Quiz 2 - Modules 5 & 6 Flashcards
1
Q
How Breathing Occurs
A
- diaphragm contacts, moves down, makes thoracic cavity bigger
- increases volume and decreases pressure
- diaphram relaxes, moves up
- decreases volume and increases pressure
- If two areas of different pressure communicate, gas will move from area of higher pressure to area of lower pressure
2
Q
Chest Tube Thoracostomy
A
placing a hollow plastic tube between the ribs and into the chest to drain fluid or air from around the lungs in pleural space
* reestablish intrapleural pressure
* promote lung expansion and restore adequate oxygenation
* drains for hemo/pneumothorax, pleural effusion
* want to remove air/fluid promptly
* prevent air/fluid from returning
* restore negative pressure
3
Q
Pneumothorax
A
- Air between pleural space
- Occurs from central line placement, chest surgery, trauma to chest wall, traumatic intubation, mechanical ventilation
- Chest tube placement in upper thoracic cavity towards apex of the lungs
4
Q
Hemothorax
A
- Blood in pleural space
- Occurs from chest surgery, central line placement, chest trauma
- Chest tube placement towards lower aspect of thoracic cavity towards base of the lung
5
Q
Pleural Effusion
A
Transudate or exudate in pleural space
* Transudate: clear fluid from CHF, malnutrition, renal or liver failure
* Exudate: cloudy fluid with cells and proteins from TB and pneumonia
6
Q
Chest Tube Placement Check-Off
A
- consent
- correct placement - CXR
- sutured in place
- airtight dressing
- local anesthetic
- supplemental O2
- monitor for hypotention with loss of fluids
- need thoracotomy tray: larger tubes for liquid, smaller for air
- pleural vac for drainage
- positioning dependent on air/fluid
7
Q
Disposable 3 Chamber System
A
- Drainage collection
- Water seal
- Suction chamber: one for wet and one for dry
8
Q
Water Seal Chamber
A
- Tube from patient in 2 cm of water
- Prevents air and fluid from coming back into pleura
- Tidals with respirations: normal fluctuations that increase with inspiration and decrease with expiration (opposite on ventilator)
- No tidals: tube may be kinked or clamped
- Bubbling: air leak, can clamp in different places to find it
9
Q
Collection Chamber
A
- Keep upright below patient’s chest
- Assess color in drainage, report excessive
- Mark right on unit q1 hr every 24 hrs then q8 hrs - do not empty
- Encourage frequent position changes and coughing
10
Q
Wet Suction
A
- For harder secretions that need to be drained
- Fill suction control chamber with 20 cm of water
- Degree of suction is set by water level
- Gentle bubbles: normal
11
Q
Dry Suction
A
- No water column
- Suction monitor is below
- Dial control on side of unit
- Balances wall suction
12
Q
Care Considerations with Chest Tubes
A
- Assess for subq emphysema: collection of air in tissues under the skin, can threaten airway
- Assess for resp status, drainage, occlusive dressing, connections are taped, tubing is free of kinks, no infection at site
13
Q
Tension Pneumothorax
A
- S/S: trachial deviation towards pneumo, absent breath sounds on one side, JVD, resp distress, asym lung expansion, cyanosis, low BP/shock, organs get pushed
- Never clamp tube unless necessary: replacing unit or finding air leak
- Do not strip or milk tubing since it generated extreme negative pressure
14
Q
Emergency Equiptment for Chest Tube
A
- 2 Kelly clamps
- 1 vaseline gauze
- 4x4 gauze
- New drainage system
- Sterile water: 250mL container
15
Q
Dislodged Chest Tube
A
- Cover with sterile gauze and tape it on 3 sides to allow air to escape - can cause tension pneumo
16
Q
Chest Tube Removal
A
- Indications: Improved resp status, symmetrical rise and fall of chest, bilateral breath sounds, decreased chest tube drainage, absence of bubbling, improved CXR findings
- Assess breath sounds, RR, O2 levels, pain before and after
- Meds 30 mins prior
- Allow patient to bare down to prevent air from entering pleural space
- Site secured with occlusive dressing and heavy weight stretch tape
- CHR placed to ensure lung is fully inflated
17
Q
Respiratory Artificial Airways
A
- For patients with decreased level of consciousness and airway is at risk for obstruction or become obstructed
- Maintains airway patency
- Aids in removal of secretions
- Risk for infection and airway injury
- Clean technique for oral airway, sterile for endotrach and trach
- Need to stay in correct position
18
Q
Oropharyngeal Airway
A
- Used to keep upper airway patent when at risk of being obstructed by tongue or secretions
- Extends from teeth to oropharynx - maintains tongue in normal position
- Measuring: corner of patient’s mouth to angle or jaw below the ear
- If too small: tongue will not stay positioned in anterior part of mouth
- Too large: push tongue towards epiglottis and obstruct airway
- Triggers gag reflex
- To insert: curved part goes upwards until reaches back of the mouth, then is rotated 180 degrees
19
Q
Nasopharyngeal Airway
A
- Keeps upper airway patent
- Inserted through nares and extend to pharynx
- Measured from nose to angle of jaw
- No gag reflex, for patients that are alert
20
Q
