Procedures Flashcards
Bronchoscopy
Bronchoscopy is an invasive procedure that inspect the larynx, trachea and the bronchi through a tube. It is used to visualize the lungs, to find any tumor, cancer or strictures in the lungs, get a biopsy and to find any source of bleeding. This is done either by a rigid or flexible fiberoptic bronchoscopy. (Hinkle and Cheever, 2017 p505)
The role of a nurse prior to the procedure:
Verify the consent has been obtained.
Patients must be NPO (4-8 hrs) prior to procedure to reduce the risk of aspiration.
The procedure should be explained to the patient to reduce fear and anxiety.
Sedatives or opioids are given to inhibit vagal stimulation.
Ensure denture and prostheses are removed
General anesthesia is given if it’s a rigid bronchoscopy and local anesthesia for fiberoptic bronchoscopy.
A topical anesthesia such as lidocaine is dropped onto the epiglottis and vocal cord or sprayed onto the pharynx to suppress cough reflex.
After procedure, pt remains NPO until gag reflex is returned and then ice chips are offered then fluids.
The nurse monitors vitals and respiratory status.
Pt education includes reporting any SOB or bleeding also a small amount of blood-tinged sputum is normal.
peak flow meter
Peak flow measurement is done with a peak flow meter by measuring the highest airflow during a forced expiration. It should be done daily and is tailored to every individual who meets 2 or more of the criteria:
Moderate or severe persistent asthma.
Poor perception of changes in airflow or worsening symptoms
Unexplained response to environmental or occupational exposures.
At the discretion of the clinician and patient.
The peak flows are monitored for 2 - 3 weeks after receiving optimal asthma therapy and it is considered an adjunct to asthma management. It is a great way to manage asthma. (Hinkle and Cheever, 2017 p661-663).
Patient teaching by nurse: how to use the meter.
While sitting up straight, the patient should take a deep breath and place his/ her lips around the mouthpiece forming a tight seal then exhales fast and hard into the meter.
The volume will be measured in the color zone of their personal best.
The green zone: 80% - 100% - signifies that the pt is doing well with no cough, wheeze, chest tightness or SOB and can do usual activities.
Yellow zone: 60% - 80% - indicates that asthma is getting worse with coughing, wheezing, chest tightness and SOB. Pt wakes during the night due to asthma and can do little activity.
Red zone: less than 60% - this is a medical emergency! Unable to do any activity with severe SOB, quick relief medications do not help as symptoms get worse after 24 hrs in the yellow zone. Patients should seek medical attention immediately.
Additional implementation includes education of health care providers, establishment of programs for asthma education and outpatient follow up care for patients also a focus on chronic management versus acute episodic care.
MDI
An MDI (short for metered dose inhaler), is a small hand held respiratory device that delivers a certain amount of medication needed for the patient. The medication is dispersed as a mist through a pressurized canister. This mist of medication is administered through the mouth and will then facilitate into your lungs. It is used in patients with certain respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD).
STEPS:
Remove the cap of the canister and hold the inhaler upright
Thoroughly shake the inhaler (the purpose for this is that its helps in mixing the medication so you get the right amount of each)
Instruct the patient to sit or stand upright.
Instruct the patient to breathe out slowly and all the way.
There are two techniques that can be used when using an MDI:
One technique is known as the open-mouth technique. The way this technique works is by placing the pMDI 2 finger widths away from lips. With mouth open and tongue flat, tilt outlet of the pMDI so that it is pointed toward the upper back of the mouth. Actuate the pMDI and begin to breathe in slowly. Breathe slowly and deeply through the mouth and try to hold breath for 10 seconds.
The second technique is known as the closed-mouth technique. The way this work is by placing the pMDI between the teeth and making sure the tongue is flat under the mouth-piece and does not block pMDI. Instruct the patient to seal the lips around the mouthpiece and actuate the pMDI. Have the patient breathe in slowly through the mouth and try to hold breath for 10 seconds.
Repeat puffs as directed, allowing 1 minute between puffs. There is no need to wait for other medications.
Apply the cap to the pMDI for storage.
