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273 Cards in this Set
- Front
- Back
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Reasons for IV Therapy |
Replace/correct F + E Maintain/restore Fluid V (shock/dehydration) Route for med admin Transfuse blood Nutrition (TPN + Lipids) |
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Crystalloids VS Colloids |
Crystalloids -small molecules that diffuse through capillary walls, depending on solute concentration, fluids may be: isotonic, hypertonic, or hypotonic. Colloids - larger molecules that can not diffuse through capillary walls, stays in the vascular system, - blood and blood products (5% albumin, French Frozen Plasma FFP) - Synthetic colloids (Dextran, Pentaspan, Voluven) |
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Osmosis, Osmolality, Osmolarity |
Osmosis - movement of H20 from [high water] to [low water] Osmolality - [of dissolved particles inside the blood] Normal is 280-100mmol/L - Greater than 300 = high solute/low H20 (dehydration) - Less than 280 = low solute/high H20 (over hydration) - Can be assessed through blood or urine testing Osmolarity - osmolar concentration in one litre of fluid outside of the body (IV fluids) |
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pH |
Concentration of H+ in solution Neutral 7.35-7.45 - treat w normal saline Acid pH <7.35 - treat w D5W (pH 4.5) Base >745 - treat with Dilantin pH 12 If client admitted with dehydration r/t D+V should initially give them ISOTONIC solution to rehydrate then treat the imbalances. |
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Hypotonic Solutions |
Lower than serum osmolarity. Fluid shifts into the cells and interstitial spaces. Hydrates cells but reduces fluid in the blood. Hypotonic solutions cause a shift of fluid from the vascular system into cells. Caution - can cause an increase in ICP (intracranial pressure) and intravascular hypovolemia (decreased blood volume) - Don't use on patient with brain injury Examples: 0.45% saline |
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Isotonic Solutions |
Have a 'normal' osmolarity as serum and body fluids. Stays where it is infused (blood). The least irritating to the endothelial lining of the vein wall. Used FOR REHYDRATION INITIALLY Examples: 1. Ringers Lactate (275 osmolality) 2. Normal Saline (308) 3. 5% Dextrose (252) 4. 5% Albumin (308) 5. Hetastarch (310) |
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Hypertonic Solutions |
Osmolarity higher than serum osmolarity. Pulls fluid from the interstitial and intracellular compartments. Greatly expands intravascular compartment (blood). Watch for circulatory overload. Pull from the cellular compartment. May be used cautiously to decrease deem (cerebral, pulmonary, peripheral) Do not give to pts with renal or cardiac impairment. Increased risk of vessel damage. Examples: 1. 5% Dextrose in 0.45% Saline (406) 2. 5% Dextrose in NS (560) 3. 10% Dextrose 4. 3% NS (1025) 5. 25% Albumin (1500) |
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Sodium - hypo and hyper symptoms + nuring implications |
Normally 136-145mmol/L Hypernatremia - dry mucous membranes, thirst, agitation, restlessness, hyperreflexia, mania and convulsions Hyponatremia - weakness, confusion, lethargy, stupor, coma Nursing Implications - assess cause, consider sodium intake/water intake, physical assessment, notify Doc, possible iV therapy |
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Potassium - hyper + hypo + implications |
Normally 3.5-5.0 mmol/L Essential for cardiac function, muscle contraction, oncotic pressure, cellular electrical neutrality. Hyperkalemia - cardiac arrest, ECG changes (peaked T waves, widened WRS, Depressed ST), irritability, nausea, vomiting, diarrhea Hypokalemia - arrhythmias, weakness, paralysis, hyporeflexia, increased sensitivity to Digoxin, ECG changes (flattened T waves, prominent U waves) Implications - lab values, physical assessment, notify Doc, IV therapy, cardiac monitoring, treat quickly to prevent cardiac arrest |
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Assessing Fluid and Electrolyte Status |
Weight patient daily Record intake/output Lab Values - urine specific gravity, hematocrit, electrolytes, BUN, creatinine, eGFR Alterer LOC - may be dehydrated, decreased blood to brain from low BP Overload Signs - periorbital and peripheral edema, ascites (abdominal swelling), crackles in lungs, bulging fontanelle (baby), polyuria, diuresis, hypertension, tachycardia, tachypnea (breathing faster r/t wet lungs), altered mental status, anasarca (general edema) Deficit Signs - dry mucous membranes, sunken orbits, depressed fontanelle (baby), concentrated urine, decreased urine output, hypotension, tachycardia, altered mental status |
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Complications with IV Therapy |
Fluid Overload or Deficit Pain Electrolyte abnormalities Tissue damage Septicemia (blood poisoning) |
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IV Irritants vs IV Vesicants |
The greater the deviation from normal pH the greater potential for vein irritation, pain, inflammation along the vein. Peniccilins, cephlosporins, amphotericin, acyclovir, diazepham, potassium IV Vesicants - Medications/solutions that can cause severe tissue damage if they leak into submit tissues. Antineoplastics, cincristine, calcium solution, nitroprusside, viblastine, doxorubicin, KCL IV additives, contrast medium. To prevent vein damage: dilute medication if safe for patient (Renal, cardiac), use larger blood vessels, infuse at a low rate |
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Infusion Site Options: 1. Peripheral 2. Subcut 3. Central IV |
Peripheral IV - most common, can be inserted by nurses, generally place in hand or arm, may be placed in foot/ankle. IV catheters range from small (24g) to big (14g), use 0.5-1 inch length Subcutaneous Infusion (hypodermoclysis) - infusion of isotonic solutions via a hypodermoclysis needle or IV Catheter into the subcutaneous tissue. Effective in preventing dehydration, administration of opioids, some sedation, useful in terminally ill clients and very elderly. Can only be infused at 70mL/hour so thats not fast enough to rehydrate someone. Use 23-25g butterfly needle at 30-45 degree, NS or 2/3 +1/3 for rehydration, absorbed from submit into blood, infusion by gravity (only slow), can be used for insulin or hydration Central IV - used with critically ill or high risk patients, may be placed subclavian, jugular, or femolar, inserted by physicians, PICC lines are placed electively and generally via the brachial vein. |
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Supplies for IV Therapy |
IV fluids (fluid ordered/size of bag, check expiration date, sterile seals intact, solution is clear) IV administration set (tubing) and secondary tubing) - buretrol Micro-drip set 60ggts/mL - macro-drip set 10-15ggts/mL IV pump IV pole Additional supples - IV cannula, tourniquet, alcohol swabs, gloves, dressing, supplies, saline lock adapter. |
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IV Assessment |
What is the Order? Is the correct solution hanging? Correct drip rate? Asses site and IV every 1-2 hours At the start and end of shift calculate: amount already infused form bag and amount to be absorbed (TBA) Check IV site/sites and assess for complications, identify any issues and intervene if needed. |
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Volume per Hour Calculation |
total volume/ total time = volume per hour IV NS 1000mL over 8 hours Run IV at 125mL/hr |
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Drip Calculation |
Volume (mL/hr) x drip factor (tubing) ----------------------------------------------------- timing (60min) = rate (drops/min) NS 100mL/hour to be given with 10ggt/mL tubing 100x10/60 - 17ggts/min |
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Saline Lock |
Short term access devices used to access the site for intermittent infusion and to maintain access in care of emergency. Flushing and locking required to maintain potency - usually twice a day Turbulent flow = stop/start technique is used Catheter is locked/clamped after flusing As you are clamping, push are in - causes positive pressure and keeps vessel open |
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Piggy Back (secondary IV) Calculation Medication Label |
Medications are usually given via Minibags, meds are fluids or powders which requires reconstitution. Routeinely used for: antibiotics, antiemetics (prevent vomiting), and analgesia Pharmacy Guidelines will tell you: 1. Dilution solution 2. Amount of solution for med 3. Time to infuse IF saline lock - check hospital policy for flushing before/after. Calculating Secondary IV Rate: Minibag voluem x drip factor/mins = drops/min Medication labels Include: 1. Time added 2. Name/dose of drug 3. Name/room of pt 4. Added by whom: nurse 5. Date/time med was added 6. Name of IV solution 7. Time for administration 8. Sometimes expiry date (how long the med is stable after mixed) |
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Troubleshooting Problems with IV
Troubleshooting Complications |
Monitor IV therapy every 30 to 60 minutes to maintain the IV flow rate ordered. • Do not arbitrarily speed up or slow down an IV that is behind or ahead of schedule. • Know your institution’s policy regarding the recalculation of IV flow rates. An IV should not varymore than 25% from its original flow rate. Contact the prescriber for a new IV order if the recalculated flow rate exceeds 25% of the original flow rate. Troubleshooting Complications: bleeding/bruising, phlebitis, infection, infiltration, pain, errors (rate/drug related), accidental dislodgement of catheter, broken catheter |
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IV slow or no flow |
Check height of IV fluids relative to patient Check tubing for kinks Position of catheter - patient position Check site for complications Check clamps Check rate - pump or manual - is it set correctly? Rate behind/ahead of schedule: remaining volume (mL) / hours remaining in shift |
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Air in IV tubing |
Potential Causes: - Container has run dry - Loose connections - Air in syringe during saline lock flush Possible Result - air embolus = fatal Symptoms of air embolus: cyanosis, loss of consciousness, weak, rapid pulse, drop in BP, respiratory distress |
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Incorrect Solution |
Slow rate to a minimum Assess client Verify Orders Get correct solution Notify Doc - if needed Follow incident reporting procedure for hospital Documentation |
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Dressing an IV Site and discontinuing an IV site |
If the IV site is intact and infusing well but the dressing is coming off - redress the site If the IV need to be removed (because the catheter is dislodged, complications, or lno longer needed) Consider need for IV restart - can drug route be changed to avoid another IV? After catheter removed, assess cather tip to ensure it is intact Document |
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Phlebitis |
Inflammation of vein r/t irritation. Can be chemical- fluid/medications Can be mechanical - IV catheter Symptoms: swelling, discomfort, redness along course of vein (streaking), pain, erythema, warmth May develop thrombus at site of irritation - thrombophlebitis, embolus Interventions: 1. Stop drug/infusion 2. Discontinue IV 3. Set up new system and restart IV (other arm) 4. Apply warm, moist compress 5. Document - note if the client was receiving medication at the time and discuss plan with physician, if patient did not receive full dose of medication. 6. Notify MD - not urgent unless client has S/S of fever, severe pain, did not receive a full dose etc |
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Localized Infection Interventions |
Stop IV and remove catheter immediately. Clean IV site/assess for discharge Culture catheter tip/wound drainage if ordered Notify MD - may need topical/systemic antibiotic Set up new IV - on other arm, away from infection Document assessment findings, interventions and evaluation. |
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Infiltration Interventions |
Stop Infusion Discontinue IV Set up new system and start IV (other arm) Apply warm compress/heat to facilitate absorption Elevate arm Notify MD *not urgent unless circulation is compromised. Document |
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Extravasation |
