NURSING INTERVENTIONS Q#1 Flashcards
COPD
❖ NURSING MANAGEMENT
→ Dyspnea is the most common problem related to eating.
▪ 4 to 6 small meals a day to prevent the stomach from pushing up the diaphragm.
▪ Use bronchodilator 30 minutes before a meal to reduce dyspnea due to bronchospasm.
▪ Give foods that are easy to chew and not gas forming.
✓ Avoid dry foods because it can stimulate coughing.
✓ Avoid milk and chocolate because it can thicken the mucus.
✓ Avoid caffeinated beverages because these act as a mild diuretic and can result to dehydration making the mucus thick.
▪ Place seated or in high fowler’s position for meals.
▪ Eat meals when energy levels are at their highest (usually MORNING).
▪ Eat slowly and avoid swallowing air.
▪ Limit salt intake as this can cause fluid retention, making breathing more difficult.
▪ Avoid fluids prior to meals to avoid bloating.
▪ Drink fluids at the end of the meal.
▪ Wear a nasal cannula while eating to optimize oxygen intake, required for food metabolism.
COPD
❖ NURSING MANAGEMENT
→ Imbalanced Nutrition: less than body requirements
▪ A diet high in proteins and fats without excess carbohydrates to minimize carbon dioxide production during metabolism.
▪ Glucerna or Ensure – high in proteins
✓ given to postop patients or aged due to lack of appetite
✓ Ensure (low protein, more glucose)
✓ Glucerna (high protein, low glucose)
COPD
❖ NURSING MANAGEMENT
→ Ineffective Airway Clearance
▪ Chest Physiotherapy and Postural Drainage
✓ To loosen secretions and helps move secretions into central airways.
▪ Encourage Fluid Intake of at least 2L to 2.5L daily because adequate fluid intake helps keep the mucous secretions thin.
▪ Place patient in a high fowler’s or orthopneic position to promote lung expansion.
▪ Turn patient every 2 hours to help mobilize the mucus.
▪ Encourage coughing and deep breathing at least every 2 hours while awake to promote lung expansion and mobilization of mucus; and advise the patient to do this in a seated upright position while leaning forward to increase the effectiveness of coughing
❖ METERED-DOSE INHALER (MDI)
→ If the patient with asthma is taking bronchodilators and steroids:
▪ Give the bronchodilator first, to cause dilation of the bronchi. This allows the steroids to pass through and stop the inflammation.
▪ If the steroid is given first, it will not be absorbed since the bronchi are constricted.
▪ Taking steroids with an MDI can cause some of the steroids to remain in the mouth, which may reduce Immunoglobulin A levels and lead to Oral Candidiasis. Therefore, after administration, it is advisable to instruct the patient to gargle or use a spacer.
ASTHMA
❖ HOUSE DUST CONTROL MEASURES
→ Use a hypoallergenic pillow.
→ No cleaning chores and stay away from someone who is cleaning.
→ Use a damp cloth to wipe the chairs, tables to avoid the dust to be suspended in the air.
→ Old books, magazines, newspapers should be kept outside the bedroom.
→ Pillow and mattresses should be exposed to the sun for 1 hour every 2 weeks.
→ Clean the filter of your aircon every 2 weeks.
→ If you are going to be exposed to dust, get a handkerchief, wet it with water, squeeze it and use it as a mask
ASTHMA
❖ METERED-DOSE INHALER (MDI)
→ MDI Teaching Points
▪ Wait 30 seconds between inhalation of same medication.
▪ Wait 5-10 minutes between inhalations of different medications.
▪ Inform the patient to start to breathe in slowly for 3 to 5 seconds, to draw in the medication.
▪ Instruct the patient to hold his breath for 10 seconds, to allow medicine to go deeply into his lungs.
▪ The client exhales and then squeezes the canister as the next inspiration occurs.
ASTHMA
❖ METERED-DOSE INHALER (MDI)
→ How to Use MDI:
▪ Shake the medicine.
▪ Hold the MDI so that the mouthpiece is at the bottom. Open your mouth and position the mouthpiece 1 ½ to 2 inches in front of your mouth. Breathe out normally.
▪ Press the MDI down once to release a spray of medicine into your mouth while breathing in slowly. Continue to breathe in as slowly and deeply as possible.
▪ Hold your breath for 10 seconds, and then breathe out slowly
ASTHMA
❖ NURSING MANAGEMENT: STEROIDS
→ If patient is using MDI: Instruct the patient to gargle after each administration to avoid oral candidiasis.
→ Advise patient to increase intake of foods high in Vitamin C such as papaya, guava, oranges, kalamansi, strawberry, melons, tomatoes, malunggay, gabi leaves, alugbati leaves, cauliflower, ampalaya leaves, and green pepper because vitamin C works by blocking the release of histamine.
→ Advise patient to drink coffee, tea, cocoa, or dark chocolate because these drinks dilate the bronchial tubes making it easier for asthmatics to breathe.
▪ Coffee (highest amount of caffeine)
▪ 2-3 cups of coffee/day
▪ Caffeine can cause insomnia.
▪ Use caffeine as a supplement to the treatment.
▪ It can increase cardiac rate and cause palpitation so don’t advise this to patients with heart problems.
