inserted upside down once you get to back turn it around
Atalectasis
Alveoli collapse
predisposes pt to pnemonia
Therapeutic Coughing and Breathing
Intentional deep breaths
good for post op pts
Abdominal breathing
lets pt know they are taking a deep breath
Cascade Cough
take 2 - 3 slow deep breaths
on the 3rd hold and cough 2 - 3x
helps to get mucus in lower airways out
Incentive Spirometer
set a goal and have pt breathe into it to reach goal
trying to get mucous in lower airways out
Postural Drainage
Place them in specific position to help drain a particular area of lung
also use vibrator to help with this
Clapping
Cupping - cause vibration to looses phlegm
cystic fibrosis pts do this 2-3 x day
Nasopharngeal
goes thru nose to nasopharnx
helpful for suctioning thru nose
Endotracheal Tube
can not eat solid foods with this
insert laryngoscope first fotr light then insert endotracheal tube
usually not done alone
Ideal in emergency situations
cant keep in forever
if pts sill require artificial airway after 2 wks- this is replaced with ah tracheostomy tube
Tracheostomy TUbe
can be in place forever if needed
these have a balloon
if pt pukes it can go all the way to lungs - this is the reason for the balloon - it prevents aspiration
Most trach tubes have
2 parts
1. outer lumen
2. inner canula - almost always are disposable
if pt is at home they clean the inner canula
Fenestrated allows
Talking
When doing trach care it is important that
trach stays in place
always held in place when cleaning
always have emergency trach in room
Considerations for suctioning
use if pt can not cough up secretions
obtain pso2 before suctioning
Pressure to use when suctioning
infants 80-100 mm Hg
Children 100-120
Adults 100-150
patient position is upright
Oral/Pharngeal suctioning is
Clean procedure
Tracheal suctioning is
Aseptic Procedure
anything past back of throat needs to be sterile
\Methods of suctioning
oral
nasopharyngeal
nasotracheal
artificial airways
Complications of suctioning
O2 desaturation
cardiac dysrhymias
vagal stimulation - bradycardia
Trauma to mucosa
induced vomiting
Infection
Suction catheters
sized in french and mm
catheter should not occlude more than 1/2 the diameter of the airway
For obtstructive sleep apnea
use CPAP
BiPap
Peak Expiratory Flow Rate
asthma
Reactive airway - what asthma is called in children
measure with peak flow meter - take deep breath in and forcefully blow out
Resp Meds
If unable to use inhaler - use a nebulizer
pt breathes thru mouthpiece withmedicaiton in it
more effective than inhaler
known as breathing treatment
Dont suction longer than
15 seconds per time
Repeat after 1 -2 min
Cough is an unexpected outcome for -
NG Insertion
Cough is an expected outcome for
Suctioning
Dysphagia
difficulty swallowing
dysphasia
difficulty talking
Enteral
Pertains to GI system
Feeding liquids enterally- can it be delegated
yes
When feeding patients enterally (Intubation)
assess for dysphagia
position of patients - sitting up as high as possible/ best in chair
No liquids if having problems with dysphagia
if on swallowing precautions
no straws
do not mix solids with liquids
pts have more problems with liquids than solids
may need to thicken liquids
dysphagia can result from
fluid going into trachea
this is #1 risk for stroke pts
spinal cord injuries
elderly pts
post op pts
signs pt has dysphagia
pts will pocket food
gurgling sounds
coughing
c/o pain
Dysphagia needs to be reported and who needs to be notifed for consult?
Speech therapist
do not give pts with dyphagia -
fluids in between bites - you needn to ensure they are swallowing remind them to swallow, then swallow again
Types of Diets
Clear
Full
Soft
Regular
Therapeutic
Clear Diet
broth, apple juice, jellow, tea, 7 up
if you can see through it
used when pt has increase nausea or post op
it pt is ok with clear you can go to full
Full diet
cream soup
milk
pudding
Soft Diet
mechanically soft
food that is easy to chew
can be regular food that is ground up
may be for pts with no teeth
Regular diet
anything
Therapeutic Diet
ie diabetic pts on specific diet, calorie specific
heart healthy diet - low sodium, low fat
renal diet- low potassium
hepatic diet- low protein
Indications for GI tubes - Gastric Intubation
Tube into stomach - reason is for severe dysphagia
Gavage
Provide pt wtih food with severe dysphagia of unconscious pt
NUTRITION
this pt has no problems with GI system
Lavage
Tube into stomach to withdraw liquids
can be from drug overdose or to take out blood
THIS WASHES STOMACH OUT
Decompression
If pt has decreased peristalsis = pt has increased gastric acid
this is used for pts with problems in GI system, used to empty out stomach to prevent vomiting
also done if gut needs to rest
pts not eating in thsi situation
bc typically short term situation
if pt needs to have decompression for a prolonged period of
time, pt is put on Total Parenteral Nutrition via IV
If a tube is in pt for decompression and he says im nauseous what do you assess?
check if tube is plugged
look for stomach distension
tube could also be in wrong location
check placement and flush tube
Types of tubes
Single Lumen (Levin)
Central Lumen (Salem Pump)
Small bore (dobhoff)
Gastrostomy/Jejunostomy
PEG tube
Single Lumen
Levin
Not left in pts for prolonged period
Used mainly for Lavage
Central Lumen with air port
salem pump
single lumen with air vent
used mainly for deCompression
intermittent sucion
Small bore feeding tube
Dobhoff
Used for Gavage
small diameter
cant be left in for longer time frame than 4-6 wks
first step used to provide nutrition to pt
Gastrostomy / Jejunostomy tube
more long term
inserted directly into stomach
just poke hole and stick in
Specialty tube - Sengstaken Blakemore
used to compress esophagus
used for pts with ascites in esophagus
not used for feeding
only dif btwn PEG and Gastrostomy
the way its inserted
PEG tube
type of gastrostomy tube
used if obese
down esophagus into stomach and poke hole out
Lavage do you do xray
No
Gavage do you do xray
Yes
very small
stylet stays in until xray
must have order to insert
Salem Pump do you do xray?