Definiton: leakage of irritating fluids into surrounding tissue (chemotherapy drugs, nitroglycerine, adrenaline, dopamine, TPN, Potassium, chloride, antibiotics) causing tissue damage: - Due to increased pressure - Due to vein puncture Potential Outcomes: pain, redness, irritation, tissue necrosis, loss of limb Interventions: 1. Stop infusion immediately 2. Withdraw any fluid form IV cannula if possible, then remove 3. Notify Doc and pharmacist IMMEDIATELY 4. Warm/cold compress depending on drug. 5. Antidote depending on drug 6. Set up new system and restart IV (other arm) 7. Document thoroughly - consider if photo should be taken 8. Patient and family will need to be advised |
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Reasons for Blood Transfusions |
1. Restore circulating blood volume (hemorrhage, trauma, surgery, hypovolemic shock, burns) 2. Correct RBC deficiency and improve oxygen carrying capacity of blood (anemic) 3. Maintain blood's clotting ability (pt's with bone marrow suppression) 4. Provide select blood components as replacement therapy (clotting factors, platelets, etc) |
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Function of Plasma, RBC, WBC, Platelets |
Plasma - makes 55% of blood, plasma circulates dissolved nutrients, such as glucose, amino acids and fatty acids (dissolved in blood or attached to plasma proteins), removes waste products, such as CO2, urea, lactic acid. RBC (erythrocytes) - contain hemoglobin (iron-containing protein), hemoglobin facilitates transportation of oxygen by reversibly binding to its respiratory gas and greatly increasingly its solubility in blood. WBC - part of immune system - destroy/remove old/aberrant cells/cellular debris. Attacks infectious agents (pathogens) and foreign substances. Platelets - responsible for clotting (coagulation), they change fibrinogen into fibrin. Fibrin creates a mesh onto which RBCs collect and clot. This stops bleeding or potential bleeding. Also helps to prevent bacteria from entering body. |
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Types of Transfusions |
Whole Blood Packed RBCs Platelets Albumin (5% or 25%) Fresh Frozen Plasma (FFP) Cryoprecipitate IVIG (IV immunoglobulins) NB - blood products only compatible with Normal Saline Do not add any drugs or additives to blood products. |
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Whole Blood Transfusions |
Whole blood or packed cells are transfused where major blood loss occurs. |
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Packed RBCs (PRBCs) |
Once plasma has been removed from whole blood, additives are used to re-suspend red cells (maintain red cells in optimum condition during storage) Indications: 1. RBCs improve oxygen-carrying capacity 2. Useful as a volume expander after acute blood loss 4. Symptomatic Anemia |
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Platelet Infusions |
Indications: 1. Severe micro-vascular bleeding occurs (disseminated intravascular coagulation) 2. For patients with platelet count of less than 10,000 to 20,000 3. Patients with platelet count of less than 50,000 who are bleeding |
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Albumin Transfusions |
5% Albumin - solution used for volume expander, hypovolemic shock and hypopoteinemia. 25% solution used for severe burns and low albumin levels. Accidentally administering 25% albumin instead of 5% in error may result in severe circulatory overload. Burns (b/c theres a large amount of fluid loss and patients will have leaky vessels) |
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Fresh Frozen Plasma (FFP) |
Indications: active bleeding, replacement of plasma coagulation factors when simultaneously blood volume expansion is required. Contains all clotting factors except platelets and is frozen to preserve factor V and VIII Risk of hypovolemia |
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Cryoprecipitate |
Obtained from FFP after slow thawing. Indications - given to increase fibrinogen level (patient who has developed DIC). Also used for bleeding or immediately prior to an invasive procedure in patients with significant hypofibrinogenemia. Advantage - can replace these factors without the hypervolemia risk with FFP |
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Intravenous Immunoglobulins (IVIG) |
IVIG is a protein replacement therapy for patients which have decreased or abolished antibody production capabilities . Indications: 1. Immune deficiencies 2. Inflammatory and autoimmune disease 3. Acute infections IVIG is administered to maintain adequate antibody levels to prevent infections and confers a passive immunity. |
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Nursing Assessment. |
Neuro - confusion, decreased energy, LOC, hypoxemia. Respiratory - increased RR and effort, cyanosis, SOB, is O2 saturation affected by low Hgb? Cardiac - low BP indicates low circulating volume. Increase HR means compensatory mechanisms. Will patient's HR increase if he/she is receiving beta blockers? Active Bleeding - hemorrhage due to trauma, surgery, hemorrhagic shock/inability to clot effectively. Current Treatments - chemotherapy alters a persons RBC, WBC and platelets. Factor Deficiencies (factor 1, 2, 5, 7. 8. 10, 11, 13, vit K) Lab Values - hemoglobin, platelets, albumin, hematocrit |
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Normal Blood Volumes |
Pre-term Babies: 100ml/kg Infants 80mL/kg Children 70ml/kh Adult male 70-75 ml/kg (5-6L) Adult female 60-65 ml/kg (4-5L) |
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Preparing For Blood Transfusions |
Make sure you know why patient is receiving blood and what monitoring you need to perform. Client requires a valid consent for transfusion. Content valid for up to one year although new one may be needed for each hospital admission. Call the blood bank to see if blood sample for group and screen (G&S) is needed. Call the blood collection team to come and draw the blood, if needed. Follow your hospital protocol to requisition the ordered blood product. Check IV is working by flushing it. Consent. Blood Cross Typing - All these three things need to be done before you can even order blood, do not order blood until all those things are in place. |
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When Blood Product is Ready |
DO not pick blood up until patient is ready - Consent signed - IV patent and connected to blood tubing Blood product and order are verified by two individuals when the product is released from the blood bank. Check again before its administered. |
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Checking Blood Products |
At bedside, 2 staff verify pt ID on transfusion record, label on blood product and clients bracelet. 2 staff verify that the blood product info on transfusion record and product match (type of product, product ID # and product Type (A,B,O) compatible with pt blood type. Each practitioner will verify information independently and will sign the transfusion record. Student Nurses are unable to check/hang blood |
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Initiating Blood Transfusion |
Before starting transusion take vitals and listen to chest. Start transfusion slowly (50mL/Hr) for 15 min Check on pt and repeat vital signs (q15 for first hour, q30 for next, q1 until finished) Document each set of VS on the transfusion record. If no complications after 15 mins - increase rate to infuse as ordered by physician. Note - blood must be started within 30 mins of leaving blood bank and be completely infused within 4 hours. Return product to blood bank if unable to transfuse product. Blood cannot be safely stored in ward fridge. Repeat vital signs after each unit. Assess patient for any reaction/symptoms |
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Reaction to blood products |
Incompatible product - identification errors Donor WBC and cytokines Donor antibodies Bacteria Allergens Donor viruses/parasites |
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Trasnfusion Compatibility |
O can receive only O A can receive A or O B can receive B or O AB can receive AB, A, B, O O donated to O, A, B, AB A donated to A, AB B donated to B, AB AB donated only to AB In emergency situation, O and Rh (negative) blood is used |
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Transfusion Risks |
Immediate Risks 1. Allergic (minor) 2. Allergic (severe) - anaphylaxis 3. Febrile (non-hemolytic) - fever 4. Fever (hemolytic - ruptured RBCs) - fever 5. TRALI (transfusion related acute lung injury) 6. TACO (transfusion associated circulatory overload) Delayed Reactions post transfusion 1. Iron overload 2. PTP (post transfusion purpura) 3. Delayed hemolytic 4. Tranfusion associated graft vs host disease (T A-GVHD) |
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Allergic (minor) |
S/S - itching, flushing, rash, swelling, occur 2-3 hours from start of transfusion Interventions - Consult with physician. - Anticipate an antihistamine order (diphenhydramine) - Continue transfusion with caution - Report mild reactions to Blood Bank with reaction slip only |
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Allergic (Severe) |
S/S - Urticaria (rash), erythema (red), anxiety, respiratory distress, hypotension, laryngeal/pharyngeal edema, bronchospasm, nausea, vomiting, dyspnea, cyanosis, tachycardia, substernal pain, loss of consciousness, cardiac arrhythmia, cardiac arrest. Severe Allergic reaction within 2-3 hours of start of transfusion. Anaphylactic - usually 1-45 mins after small V of product transfused. Interventions: 1. STOP transfusion and replace IV line Assess patient Ask for another nurse to assist you DO NOT Leave pt alone Notify MD immediately Expect the following orders: 1. Medciations - epinephrine, corticosteroids, antihistamines, vasopressors 2. oxygen therapy 3. Send sample to blood bank to test for Anti IgA antibodies - patient may require IgA deficient blood components. |
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Febrile (Non-hemolytic) |
Occurs during transfusion, usually toward the end or when the transfusion is complete. S/S - fever with no breakdown in RBCs, Temperature increase over 38 celsius, or greater than 1 degree higher from pre-transfusion value, chills, rigours, headache, malaise, vomiting, nausea. Intervention: 1. Consult with physician. 2. Continue transfusion, as per MD, cautiously once temp decreases and if blood product is still viable (within 4 hours) 3. Anticipate antipyretics (acetaminophen) 4. Report mild reactions to blood bank with reaction slip only |
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Febrile (hemolytic) |
S/S (early phase - fever, pink tinged urine, anxiety, hypotension, flank pain. S/S (late phase) - generalized bleeding (DIC), hypotension. Interventions 1. STOP transfusion and replace IV line 2. Assess patient 3. Ask for another nurse to assist you 4. DO NOT leave pt side 5. Monitor for hypotension, renal failure, DIC 6. Notify MD immediately 7. Anticipate - IV bolus to maintain BP and kidney function |
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TRALI - transfusion related acute lung injury |
S/S - typically seen during or within 6 hours, rapid onset of dyspnea and tachypnea, may be associated with fever, cyanosis, hypotension, pulmonary crackles. Interventions 1. STOP transfusion and replace IV line 2. Assess pt 3. Ask for another nurse to assist you 4. DO NOT leave pt alone 5. Monitor for respiratory distress 6. Notify MD immediately 7. Anticipate the following orders: - Oxygen, STAT portable Chest X-ray, intubation and ventilation, vasopressors |
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Acute Hypotensive Transfusion Reaction |
Onset within 5 minutes after beginning of transfusion S/S - flushing, abrupt onset of hypotension with or without bradycardia, nausea, dyspnea, urticaria (rash) Interventions: 1. STOP transfusion and replace IV line - anticipate giving IV fluids rapidly to treat hypotension 2. Assess pt 3. Ask for another nurse to assist you 4. DO NOT leave pt alone 5. Monitor for acute hypotension 6. Notify MD immediately 7. Anticipate the following orders: - oxygen, IV fluid resuscitation, vasopressors. MD may choose to hold antihypertensives especially ACE inhibitors |
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TACO - transfusion associated circulatory overlaod |
