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Oxygenation Ch. 14 & Elimination and Gastric Intubation Ch. 15 Fund.
Terms in this set (64)
Before the Skill:
- Refer to medical record, care plan, or Kardex for special interventions.
- Introduce yourself; name & title.
- Identify patient.
- Explain procedure./Patient teaching.
- Assess patient.
- Hand hygiene./Assemble equipment.
- Prepare patient for intervention.
During the Skill
- Promote patient involvement.
- Assess patients tolerance.
Completion of Procedure
- Assist th patient to a position of comfort, and place needed items within easy reach.
- Lower bed to lowest position.
- Remove gloves./ Hand hygiene.
- Document 📄./ Report any unexpected outcomes.
Relieve inflammation of the conjunctiva. Apply antiseptic solution, or flush out exudate or caustic solutions.
- Warm saline and small syringe 💉 or eye dropper are used to instill a few hundred mL of solution.
- Inner to outer canthus.
- Never allow the syringe tip to touch the eye!
Morgan Therapeutic Lens
A copious irrigation of the eye with use of intravenous tubing and bag connected to lens
Using a small syringe and solution at body temperature, the nurse can cleanse a patient's external auditory canal of excess cerumen or exudate from a lesion or inflamed area.
- Irrigation is contraindicated if the patient has a cold, a high temperature, an ear infection, or an injured or ruptured tympanic membrane.
Skills for Heat and Cold Therapy
The nurse should:
- Understand the normal responses to local temperature variations.
- Assess the integrity of the body part.
- Determine patients ability to sense temperature variations.
- Ensure proper operation of equipment.
- Normal skin temperature is 93.2 F
- Excessive heat causes a burning sensation.
- Cold produces a numbing sensation before pain.
Blood flow through vasodialation.
- Continuous exposure to heat damaged epithelial cells.
- The skins tissue can freeze on exposure to extreme cold.
Warm applications are contraindicated when?
The patient has an acute localized inflammation; cardiovascular problems; or active bleeding.
Cold applications are contraindicated when?
If the site of the injury is edematous or the patient has impaired circulation or is shivering.
Before he was applied, the patient should understand its purpose, the symptoms of the temperature exposure, and precautions to get to prevent injury.
A prerequisite to heat or cold application as a physicians order, which should include body site and type, frequency, and duration of application.
Moist or Dry Applications
Heat and cold application can be administered and dry or moist forms.
- The types of injury, the location of the body part, in the presence of drainage or inflammation or factors to be considered.
Hot Moist Compresses
For open wounds, sterile, hot, moist compresses improve circulation, relieve edema, and promote consolidation of purulent exudate.
- Promotes circulation.
- Lessens edema.
- Increases muscle relaxation.
- Provides a means to debride wounds and apply medicated solution.
- A soul can also be accomplished by wrapping the body part and dressing and saturating them with warm solution or by whirlpool treatment.
Paraffin Baths 🛁
- Bath consist of mixture of heated paraffin wax and mineral oil.
- patients with painful arthritis or other joint discomfort of the hand and feet benefit most from these baths.
Aquathermia (Water-Flow) Pads
- This is used to treat muscle sprains in areas of mild inflammation or a demon.
- This consists of waterproof plastic or rubber pad connected by two hoses to an electrical unit that has a heating element and a motor.
Commercial Hot Packs
- Commercially prepared, disposable hot packs apply warm, dry heat to an injured area.
- Sticking, meeting, or squeezing the pack mixes the chemicals in releases the heat.
Electrical Heating Pads
- Pad consist of electrical coil enclosed within a waterproof pad covered with cotton or flannel cloth.
- The pad is connected to an electric cord that has a temperature regulating unit for a high, medium, or low setting.
Cold Most and Dry Compresses
- Call compresses should be applied for 20 minutes at a temperature of 59°F to relieve inflammation and edema.
- Commercially prepared cold packs are available for dry application.
- The nurse should observe for burning or numbness, mottling of the skin, erythema, extreme paleness, or cyanosis.
Which of these is incorrect regarding heat and cold therapy?
A. Maintain proper temperature of heat or cold applications.
B. The applications can be left for any length of time.
C. Check the patient skin for excess of redness in pain during application and to report any such adverse reaction to the nurse.
D. Report to the nurse when the treatment is complete so the nurse has the opportunity to evaluate the patient response.
Ice bags or Collars
Used for muscle sprain, localized hemorrhage, or hematoma.
