juven  Peptide based: peptamen, vital, crucial, optimental, perative, peptinex, alitraq  Free amino acids: vivonex  Modular: beneprotein, benefiber, polycose, moducal, MCT oil, microlipid  Pediatric o Standard: resource just for kids, pediasure, compleat pediatric, nutren jr. o Fiber: resource just for kids with fiber, pediasure with fiber, nutren with fiber o Elemental: vivonex pediatric, petamen jr., pediatric peptinex DT o Infants: infant formula  Subtrates: CHO, protein, fat (consider patients ability to digest, absorb nutrients)  Elemental vs intact forumula: use products with MCTs if unsure of ability to digest fats  Tolerance factors: osmolarity, calorie, and nutrient densities, residue content  Types of feeding (methods)  Pumps o Have alarms to notify the nurse when the tubing is empty or when there is an  occlusion o Often have a flushing system that flushes 30cc of water in every hour to avoid  clogging of tube  Gravity drip o When using this method, you must calculate the drip rate of the feeding in order  not to feed to quickly or too slowly  Funnel technique   Injection technique  Osmolarity vs. osmolality  Osmolarity: measure of osmotically active particles per liter of solution  Osmolality: measure of osmotically active particles per kg of solvent in which particles are dispersed (the number of particles in a solution of water) o Isotonic formula= 270-330 mOsm o Hypertonic= >400 mOsm, may cause gastric retention, N/V, diarrhea, loss of electrolytes, or dehydration o Enteral feedings range from <300 to 700 mOsm/kg (hyperosmolar), contrain 1-2 kcal/ml, most are lactose free o The higher the caloric density, the longer the emptying rate from the stomach to the small intestine o Formulas with high osmolality may cause shift of water into intestinal space= diarrhea o Medications tend to be hypertonic, particularly elixirs, may need to be diluted to decrease hyper tonicity o Lower osmolality: large proteins, large starch molecules o Higher osmolality: hydrolyzed protein or amino acids, disaccharides, smaller particles  Feeding complications  Diarrhea- number one problem, may need to slow formula, may need to change formula  Aspiration- keep HOB up at all times  Tube obstruction- from inadequate flushing, pill fragments, formula residue  adhering to the tube or physical incompatibilities between formula and medication  Nausea, vomiting, cramping­ from rapid administration, lactose intolerance,  contaminated formula, formula being too cold, or atrophied GI villi  Hyperglycemia­ common to do accu­checks for first 3 days until pancreas can  catch up  Dumping syndrome­ rapid emptying (I.E. Dumping of the stomach contents) into  the small intestine.  Symptoms are:  increased peristalsis, diarrhea, cramping,  hyperactive bowel sounds  Medications through NG tube  Enteric coated or slow release medications, drugs that irritate the mucous membranes, and chewable or SL cannot be given through tube (example: antacid given through J-tube will bypass stomach where its supposed to work)  You may open slow-release capsules and put them down tube if the tube is large bore and you flush well  Always check bowel sounds before giving meds, if no bowel sounds the meds will remain in stomach  Always check placement before giving meds  Crush medicine well and dilute with water and give one at a time  Keep HOB up at least 30 degrees  Turn off feeding and wait 15-30 minutes  Kink tubing and remover plunger and connect tubing  Pour 30 cc water to clear tube and keep tube 18” above patient  Give meds one by one and flush with 15 cc water between with a final flush of 60 cc  Wait 30 minutes before restarting feeding  You can put a small amount of pressure to facilitate, but too much pressure can rupture the stomach  Meeting nutritional needs  Calculate kcal, protein, fluid, and nutrient needs according to age, sex, medical status  Select appropriate formula based on nutritional needs, feeding route, and GI function  Indirect calorimetry: the gold standard, particularly with critically ill, obese, patients who do not respond well to treatment  25-35 kcal/kg in non-obese patients  20-21 kcal/kg in obese patients (BMI <30)  Protein o 0.8-1.0 g/kg for maintenance o 1.25 g/kg for mild stress o 1.5 for moderate stress o 1.75-2.0 for severe stress, trauma, burns  Fluid needs o Based on weight st  100 ml/kg for 1 kg  50 ml/kg for next 10 kg  20 ml/kg above 20 kg o Based on weight and age  16-30 years and active: 40 ml/kg  20-55 years: 35 ml/kg  55-75 years: 30-35 ml/kg o Energy needs  1 ml/kcal or 30-35 ml/kg BW  Water flushes o Irrigate tube every 4 hours with 20-60 ml water with continuous feeds o Irrigate tubes before and after each intermittent bolus feed with 20-60 ml water o In case of clogging, tube should be flushed with 60ml syringe with 30-60 ml warm water o Use smaller volume for fluid restricted patients  Nutritional monitoring o Weigh at