S/S = headache, hypertension, neck vein distention, dyspnea, orthopnea, crackles, restlessness, altered LOC, tachycardia Interventions: 1. STOP transfusion and replace IV line - anticipate giving minimal IV fluids with fluid over load 2. Asses pt and assist into a position to ease breathing 3. Ask for another nurse to assist you 4. DO NOT leave pt alone 5. Monitor for acute respiratory failure 6. Notify MD immediately 7. Notify RRT to assist with resp. distress 8. Anticipate the following orders: - Diuretics, oxygen, STAT chest x-ray |
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Autologous Blood Transfusion |
Types: 1. Preoperative autologous blood 2. Intraoperative hemodilution 3. Intraoperative blood salvage (cell saver) 4. Postoperative blood salvage |
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Therapeutic Agents for managing anemia |
Iron Folic Acid Vitamin B12 Recombinant erythroprotein |
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Autologous Donation and blood salvage |
Preoperative autologous donation Intraoperative hemodilution Intraoperative cell saving techniques Autologous Donation - Removing whole blood from a person and transfusing it back into same person. Allergic reaction, transmission of disease are avoided. person donated blood before a panned surgical procedure, blood can be frozen for up to 10 years, beneficial to patient with rare blood type or any pt who expects to require limited blood support during major surgical procedure |
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Surgical |
Hemostasis technique (topical hemostats, surgical, gel foam) |
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Volume expanders |
Crystalloids: ringers lactate, normal saline Colloids: Dextrane, Pentastarch, Voluven |
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Pharmacological Agents for Bleeding |
DDAVP (desmopressin) for individuals with clotting disorders Anti-fibrinolytic Vitamin K |
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CVAD |
Central Vascular Access Devices - A flexible catheter inserted into a large central vein with the tip in the superior or inferior vena cava (SVC or IVC) Normally it only goes into IVC if the entrance site of the port was in the femoral vein |
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Indictions for CVAD insertion |
Patient requires long-term therapy. Medications with extreme variations in pH. Therapy includes infusion of highly osmolar solutions, vesicants or irritants. Access for bloodworm. Peripheral veins are inaccessible. Multiple infusions of fluids, blood products, medications or TPN (total parenteral nutrition) |
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Compare and Contrast PIV and Central Lines |
Percutaneous = short term, not every type of therapy can be administered, used when theres good access to peripheral venous access, blood transfusions Central line = long term, can be used for short term (some drugs can only be given centrally), blood work, multiple infusions, med can be harmful to peripheral veins like chemo, meds with extreme pH, any type of therapy can be used with central, venous flow rate 2-2.5L/min, superior hemodilutions of meds, post insertion x-ray required, poor inaccessible peripheral venous access, blood transfusions (can also be given peripherally), TPN |
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Central Vascular Access Devices |
Percutenous, Non-tunneled CVAD (subclavian, jugular, femoral) Peripherally Inserted Central Catheter (PICC) Tunneled CVAD (Hickman) Implanted Vascular Access Device (IVAD) (Port-a-cath) IV lines are considered central or peripheral based on where the catheter tip ends inside the body - not where it enters through the skin |
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Percutaneous Non-tunneled CVAD |
Subclavian, Jugular, Femoral) Used in hospital, not community Short term-access devices 7-10 days Can be placed in a short period of time if urgently needed. Inserted at the bedside by the physician. |
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PICC |
Peripherally Inserted Central Catheter Long-term, placed by physicians in Radiology Department or specially prepared nurses at the pt's bedside. Inserted into the basilica, median cubital or cephalic veins (antecubital veins), and advanced to SVC Used in the hospital and community Single or double lumen |
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Tunneled CVAD - Hickman Lines |
Long-term, flexible, surgically placed Threaded through the subclavian vein or internal jugular into the SVC. Dacron cuff inside body which supports in growth of tissue, prevents dislodgment and provides a barrier to infection. Single and multiple lumens. Tunneled under skin and exists chest wall. Entrance site - incision made for insertion of catheter, sutured closed. Exist site - where catheter exits body Dressing site If you're not getting blood out, it could have migrated out of the spot, if you're getting arrythmias it could have migrated into heart. |
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Implanted CVAD |
Port-a-Cath Long-term, surgically implanted system that contains a self-sealing injection port connected to a catheter. The entire system is implanted, when not in use there is nothing exposed out of the body. Requires special non-coring needle (Huber needle) to access Advantages: less chance of it becoming dislodged because it's under the skin, decreased infection rate when accessed sterile, we use special Huber needle to access it (its bent) |
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Parenteral Nutrition |
Peripheral Parenteral Nutrition (PN) - isotonic or hypotonic IV nutrient solution administered through a peripheral catheter. Total Parenteral Nutriton (TPN) - hypertonic solution of nutrients to meet almost all caloric and nutritional needs administered through a central catheter. Lipid Emulsions: 20% or 30% lipids used for people who can't take food orally, if they have a shortened GI tract etc Nursing Management - monitor VS every 4-8 hours, collect daily weights (check for dehydration), change dressing over catheter site every other day or once a week, look for inflammation, |
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CVAD Nursing Assessments |
Assess the site for pain, tenderness, redness, temp, deem, exudate (what is it), dressing condition Infusion status - right fluid? right rate? infusing well? can I flush it? tubing (caught on anything, need to be changed? Change tubing every 3 days, no one is going to tell you when its time to change it, whatever is attached to your patient you are responsible for it. Assess for complications - if it was just inserted there may be discomfort but if there is discomfort in 2 weeks or if theres purulent exudate then theres an issue. |
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CVAD Complications |
Infection Air embolus Dislodgement of catheter Catheter occlusion Damaged CVAD - external ones Migration of Catheter tip Thrombosis Pinch-off syndrome |
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CVAD Complications: Infection |
Assessment Findings - pain, inflammation, redness, exudate, temperature, fever, chills, malaiase Cause - poor aseptic technique, immunosuppressed. Interventions: Local - culture of drainage from site, warm moist compress, catheter removal if indicated Systemic - blood cultures, antibiotic therapy, catheter removal if indicated. Notify MD |
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CVAD Complications: Air Embolus |
Assessment Findings - chest pain, cyanosis, altered BP/pulse, respiratory distress Cause - accidental injection of air, catheter breaking Intervention: 1. Clamp Line 2. Place pt on left side with head down - we don't want air to get to brain and this slows circulation 3. Notify MD 4. Monitor VS 5. Administer O2 6. With order, initiate peripheral IV |
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CVAD Complications: dislodgement of catheter |
Assessment Findings - Leakage from catheter or exit site, decrease in external CVAD length Cause - accidental tension on the line d/t pt or nurse inattention Intervention 1. Secure catheter with tape 2. Observe for absence of suture 3. Observe for protrusion of Dacron cuff from exit 4. Notify MD 5. Anticipate x-ray of site 6. Do not use line until tip placement verified |
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CVAD Complications: catheter Occlusion |
Assessment FIndings - unable to administer IV fluids, no flow, unable to aspirate Cause - poor flushing previously, catheter migration, coagulopathies (precipitate buildup in lumen), clamped or kinked catheter, tip against vessel wall, thrombosis Intervention 1. Flush catheter gently - do not force or it can cause catheter to rupture or dislodge the clot 2. Do not use the catheter 3. Notify MD 4. May require TPA or an agent to counteract drug precipitate or lipid sludge (anticoagulant or thrombolytic agents) 5. Instruct pt to change position, raise arm and cough |
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CVAD Complications: Damaged CVAD |
Assessment Findigns - leakage from external catheter, pockets of swelling along catheter path. Cause - prolonged use, accidental tension on the line. Intervention - ??? |
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CVAD Complications: migration of catheter tip |
Assessment Findings - inability to inject fluids, arrhythmias, pt complains of "gurgling" sound in ear, you'll notice change in length of tubing or the fact that they have abnormal heart rhythm, Cause - change in intra-thoracic pressure because of coughing, sneezing or vomiting Interventions 1. Discontinue infusion 2. Notify MD 3. Anticipate Xray to verify position |
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CVAD Complications: Thrombosis |
Assessment Findings - engorged peripheral veins in arm or chest wall, tenderness and edema of neck, shoulder, arm on catheter side, impaired movement of neck/jaw Cause - poor flushing previously, coagulopathies Intervention ?? |
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CVAD Complications: Pinch-off Syndrome |
Assessment Findings - resistance to flush, inability to withdraw blood Cause - patient positioning (flow may be restored with a position change), catheter tip migration Intervention 1. Notify MD 2. Anticipate chest xray for catheter compression between clavicle and rib 3. Catheter removal is usually indicated because compression can lead to catheter fracture and emboli. Don't want it to fracture and migrate through body |
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CVAD DRESSINGS |
Remove existing dressing and inspect site for redness, swelling, drainage. Wear a surgical mask and avoid breathing on site. Use a "no touch aseptic technique" - using one side of a chlorhexidine swabstick cleanse from the centre outward using a circular motion covering 5-5cm area Using the other side of the chlorehexidine swabsitck cleans 5cm up the catheter (proximal to distal). 30-second friction rub required, allow to dry. Non-tunneled CVA - inspect external length and sutures - if suture is loose - notify MD NB - students are not allowed to change central line dressings. |
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Transfusion documentation |
Componentinfused and amount Unitnumber and expiration date ABO andRh type of the blood component and the patient Length ofinfusion time Unexpectedoutcomes or transfusion reactions |
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Voiding, Mictrurition, Diuresis |
Voiding - to void/pee Micturition - when it actually leaves the urethra Diuresis - increase the voiding amount (diuretics) |
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Factors that influence urination |
Disease conditions Fluid balance Medications Surgical procedures Psychological factors Hygiene Growth and development Psychosocial and cultural Cerebrovascular accident (urinary incontinence) MS - urgency, frequency, urge incontinence (bladder relaxes and causes urinary retention) Parkinsons's - overactive bladder Diabetes - impaired bladder contractility, reduced sensation, incomplete emptying Alzhiemers - inability to sense full bladder Enlarged prostate (benign prostatic hyperplasia) - obstruvtive, intermittent stream, straining End Stage Renal Disease - "uremic syndrome" - increase in nitrogenous waste in urine, altered regulatory functions |
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Transient urinary incontinence |
Urine loss resulting from causes outside of or affecting urinary system - dementia, infection, UTI, stool impaction Resolves when underlying causes are treated |
