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2010-11-10 23:43:50
pt skills test

Pt skills test 3
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  1. S & S of Hypoxia
    • increased/irregular pulse
    • dysrhythmias
    • increased BP
    • increased Resp
    • Restlessness
    • agitation
    • anxiety
    • apprehension
    • altered consciousness
    • confusion
    • fatigue
    • dizziness
    • cyanosis - late sign
  2. Nasal Canula
    L ---> %
    • 0.5-6L/ min
    • greater than 6 liters it becomes ineffective
    • high flow is irritating to nose
    • use low flow system
    • This is the 1st line to use
    • 22-44% of fractured inspired oxygen (flo2)
    • Most common rx for nasal canula is 2 liters
    • room air is 21% oxygen
    • every liter of 02 add 3 (ie 1 L = 21 +3+ 24%)
    • this does dry out mucous membranes
    • anything higher than 2L a humidifier is added to the flow. this does not have to be per can order this
  3. Simple Face Mask
    % ----> L
    • Used if pt did not respond well to nasal canula and pt's 02 levels are still low
    • ordered in %
    • delivers 40 - 60% flO2 (5-8L/min)
    • low flow system
  4. Venturi Face Mask
    • Able to fine tune this
    • able to calibrate more than a simple face mask
    • advantage to this is the regulator
    • o2 concentration is more precise
    • delivers 24-60% flo2
  5. Never overoxygenate a pt with COPD
    • they live with low amounts of 02- body views this as normal, they have higher amts of CO2
    • normal spo2 is 89%
  6. Partial Rebreathing Mask
    • pt rebreathes exhaled air in conjuction with source o2
    • minimum liter flow 6L/min
    • delivers up to 90-95% flo2
    • bas should not collapse during inspiration
    • low flow system
  7. Non Rebreathing Mask
    • one way port allows exhaled air to leave mask prevents room air from entering
    • last stage before intubation
    • delivers 60-100% flO2
    • bag should not collapse
    • minimum liter flow 6L/min
    • low flow/high flow system
  8. Face Tent
    • alternative to nasal canula
    • not for serious situations
    • great substitute if pt is having problems with nose
  9. Oxygen Hood
  10. Incubator
  11. Tracheostomy Collar
    • Fits over trach tube
    • equivalent to about 2 liters of o2
    • gets air thru trach
  12. T Tube
    • fits over trach
    • get air in - fits tighter than trach collar
  13. C Pap
    • Most commonly used with patients who have sleep apnea
    • keeps positive pressure on
    • helps to keep airway open
    • can be used with pt's who use supplemental O2
    • **this is positive airway pressure**
  14. Adding Humidity
    • always add humidity when delivering O2 through artificial airway
    • Humidifier
    • Nebulizer
  15. Airway Management:
    • Therapeutic Coughing and breathing - helps keep alveoli inflated
    • Incentive spirometer- blow into tube - lets pt see how high
    • Postural Drainage and clapping - best posture is sitting up - splint pt if they had abdmonal surgery
    • Hydration- looses phlegm
  16. Artificial Airways
    oral, nasopharyngeal, endotracheal tube, tracheostomy
  17. Least invasive artificial airway
    • Oral
    • fits over tongue
    • holds tongue in place
    • good to use with unconscous pts
    • they need to be measured before insertion
    • inserted upside down once you get to back turn it around
  18. Atalectasis
    • Alveoli collapse
    • predisposes pt to pnemonia
  19. Therapeutic Coughing and Breathing
    • Intentional deep breaths
    • good for post op pts
  20. Abdominal breathing
    lets pt know they are taking a deep breath
  21. Cascade Cough
    • take 2 - 3 slow deep breaths
    • on the 3rd hold and cough 2 - 3x
    • helps to get mucus in lower airways out
  22. Incentive Spirometer
    • set a goal and have pt breathe into it to reach goal
    • trying to get mucous in lower airways out
  23. Postural Drainage
    • Place them in specific position to help drain a particular area of lung
    • also use vibrator to help with this
  24. Clapping
    • Cupping - cause vibration to looses phlegm
    • cystic fibrosis pts do this 2-3 x day
  25. Nasopharngeal
    • goes thru nose to nasopharnx
    • helpful for suctioning thru nose
  26. 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
  27. 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
  28. 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
  29. Fenestrated allows
  30. When doing trach care it is important that
    • trach stays in place
    • always held in place when cleaning
    • always have emergency trach in room
  31. Considerations for suctioning
    • use if pt can not cough up secretions
    • obtain pso2 before suctioning
  32. Pressure to use when suctioning
    • infants 80-100 mm Hg
    • Children 100-120
    • Adults 100-150
    • patient position is upright
  33. Oral/Pharngeal suctioning is
    Clean procedure
  34. Tracheal suctioning is
    Aseptic Procedure