Endotrachial Tube
A
- Used to administer mechanical ventilation, relieve upper airway obstruction, protect against aspiration, or clear copious amounts of secretions
- Short term, not more than 14 days, put risk of infection and airway injury
- Placed either through nose or mouth past epiglottis and vocal cords into the trachea and down when it bifurcates into bronchi
- Use Laryngoscope to visualize patient anatomy, has light in it
- Size determined by age and size of patient
- Adults will have cuff that is inflated with air after insertion to prevent air from leaking around the tube and prevent oral and gastric secretions from being aspirated
21
Q
Laryngeal Mask Airway
A
- Used for paramedics or other less experienced providers, fast and accurate placement regardless of circumstances
- Less gastric distention, not induce aspiration
- Good for when patient does not need to be intubated for long time or placement of ET tube not feasible
22
Q
Tracheostomy Tube
A
- Used to establish a surgical airway via tracheotomy
- Placed below level of larynx – unable to speak
- May be permanent or temporary
- indications: replace ET tube, mechanical vent, acute or chronic airway obstruction, copious secretions
23
Q
Nurse’s Role in Intubation
A
- Check and assemble equipment
- Hand equiptment to provider
- Check pulse ox
- Secure tape or ET holder to prevent deviation
- CXR and ABG
- Confirm tube position via auscultation, bilateral chest rise, tube locator at teeth (20-25cm), CO2 detector - pH sensitive and will turn purple to yellow
- False positives whenwhen gastric contents, mucus, epi come in contact – will permanently change to yellow and not fluctuate
24
Q
Stabilizing ETT
A
- Use tape or prepackaged ET tube holder with Velcro
- Assess resp status every 2 hrs
- Assess nasal and oral mucosa for redness or irritation
- Place patient in semi fowlers or side lying - reposition every 2 hours
- Monitor cuff pressure: 20-25mm to minimalize risk of necrosis
- Oral care every 4 hours using antibacterial solution and use bite block to avoid biting down on tube
- Communicate frequently with patient and give them means to communicate with like a white board
25
Q
Metal Trach Tube
A
Temp sensitive, must be protected from heat and cold to prevent tissue injury
26
Q
Double Cannula
A
- Contains outer and inner cannula
- Permanent inner cannula: take out, clean, put back in
- Disposable inner cannula: can dispose and get new one
27
Q
Parts of Trach Tube
A
- Outer cannula: outer tube that holds trach open
- Obturator: inserted into the main body of the tracheostomy tube and acts as a guide to help place the trach tube into the airway
- Inner cannula: held in place by twist lock or pressure clip at base of flange
- Flange: Have holes to hold trach in place with tape or Velcro
- Cuff: Balloon around distal end of cannula, forms seal
28
Q
Cuffed Trach Tubes
A
- Decreases risk of aspiration
- Seal between upper and lower airway
- Necessary for ventilated patients
- Not inflated for purpose of anchoring the trach in throat but used to direct flow of air
- Cannot talk
29
Q
Uncuffed Trach Tubes
A
- Minimal/no risk for aspiration
- No foreseeable need for mech vent
- Peds patients
30
Q
Cuff Considerations
A
- Deflation: slow, suction first, deflate during peak inspiration, before oral feeding
31
Q
Fenestrated Trach Tube
A
- Has an opening in the tube above the cuff, which allows air to enter so that the patient is able to speak with the tube in place
- Opening plugged to force air upwards to larynx
- Outer cannula has openings on posterior wall
- For vent weaning
32
Q
Trach Care Considerations
A
- Humidification: Keeps secretions thin and avoid mucus plugs
- Stoma care: Stoma and dressing clean and dry, Pre-cut non-raveling dressing under face plate
- Secure with 2 people
33
Q
Emergency Equiptment
A
- Tube dislodgement and decannulation are problems during first 72 hours
- Have obturator, suction, O2, 2 new tubes - one same size and one smaller, bag valve mask
34
Q
Accidental Decannulation
A
- Immediately call for assistance and stay with patient
- Replace with new spare tube or use obturator to keep stoma open
- Prepare for vent if resp distress occurs
35
Q
Suctioning
A
- PRN procedure, only when needed
- Removed from nose and mouth for patient airway and block gas exchange
- Lost control to swallow like stroke or unconscious
- Frequent suctioning can cause trauma to mucosa and cause hemorrhage and edema
- Oro: clean tech
- Naso, ET, Trach: sterile
- Nasotracheal suctioning can cause hypoxemia, infections in lungs, atelestasis, and cardiac arrest – vasovagal reaction
- Have patient manage own secretions with turning and coughing/deep breathing every 2 hrs after surgery
36
Q
Closed System Suction Methods
A
- Use reusable suction catheter in plastic sheath, does not disconnect system
- Patients attached to vent – reduces risk of hypoxia and infection
- Use for 24 hours
- Use PPE - do not need sterile gloves
37
Q
Open System Suctioning
A
- Disconnecting the patient from the ventilator and introducing a single‐use suction catheter into the patient’s endotracheal tube.