After inhalation, rinse mouth with water when using a corticosteroid-containing pMDI (The purpose of rinsing after the use of corticosteroids is because this anti inflammatory can cause hoarseness, throat irritation, and oral thrush. Rinsing will help prevent these issues from occurring)
Make sure that the pMDI mouthpiece is cleaned on a regular basis as well as the nozzle of the canister
Note that the patient may also be recommend to use a spacer for their MDI. This is a holding chamber that helps filter the medication between the inhaler and the mouth. The purpose of the filtering through the chamber is to help the medication facilitate straight into where your lungs need it. This allows for less medication to end up in the mouth or throat which will help in less irritation from occurring.
oxygen delivery
Oxygen therapy is provided to patients who need oxygen transported into the blood to prevent labored breathing by the patient. If the patient has a change in their breathing, they may need additional oxygen. (Hinkle & Cheever, p.511). When we breathe room air, we are breathing in a total of 21% oxygen. There are low-flow delivery systems, the patient breathes some room air as well as oxygen. Then there are high flow delivery systems that completely provide the oxygen. Oxygen is a medication so you should have a doctor’s order, it is determined by the patient’s arterial blood gas levels. In emergency situations you can provide oxygen to patient as a rescue measure and then put in a request for a doctor’s order.
Nasal Cannula
Suggested FLOW Rate (L/min) 1-2 3-5 6 O2 Percentage Setting 24–28 32–40 44 A nasal cannula is used when the patient requires a low-to-medium concentration of oxygen usually a patient with chronic lung disease (Taylor, Lynn & Bartlett, p. 1535). This method allows the patient to move in bed, talk, cough, and eat without interrupting oxygen flow. It is lightweight for the patient to carry if needed, it is inexpensive, and you don’t have to remove while eating (Hinkle & Cheever, p.513). Nursing considerations are skin breakdown over the ears and nares. The drying of the nasal mucosa, but you do not want petroleum to moisten the nares, it should never be used around oxygen delivery systems. Mask, nonrebreathing Suggested FLOW Rate (L/min)
10–15
O2 Percentage Setting
80–95
Nonrebreathing masks have a one-way valve, this prevents the patient from breathing in room air during inhalation. The nonrebreather mask has a reservoir bag that should be inflated prior to usage, the patient does not exhale into this bag, their expired air exits through the mask (Hinkle & Cheever, p.514). This is a low-flow oxygen system that can be given to a patient with a pneumothorax, they need a high concentration of supplemental oxygen to treat hypoxemia (Hinkle & Cheever, p.631).
Nursing considerations for the patient; they must remove the mask to eat. The mask doesn’t fit snugly around the face, so the patient does not get the full benefit of non-rebreather, it is considered a high concentration of oxygen but that is affected by the fit.
Mask, Venturi
Suggested FLOW Rate (L/min)
4–6
O2 Percentage Setting
24, 26, 28
6–8
30, 35, 40
A Venturi mask is the most reliable and accurate method for delivering precise concentrations of oxygen. The mask allows a constant flow of room air blended with a fixed flow of oxygen. It is used primarily for patients with COPD because it can accurately provide appropriate levels of supplemental oxygen, it avoids the risk of suppressing the hypoxic drive. (Hinkle & Cheever, p.514). This method allows a constant oxygen concentration to be inhaled regardless of the depth or rate of respiration.
Nursing considerations: you must remove the mask to eat. Provides low level of oxygen but additional humidity is available. You must closely monitor the patients receiving this method of oxygen especially COPD patients.
For all oxygen methods there are gerontological considerations, you must educate the patient to maintain adequate nutrition. It can diminish the excess buildup of carbon dioxide and maintain optimal respiratory functioning. The surface area of the lungs decreases, this reduces ventilation and respiratory gas exchange. (Hinkle & Cheever, p.515)
At home considerations for patients on oxygen:
Don’t smoke!
Keep oils that can burn away from 0xgen.
Don’t keep it close to a wall, allow for ventilation.
Keep away from stove
Advise local fire department your house has a person on oxygen.