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Urge Incontinence |
urine loss associated with or immediately preceded by a sudden andurgent need to void that cannot be postponed, causes urinary frequency (need tovoid more often than every two hours) and nocturia (voiding overnight),treatment: bladder training, scheduled toileting, pelvic floor muscleexercises, anticholinergic medications |
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Stress incontinence |
generally small volume (<50mL) urine loss resulting fromincreased intra-abdominal pressure (coughing, sneezing, laughing, lifting).Caused by weak pelvic floor muscles, obesity. Treatment includes lifestylemodifications, medications (estrogen replacement), surgery, artificialsphincter |
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Mixed incontinence |
features both stress and urge incontinence. |
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Functional incontinence |
urine loss caused by alterations in cognitive orphysical function or by environmental factors. The person has bladder controlbut is unable to reach the toilet. Causes include confusion, difficultyremoving clothing, or immobility. Treatment includes habit retraining, environmentalalterations, scheduled toileting, condom catheter (men), protectiveundergarments |
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Overflow incontinence |
Small or large amounts of urine loss associated with overdistention of the bladder. The person may feel as if the bladder is nevercompletelty empty. Caused by bladder outlet obstruction, fecal impaction,diabetes, spinal cord injury, prostate enlargement, or severe uterine prolapse |
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Relax incontinence |
involuntary urine loss that occurs at somewhatpredictable intervals, the person is unaware that the bladder is filling anddoes not feel the urge to void, but the bladder contracts spontaneously. Causesinclude spinal cord dysfunction (inhibition of cerebral awareness or impairmentof the reflex arc). Treatment includes anticholinergic medications, surgery,intermittent catheterization, in-dwelling or condom catheter. |
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Total Incontinence |
continuous and unpredictable loss of urinecaused by damage to the nerves that control the bladder. Causes include spinaldeformities such as spina bifida or scoliosis, spinal cord injury, or advanceddisease such as MS or Alzheimer’s. Treatment includes artificial sphincter,surgery, urinary diversion. |
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UTI |
Escherichia Coli – most frequent causative pathogen Bacteria in the urinemay lead to the spread of organisms into the kidneys and the bloodstreamleading to urosepsis. o Bacteria usuallyenter the urinary tract by ascending the urethra. They inhabit the distalurethra, external genitalia, and vagina in women. Organisms enter the urethralmeatus easily and travel up the inner mucosal lining to the bladder. Women aremore susceptible to infection because of the short urethra and the proximity fothe vaginal vestibule and rectum to the urethral meatus. § Signs and symptoms: pain or burning sensation during urinary (Dysuria) as urine flows over inflamedtissues, fever, chills, nausea, vomiting and malaise, inflammation of thebladder causes frequent and urgent sensation of need to void, blood tingedurine (hematuria), urine appearsconcentrated and cloudy because of the presence of WBC or bacteria |
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Over Active Bladder Syndrome |
symptom based syndrome characterized by presenceof urgency, the sudden and compelling desire to void that is difficult topostpone. Similar to urge incontinence, it can be idiopathic but is commonlyattributed to changes associated with nervous system disorders and overflowobstruction. |
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Nocturia |
waking at night to void, associated with agingand overactive bladder and enlarged prostate in men. Pts with peripheral edemamay experience this because lying down facilitates reabsorption of pooled fluidand leads to increased urinary output overnight. Treatment includes reducingfluid intake in the evening, elevating the feet for one to two hours beforebedtime to encourage return of fluid from the lower extremities, medication toreduce the volume of urine produced overnight and to relax the bladder muscle. |
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Urinary Retention |
accumulation of urine in the bladder as a resultof the bladder’s inability to empty. Normally, urine production slowly fillsthe bladder and prevents activation of stretch receptors until the bladderdistends to a certain extent. The micturition reflex then occurs and thebladder empties. Caused by underactive or acontractile detrusor muscle,urethral obstruction, surgical or childbirth trauma, alterations in motor orsensory innervation of the bladder, medication side effects, fecal impaction,urethral stricture, a narrowing of the urethral canal that can be congenital oracquired as a result of infection or trauma. Signs include absence of urineoutput over several hours, bladder distention, restlessness, diaphoresis,moderate to extreme abdominal discomfort. |
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Urinary DIversions |
A urinary stoma to divert the flow of urine from the kidneysdirectly to the abdominal surface. May be temporary or permanent. Risk forlocal irritation and skin breakdown o Implications – cancer of the bladder, trauma, radiation injury to the bladder,fistulas, chronic cystitis o Continent Pouch – provides urinary storage in a leak-proof pouch. o Ureterostomy – bringing the end of one or both ureters to the abdominal surface o Transureteroureterostomy – Connects the ureters and bringsone out through the abdominal wall (to avoid the need for two collectingdevices). In some cases a tube may need to be placed directly into the renalpelvis to provide urinary drainage, this is called a nephrostomy |
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Urinary Incontinence |
Involuntary loss of urine |
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Purposes and indications for Short term indwelling catheterization |
left in no longer than 21 days, take it out assoon as possible, used in patients who have an obstruction (enlarged prostate),used for pre and post operatively, prevention of urethral obstruction caused byblood clots, used also for accurate monitoring of urinary output in criticallyill patients, measure intake/output closely, used if patient had surgery,double-lumen catheters |
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Purposes and indications for Long-term indwelling catheterization |
left in for up to 3 months, used when chronicurinary retention is not manageable by intermittent catherization such assevere urinary retention, presence of stage 3 and 4 pressure ulcers that cannotheal because of continual incontinence, terminal illness when bed linen changesare painful for the patient, double-lumen catheters |
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Purposes and indications for Intermittent Catheterization |
relief of discomfort from acute bladerdistention, to obtain a sterile urine specimen, sometimes used to instill amedication, used when required to assess residual urine after urination or asan alternative to long-term indwelling catheterization (paralysis) –Spinodifiba, MS, paraplegic, uses single-lumen catheter |
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Assessment - Subjective Data |
Pattern of urination Factors affecting urination (past/current health hx, medications, surgeries and treatments, nutrition, bowel elimination, activity/mobility, pain, self-concept, relationships/sexuality |
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Assessment - Physical assessment |
Method of elimination Bladder scanning Skin Assessment of urine: Colour, clarity, odour (fruity - diabetes) Intake/output |
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Assessment of symptoms |
Incontinence Urgency Dysuria - painful urination Frequency - more than 8x/day Hesitancy- difficulty urinating Polyuria - lots of pee Oligura - decreased ability to form urine (less than 160cc/kg/hr) Anuria - cannot form urine Dribbling Nocturia - getting up at night to void Hematuria - blood in urine (prostate surgery) Retention - lot of urine in bladder Elevated Post-void residual urine (over 100mL) |
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Routine Urinalysis |
Random and first morning - non sterile container |
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Specific Gravity |
Concentration of particles (wastes/electrolytes) High = concentrated urine Low = dilute urine Measured with refractometer |
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Timed Urine Specimen |
Collected at specific time of day (glucose 2 hours after meal) |
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Culture and sensitivty |
Examines bacteria, collected aseptically using sterile container. Used to diagnose UTI's in suspected pt |
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Blood tests Non-invasive tests Invasive tests |
Blood tests (BUN, Creatinine, eGFR, electrolytes) NonInvasive tests (bladder scan, KUB kidney ureter bladder xray, ultrasound, IVP, CT, MRI) Invasive tests (cystoscopy - insert though urethra to bladder to take pics of whats going on in bladder) |
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Medications r/t urination |
Diuretics (lasix, furosemide) - prevent reabsorption of H20/electrolytes - increases urination - take these in morning so they don't pee at night. Anticholinergics ACE inhibitors Antispasmodics Opioids |
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Potential Nursing Diagnosis |
Disturbed body image self esteem, situational ow Social interactions, impaired or social isolation Pain (with urination) Impaired skin integrity (perineal) Imbalanced fluid volume |
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Intermittent Catheter |
a straight,single-use catheter is introduced long enough to drain the bladder. Done tocheck for residual urine in the bladder and to obtain specimens. When thebladder is empty, the catheter is immediately withdrawn. Made of rubber (softerand more flexible) |
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Indwelling Catheter |
remains in placeuntil patient is able to void voluntarily and completely, or as long asaccurate measurements are needed. Have a balloon for inflation to keep them inplace. Recommended balloon size for an adult is 5mL. |
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Single Lumen Catheter |
Used for intermittent |
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Double Lumen catheters |
Used for indwelling catheter, one lumen for urinary drainage, second lumen used to inflate the balloon to keep the catheter in place |
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Triple Lumen Catheters |
are used for continuous bladder irrigation orwhen it becomes necessary to instill medications into the bladder. One lumendrains the bladder, a second lumen is used to inflate the balloon and a thirdlumen delivers irrigation fluid into the bladder. |
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Coude |
elbowed/curved catheter is used for males withprostate hypertrophy. Less traumatic during insertion because it is stiffer andeasier to control than a Foley catheter. |
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Size of urinary catheter |
based on the French (Fr) scale, reflects theinternal diameter of catheter, 14-16 Fr is most common. |
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Latex atheters |
Special coatings reduce urethral irritation |
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Silicone Catheters |
Have large internal diameter, helpful in patients that require frequent catheter changes |
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Antimicrobial Catehter |
Coated with silver or an antibiotic |
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Condom Catheter |
Safe noninvasive made of soft silicone, reduces friction |
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Suprapubic Catheterization |