    anything past back of throat needs to be sterile
  35. \Methods of suctioning
    • oral
    • nasopharyngeal
    • nasotracheal
    • artificial airways
  36. Complications of suctioning
    • O2 desaturation
    • cardiac dysrhymias
    • vagal stimulation - bradycardia
    • Trauma to mucosa
    • induced vomiting
    • Infection
  37. Suction catheters
    • sized in french and mm
    • catheter should not occlude more than 1/2 the diameter of the airway
  38. For obtstructive sleep apnea
    • use CPAP
    • BiPap
  39. 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
  40. 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
  41. Dont suction longer than
    • 15 seconds per time
    • Repeat after 1 -2 min
  42. Cough is an unexpected outcome for -
    NG Insertion
  43. Cough is an expected outcome for
  44. Dysphagia
    difficulty swallowing
  45. dysphasia
    difficulty talking
  46. Enteral
    Pertains to GI system
  47. Feeding liquids enterally- can it be delegated
  48. 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
  49. 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
  50. dysphagia can result from
    • fluid going into trachea
    • this is #1 risk for stroke pts
    • spinal cord injuries
    • elderly pts
    • post op pts
  51. signs pt has dysphagia
    • pts will pocket food
    • gurgling sounds
    • coughing
    • c/o pain
  52. Dysphagia needs to be reported and who needs to be notifed for consult?
    Speech therapist
  53. do not give pts with dyphagia -
    fluids in between bites - you needn to ensure they are swallowing remind them to swallow, then swallow again
  54. Types of Diets
    • Clear
    • Full
    • Soft
    • Regular
    • Therapeutic
  55. 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
  56. Full diet
    • cream soup
    • milk
    • pudding
  57. 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
  58. Regular diet
  59. 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
  60. Indications for GI tubes - Gastric Intubation
    Tube into stomach - reason is for severe dysphagia
  61. Gavage
    • Provide pt wtih food with severe dysphagia of unconscious pt
    • this pt has no problems with GI system
  62. Lavage
    • Tube into stomach to withdraw liquids
    • can be from drug overdose or to take out blood
  63. 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
  64. 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
  65. Types of tubes
    • Single Lumen (Levin)
    • Central Lumen (Salem Pump)
    • Small bore (dobhoff)
    • Gastrostomy/Jejunostomy
    • PEG tube
  66. Single Lumen
    • Levin
    • Not left in pts for prolonged period
    • Used mainly for Lavage
  67. Central Lumen with air port
    • salem pump
    • single lumen with air vent
    • used mainly for deCompression
    • intermittent sucion
  68. 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
  69. Gastrostomy / Jejunostomy tube
    • more long term
    • inserted directly into stomach
    • just poke hole and stick in
  70. Specialty tube - Sengstaken Blakemore
    • used to compress esophagus
    • used for pts with ascites in esophagus
    • not used for feeding
  71. only dif btwn PEG and Gastrostomy
    the way its inserted
  72. PEG tube
    • type of gastrostomy tube
    • used if obese
    • down esophagus into stomach and poke hole out
  73. Lavage do you do xray
  74. Gavage do you do xray
    • Yes
    • very small
    • stylet stays in until xray
    • must have order to insert
  75. Salem Pump do you do xray?
    • No
    • its for short term gavage and decompression
  76. Placement -
    you do xray on gavage bc
    • its so small
    • and bc your putting food into lung if not placed correctly
  77. 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
  78. What is the main reason why GI tubes cant be left in long term?
    Skin and mucosal Irritation
  79. 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
  80. Who is at risk for fluid/electrolyte imbalance?
    pts on suctioning and decompression
  81. 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 -
  82. 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
  83. Methods of feeding
    • Bolus
    • Continuous
    • Bag
  84. Bolus feeding
    • give a feeding all at once large amount
    • gravity feeding
  85. Continuous Feeding
    pump that regulates food, getting fed 24 hrs
  86. Alway flush tube before feeding by
    putting syringe into tube - pour liquid into syringe
  87. 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
  88. Residuals are checked -
    every 4 hours when on continuous feeding

    If on bolus feeding- they are checked every time you give food
  89. You should not see any more that _______ residual volume?
  90. 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
  91. what do you do with the residual volume?
    you pull out everything and then put everything back in
  92. 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
  93. how much water do you flush with ?
    • before 10 ml
    • after 30-50
    • it pt is on fluid restriction that needs to be counted on Intake
  94. 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
  95. What kind of water do you flush with?
  96. I & O can be done without order?
  97. How often do you record I&O
    every 24 hrs
  98. Hats are used for
    measuring urine output, and collecting specimens
  99. Accessories used for incontinence?
    Briefs - usually only indicated for frequent incontinence, check every 2 hrs
  100. External Catheter also known as Condom Catheters - used for?
    Incontinence of men
  101. 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
  102. Types of catheters
    • Straight Catheter - Red Robinson
    • Indwelling Catheter - Foley
    • Suprapubic Catheter
  103. Straight catheter
    • red robinson
    • used for specimen collection
    • relieve retention - urine that remains behind
    • No balloons
    • Insert into bladder, urine comes out, collect specimen
  104. 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
  105. Standard Catheter size
    Standard Balloon Size
    • 14-16 French Standard Catheter
    • 5-10 ml balloon size
  106. Suprapubic Catheter
    • surgically created opening in wall of pelvis
    • could be used due to chronic infections
  107. Women position for catheter
    • Dorsal Recumbant - legs abducted
    • optional position is side lying
    • make sure u can see urethra
  108. To insert a catheter it is a _______technique
  109. when inserting catheter for men - you need to use more
    lubrication compared to women
  110. Types of collection bags:
    • Regular catheter bag
    • leg bag
    • bag with attached urometer
    • Bag with temperature probe
  111. Regular catheter bag
    • needs to be changed weekly if used long term
    • hand below level of bladder
  112. 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
  113. Bag with attached urometer
    • able to see measurements
    • strict hourly measurements
    • used to obtain I&O
  114. Bag with temperature probe
    • measures core temp of bladder
    • critical care pts
  115. Continuous Bladder Irrigation
    • 3 way irrigation system
    • used for pts with bleeding
    • post op
    • prostate issues
  116. Continuous Bladder Irrigation is done for how long?
    24 hours
  117. 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
  118. Urine specimens
    • Clear Catch - pt should start stream then catch 20-30 ml
    • sterile specimen from catheter
  119. For 24 hr urine collection
  120. 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
  121. when inserting catheter- - you see urine is exceeding 800 ml what do you do?
    • Clamp off
    • hold abt 2 min - then restart
    • this can cause bladder spasm