- an ice bag is ideal to prevent edema formation, control bleeding, and anesthestize the body part.
Skills for Administering Parenteral Fluids
The overall goal of fluid IV administration is to correct or prevent fluid and electrolyte in balances.
Indications for IV therapy:
- Poor tissue absorption.
- Inadequate G.I. tract function.
- Need to maintain medication that optimum levels.
The nurse should and will observe the following guidelines of administering parenteral fluids:
- Monitor the solution drop rate at the order and fusion rate. Infused amount of prescribed solution.
- Maintain the patency of the IV catheter.
- Monitor site every 1 to 2 hours: IV line should be assessed every four hours.
- During parental therapy, the patient I&O should be recorded.
A condition of being opened and unblocked.
- Flow rate is ordered by the physician.
- Assess tubing for kinks or obstructions.
- Inspect and palpate the site for Adema, erythema, induration, heat, and discomfort.
- assess for signs and symptoms of fluid overload.
- Edema that does not subside generally indicates that the catheter is out of the vein.
- Discomfort and dysfunction may also indicate that the solution has infiltrated.
- An infiltrated arm will feel cool, and the skin may have a blanched appearance.
- The solution is discontinued and another site is used to continue therapy, preferably the opposite extremity.
Classic signs of phlebitis:
Erythema, warmth, edema, and discomfort.
- applying warm compresses to the inflamed area Lessens discomfort.
Signs and symptoms of septicemia:
Fever, chills, prostration, pain, headache, nausea, and vomiting.
- Antibiotic therapy is vigorously initiated a blood cultures verify a septicemic condition.
A systemic infection occurs from pathogens introduced into the circulating bloodstream.
Blood Transfusion Therapy
Most commonly used to replace blood loss.
- Individuals may store their own blood before anticipated surgery for infusion during hospitalization.
- The fear of HIV infection has led some patients to refuse blood products.
Can be used for patients who refuse blood transfusions because of the personal or religious beliefs.
Autologus Blood Transfusion
A process of collecting a patient's lost blood during surgery or after a traumatic injury and infusing it intravenously into the patient.
- It is used in cardiac thoracic surgery or after traumatic chest injury.
- The blood should be administered immediately or not more than six hours after initial collection.
Initiating a Blood Transfusion
Nurse is responsible for assessing and monitoring the patient before, during, and after transfusion.
-Obtain informed consent.
- An infusion of 0.9% or 0.45% normal Saline is initiated.
- Follow establish protocol for obtaining the blood, double checking the compatibility of the blood with the patient's blood and identifying the patient.
- remain with the patient while slowly infusing the first 50 mL of blood.
- Assess a Patient's response and monitor vital signs.
A transfusion reaction is:
AN EMERGENCY 🚨🆘
Blood Transfusion Reactions
If the infused blood is not compatible with the patient's blood type, a reaction will occur.
Signs and symptoms of a blood transfusion reaction:
- Patient states not feeling right.
- Chills, fever, low back pain, pruitis, hypotension, nausea and vomiting, decreased urine output, chest pain, dyspnea.
Is a transfusion reaction is suspected:
- Stop the infusion.
- Keep the van open with 0.9% or 0.45% sodium chloride solution.
- Notify the physician and the blood bank.
- Monitor vital signs and urine output every 15 minutes.
- Reassure and support the patient.
- Send remaining blood to the blood bank for analysis.
- Goal of oxygen therapy is to prevent or relieve hypoxia.
- Any patient with impaired tissue, oxygenation can benefit from controlled oxygen administration.
- Oxygen should be treated as a drug.
- The dosage or concentration of oxygen should be ordered and continuously monitored.
Simple face mask
- 6-10 l/min
- FiO2: 0.44-0.60
Face mask with reservoir bag
Adjustable Venturi Valve
Nonrebreathing mask with reservoir
Delivers 95% oxygen at 10 to 12 L/min.
Two valves added to re-breathing mask prevents:
- Entrainment if room air during inspiration.
- Retention of exhaled gases during expiration.
A hollow tube inserted within the trachea to deliver oxygen.
- Inserted between second and third tracheal cartlidges.
Surgical opening into the trachea.
- is performed to provide the patient with a patent airway.
How many attempts can the nurse make to perform tracheal suctioning at one time?