→ Oral Steroid:
▪ Advise patient to take this in full stomach (1 hour after a meal) to avoid GI irritation
▪ Advise patient to avoid foods high in sodium because steroids cause sodium retention and may result to edema.
▪ Advise patient to never discontinue taking this medication abruptly because prolonged use of steroids decrease the ability of the adrenal cortex to produce steroids and can cause Addisonian Crisis.
▪ Advise the patient to take this medication in the morning rather than in the evening because it can stimulate the central nervous system, leading to increased alertness, which may result in insomnia.
ASTHMA
Glucocorticoids
Steroids are better taken via MDI ___
▪ Steroids are better taken via MDI because when taken orally, they can cause numerous side effects. These side effects include adrenal suppression, Cushing syndrome, GI irritation, decreased immune system function making the patient more prone to infections, osteoporosis (if taken for more than 3 months), sodium retention resulting in weight gain, increased appetite, and hyperglycemia. When using an MDI, these oral side effects are avoided because the medication acts directly on the lungs. However, one of the disadvantages of MDI is that after using it, some steroids may remain in the mouth, potentially reducing Immunoglobulin A levels and leading to infections such as oral candidiasis. To prevent this, instruct the patient to gargle, use mouthwash, or employ a spacer.
▪ Spacer should be used because it increases the delivery of the drug to the lungs and decreases deposition of the drug on the oropharyngeal mucosa
PNEUMOTHORAX
NURSING CARE FOR TUBES
㾎 For any kind of tube = SEMI-FOWLER’S AND SITTING POSITION
㾎 Tube should always be potent, no kinks, no dependent loop, no lying on the tube
㾎 Long dependent loop can completely block fluid drainage within 30 minutes
㾎 Do not allow tube to lie on floor
㾎 Bottle should always be below the chest
㾎 Observe water fluctuation – 2-5cm is normal
㾎 If not normal there may be DOB and shortness of breath
㾎 Auscultate for crackles and rales – plenty of fluids in the lungs – 1st breathing exercises and if no improvement suction
㾎 0% fluctuation – there may be blood, kink, lying over tube, long dependent loop, lung has already re-expanded – chest x-ray to confirm
㾎 Observe for bubbles – continuous bubbling should only be in control bottle, continuous in water seal bottle may indicate that there is crack on the bottle/leak/rubber is not well sealed/rubber destroyed and air can pass
㾎 Observe amount and color of output
㾎 Clamping is only done 30 seconds when changing, remove cover not the tubes
㾎 Tube stripping (milking) should not be done – exert pressure
㾎 Milking, tapping, stripping does not improve drainage of fluid from the chest
㾎 The patient can ambulate see to it drainage is below the chest
TRACHEOSTOMY CARE KIT
㾎 With sterile swabs moistened in sterile saline solution
㾎 Pat the skin dry to prevent skin breakdown
㾎 Use saline solution or half hydrogen peroxide and half saline solution to clean non disposable inner cannulas to soften the secretions
㾎 Hydrogen peroxide not to be used to clean the skin around the stoma as it can damage the tissues.
㾎 Use each applicator or sponge only once
㾎 Tap dry the cannula against the sterile basin to remove large water droplets
A wet cannula should not be inserted because water is a lung irritant (aspiration pneumonia)
㾎 Rinse the inner cannula by pouring sterile water or saline solution
㾎 Never place anything with loose fibers around the stoma because they can cause irritation and can enter lungs
㾎 Secure the tubes – the tie should be able to be inserted with 2 fingers for it not to be too tight.
㾎 Do not tie around the carotid artery and vertebral artery
㾎 Use split sponge
TONSILITIS
POST-OP CARE: TONSILLECTOMY
→ Apply ice collar because it causes vasoconstriction which stops bleeding, relieve pain and reduces edema.
→ Gentle gargle with warm saline or a pinch of salt 3 to 4 times daily because this can attract water which can lessen the edema; and it thins the mucus, making it easier for the patient to expectorate phlegm.
→ Use of acetaminophen to relieve pain.
→ Elevate the head 45 degree when client is fully awake because this position decreases surgical edema and increases lung expansion.
→ Instruct patient not to cough, clear the throat, blow the nose, and use a straw for 1 to 2 weeks because these actions increase pressure on the suture line and may cause disruption and bleeding.
→ Instruct patient to avoid carbonated fluid and fluids high in citrus content because it is caustic to the surgical site and may disrupt the suture line.
▪ Because these can irritate the wounds.
▪ Carbonate (high in sugar) is a good medium for the growth of bacteria.
→ Encourage them to first try ice chips, followed by small sips of cold fluids, popsicles, and then full liquids.
→ Advise patient to add soft food, gelatin, sherbet as tolerated after the first 24 hours postoperatively.
→ Avoid spicy foods and rough-textured foods such as popcorn, peanuts, crackers, granola, cereal, and whole-grain bread because these may lead to coughing and affect the suture line.
→ Avoid milk, bananas, cheese, yogurt, and French fries because these can thicken the mucus.
→ If the patient vomits large amounts of dark blood or bright-red blood at frequent intervals, pulse rate and temperature rise and the patient is restless, notify the surgeon immediately.
→ Advise patient to avoid vigorous toothbrushing or gargling because these can cause bleeding.