least 3x/week o S/S of edema, dehydration daily o Fluid I&O daily (easy to lose track of irrigants) o Adequacy of intake 2x/week o Nitrogen balance weekly if appropriate o Serum electrolytes, BUN, creatinine 2-3X/week o Serum glucose, calcium, magnesium, phosphorus weekly o Stool output and consistency daily o Gastric residuals (associated with clogging tube and collapses modern soft NG tubes)  Selection of feeding route  Algorithm or decision tree  Adequate oral intake  Oral intake + supplements  Enteral nutrition support o Medical status o Risk for aspiration o Advantages and disadvantages o Enteral access device Length of  Pros Cons use Nasogastric tube (NGT;  Short­term  Easy to place, variety of sizes Not indicated if bleeding disorder, nasal/facial through the nose) use available for patient comfort fractures and certain esophageal disorders Orogastric tube (through thShort­term  Lower incidence of sinusitis thaNot tolerated for long periods of time in alert  mouth) use NGTs patients; tube may damage teeth Nasoenteric tube (generallyShort­term  Smaller diameter than NGTs and  May be difficult to position; smaller size tubes thought of as a tube beyonduse less patient discomfort; may be used may make administration of some medications the stomach) in delayed gastric emptying difficult, and an infusion pump is needed Oroenteric tube (postpyloriShort­term  Same as orogastric tubes Same as orogastric tubes feeding tube) use Gastrostomy tube (can be  Short­term  Easily cared for and replaceableCompared with oral and nasal route, this  placed radiologically,  useLong­term large size tube allow for bolus  technique is more invasive endoscopically or surgicalluse feeding, and administration of  medications Jejunostomy tube (can beLong­term  Decreases the risk of food aTechnically more difficult to place; smaller  placed radiologically,  use fluids passing into the lungs; allows  size tubes may make administration of some  endoscopically or surgically) for early postoperative feedmedications more difficult, and an infusion  pump is needed  Tracheostomy o A tracheostomy is an opening in the anterior wall of the trachea, below the cricoid cartilage, which is kept open by the insertion of a tube o Indications for a tracheostomy  Upper airway obstruction  Infection, malignancy, vocal cord palsy, foreign bodies, trauma  Respiratory insufficiency, poor cough  Advanced lung disease, prolonged artificial ventilation support  Prolonged artificial airway  If a pt. requires artificial ventilation for a period longer than 10- 14 days it is recommended that a tracheostomy be inserted  Impaired swallow  When a patient has significantly impaired swallow along with an ineffective cough he/she will be at risk of aspiration of saliva and any oral intake o The initial type of tube is a plain cuffed tube, which allows ventilation and protects from aspiration o Techniques to insert  Surgical (open or formal)  Percutaneous dilatational  Can eliminate risks associated with transporting the critically ill patient as it is most often done at the bedside o You need consent to put in a tracheostomy tube and inform patient of the risks and the aftercare o Chest x-ray is used to confirm position and rule out complication (such as pneumothorax) o You must have emergency replacement equipment at the bedside at all times o Conscious patients should be positioned upright, unconscious patients should be in semi-fowlers and make sure head does not droop into their chest (kink tubing), you can turn patients on side o Do not give pain medications for a trach tube, they should never hurt o Obturator- has round tip and is used to keep hole open  Nurse is not allowed to re-insert trach if it falls out  Keep obturator, inner cannula, strings at bedside o Purpose of the inner cannula is to keep the outer cannula patent  First thing you do in the morning for someone with a trach is clean their inner cannula to get rid of dried on secretions o You know theres a leak in the trach tube if the patient can speak o If you have injuries to the spine you intubate through the nose, if you have major facial trauma you intubate through the mouth o Decision to get trach and come off mechanical ventilation you do a drug holiday- come off propofol, they must wake up and be able to follow you with eyes, have good ABGs, have normal total protein (feed with ensure), and be able to breath on own  Long term mechanical ventilation can lead to pulmonary hypertension or cor pulmonale o Goal for mechanical ventilation is to turn down slowly to wean  40% oxygen- nasal cannula  Room air is 21%  Cant give newborns 100% oxygen o Types of tube  Most adult tubes are systems with a removable inner cannula  Cuffed tube  Cuff at the distal end of the tube which inflated with air will permit positive pressure ventilation and reduce risk of aspiration  Patient cannot speak with this  Used to prevent aspiration