- Increased risk for hypoxia because not providing oxygen – sucking it out
- Can stim Vagus nerve - HR could drop
- Sterile cath for every suction session
- Use sterile gloves
38
Q
Suctioning Pre-Assessment
A
- Baseline
- Look for signs of hypoxia: restlessness, adventitious breath sounds, decreased O2 sat, tachypnea/cardia
- Effectiveness of coughing
- History of deviated septum, nasal polyps, epistaxis, nasal injury, or swelling
- Need for meds prior
39
Q
Suctioning Guidelines
A
- Pre and post assessment after each suction
- Test suction prior
- Hyperoxygenate them with deep breaths or supplemental
- 3 passes only, 10-15 sec per pass, 30 sec-1 min b/w passess
- Suction at 100-125mmHg
40
Q
Lavage
A
- Cleaning and removing stomach contents
- Used in drug overdose
- Activated charcoal to absorb poisons, limits toxins entering the bloodstream; alcohol, iron, lithium, metals – not very well absorbed – need an anecdote or polyethylene solution
- Contra: injesting poison, hydrocarbon, corrosive substances or someone has absent protective airway reflexes
- Therapy for hyper or hypothermia to stabilize body temperature
41
Q
Decompression
A
- Removes gas and fluids
- Tube connected to suction and removes stomach contents
- Remains in place until normal bowel movements resume
- Indications: rest GI tract from severe V and D, bowel obstruction, paralytic ileus, surgery on stomach or intestine OR clear GI tract - promote healing and allow peristalsis to resume
- Patient is NPO, oral meds can be given but suction must be turned off until absorbed
42
Q
Compression
A
- An emergency procedure used to stop bleeding from the upper digestive tract
43
Q
NG Tubes
A
- Long, thin, polyurethane, silicon tube, many holes at the end of tube
- Inserted in nasally or orally to administer or remove substances from stomach
- Sizes 4-18 French, broken down by age group
44
Q
Single Lumen - Levin
A
- 14-18 French and 125 cm long
- Used for stomach decompression, withdrawing specimens, washing the stomach free of toxic substances, and irrigating stomach and treat upper GI bleeds
- Connected to low-intermittent suction, could cause erosion or tearing of stomach lining if any higher
- Can be used to administer meds or feedings
45
Q
Double Lumen - Salem Sump
A
- Most common, 14-18 Fr
- Used for irrigation and tube feeding, preferred for gastric decompression
- Can be used for continuous suction since it is double lumen tube
- Blue vent is always open to air for continuous atmospheric irrigation
- Prevent reflux by having blue vent port above patient’s waist
- Lumens have openings at both ends for air flow
- Irrigating large lumen – inject 20mL of air into blue vent to reestablish buffer of air between gastric contents and vent
- Never clamp off air vent or connect to suction or irrigation
46
Q
Dobhoff Tube
A
- Used for enteral nutrition or med administration
- Inserted using guide wire
- Go into jejunum or duodenal areas
47
Q
Tubes for Upper GI Bleeding for Varices – Sengstaken-Blakemore
A
- Two lumens inflate gastric and esophageal balloons: one inflates in stomach, one inflates as tamponade to reduce gastoint hemorrhage
- 3rd lumen reserved for gastric suction or drainage
- Can be inserted orally or nasally
- Compresses esophageal varices or reduce gastrointestinal hemorrhage
- ET intubation is strongly advised to secure intubation before insertion
- Only for emergencies
48
Q
NG Suction
A
- Prepare for gastric decompression – have suction device in and collection container
- Use lowest suction setting possible, check suction gauges every 2-4 hrs to make sure GI contents are being suctioned up
- Pigtail must be above level of stomach - pin to patient’s gown
- Intermittent suction: Provides alternating periods of gastric tube suction force followed by release, reduces risk of mucosal erosion; in Salem Sump and Levin
- Continous suction: only in Salem sump tube – with air vent that prevents excessive neg pressure from dev in stomach, double lumen
49
Q
Inserting NG Tube
A
- Pre-Assessment: inspect nares and patency, have pt occlude one nostril and breathe to see which one is best, test gag reflex, have suction available incase of vom
- Measuring tip of nose to tip of the ear down to xiphoid process
- Can use topical anesthetic or use lubricant
- Position into high-fowlers
- Encourage deep breathing through their mouth
- Advance tube towards posterior pharynx, go up first a little bit, have them tilt head forward and drink water slowly
- Secure with tape