involves surgical placement of a catheterthrough the abdominal wall above the symphysis pubis and into the urinarybladder. A physician performs the procedure under local or general anesthesia.The catheter is anchored in place with sutures, a commercially prepared bodyseal, or both. Urine drains into a urinary drainage bag. Maintenanceof the tubing and drainage bag is the same as for an in-dwelling catheter. Thesuprapubic catheter is relatively painless and reduces the incidence ofinfection commonly seen with in-dwelling catheters. Sediment, clots, encrustations,or the abdominal wall itself can block the suprapubic catheter. Adequate fluidintake will help minimize the risk of blockage by sediment or infection due tostagnation. The suprapubic catheter must remain patent at all times. You mustmonitor the patient's intake and output carefully, monitor the appearance ofurine, and observe for signs of infection (e.g., fever and chills). Youalso should administer skin care around the insertion site. |
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Ilial Loop of Conduit |
involved separating aloop of intestinal ileum with its blood supply intact. The ureters areimplanted into the isolated segment of ileum. The remaining ileum isreconnected to the rest of the digestive tract. The ileal segment can then beused as a conduit for continuous urine drainage or fashioned into a continentresrvoir. The continent pouch is constructed to provide urinary storage in aleak-proof pouch. The portion of the ileum connected to the abdominal wall actsas a continent nipple and intermittent catheterization is therefore needed foremptying. The disadvantage of an ileal conduit or reservoir is that if urineoutflow becomes obstructed, irreversible damage to the kidneys can occursecondary to chronic infections or hydronephrosis. |
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ureterostomy |
involves bringing theend of one or both ureters to the abdominal surface. To avoid the need for twocollecting devices, a transureteroureterostomy connects the ureters and bringone out through the abdominal wall. In some cases, a tube may need to be placeddirectly into the renal pelvis to provide urinary drainage. |
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Vesicostomy |
surgical opening inthe bladder to allow urine drainage and prevents urine from being trappedinside the body. Usually performed in babies and very young children, usually temporary |
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Length of use Latex/rubber Silicone |
latex/rubber - up to 3 weeks Silicone - up to 2-3 months Use sterile water to inflate balloons |
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Methods to Promote Urinary Function |
Provide privacy, promote normal positioning, maintain normal habits, routine toiling, promote adequate fluid intake, allow sufficient time, assist with pricier and hand washing, continence training exercises |
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Evaluation of urination function |
privacy is provided, client tolerance safety, effectiveness: Client is abel to void Client urinary function is improving Episodes of incontinence are decreasing in frequency. Peri-area skin condition is improving. |
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Clean Catch Urine Sample |
Give pt supplies to perform peri-area cleansing, assist as needed. Open kit and ensure sterility is maintained. Position pt on bedpan, if it is being used Place container in position to catch 30-60mL of urine after stream is initiated. Remove container from urine stream before urine flow stops and finish voiding. Replace cap on sercurely. Do not touch the inside of the cap. remove gloves and hand hygeine |
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Evaluation of condom catheter |
Client tolerance. Complications - recheck client 30 mins later to assess skin condition, no skin breakdown initially or over time, no leakage of urine. Cient indicates an understanding of rationale for condom catheter use. Client's questions are answered. |
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Purpose of suctioning |
Trach patients - prevents mucous plug formation, done before meals, before going to sleep, when RR increases, when mucous is heard/felt in airway. Non-trach - increased RR, tachycardia, difficulty talking, decreased O2. If pt's secretions are audible. Necessary when pt unable to clear respiratory tract secretions with coughing. Sterile technique is used. Not a pleasant experience. Suction if Gtube fed, copious amounts of secretions, used to maintain potency. Clients request. Includes: oral suctioning, nasal suctioning, tracheal suctioning via tracheostomy/endotracheal tube |
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Complications of Suctioning |
Removes secretions as well as OXYGEN Suction pressure too high can cause mucosa damage/bleeding Suction too low may not clear secretions and be ineffective. Suction catheter diameter less than 50% diameter of trach tube. Use PPE (goggles, mask, face shield) Broncho Spasm - cough/sputter Nosocomial pulmonary tract infection - give them infection by not using proper technique. Sepsis. Cardiac arrest Do not suction for ove 10-15 seconds or you can cause HYPOXIA. Hyper oxygenation between suctions to help with this. Pre oxygenate with 100% O2 before, during and after. Use a suction catheter that is 50% of the diameter of the endotracheal tube inner diameter. Set the pressure to 80-100mgHG, start with 80 and go up. Only do intermittent suctioning. |
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Reason for chest tubes |
Used to remove air influence from pleural space, prevent air/fluid from reentering pleural space and establish normal intrapleural/intrapulmonary pressure. Used after chest surgery, chest trauma, pneumothorax or hemothorax to promote lung expansion. |
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Factors Affecting Oxygenation |
Decreased O2 carrying capacity Decreased O2 inspired concentration from obstruction or COPD. Hypovolemia- decreased circulating volume, lower BP, blood circulates slow. Pregnancy - lung volume smaller Obesity Musculoskeletal abnormalities - curvature of spine Trauma (pain, abdominal surgery, punctures, stabbing, gun shot, broken rib) |
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Chest Tube |
Assess 1. Pulmonary status (chest movemnt, decreased breath, agnosis, cyanosis) 2. Vital Signs, pain Observe - the dressing must be sealed, tubing, drainage. Hemostats: air leak, emptying, ready to d/c Position - semi F or High F Tube Connections - vents Avoid excessive tubing. Safe hang mark HH evaluate Never kink/clamp tube Only clamp if: 1. Surgeon asks you to do it 2. After few days, pt is okay and does not need chest tube if there is less than 50-60mL in 24 hours |
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LSI (lung scene investigators) |
LSI - used to determine lung capacity Oximetry - O2 saturations Arterial Blood Gases Pulmonary Function tests - capacity of lungs Peak flow meter Specimens (C&S - bacteria, AFB - acid fast basilli test, MRSA) Chest xray - accumulation of fluid CT - tumour MRI - tumour Ventilation perfusion scan Pulmonary angiography PET- cancer CBC = WBC for infection, RBC obtain O2 |
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Air leak |
Intermittent bubbling in water seal when patient with pneumothorax exhales/coughs. Continuous bubbling of chamber means large air leak. Check drain for disconnection, notify MD if something is wrong immediately. |
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If Tubing Disconnects from drainage unit |
Instruct pt to exhale as much as possible into car. Rids the pleural space of as much air as possible. Cleanse the tips of the tubing and reconnect quickly. If the drainage unit is broken the end of the chest tube can be quickly submerged into a container of sterile water to restablish the seal. |
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Bronchoscopy |
Used to get a sample, can be used to clean people out when they have so much goop they're airways aren't working properly. |
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Needle Biopsy |
Used to collect specimen when they think there is something odd so they send it to get tested and see if everything is okay |
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Thoracentesis |
Drain out fluid to be tested. Sometimes attached to a bag to drain |
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Goal for all clients with chest tubes |
Promotion and maintenance of lung expansion. Ambition, positioning, respiratory muscle training, chest physiotherapy, breathing exercises (promote expansion of lungs) |
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Deep Breathing and Coughin |
By coughing your body creates your own positive pressure to help keep airways open |
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Non-invasive ventilation CPAP |
CPAP- continuous positive airway pressure Used first and then BPAP used (by-level positive airway pressure) If BPAP doesn't work then put on a ventilator. |
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Obstructive Sleep Apnea |
Common in clients with small airways, obesity, structural issues, inflamed tonsils. More common thank you think - 34% mens dn 17% women Airway obstruction causes the client to stop breathing. The client wakes up and gasps and falls back asleep. Can occur more than 50x/hour. Diagnosed through a sleep study. Clients spend the night in a sleep clinic with continuous monitoring, O2 may fall into the 70% range during apnea spells. During Sleep: pharyngeal muscles relax, allowing airway to close results in repeated apneic episodes. Clincial Manifestations - snoring, frequent waking at night, insomnia, excessive sleepiness, hypertension, cardiac dysrhythmias. |
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Central Sleep Apnea |
Less common than OSA
Approc 15% of apnea are from CSA May occur as a results of brain injury from stroke, tumour or infection (meningitis) Seen in clients with COPD - airways are open however the client has periods of apnea. |
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CPAP |
Continuous Positive Airway Pressure Most commonly used for OBSTRUCTIVE SLEEP APNEA. Nasal CPAP delivered through full or partial face mask or nasal pillows. |
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Noninvasive PPV |
Noninvasivebilevel positive-pressure ventilation. Amask is placed over the nose or nose andmouth. Positive pressure from a mechanical ventilator assists the patient’sbreathing efforts, decreasingthe work of breathing. There is an upper limit and lower limit to prevent your lungs from collapsing. When someone is in respiratory distress- go in step wise procedures to find the right treatment. |
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Airway Obstruction |
Complete obstruction = medical emergency
Partial Obstruction - results from aspiration of food/foreign body, laryngeal edema (irritation from indwelling tube - needs steroids), CNS depression, allergic reactions Symptoms - stridor, use of accessory muscles, suprasternal and intercostal retractions, wheezing, restlessness, tachycardia, cyanosis |
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Artificial Airways: 1. Oral airway 2. Endotracheal/tracheal airways 3. Tracheostomy |
1. Oral airway - prevents obstruction of the trachea by displacement of tongue into oropharynx, needed in unconscious with cranial nerve damage/stroke patients. 2. Endotracheal/tracheal airways - short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions. For patients who need to be ventilated 3. Tracheostomy - long-term assistance, surgical incision made into trachea, (3+ days) |
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Indiciations for Tracheostomy |
Tracheotomy - surgical incision into the trachea for the purpose of establishing an airway. Tracheostomy - stoma/opening that results. Can be cuffed/cuffless, fenestrated or non-fenestrated. Purpose - used to bypass an upper airway tumour/body obstruction. |
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Tracheostomy Tubes Cuffed Uncuffed Fenestrated |
Cuffed - the cuff is bonded to the tube, prevents air from moving around the track tube and trachea, be careful with how much you inflate the cuff, stop using if it is not necessary anymore, when you need a good seal so air definitely goes into lungs. Uncuffed - allows air to flow freely around the tracheotomy tube through the larynx, reduces the risk of tracheal damage, when they're not on mechanical ventilation. Fenestrated - allows air to go over vocal chords and allows them to speak when the external opening is capped and the cuff is deflated, restores more of a normal airflow, allows air/secretions to pass up and down the airway |