and used for patients on mechanical ventilation  Uncuffed  A tube used for patients with breathing for themselves and able to swallow safely  Common with patient with vocal cord palsies and respiratory disease to allow access to secretion and decrease work of breathing  Fenestrated tubes  Have one or several holes on the outer curvature of the tube shaft  The holes allow greater passage of air into the upper airway when using a speaking valve  Useful for patients with smaller tracheas and during weaning  Longer length tubes  For certain patients the standard length tubes will not safely pass through the pre-tracheal space and into the trachea at the correct angle  An adjustable (flanged tube) or longer tube  Silver tubes  Popular patient choice  Have an integral speaking valve on one of the inner tubes making it a less obvious product compared to standard tubes when using a speaking valve attachment o Humidification  With a tracheostomy, inspired and expired air is not passed through the upper airway, which normally warms, filters, and humidifies air and limits moister loss  Water bath humidification  Loosens secretions and keeps sputum moist so it can be suctioned  Acutely ill patients  Hard to keep a balance between supplying warm, moist air and the patient saying its too hot  Disposable heat-moisture exchange unit (HME)  Patient must be able to sit upright and have less oxygen requirements and no other organ dysfunction  Fits onto end of the trach tube and has an attachment for oxygen  When it gets filled with sputum it must be replaces  Oxygen delivered should be now more than 4 L  Isothermic saturation boundary (ISB)- when heat and humidity drop below 37 degrees Celsius and 100%, which causes stress on the mucosal lining  When air is below room temperature, bronchoconstriction can occur which will reduce airflow and bring decreased oxygenation and oxygen saturation of Hgb  Is humidification is assessed and delivered appropriately, then the need for suctioning may be reduced  Indication for humidification include thicker or tenacious secretions, which the patient finds hard to clear o Suctioning the inner tube  Suctioning is required because the tracheostomy may prevent the patient from increasing his/her intraabdominal pressure sufficiently to enable him/her to cough and clear secretions  Suctions during removal, never during insertion and suction intermittently  Suctions oropharygeal cavity until you reach the gag reflex  Criteria for suctioning patients  Course breath sounds (crackles)  Noisy breathing  Increased or decreased rate of respiration  Decreased oxygen saturation  Copious secretions (but not if the patient has pulmonary edema- suctioning can exacerbate pulmonary hypertension and pulmonary edema)  Patient attempting to cough or clear secretions  Use a non-fenestrated inner cannula when suctioning  Hyper oxygenate by preoxygenation or deep breathing to reduce suction-induced hypoxemia in patients who are hypoxemic before suctioning (<92%)  Hyperinflation is not recommended for adults to improve oxygenation before suctioning in preoxygenated patients who undergo coronary artery bypass graft surgery  Caution should be employed in other populations as well because it may increase the mean arterial blood pressure  Ventilation should be increased by rate, not by volume to minimize increases in ICP  Use a ventilator for oxygen delivery instead of an MRB if oxygen delivery is a concern (MRB may give hyperinflations)  Use caution when suctioning a patient with head injury, infants, and children (increased risk of ICP)  Regular or infused rate of analgesia may be given to reduce pain of suctioning so often  Use sterile saline to keep the body composition isotonic (sterile water can be used for people without free water issues)  Do not use saline flush to assist with removing sputum because saline may not be recovered with suctioning and can cause infection or push bacteria further into lungs  Always use a sterile hand to hold the suction catheter  Trach may cause irritation which may lead to increased sputum production  Indication for suctioning include audible or visible secretions, increased coughing/rise in airway pressure, suspected aspiration, deteriorating peripheral oxygen saturations, reduced airflow, high pressure alarm going off  Hyper oxygenation and hyperinflation both before and after suctioning prevent suction-induced hypoxemia and subsequent arrhythmias  Hyperinflation can be achieved by asking pt. to take some deep breaths  Suctioning should take no longer than 10-15 seconds and should be repeated until secretions run clear  Do not suction for more than 5 seconds for an infant and 10 seconds for a child (can cause hypoxia)  Pediatric trach tube is shorter and narrower than an adult and does not have an inner cannula which predisposes them to respiratory infect  Bronchiolitis, pneumonia, RSV causes