No
its for short term gavage and decompression
Placement -
you do xray on gavage bc
its so small
and bc your putting food into lung if not placed correctly
How do you kow the other tubes are in place since you dont do xray?
aspiration - apprearance could be yellow or green
coffee ground color is old blood
check pH - should be less than 4
What is the main reason why GI tubes cant be left in long term?
Skin and mucosal Irritation
pts with GI tubes need what considerations?
Skin and mucosal - check for breakdown/irritation
check mouth care- dry mouth can lead to breakdown, rinse mouth every 2-3 hrs
Fluid and Electrolyte Balance- by sucking out/inserting fluids - need to make sure the balance is normal especially for pts with suctioning
Who is at risk for fluid/electrolyte imbalance?
pts on suctioning and decompression
Enteral Feeding- considerations
Head of Bed (HOB) must be elevated at least 30 degrees
if you need to lay them down for any reason- feeding must be stopped
check placement prior to feeding -
after initial check of enteral feeding when do you check again?
check every 4-6 hrs no matter what
if it is set to suction and then you need to give them meds - you have to check it again after you put it back on after meds
ie - if you ck pt at 730, you feed them at 9, you still have to check,
4 hrs is minimum to ck patient
Methods of feeding
Bolus
Continuous
Bag
Bolus feeding
give a feeding all at once large amount
gravity feeding
Continuous Feeding
pump that regulates food, getting fed 24 hrs
Alway flush tube before feeding by
putting syringe into tube - pour liquid into syringe
Checking Residuals
what is left in stomach
what is left over
need to make sure food is digested
need to check residuals every 4 hrs
Residuals are checked -
every 4 hours when on continuous feeding
If on bolus feeding- they are checked every time you give food
You should not see any more that _______ residual volume?
75
If residuals are too high what do you do?
turn off pump for 1 hr
re check
if it has gone down, then restart
you dont need to confer with doctor for this
what do you do with the residual volume?
you pull out everything and then put everything back in
When administering medications
verify correct placement of tube
meds should be in liquid form
if not modify the form - remember certain meds cant be crushed (ER and enteric coated)
flush tube before and after meds are given
how much water do you flush with ?
q
before 10 ml
after 30-50
it pt is on fluid restriction that needs to be counted on Intake
When giving meds to pt with food - do not
do not mix all meds wtih food
reason- bc if they stop eating you dont know what they have taken or not taken
What kind of water do you flush with?
Tap
I & O can be done without order?
yes
How often do you record I&O
every 24 hrs
Hats are used for
measuring urine output, and collecting specimens
Accessories used for incontinence?
Briefs - usually only indicated for frequent incontinence, check every 2 hrs
External Catheter also known as Condom Catheters - used for?
Incontinence of men
Incontinence is not a reason for a catheter?
True
Too high risk for UTI
used for pts with ulcers
but if skin is intact - brief is #1
Types of catheters
Straight Catheter - Red Robinson
Indwelling Catheter - Foley
Suprapubic Catheter
Straight catheter
red robinson
used for specimen collection
relieve retention - urine that remains behind
No balloons
Insert into bladder, urine comes out, collect specimen
Indwelling Foley Catheter
Has a main lumen
drains urine out of bladder
bigger the balloon the more irritating it is - can cause bladder spasms
Big ballons are for pts with chronic use of catheters
Foleys are taken out as soon as possible
also used to obtain I & O's
Standard Catheter size
Standard Balloon Size
14-16 French Standard Catheter
5-10 ml balloon size
Suprapubic Catheter
surgically created opening in wall of pelvis
could be used due to chronic infections
Women position for catheter
Dorsal Recumbant - legs abducted
optional position is side lying
make sure u can see urethra
To insert a catheter it is a _______technique
Sterile
when inserting catheter for men - you need to use more
lubrication compared to women
Types of collection bags:
Regular catheter bag
leg bag
bag with attached urometer
Bag with temperature probe
Regular catheter bag
needs to be changed weekly if used long term
hand below level of bladder
Leg Bag
mobile pts with catheters
attached to leg - when you lay down it goes back up to bladder - so at night pt MUST wear a regular bag
Bag with attached urometer
able to see measurements
strict hourly measurements
used to obtain I&O
Bag with temperature probe
measures core temp of bladder
critical care pts
Continuous Bladder Irrigation
3 way irrigation system
used for pts with bleeding
post op
prostate issues
Continuous Bladder Irrigation is done for how long?
24 hours
Why do continuous bladder irrigation?
used to keep catheter patent
adjust flow based on urine color
empty bag frequently and record I&O
you are flushing the bladder - - as urine gets lighter - - you can slow down the flow of irrigation
Urine specimens
Clear Catch - pt should start stream then catch 20-30 ml
sterile specimen from catheter
For 24 hr urine collection
collect ALL urine expected in 24 hrs
place in dark containers and keep on ice
If they have a bad - cover with a towel and put on ice- the bag can be used to collect the 24 hr urine
ie - at 1310 you start the collection time- that urine is thrown out...then from that point on (after urination) you collect everything until 1310 then next day
when inserting catheter- - you see urine is exceeding 800 ml what do you do?