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Trach/Stoma Site Assessment |
Assess dressing for secretions/bleeding, assess skin around the trach for redness, drainage (always change the dressing even if it is clean/dry), secretions, bleeding, change dressings and do stoma care at least once a shift, if it is a brand new dressing (do care every hour d/t bleeding), look at stoma site (clean with saline), clean the inner cannula, if its disposable (throw it out, suction, put inner cannula in and replace new dressing/ties - usually every 24 hours) |
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Suctioning the Trach |
Secretions may build up within the inner cannula and narrows the passage, if unable to insert catheter or clear airway, pull out cannula and observe if copious secretions, if disposable discard and replace with new one of the same size, if not disposable clean and reinsert |
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Early Complications Trach |
Bleeding, pneuomothorax Pneumomediastinum -air collection in pneuma space. Subcutaneous emphysema - collection of air underneath the skin and when pressed sounds crackly. Damage to the esophagus (fistulas can develop) Injury to the laryngeal nerve that moves the vocal cords. Tracheeostomy tube can be blocked by blood clots, mucus or pressure of the airway walls (blockages can be prevented by suctioning, humidifying the air, selecting the appropriate tracheostomy tube. Teach can stay for 7 days. |
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Later Complications - Trach |
Accidental removal of trach tube Infection in the trachea and around the track tube. Tracheal injury from (pressure from the tube, bacteria that cause infections/form scar tissue, friction from a tube that moves too much) These complications can usually be prevented. There should always be a new trach tube at bed side for emergencies. Tracheomalacia - erosion of trachea. Tracheo-esophageal fistula. Development of granulation tissue which could prevent the client from having the trach removed (may require surgery to remove tissue) Once the trach tube is removed, the opening may not close on its own (tubes remaining in place for 16 weeks or longer are more at risk for needing surgical closure. |
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Cuff COmplications |
Pressure from the cuff can cause damage to the trachea, necrosis, low pressure cuffs are used, pressure should be monitored by RRT. |
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Accidental Extubation |
Call for assistance, maintain patent airway, replace old trach tube with new tube, observe vital signs and signs of respiratory distress |
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Hard, reddened areas with or without excessive foul-smelling secretions |
This indicates possible infection Notify MD Increase frequency of tube care Remove inner cannula if applicable for cleaning/suctioning |
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Insecure Tube, artifical airway moves in/out, coughed out by client |
Assess the client's respiratory status Observe for the presence of mucus plugs Adjust or apply new ties |
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Breakdown, pressure areas, or stomatitis |
Increase frequency of tube care Make sure skin areas are clean/dry |
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Trach Obstruction
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Skin colour = pale/cyanotic
Increased RR, P, BP Decreased O2 sat Use of accessory muscles, flared nostrils, inability to lie flat Laboured breathing Clammy diaphoresis Decreased LOC/changes to behaviour Distress/anxiety/restlessness |
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Infection of trach tube symptoms
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Fever Elevated WBC Purulent sputum Diaphoresis (sweating) Congestion Cough Decreased LOC |
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trach clients who are at risk for complications |
Children/infants Smokers - thicker secretions, narrow airway, slow down healing Alcohol abusers Diabetics Immunocompromised pt Chronic disease Respiratory infection Steroids/cortisone |
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When/how do you clean inner cannula Purpose of cork |
Every 8 hours or as needed Suction pt prior to trach care Clean around stoma w Q-tip Move from stoma outwards Clean faceplate with normal saline Dry stoma area if needed and apply 4x4 gauze Trach ties changed when soiled/wet - need two people - ensure one finger can fit beneath ties Corked - clog the top of the trach to find out if pt needs the trach anymore |
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Documentation - trach |
Thorough Respiratory assessment every 4 hours Trach care Changing of inner cannula How pt is toleration suctioning/corking Detailed assessment of secretions, consistency, amount, colour Suctioning frequency Pts LOC Nutrition/NG feeds |
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Chest tubes - purpose and indications |
Purpose - remove air/fluid/pus from pleural space, facilitates re-expansion of the lung to restore normal breathing dynamics, prevent accumulation of fluid around the heart post cardiac surgery Indications - pneumothorax or hemothorax |
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Pneumothorax Tension pneumothorax |
oCollection of air in pleural space, can happen spontaneously, pneumas can occur after central line insertion, after chest surgery, after trauma to chest, after traumatic airway intubation Symptoms - chest pain/dyspnea (SOB) May hear decreased breath or no breath sounds May see lack of movement on affected sides - asymmetrical Important to remember: if air continues to collect in chest, the pressure in that collection can rise, and push the whole mediastinum over to the other side - this is called tension pneumothorax - LIFE THREATENING - call surgeon Symptoms - respiratory distress (shallow, rapid RR), dyspnea, air hunger, decreased O2 sat) |
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Hemothorax |
Collection of blood in pleural space, possibly from surgery, maybe from a traumatic inhury |
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Spontaneous Pneumothorax |
Usually caused by rupture of a small bleb (enlarged air sac - on the lungs surface) - COPD emphysema Seen in tall thin males who smoke (decreased SA, stress on lung) Complciations of pre-existing lung disease such as COPD, cystic fibrosis, necrotizing pneumonia |
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Traumatic Pneumothorax |
Blunt trauma (body struck by blunt object, external injury may appear minor but can mask life-threatening internal injuries) Penetrating trauma (foreign body impales/passes through body tissues, stab/bullet wound) |
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Rib Fracture |
Most common type of chest injury from trauma Ribs 5-10 most common Clinical manifestations - pain (especially on inspiration) Main goal of treatment - decrease pain so pt can breathe adequately/promote good chest expansion |
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Flail Chest |
Results from MULTIPLE RIB FRACTURE - causing instability of chest wall. The affected flail area will move during respiration, sucked in during inspiration, bulges out during expiration Ensure: adequate ventilation, administer humidified O2, IV solution, Pain control |
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Iatrogenic |
Invasive/therapeutic procedure - causes puncture in lung such as needle aspiration, thoracentesis, CVAD (central vascular access divide) Used for patients on positive pressure ventilation with weak lungs |
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Post-op procedure where chest/pleural wall is disturbed |
Lobectomy or lung surgery Lung transplant Heart transplant CABG - coronary artery bypass graft |
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Pleural Effusion |
Fluid in pleural space - put - lymph - blood - serous fluid - fluid occupies space the lung would usually fill - direct compression of lung tissue Manifestations - muffed/absent breath sounds, dullness |
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Air in Chest Tubes |
If you see air going in the water filled chamber it shows you that you still need to get more air out |
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Chest Drainage Systems |
Collection Chamber - fluid drains into chest tube and into Chest Drainage Unit (CDU) collection chamber. Water-seal Chamber - one way valve - air can drain from chest cavity but can't go back into patient. Suction COntrol Regulator - attaches to wall suction |
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Heimlich Valve |
Can be used in place of a CDU It is a one way valve - fluid and air comes out Connect to drainage bag if excess fluid |
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Tube Size and Placement - Chest tube |
16-24 French - pneumothorax (serous drainage) 28-36 French - hemothorax or empyema (pus) 30 French - common type Air Rises - place the chest tube in the apex of the lung in the 2 ICS, MCL Fluid Sinks - tube is placed laterally near the base of the lung - 4-5 ICS MAL |
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Removal of Chest Tube |
Removed when the lungs are re-expanded and fluid drainage has ceased Suction is discontinued Gravity drainage Notify physician if its draining copious amounts greater than 4-6cc/kg/hour former than two hours as it could indicate you perforated something other than the chest |
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Assesment and Monitoring Chest Tube |
Patient Respiratory status (RR/depth/effot/symmetry, breath sounds/lack of, use of accessory muscles) Comfort/pain - analgesia Drainage - volume, colour, viscosity Dressing - clean/dry/intact/secure Chest Drainage System - check insertion site, all connections, kinks, dependent loop Collection Chamber - level of drainage, fluctuation, bubbling |
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Milking or Stripping of Chest tubes |
Routine milking/stripping of chest tubes to maintain patency is no longer recommended. It can cause dangerously high intrapleural pressure and damage to pleural tissue. It is done if the drainage slows down - you milk it by getting alcohol wipe and wrapping it around the tube and pull down to get fluid to go out, this increases pressure - causes damage |
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Clamping of Chest Tubes |
When tube is accidentally disconnected/no longer advocated. There is danger of rapid accumulation of air in pleural space, causing tension pneumothorax. Only in emergency situation such as if the tube gets cut you clamp it to set up a new chamber |
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Purposes of Surgery |
Diagnosis, cure or repair, palliation, exploration, cosmetic improvement |
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Nursing Assessment |
Goal is to identify risk factors, plan care to ensure client safety Establish baseline data, identify meds and herbs taken that may affect surgical outcome, identify, document and communicate results of lab/diagnostic tests. Determine psychological status to reinforce coping strategies. Identify cultural and ethnic factors that may affect surgical experience. Determine receipt of adequate info from surgeon in order to sign informed consent. Use common language or translators if needed. |
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Common Lab Values INR PT pTT Hematocrit (HCT) Hemoglobin (Hb) Platelet count WBC Almbumin BUN Creatinine Glucose Sodium Potassium |
INR (0.9-1.2) PT (10-13seconds) PTT (28-38 seconds) Hematocrit (HCT) (M:0.42-0.52) (F:0.37-0.46) Hemoglobin (Hb) (M: 140-147g/L) (F:123-157g/L) Platelet count (130-400 10^9/L) WBC (4-10 x10^9/L) Almbumin (35-50g/L) BUN (2.4-8.0mmol/L) Creatinine (M:70-120) (F:50-90) Glucose (3.3-5.8) Sodium (135-145) Potassium (3.5-5.0) |
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Nursing Assessment: 1. Cardiovascular System 2. Respiratory System 3. Urinary System 4. Hepatic System |
Cardiovascular - report problems for effective monitoring, use of cardiac drugs, presence of pakemaker/MI Respiratory - recent airway infection (procedure should be cancelled r/t risk of bronchospasm/decreased O2sat). Smokers encourages to quit 6weeks before procedure - decreases risk of complications Urinary - history of urinary/renal disease, renal dysfunction contributes to (F/E, increased risk of infection, coagulopathies, impaired wound healing, altered response to drugs and their elimination) Hepatic - consider the presence of liver disease if there is a history of: jaundice, hepatitis, alcohol abuse. Liver function tests: ALT, AST, ALP, Bilirubin levels |