increased secretions which clog the tube faster  Need to use a smaller suction catheter  To avoid mucosal damage, a maximum pressure setting of 150 mmHg/20kPa is recommended  Each suction catheter should be inserted 0.5-1 cm below the level of the tube for the conscious patient, or until the patient coughs  Select a suction catheter no larger than half the inner diameter of the tube to prevent hypoxemia and trauma  Keep inner cannula in situ for the procedure to allow cleaning after suctioning (plain inner tube, not fenestrated)  Wear gloves, eye protection, and a gown  Suction tubing and containers should be changed every 24 hours  In line suctioning catheter can be used for 24 hours  You don’t need to disconnect it  Is covered by a sterile plastic sheath  Has numbers to measure how far you go  There is no such thing as a suction q2h order, you suction as needed  MRB- manual resuscitation bag  One size does not fit all (infant, child, adult)  If suctioning an infant, do not turn up more than 40-60  Children 60-80  Adults 80-120 o Care of inner tube  Main benefit of inner tube is to allow removal and cleaning to keep a patent airway  Clean with sterile water or saline (do not use hydrogen peroxide, tap water can be used if patient is in good health)  Hydrogen peroxide can lead to degranulation and can lead to tracheaesophageal fistula  Inner tube should be removed and cleaned every 1-8 hours, depending on volume of secretions  Have a spare inner cannula at the bedside if available o Wound care and tape/dressing changes  Keep clean and dry  Change dressing each day or more often if it is soiled (especially post op)  Blood in the tube can have many causes (post op (normal), cancer, TB)  Clean with normal saline and use gauze or wipes that do not shed fibers in stoma  Dressing should be thin, absorbent, pre-cut  Have two people to change the dressing and tube cotton so that one person can hold tube in place while the dressing is changed to prevent decannulation (surgeon might suture tube to skin to avoid this)  If you must do it alone, put on new dressing and then take off the old  Ties or Velcro tapes should be changed daily (more if soiled)  Allow 1-2 fingers to fit between neck and tapes o Tube changes  Should be changed when they have been in place for maximum duration (28 days)  Use caution in patients who:  Are obese, agitated, or have anatomical abnormalities  Have excess granulation tissue in or around the stoma  Require a tube change within 72 hours post insertion  Have a tight stoma  Replace single lumen tubes every 7-10 days to prevent obstruction  Double lumen tubes are changed every 4-8 weeks  Tracheostomy tract is still forming during the first 5 days and a change during that time may result in losing the tract or the formation of false tract  Indications for emergency tube changes  Cuff failure  Tube displacement  Tube misplacement  Tube blockage  Change to another size or type of tube in resuscitation scenarios  Keep patient NPO for 4 hours before tube change  Position patient supine with neck extended by a roll under shoulders  Always record where the tube is at the lip to track movement (movement of tube predisposes patient to tracheal trauma or tube dislodgment and indicates the need for another size airway) o Cuff management  Cuffed tubes should have the cuff inflated to ensure that air only travels inside the tube and not around it (ensures pt. does not lose tidal volumes and protects food/fluid from entering lungs)  Tracheal capillary obstruction occurs at 37 mmHg and therefore requires a maximum cuff pressure of 25 mmHg  Pressure of cuff against tracheal mucosa can be monitored by a manometer  Check cuff at least once a shift (every 4-8 hours) and whenever the cuff is reinflated  Deflate cuff routinely (at least once every 8 hours) to prevent scar tissue from building  Cuff over inflation may increase ischemia or necrosis of tracheal tissue  When the patient requires cuff inflation they are to be NPO (give food through ng tube) to prevent aspiration (inflated cuff disguises signs of aspiration)  Cuff puts pressure on esophagus and anchors the larynx which reduces the element of swallowing  For a speaking valve to work the cuff must be completely deflated to allow air to pass around the tube o Sputum specimens  Use a sputum trap and attach the suction tubing to one port on the jar  On the other port attach the suction catheter  To collect a scant specimen, cleanse the suction catheter with 5m sterile .9% sodium chloride or sterile water to flush sputum into sputum trap o Emergency management  Overproduction of sputum  Coughing, irritation or the trachea, undue movement of the trach tube  Multiple suctioning attempts of dry, hard secretions  Sputum plug blocking a terminal airway or blocking the trach tube  Compromised cuff integrity, vomitus and aspiration of stomach contents, dysphagia  Use the following