Device Suggested Flow Rate Oxygen%
Nasal Cannula 1-2L 24-48%
3-5L 32-40%
6L 44%
Partial rebreather mask 8-11L 50-75%
Nonrebreather mask 10-15L 80-95%
suctioning
Oropharyngeal Procedure:
The expected patient outcome is to remove/clear out any secretions, improve breathing, and prevent in foreign substances from obstructing in the airway
Oropharyngeal procedure steps:
- Check physician’s orders (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Follow aseptic techniques for all suctioning of the airway in order to minimize the spread of bacteria
- Obtain the Necessary Equipment such as disposable suction equipment/sterile, disposable suction catheters, sterile water basin, sterile gloves, suction apparatus (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Identify patients name, DOB, and check his/her hospital identification bracelet (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Place the patient in a semi-Fowler’s position. This position is a semi-sitting position in which the patient manages secretions better and breathes easier. Make sure that the head is not tilted forward
- Turn on the suction apparatus
- Open the sterile solution basin on the bedside table. Pour the sterile solution into the solution basin without contaminating the solution, basin, or sterile field (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Open the package of sterile gloves
- Oxygenate the Patient. Provide additional oxygen for the patient prior to suctioning in order to prevent further hypoxemia. Suctioning removes available air and oxygen as well as removing accumulated secretions. If the patient is on oxygen therapy, increase the percentage of oxygen to 100 percent for one minute NOTE: If the patient has a respiratory disease, check with the supervisor before increasing oxygen. (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Put on Sterile Glove
a. (If only one sterile glove is available, put it on your dominant hand. Use the gloved hand to handle sterile items. The gloved hand must remain sterile throughout the procedure)
b. If two sterile gloves are available, put one glove on your non-dominate hand. Then put the remaining glove on your dominate hand. Your gloved dominate hand will be used to handle sterile items and must remain sterile throughout the procedure. The glove on the other hand provides protection to you and is used to handle non-sterile items (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.) - Remove the sterile catheter from the package with the sterile (dominant) hand. Keep the catheter coiled to prevent contamination (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Attach Catheter to Suction Tubing (this catheter is known as a yankauer). Attach the suction catheter to the tubing from the suction apparatus When performing this step, hold the suction catheter in the gloved dominate hand and hold the tubing from the suction apparatus in the non-sterile (ungloved) hand (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Test Patency of Catheter (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
Turn the suction apparatus on with the non-sterile hand. (2) Hold the catheter in the sterile hand and insert the tip in the basin of sterile solution. (3) Place the thumb of the non-sterile hard over the suction port and observe the fluid entering the drainage bottle. If no fluid enters the drainage bottle, the catheter is blocked (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Once everything is set up and verified ask the patient to cough (if possible). This will help to bring up secretions to the back of the throat so they can be easily removed (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Insert the tip of the catheter into the patient’s mouth, then back into the pharynx without using suction (be careful when advancing the catheter too far into the back of the patient’s throat because this may stimulate the gag reflex)
- Apply intermittent suction by placing the thumb of the non-sterile hand over the suction port. DO NOT suction for longer than 10 to 15 seconds. The reason for this is because it can cause dysrythmias, bradycardia and oxygen deprivation)
- Slowly withdraw the catheter using a rotating motion. This prevents sucking mucous membrane tissue into the catheter (make sure to observe the patient throughout the procedure for color change or increased pulse rate or changing of breath sound)
- Clear the catheter by inserting the tip in the sterile solution and suction the solution through the catheter (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
- Reassess patient and allow the patient to rest between suctioning. Reoxygenate the patient before each suctioning
- After suction is complete turn off the suction apparatus and disconnect the catheter from the suction tubing. Dispose of used items
- Wash hands thoroughly
- Make the patient comfortable and provide call bell within reach
- Document procedure (record the time, patient’s respiration rate, description of respirations (labored, noisy, etc.), procedure used, and the type and amount of secretions obtained (“Oral, Nasopharyngeal, And Nasotracheal Suctioning”, n.d.)
Asthma action plan
- What education would you provide for a patient newly diagnosed with asthma? Include teaching for the asthma action plan, a metered dose inhaler and the purpose of a peak flow meter. Identify key concepts from the associated videos pertaining to this question.
Patient education is a critical component of care for patient with asthma. Multiple inhalers, different types of inhalers, antiallergy therapy are essential for long term control. (Hinkle, 2018, p603)
The patient needs to identify possible trigger and measures to prevent episode.
The patient needs to recognize symptoms on the intermittent episode, and for long term management.
The patient needs to know about the management of medication and proper administration.
-allow 5 minutes to elapse before taking the other inhale medication.
- allow 1 minute to elapse before taking same inhale medication.
- Benefits of meter dose inhaler
A metered dose inhaler works to give you an exact metered dose that dose every single time you use it.
This makes medication work so effectively and quickly.
-Steps
Wash your hands thoroughly with soap and warm water.
Remove the cap and hold the inhaler upright.
Shake the inhaler.
Breathe out slowly through your mouth.