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Nursing Assessment 1. Integumentary System 2. Musculoskeletal System 3. Endocrine System 4. Immune System |
Integumentary - history of skin, musculoskeletal problems, history of pressure ulcers (extra padding during procedure - affects post op healing) Musculoskeletal - identify joints affected with arthritis, mobility restriction may affect positioning and ambulation, bring mobility aids to surgery Endocrine - clients with DIABETES (capillary blood glucose test morning of surgery for BASELINE) They are especially at risk for hypo/hyperglycemia, ketosis, cardiovascular alterations, delayed wound healing, infection Immune - compromised immune system/immunosupprive drugs can have: delayed wound healing, increased risk for infection |
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Nursing Assessment 1. Fluid and electrolyte Status 2. Nutritional Status (obesity) |
F/E - vomiting, diarrhea, difficulty swallowing can cause imbalance, identify drugs that alter status (diuretics, evaluate serum electrolyte levels), NPO status - may require additional F/E to prevent dehydration Nutritional - stress/cardiac and pulmonary sytems, increased risk of wound dehiscence and infection, slower recovery from anaesthesia, slower recovery from anesthesia, slower wound healing |
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Nursing Management - Pre op teaching |
Client has right to know what to expect and how to participate - increases client satisfaction, reduces fear, anxiety, stress, pain and vomiting Client should be able to describe: post-op monitoring/therapies, surgical procedures, post-op treatment, post-op activity resume, pain relief measures, feelings regarding surgery, reasons for pre-op instructions/exercises, time of surgery, identify post-op unit and location of family during surgery |
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Legal Preparation Before surgery tests |
All required forms are signed and in chart - informed consent, blood transfusions, advance directives, power of attorney. Diagnostic tests (blood, CXR, CT scan), pregnancy testing, allergies, blood types |
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Informed Consent must include |
Adequate disclose Understanding/comprehension Operative consent must be signed before any pre-op med is given Voluntarily given consent |
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Pee |
Before surgery always |
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Pre-op Meds |
Sedative/amnestic (benzodiazepines/barbiturates) Anticholinergics (reduce sensation) Narcotics (decrease anasthesia requirements and pain) Antiemetics (decrease post-op nausea/vomiting) |
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During operation Nursing Jobs |
Prepare room with surgical team
Practices in the role of circulating/scrub nurse Client advocate throughout surgery Must understand surgery and interventions |
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Admit client includes Nursing Diagnoses |
Reassessment, last min questions, review charts, question about valuable/prostheses/contacts/last intake of food/fluid, warm blanket/pillow Identify nursing diagnosis: anxiety disturbed body image risk for infection deficient knowledge acute pain delayed surgery recovery |
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Positioning patient |
Accessibility of operative site Administration/monitor anaesthetic agents Maintain airway Correct-skeletal alignment Prevent pressure on nerves, skin, bony prominences, eyes Provide for adequate thoracic excursion Prevent occlusion of arteries and veins Provide modesty in exposure Recognize and respect needs such as pain/deformities Prevent injury (client will not feel pain impulses d/t anesthesia, secure extremities, provide adequate padding/support) |
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Preparing surgical site |
Scrubbing or cleaning around surgical site with antimicrobial agents Use circular motion from clean to dirty area Hair may be removed with clippers |
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General Anaesthesia |
Loss of sensation with loss of consciousness Relaxation of skeletal muscle Used for: skeletal muscle relaxation, long periods of time, awkward positions and extremely anxious clients |
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Conscious Sedation |
Used for procedures that do not require complete anaesthesia Combination of sedative-hypnotic and opioid drugs. Provides analgesia, relieves anxiety and/or provides amnesia. Drug-induced depression of consciousness Client maintains own airway but yet achieves pain control. |
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IV induction Agents Inhalation Agents + complications |
IV induction - induce pleasant sleep, rapid onset Inhalation agents - enter body through alveoli, rapid excretion by ventilation. Compications - coughing, laryngospasm, bronchospasm, increase secretions, respiratory depression |
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Local Anaesthesia Produces: |
Autonomic nervous system blockade. Anaesthesia Skeletal muscle paralysis in the nerve Loss of sensation without loss of consciousness Little systemic absorption Little residual "hangover" Possible discomfort Hypotension Seizures |
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Regional Anaesthesia |
Epidural Loss of sensation in body region without loss of consciousness when specific nerve or group of nerves are blocked |
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Epidural Block |
Injection of agent into epidural Space Does not enter CSF Binds to nerve roots as they enter and exit the spinal cord. Client can remain fully conscious |
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Post-op care in PACU |
Begins immediately after surgery of neuro, pulmonary, fluid balance, discharge/drainage. Continues until client is discharged from medical care. PACU Admission: 1. Initial admission is a joint effort between anaesthesiologist, OR nurse, and pACU nurse 2. Fosters smooth transfer of care to the PACU |
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PACU Care |
Monitoring/management of: respiratory, circulatory function, pain, temp, surgical site, client's response to reversal of anaethetic, initial assessment, ECG monitoring initiated for cardiac rate and rhythm, note differences from pre-op findings, measure BP and compare baseline, assess temp, skin colour and condition Check that they're not hyperventilating from pain See if they had an epidural See if they need a PCA - check if its working properly Check their electrolytes |
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PCA
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Patient controlled analgesia |
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Why oxygen after surgery? |
Used if client had general anaesthesia/anaesthesiologist orders Helps in elimination of anaesthetic agent Meets increase O2 demand from blood loss and increased metabolism r/t repairing |
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Respiratory Complication: 1. Nursing Diagnosis 2. Nursing implementation |
Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Proper positioning to facilitate respiration and protect airway - lateral position, client allowed in supine with HOB elevated once conscious |
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Airway obstructions after surgery |
Usually an endotracheal tube is inserted during surgery and when pulled out it can cause inflammation/swelling of airway Symptoms: stridor (air squeezing through trachea) due to inflammation, anaesthetic (causes decrease in tone of pharynx muscles), Secretions (need to be suctioned) |
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Emergence Delirium (violent emergence) |
Can induce restlessness, agitation, disorientation, thrashing and shouting Caused by anaesthetic agent, hypoxia, bladder distention, pain, electrolyte abnormalities or anxiety |
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Hypothermia |
Core temperature less than 36 degrees C Occurs when heat loss exceeds production Loss of heat to cold or from body organs exposed to the air Interventions; passive re-warming raises basal metabolism, active re-warming requires application of warming devices |
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Nausea and Vomiting |
Responsible for unanticipated admission, increased discomfort, delays in discharge, and dissatisfaction with surgical experience |
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Handover from PACU to Unit |
When client arrives on Unit, give report to nurse including summaries of intra-operative and recovery room periods Receiving nurse assists with transfer of patient onto bed. In-depth assessment is performed and charted |
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Post op Care |
Start prescriptions/orders Treatment begins with administration of Oxygen therapy, volume status assessed, IVF boluses to normalize BP, drug intervention Nursing IMplementation - accurate I/O, monitor lab findings, assess infusion rate of fluid replacement and infusion site, adequate mouth care, leg exercises Early ambulation - encourage normal return of function of GI, circulatory, respiratory, urinary systems |
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Interventions for Cardiovascular problems |
Ambulation: slowly progress, monitor pushes, assess for feelings of faintness Elastic stockings or decompressive devices Unfractionated or low-molecular weight heparin to reduce risk of blood clots |
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Neurological COmplicatiosn |
LOC Orientation Ability to follow commands Size, reactivity and equality of pupils Sensory and motor Intervetions: COmplete a CNS assessment Ensure clients receiving pain medication are responsive and oriented to person, place and time Assess sensation and motor function on any client who has received a spinal or epidural anaesthetic |
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Pain and Discomfort (etiology)
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Trauma to skin/underlying tissues by incision and retraction during surgery. Reflex muscle spasms around the incision Tension and muscle spasms d/t anxiety/fear Deep breathing, coughing and changing position Pressure in internal viscera Diagnosis: acute pain or anxiety Epidural Analgesia - infusion of pain-relieving medications through a catheter placed into epidural space that delivers meds directly to opiate receptors in spinal cord, administration may be intermittent or constant |
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Patient Controlled analgesia |
PCA provides immediate analgesia, maintains a constant, steady blood level of analgesic agent, involves self-administration of predetermined doses of analgesia by the client |
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Aleterations in TEmp |
Mild Elevation (up to 38 in first 48 hours) could be a stress response Moderate elevation (over 38) caused by respiratory congestion or atelectasis After 48 hours a moderate to marked elevation (higher than 37.7 usually indicates infection) Diagnosis: Hypothermia Risk for imbalanced body temp Hyperthermia |
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Potetntial GI problems
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Nausea and vomiting - after abdomen surgery Responsible for unanticipated admission, increased discomfort, delays in discharge, and dissatisfaction with surgery experience Caused b: anaesthetic agents Opioids Delayed gastric emptying, slowed peristalsis Resumption of oral intake too soon after surgery Abdominal distension from decreased peristalsis caused by handling of bowel during surgery. Swallowed air and GI secretions may accumulate in colon, producing distension and gas pains |
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Paralytic Ileus
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Small bowel obstruction that results when peristalsis stops. Bowel lumen remains patent, but contents of intestine are not propelled forwards, producing sever nausea, and vomiting |
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Hiccups