checklist to assess and monitor patient during emergency:  Airway o Check patency by removing IC, observe for blockage o If blocked, replace using space IC o If not blocked, reinsert non-fenestrated IC and suction  Breathing o Assess for breathing (look, listen, feel) o If breathing is absent or RR <5 or >36, activate your ERT o If spontaneous breathing is present, oxygenate with 15L of oxygen applied to trach site (if tube IS NOT blocked), the mouth and nose (if tube IS blocked), laryngectomy stoma (when pt. had one)  Auscultate o Listen to audible breath sounds that may indicate the need to suction o Listen for gross cuff leak sound (stethoscope over neck region)  Insert 5 mL air into pilot tube, if cuff leak persists, insert further 5 mL  Check cuff pressure with manometer  If nil response, cuff may be inoperative, change trach tube uner controlled conditions or activate ERT o Use stethoscope to listen for air entry into the apices, mid- zone and bases  Decreased or absent air entry indicates reduced gas exchange, leading to respiratory distress  In the presence of an adjustable flange trach tube, ensure tube had not migrated up or down from previous position o Use stethoscope to listen for breath sounds: fine or coarse crackles or wheeze  Fine crackles heard in the bases may indicate fluid overload or cardiac dysfunction  Coarse crackles heard in the apices/mid-zone and over large airways indicate sputum  Wheeze generally indicates narrowing of airways causing respiratory distress (check for history of asthma, allergy, or new pharmacotherapy)  Suction o Insert non-fenestrated inner cannula o Suction sputum, assess for ease of insertion of catheter o Remove IC if there is difficulty in insertion suction catheter o Allow patient to rest between suction passes (oxygenate) o Active ERT if there is an obstructed airway not removed by suction  Circulation o Assess patients carotid pulse, color of skin, and level of anxiety o Assess VS o If an emergency, call ERT o Perform full physical assessment, review medication charts, blood results, refer issues to your team leader  Chest Tubes o Two common clinical conditions require pleural drainage  Rupture of the surface of the lung (such as a bleb) or a tracheobronchial tree, allowing air and possible serosanguinous fluid into the pleural space while the chest wall remains intact  External penetration of the chest wall resulting from surgical intervention or trauma (such as a gunshot wound or stabbing), allowing air and blood or serosanguinous fluid from damaged tissues into the lungs o Pleural effusion  Increased pleural fluid entry or decrease fluid exit from the lungs  Cancer, infection, pancreatitis, connective tissue disease, autoimmune diseases, asbestos exposure, certain drugs, or collagen vascular diseases can cause pleural effusion  Patient usually needs a diagnostic thorocentesis and pleural fluid analysis to determine cause o Pneumothorax  Air enters the pleural space and the negative pressure between the pleurae vanishes, allowing the lung to collapse  Open pneumothorax- air enters pleural space through traumatic penetration of the chest wall by gunshot wound, stabbing, impalement, or other similar trauma, leaving the pleural space open to the atmosphere  Closed pneumothorax- air enters the pleural space through rupture of the lung and visceral pleura (such as barotrauma from mechanical ventilation), but the chest wall remains intact  Spontaneous pneumothorax- patient experiences a pneumothorax for no obvious reason  More common in young men who have a growth spurt during which skeletal growth exceeds lung growth (tension of the pleurae at the apex, where rupture is most likely to occur)  Can also occur when an emphysematous bleb on the lung surface ruptures (SOB and pleuritic chest pain) caused by insertion of subclavian IV line  Secondary pneumothorax is caused by an underlying disease such as emphysema  Signs and symptoms of pneumothorax  Sharp chest pain that worsens on inspiration or coughing because atmosphere air irritates pleura  Fatigue  Rapid heart rate  Low blood pressure o Tension Pneumothorax  Air continues to leak into the pleural space with no means of escape  Rapid build-up of pressure in the pleural space  Intrapleural pressure becomes positive, eliminating the normal negative intrapleural pressure  If pressure becomes high enough, the lung can completely collapse and the pressure can be transmitted to the mediastinum  Mediastinum can be pushed away from the affected side  Shift can compress the great vessels and the heart itself (venous return to the heart will be reduced, resulting in decreased cardiac output)  Blood pressure will drop  Tracheal deviation is a late sign and may be absent in some cases  Patients receiving positive pressure ventilation (ventilator or MRB) are at risk for complications from tension pneumothorax because air is being pushed into