Hold your inhaler
While you are breathing in, press down on your inhaler one time to release the medication.
Continue to breathe in slowly and as deeply as you can.
Hold your breath for 5~10 seconds, if you can, to allow the medication to reach deeply into your lungs.
Wait between puffs of your medication.
Rinse your mouth thoroughly with water.
The patient needs to know about the correct use of peak flow meter.
-Peak flow meters measure the highest volume of airflow during a forced expiration.
The patient takes deep breath and places lip around the mouthpiece, and then exhale hard and fast. Volume may be measured in color- coded zones: the green zone indicates 80%to 100%of personal best: yellow zone, 60 %to 80%; and red zone less than 60%. (Hinkle, 2018, p602)
The patient needs to learn an asthma action plan with the primary HCP and what to do if an asthma episode occurs.
-the green zone (more than 80% in peak flowmeter) means the patient is doing well (no cough, wheeze, chest tightness, or SOB) and he (she) can do usual activities. Patient can take the short acting bronchodilator (ex, albuterol) prophylactically 5~60 min before exercise. (Hinkle, 2018, p602 Figure 24-8)
-the yellow zone (50% to 79 of my best peak flow) means asthma is getting worse (cough, wheeze, chest tightness, or SOB) and can do some, but not all usual activities. (Hinkle, 2018, p602 Figure 24-8)
The patient avoid yourself from the thing that made your asthma worse.
The patient should take the short acting B-2 antagonist 2~4 puff q20 mins up to 1 hour and he (she) can add oral corticosteroid (ex, prednisone).
Check your primary HCP contact number to ready call.
Continue Monitoring.
-the red zone(50% of my best peak flow) means medical alert. The patient may experience very SOB, cough, wheeze, and chest tightness. Keep taking medication same with green zone. (Hinkle, 2018, p602 Figure 24-8)
Then call your primary HCP now.
Go to the hospital or call an ambulance.
Chest x ray
Chest X-ray
Chest X-ray is the most essential diagnostic X-ray examination. It visualizes images of the heart, lungs, airways, blood vessels, and the bones of the spine and chest. Chest-X-ray is useful to detect fluid, tumors, foreign bodies, and other pathological conditions. Chest X-ray comes in handy when respiratory symptoms are unclear and performing a chest X-ray will give a definitive view of the lungs anteriorly and posteriorly. (Hinkle and cheever, 2017 p504)
The role of a nurse for the procedure :
The nurse should inform the patient Chest X-ray does not require them to fast (NPO) and would not cause any pain.
The patient will have to wear a gown, remove any metal objects (jewelries) from the chest, and will be given a lead shield to protect them from the radiation exposure to the thyroid glands, ovaries and testicles.
The patient will be positioned in a standing, sitting, or a recumbent position in order to achieve an appropriate view of the chest
The nurse should make the patient comfortable enough to take a deep breathe and hold the breathe while the technician takes the images.
Chest X rays are obtained after full inspiration because the lungs are best visualized when they are fully aerated.
Additionally, the diaphragm is at its lowest level and the largest expanse of lung is visible.
Blood culture
Blood culture
Blood culture is needed to identify bacterial pathogens and help decide the appropriate antibiotics needed to fight the infection.( JILL,20)
The role of a nurse for the procedure :
Check the doctor’s order. Make sure to collect blood before the antibiotic therapy is initiated.
Take patients medical history and ask if they are currently on any antibiotic therapy and check for patients history of fever. Take vitals and note the temperature.
Wash your hands, gather all the necessary equipment at the bedside and put on fresh gloves.
Explain to the patient the whole procedure and start by selecting an appropriate vein and clean the site with an alcohol swab , make sure to let it dry completely.
Clean the stoppers bottles or tubes following your hospital policy.
Start venipuncture without touching the site , even if you’re wearing sterile gloves.
If using a safety syringe, draw the correct amount of blood, withdraw the needle and follow the recommended safety procedure for injecting the blood into aerobic and anaerobic media.
If a second blood culture is needed, follow hospital policy and use a seperate site to draw blood or wait the specified time to collect the specimen.
Label the specimen properly , including the venipuncture site, and document any antibiotics the patient is receiving.
Transport the specimen directly to the lab.
Don’t hold blood culture containers in your hand while transferring blood from a syringe; this increases the risk of a needle stick.
Don’t force blood from a syringe into culture bottles , the blood may splatter.