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Singultus Intermittent spasms fo diaphragm caused by irritation of phrenic nerve |
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GI nursing diagnosis |
Nausea Risk for aspiration Risk for deficient fluid volume Imbalanced nutrition: less than body requirements |
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Post op fluid and electrolyte imbalances |
Stress causes fluid retention in first 2-5 days after surgery. Fluid loss from decreased kidney perfusion, stimulating RAAS and release of aldosterone. Fluid overload possible when IV administered too rapidly, chronic disease (cardiac/renal), old people Fluid deficit from inadequate fluid replacement, decreased CO and tissue perfusion |
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Alterations in Urinary Function |
Low urinary output can be expected in first 24 hours regardless of intake r/t Increase aldosterone and ADH from stress of surgery, fluid restriction, fluid losses during surgery, drainage or diaphoresis Nursing Diagnosis: Impaired urinary elimination Potential Complication: acute urinary retention |
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Discharge Information for family/pt |
Care of wound site, dressings, bathing
Action, side effects, when and how to take medications Acitivities allowed and prohibited Dietary restrictions/modifications, symptoms to be reported |
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Chest tube = Single chamber setup |
used if only air is coming out of pt chest |
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Chest tube = two chamber setup |
Traps air, collects fluid (blood/pus), |
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Chest tube = three chamber setup |
Air, colllects fluid/pus, third part used to suction out stuff gently |
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Pursed-lip breathing |
Helps max expiration for clients with obstructive lung disease. Allows better expiration by increasing airway pressure to keep airway open during exhalation. |
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RIb fractures |
pain, tenderness, localized fracture at the site is exacerbated by in/exhalation, shallow respirators, splinting or guarding the chest protectively to minimize chest movement and possible bruising at the fracture site. PARADOXICAL RESPIRATIONS ARE SEEN WITH FLIAL CHEST |
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Flial Chest |
Floating section of ribs, results in paradoxical chest movements as it is unattached to rest of rib cage, this means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands, during exhalation (bounces outward while rest of chest is pulled inward) |
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Acute Respiratory Distress Syndrome |
Increased RR followed by dyspnea, air hunger, retraction of accessory muscles and cyanosis. |
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Venturi Mask
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Delivers most accurate O2 concentration. Best oxygen delivery system for chronic airflow limitation, as it is precise. |
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NG tube feeding |
Aspirate stomach contents should be less than 3.5 pH. Suction turned off before tubing is disconnected to check for residual volume. Suction should remain off for 30-60 minutes following med administration. Checking residual amounts: anything over 100mL requires you to hold the feeding. Do not discard feeding unless its contents are abnormal in colour |
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Measuring length of NG tube |
Place at tip of nose to earlobe then down to xiphoid process (22-26inches) |
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Colostomy bag should begin to function |
72 hours after surgery, return for peristalsis, listen for bowel sounds, check for passage of flatus. |
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UU-500 insulin compared to U-100 Insulin |
U500 is 5x as strong as U100, therefore if you were supposed to give 20u of 500 then give 4u of 100 |
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Dorsogluteal Injection Site |
Not safe to use as there is a close sciatic nerve |
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Frequent Dressing Changes |
use Montgomery Straps They prevent skin breakdown with frequent dressing changes, limit the friction/shear that could irritate the skin with frequent removal/reapplication of tape. |
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Wound Dehiscence |
Seperation of wound edges at the suture lines causes increased drainage, visible appearance of underlying tissues, usually occurs 6-8 days after surgery, avoid cough/straining, positioned in semi-fowlers position. COVER WITH STERILE DRESSINGS SOAKED WITH STERILE NORMAL SALINE. |
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Irrigating a wound PPE |
Gloves, gown and mask - causes splashing, protect yourself!! |
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Bed Cradle |
protects client's toes from breakdown due to weight from linen! |
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IV infiltration |
Immediately stop the infusion, remove IV catheter, restart infusion in another site. Coll compress doesn't promote fluid absorption. Heat should be applied after the infusion is stopped/catheter removed/new catheter inserted |
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Before infusing IV ask patient |
About personal experience with transufsion therapy, reason for transfusion |
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MOST COMMON complication associated with TPN is |
infection Monitor temp for infection. Weigh client and monitor I/O as well |
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IV meds and Parenteral nutrition solution line |
IV meds must be given through a separate IV access site - the parenteral nutrition solution line is used only for the solution. |
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Plasma Expander (for hypovolemia) |
Albumin |
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Total parenteral nutrition, monitor |
Blood glucose levels as they are at risk for hypoglycaemia, hyperglycemia, infection, fluid overload, air embolism, electrolyte imbalance. |
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First symptom of benign prostatic hematuria |
Decreased force of stream of urine |
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Why do you not insert catheter for pt with acute prostatitis |
Avoided to prevent introducing bacteria into the bladder by pushing them up the urethra Catheterization does not prolong inflammation nor does it cause rebound edema when it is removed. |
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Valsava Maneuver |
When chest tube is removed patient should: Take a deep breath, exhale and bear down |
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If chest tube is dislodged.. first thing you do |
Grasp the retention sutures and spread the opening, then if allowed can immediately to replace the tube, don't call MD first, covering tracheostomy will block the airway!! |
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How to use a spirometer |
For optimal lung expansion, bed should be 45-90degrees, inhale slowly, held for five seconds then exhaled |
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Arthroplasty |
Hip replacement |
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Antiemetic |
Treats nausea |
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What gauge do you infuse blood with |
18 g via IV control pump |
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Endotracheal tube vs |
Endotracheal - through nares or mouth into trachea, 2-4 weeks Tracheostomy - for longer periods of time, temporary or permanent, small incision in neck, cuffs are made of balloon like inflatable plastic filled with air. Trach is directly into trachea so decreases anatomic dead space, decreased damage to laryngeal and tracheal tissue, easier to breathe, better access for oral hygiene, replaced more easily if dislodged, can be used long or short term or permanently, Cuffs used to prevent aspiration of oral secretions or gastric contents into the lung |
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Closed Suction Catheter (inline) |
Closed system - Allows quicker lower airway suctioning without applying sterile gloves or mask, does not interrupt ventilation/oxygenation, , Inline suctioning devices have a rotating suction control valve |
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Hypoxia manifestations |
Restlessness, irritability, anxiety, confusion, latered LOC, fainting,increased pulse, increasesd RR/BP, cardiac dysrhythmias, pallor, dyspnea, cyanosis
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Airway maintenance |
Adequate hydration prevents thick secretions. Chest physiotherapy and nebulization, deep breathing, coughing techniques, humidification, hydration, chest percussion, vibration, incentive spirometry |
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Huff Cough |
Natural cough reflex, clears large central airways, During expiration patient states the word hug which opens the glottis, and then can do cascade cough |
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Cascade Cough
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Takes a slow, deep breath and holds it for 2 seconds, tightens upper abs, open mouth and cough during expiration, clears large volumes of sputum |
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Quad Cough
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For pt who lack ab muscles, you push in/up on ab muscles as pt breaths out - replacing the diaphragm |
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Indications for upper airways suctioning |
Increased RR wheezs or rhonchi Nasal secretions Drooling Gastric secretions/vomit in mouth Loose nonproductiecough Tactile fermitus |
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Yankaur |
Sucion device for oropharyngeal suctioning, creates negative pressure for mucus to enter, mouth, used for extremely copious amount of thick secretions, |
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Tracheal airway |
suction lower airway to optimize ventilation/oxygenation, below 90% o2 means suction, , artificial airways occludes more rapidly than natural ones |
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Chest Tube Inserted for |
to remove air or fluid from pleural space
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Safety Considerations: chest tubes |
Observe the waster seal for intermittent bubbling from its tube or a rise and fall of fluid that is in synch with respiration. Constant bubbling in the water seal or a sudden unexpectage stop of water-seal activity is considered abnormal. You should see intermittent bubbling from tube and a rise and fall in synch with respirations. If there is constant bubbling in water seal or sudden unexpected stoppage of water-seal it is abnormal. Can indicate a blockage or re-expansion. In waterless systems, look for a rise and fall of fluid in the diagnostic air leak indicator synchronous with respirations. , constant left to right bubbling/violent rocking is abnormal (air leak) |
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Expected Chest tube drainage
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Sudden decrease in drainage - possible clot or mechanical obstruction More than 250mL/hour - fresh bleeding from thorax- NOTIFY MD Drainage from pneumothorax is g generally limited, any fluid buildup is caused by chest tube insertion trauma. The chest tube promotes the removal of air from intracellular space. Colour - starts off bright red and becomes serous. Bright red indicates malignancy, pulmonary infarction or severe inflammation. Frank blood indicates hemothorax. Pus indicates empyema (collection of pus in pleural cavity) Water-Seal System - should see continuous gentle bubbling in suction control chamber when connected to suction. Waterless system - set the suction source and dial to the right amount |
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Air leaks |
Determine if it is from patient or chest tube system. Assess pt respiratory status, lung sounds, O2, RR, continuous bubbling in water seal chamber with absence of bubbles in the suction control chamber indicates a leak in the system. Ensure all tubing connection is tight. And Dressing to the site should be occlusive. |