chest under pressure  Signs and symptoms  Increased respiratory rate  Dyspnea  Pleuritic chest pain (sudden onset)  Decreased movement of affected side  Decreased breath sounds on affected side (breath sounds from unaffected side will transmit to affected side, making them diminished, not absent)  Falling blood pressure  Rising pulse  Diaphoresis  Dry cough  Tracheal deviation away from affected side  Cool, mottled skin  Subcutaneous emphysema (crackling on palation)  Manometer of ventilator will show higher inspiratory pressures and will be less likely to return to zero  MRB will be harder to squeeze  If emergency treatment is required, a needle decompression is achieved with a large-gauge needle (14 or 16) inserted into second ICS, midclavicular line (“hissing” sound will be noted, followed by rapid stabilization of vital signs) o Hemothorax  Blood collection in pleural space after thoracic surgery or chest injury  Hemopneumothorax- mix of blood and air  Typically occur if there has been an opening in the chest wall (surgery or penetrating injury), however, blood can accumulate after blunt chest trauma  Disrupted intrapleual pressure, resulting in lung collapse  Pleural effusion- after collection of fluid from the pleural space, there is a disruption of the normal balance between the amount of pleural fluid produced and the amount of fluid absorbed  Commonly seen in patients with lung and breast cancer  Signs and symptoms include pain, dyspnea, and s/s of shock  Empyema (pyothorax)- accumulation of pus in the pleural space, cause by pneumonia, lung abcess, or contamination of pleural cavity  Chylothorax- accumulation of the lymphatic fluid in the pleural space o Cardiac tamponade  Following cardiac surgery or chest trauma, blood can pool in the mediastinum cavity  Blood can collect between the pericardium and the heart, externally compressing the heart  Reduced the hearts ability to accept venous return, resulting in significantly decreased cardiac output  Emergency treatment is needle pericardiocentesis  Accumulation of blood provides medium for bacterial growth, leading to post-op infection o Most patients can tolerate a small amount of fluid or air in pleural space (<10% occupied) o Goal of chest tube drainage  Remove the fluid and/or air as quickly as possible  Prevent drained air/or fluid from re-entering the chest cavity  Re-expand the lungs and restore normal negative intrapleural pressure o Don’t put tape of nipple when securing chest tube o Patients may be hesitant to cough and deep breath because it hurts o If the chest tube if put up high (2-3 ICS) it’s to remove air, if its put lower (4-7 ICS) its to remove puss/blood/fluid o Chest tubes  Generally about 20 inches long, with four to six eyelets that act as drainage holes in the patient (distal) end and an opening for connection to the drainage system on the proximal end outside the body  Radiopaque line is added to the length of the tube so it can be seen on x-ray  Two types of chest tubes  Thoracotomy chest tube o Flexible straight or right-angle tube designed for insertion through a small incision in the chest o Typically after surgical procedure o Made of transparent medical-grade polycinyl chloride o Right angle catheters are most often used for mediastinal drainage  Trocar chest tube o Paced with removable, pointed and rigid stylet o Stylet allows the chest tube to be placed in the chest through a puncture made by the trocar (physician uses force to push stylet into chest through chest wall and soft tissue into pleural space) o Common in emergency rooms or other areas outside the operating room o May only have 2-3 eyelets for drainage o High risk for lung injury during insertion  Mediastinal chest tube is placed in the mediastinum, just below the sternum and is connected to a drainage system. The tube drains blood or fluid, preventing accumulation around the heart  Diameter of chest tube selected depends on the size of the patient, the type of drainage (air/fluid), and the expected duration of the drainage  Infants and young children: 8-12 French  Children and young adults: 16-20 French  Most adults: 24-32 French  Large adults: 36-40 French  Smaller bores are sufficient to remove air, larger bores are needed to remove fluid and blood  Traditional chest tube is a hollow catheter single lumen  If chest tube is rapidly removed, BP can drop  Three main variables affect how well blood and fluid leave the chest through the chest tube  Length of the tube  Amount of negative pressure (suction) applied  Inner diameter of the tube  o Disposable drainage systems  Include a collection chamber in which fluids drain and volume and rate of drainage can be measured, a water seal chamber that uses sterile field or a mechanical one-way calve to allow air to leave the patient and prevent air from entering the patients chest through the chest tube, and a suction control chamber