A. Only one.
B. No more than three.
C. As many as needed to complete suctioning.
D. The nurse is not permitted to perform tracheal suctioning.
It's withing the nurses scope of practice to tracheal suctioning, but the nurse should not exceed three suctioning procedures at one time.
Which size suction catheter would the nurse select to perform suctioning in an adult?
A. 6-French (Fr)
The correct size for an adult nasotracheal suction catheter is 12 French or 14 French. The nurse should select either six French or a French to suction an infant. A child would require a 10 French or 12 French suction catheter.
Which signs of hypoxia with the nurse assess for in a patient with chronic lung disease who requires intermittent oxygen? Select all that apply.
D. Increased fatigue.
E. Sinus Cardiac Rhythm
A, B, D.
Signs and symptoms of hypoxia include anxiety, cyanosis, and increased fatigue. The patient with hypoxia will be hypersensitive, not hypotensive. The patient with hypoxia can present with cardiac dysrhythmias.
Which equipment with the nurse used to ensure the prescribed rate of oxygen is delivered?
B. Nasal cannula.
C. Oxygen tubing.
D. Ventura mask.
An oxygen flow meter is used to set the prescribed rate of oxygen administration. The nasal cannula, oxygen tubing, venturi mask assist in delivery of oxygen but do not determine the rate.
With which initial respiratory pattern with a patient with hypoxia present? Eight. Increase rate and depth of respirations. B. Decreased rate and depth of respirations. C. Periods of apnea during normal respirations. D. No changes in the respiratory rate and pattern.
Which type of catheter would the nurse usefor an adult patient with prostate enlargement?
A. Mushroom catheter.
B. Coudé catheter.
C. Whistle tip catheter.
D. Robinson catheter.
Used to assist the healthcare provider and insertion of urethral catheter in a male patient with prostate enlargement. Mushroom catheters are used to drain urine from the renal pelvis of the kidney.
Which finding in a patient with a indwelling Urgent Catheter needs correction?
A. Loose fitting clothing worn.
B. Leg bag use during the day.
C. Powder noted in peroneal area.
D. Drainage bag below bladder level.
Powders and lotions should not be using the peroneal area because they can lead to infections.
How many inches did an indwelling catheter be lubricated before inserting in a male?
Because the urinary tract of a male is longer than a female, approximately 6 to 7 inches of the catheter will need to be lubricated. A female patient 1.5 to 2.0 inches of the urinary catheter should be lubricated.
To which depth is to be inserted into the rectum when administering a soapsuds enema?
A. 1 inch.
B. 4 inches.
C. 7 inches.
D. 12 inches.
B. For a standard enema, the tubing should be inserted 3 to 4 inches into the rectum. A shorter distance could cause the solution to leak. The inserting the tube more than 4 inches could result in trauma to the rectum or colon.
Which instruction with the nurse provide to a patient who is receiving oxygen via a transtracheal tube for the first time?
A. Change the catheter every three months.
B. Refrain from drinking fluids during use.
C. Reports mom ounce of clear exudate.
D. Clean the area every four hours with saline.
How much normal Celine is used to irrigate a nasogastric tube?
A. 15 ML
B. 30 ML
D. 60 ML
Which finding indicates effective intermittent sectioning for a patient with a nasogastric tube?
A. PH of aspirate of 3.5.
B. Hissing sound at the air vent.
C. Bowel sounds in all four quadrants.
D. Gurgling sounds with injecting air.
After connecting a nasogastric tube to intermittent suction, the nurse should be able to hear a hissing sound at the air vent.
How would the nurse verify placement when inserting a nasogastric tube? Select all that apply.
A. Aspirate contents.
B. Measure pH of contents.
C. Auscultate bowel sounds.
D. Irrigate tube with normal saline.
E. Listen for swoosh when injecting air.
Never flush before checking placement!
Which factor would be assessed before inserting a rectal tube into a patient with diarrhea?
A. Skin integrity.
B. Bowel sounds.
C. Peristomal area.
D. Level of orientation.
Serves as a baseline assessment before treatment.
Femestrated Tracheostomy Tube
Transtracheal Oxygen Delivery
A newer method of oxygen delivery is the transfer eagle catheter, which is inserted directly into the trachea between the second and the third tracheal cartlidges.
- delivery does not interfere with drinking, eating, or talking.
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