that uses either sterile fluid or a mechanical device to control and limit the level of suction imposed on the patient  Record every 8 hours unless otherwise indicated  Keep drainage box on the floor/less than the level of chest  Collection chamber  Permits nurse to record the amount of fluid collecting in this chamber  Draw a ling indicating the level of drainage and write the time on the front  Water seal chamber  Provides protection of the one-way valve  Used to measure pressure (when pressures on both sides are equal, the water level is the same on both arms)  Water seal chamber must be filled to 2 cm mark  Reestablishes negative pressure to re-inflate lungs  If patient can take deep breath in and out, look for fluctuation in water chamber (this is a NORMAL FINDING) and will go away when lung is totally re-inflated  Nonmechanically ventilated patients the fluid level will rise on inspiration and fall on exhalation. The opposite will occur in ventilated patients  Continuous bubbling in the water seal chamber= leakage  Shouldn’t have vigorous bubbling because it will evaporate quickly  It is normal to see a few bubbles go through the water seal with a pneumothorax, but not continuously  Sudden stoppage of activity may indicate a blockage or re- expansion  Dry seal chest drains  Mechanical one-way valve allows air to escape from the chest and prevents air from entering the chest  Does not require water to operate and is not position-sensitive the way water-filled chamber is  Protects air from entering patients chest if drain is knocked over  Look for a rise and fall of fluid in the diagnostic air-leak indicator synchronous with respirations. Continuous left-to-right bubbling or vigorous rocking is not normal and indicates a leak  Suction control chamber  Protects the patient from excess suction pressure in the pleural cavity or mediastinum  Either “wet” or “dry”  Wet suction o Regulate suction pressure transmitted to the chest by the height of a column of water in the suction control chamber o Asymmetric U-shaped manometer (narrow arm is the atmospheric vent and the large arm is the reservoir) o The amount of negative pressure that is transmitted to the patients chest is determined by the height of water in this chamber, not the level of vacuum set on the wall regulator  Dry Suction o Dial on side should be turned up (usually on -20, sometimes -40) o Regulate suction pressure mechanically rather than with a column of water o Screw-type valve that varies the size of the opening of the vacuum source, thereby limiting the amount of negative pressure that can be transmitted to the chest o Valves narrow the opening of the chest drain in order to adjust the level of negative pressure o Impractical for patients with significant pleural leaks o Quieter and easier to set up than wet units o Because it’s silent, its not as obvious when the unit is not working properly without careful examination of the front of the drain (sound of bubbling in wet units provide feedback that they’re working)  Positive pressure relief valve (PPRV)- vents accumulated pressure greater than 2cmH2O (depth of water seal)  Double collection chest drains  Designed to be connect to two chest tubes (major and minor chamber)  Used for tubes on the same side of the chest (typically when one tube is high to evacuate air and one is low to evacuate fluid)  Also used in cardio surgery when the surgeon wants to monitor drainage from two mediastina tube locations separately  Three chamber system promotes the drainage of fluid and air with controlled suction (first chamber collects fluid or blood, the second chamber is either a water seal or a one-way valve, the third chamber is for suction control)  Infant chest drainage systems  Smaller collection chamber holds less drainage than an adult unit  Tubing may have a narrower inner diameter compared to adults and has smaller connectors  Closed wound reservoirs  Used for cardiothoracic surgical patients  Bulb suction reservoirs connect to the wound drain and create suction to evacuate fluid  Any venting to the atmosphere will disrupt the system’s self- generated suction  Can only be used after the lung is expanded and air leaks have sealed o Setting up a chest drain system  Thoracostomy- procedure for inserting a chest tube  Location depends on whether the tube is used to drain air, fluid, or both  For most pneumothorax cases, the end of the tube is directed anterior and superior in the pleural space near the apex of the lung (2-3 ICS)  To drain a hemothorax or pleural effusion, the chest tube is directed inferior and posterior in the pleural space since gravity will pull fluid toward the base of the lung (midaxillary, 7-8 ICS)  Steps for tube insertion and drain setup  Get chest drain from storage (chest tube and insertion kit)  Get consent  Mark insertion site  Set up chest drain  Medicate patient or begin sedation (unless its an emergency)  Clean skin and make small incision over the rib below the selected ICS  Insert catheter through the tract  Suture tube in place (clamp tube until it is secure to prevent air from entering chest)  Open end of chest tube is attached to stepped connector on the end of the patients tubing attached to the collection chamber  Cover insertion site with sterile occlusive dressings  Place chest drain below the chest tube  Attach suction tubing from the chest drain to a vacuum source  Confirm placement with x-ray  Water seal system two chamber: add sterile solution to water seal chamber (second chamber), bringing fluid to required level  Water seal system three chamber: add sterile solution to water seal chamber and suction control (third chamber), connect tubing to suction  Dry suction system: fill water seal chamber with sterile solution, adjust suction dial to level of suction (-10 to -40), suction control chamber vent is never occluded  Waterless system two chamber: nothing is added, connect to patient  Waterless system three chamber: connect to suction source, add 15-45 mL sterile water or NS into diagnostic indicator injection port o Caring for a patient with chest drainage  Respirations- note the rate, regularity, depth, and ease of respiration. Listen for changes in breath sounds, paying particular attention to the symmetry of sounds. If breath sounds are asymmetrical, double check the chest drainage system to assure it is patent and working properly. Diminished breath sounds on affected side may indicate re- accumulation of air or fluid in pleural space. Deep breathing and coughing every hour or two to expand lungs. Teach splinting of the thoracic incision post-op (when they cough, place pillow over incision and squeeze pillow close to chest wall)  Knowledge level- assess patient’s understanding of the use of chest tube and post-op care  Pain control- parietal pleura is innervated by intercostal nerves and it sensitive to pain, regular pain assessments are critical. Failure to manage pain can lead to hypoventilation, putting patient at high risk for atelectasis and pneumonia. Be aware of risk of hypoventilation associated with opioid analgesics and PCA  Vital signs- monitor regularly. If pt. had mediastinal chest tube, listen to heart tones. Muffled or distant heart tones are one sign of cardiac tamponade  Patient position/movement- encourage ambulation if possible (mobile chest drainage systems are lighter and self contained to allow patient to ambulate with it). If chest drain is disconnected from suction, be sure the tube is open to air (do not clamp tube). Change positions in bed regularly. Avoid loops in tubing.  Only clamp tubes to locate an air leak, simulate chest tube removal, replace a drain, or connect or disconnect an in-line auto transfusion bag o Chest tube site/dressing  Regularly assess chest tube insertion site (dry and intact and palpate around the dressing and insertion site for subcutaneous emphysema that could indicate air escaping into tissue)  If subcutaneous emphysema is present, take down the dressing and carefully inspect the site where the chest tube leaves the chest wall, look for evidence drainage eyelets may have pulled out of the pleural space (such as broke sutures)  Tube movement can allow air into subcutaneous tissues (if eyelets are visible, the tube will need to be repositioned, if not eyelets are visible, re-dress the site. Notify physician)  Only change dressing if it is soiled with drainage unless required to be changed by hospital policy  If the patient has an air leak from chest (indicated by bubbling in water seal chamber), cover site with sterile dressing and tape it on three sides to allow air to escape on fourth side to avoid tension pneumothorax. Stay with patient and call physician STAT and get new equipment for a new tube placement. If there are no signs of air leak apply a sterile dressing and monitor pt. carefully for signs of respiratory distress o Tubing  Regularly assess tubing for leaks, kinks, fluid-filled depended loops, or compression or occlusion and trace the tubing from the chest wall to the collection chamber  Check tubing connection any time patient returns from a trip off the nursing unit (if it comes apart clean it with alcohol wipe and reconnect and ask them to cough to remove and residual air)  Do not manipulate (stripping or milking) chest tubes- it can lead to increased pressure on lung tissue  To find an air leak, clamp tubing close to chest wall first (if bubbling stops, it indicates a leak in the thorax or site of insertion). If the bubbling doesn’t stop, slowly move clamps down tubing to find where bubbling stops (replace tubing). If bubbling still continues, the leak is in the drainage system (replace drainage system) o Drainage fluid  Samples of drainage fluid should be taken by i


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