- Experiences resp distress, cannot speak – stop tube and withdraw
50
Q
Caring for NG Tubes
A
- Proper placement: aspirate and test pH - 3-5 in stomach, x-ray, air insertion with ausc (really for babies), CO2 detector
- Assess I&O every 8 hrs: lose too much - FVD, report excessive output
- Assess abdomen and gastric output
- Assess adequacy of suction pressure
- Secured on patient’s gown
- Oral hygiene
- Maintain tube patency with intermittent irrigation
51
Q
NG Irrigation
A
- Every 4 hours
- Before: ensure placement, check aspiration, measure amount of irrigate in 60mL syringe and instill 20-30mL
- Disconnect proximal end of NG tube from distal end of the suction and slowly instill irrigate into tube
- Irrigate air vent with 20mL of air afterwards
- Document amount of irrigate in intake to subtract from the output
52
Q
Documentation of Placement
A
- Type and size of tube
- Nare used
- Stomach contents: characteristics and pH
- Care done
- Patient response
- Teaching that was done
53
Q
Removing NG Tube
A
- Try to do trial run with intermittent clamping
- Placement, flushing, positioning
- Tissues and emesis basin
- Inject with 10mL of air before
- Take deep breath in and hold it – closes glottis and reduces risk of aspiration
- Pinch tube at nares and withdraw slowly , do not force
54
Q
Documentation of Removal
A
- Condition of nare skin
- I and O
- Tolerance of procedure
- Teaching: Abdominal pain, N or V, Bloating
55
Q
Ostomies
A
- Process whereby an opening is created in the abdominal wall for elimination of feces or urine
- Stoma: visible part of temporary or permanent opening created in the abdominal wall during surgical procedure
- 3 Types: colostomy, ileostomy, urostomy
56
Q
Reasons for Stomas
A
- Carcinoma – bowel and bladder
- Diverticulitis
- IBD – Crohn’s, UC
- Familial polyposis
- Trauma – gun shots, stabbings
- Neurological damage – MS
- Congenital disorders
57
Q
Stoma Creation
A
- Location dependent on waistline, skin folds, scars, type of ostomy performed
- Should look shiny, wet, and red
- Can be protruding, with the skin, or retracted
58
Q
Colostomy
A
- Portion of diseased large intestine is removed or bypassed
- Remaining portion is brought through abdominal wall to form stoma
- May be temporary or permanent
- Effluent from colostomies is thicker and more formed the further down the large intestine the stoma is placed
59
Q
End Colostomy
A
Damaged section of bowel is removed and working end is brought through the abdomen to skin surface – usually permanent
60
Q
Loop Colostomy
A
Loop of bowel is brought to the abdomen to the skin surface and supported by plastic ridge rod, transverse: relieve perforation or obstruction, wall with proximal and distal bowel, two openings to the one stoma
* Proximal end drains stool, distal drains mucus
* Bridge can be removed in 7-10 days
61
Q
Double Barrel Colostomy
A
Two separate stomas, two ends of bowel
* Distal colon not removed but bypassed, expels mucus
* Proximal: diverts feces to abdominal wall
62
Q
Placements of Colostomies
A
- Ascending colon: to the right, liquid/semi liquid, very irritating to skin
- Transverse colon: top left/middle, usually for temporary ostomies, stoma usually loop, liquid/semi formed
- Descending colon: top left, semi-formed
- Sigmoid Colon: lower left, permanent - cancer of rectum, formed output
63
Q
Ileostomy
A
- Created from terminal ileum and stoma is usually on right side of the abdomen
- Bypasses entire large intestine
- Usually done to treat colon cancer, UC, surgical removal of colon
- Stoma has smaller diameter than colostomies
- Effluent from ileostomies is usually very thin and watery at first
- Provide extra care to the skin
- Output: 1-2L per day - dehydration, need skin barriers, Dark green, loose, odorless, then thickens up from yellow to brown, empty when half or third full
- Loose residue diet, avoid high fiber or corn, popcorn, nuts (hard to digest)
64
Q
Food Blockage in Ileostomies
A
- Abdominal cramping, N/V
- Swelling of stoma
- Note output for 6 hrs
- Put warm towels on abdomen, drink tea, assume knee-chest position, massage area
- May need to replace pouch with bigger opening if stoma gets bigger
65
Q
Incontinent Diversion
A
- Stoma and external appliance to collect drainage
- Entire bladder removed: put in ileal conduit
- Small piece of terminal end of small intestine (ilium) to create drainage port from both ureters that are surgically attached
- Piece of intestine is separated from rest of intestine
- Still has blood supply
- One end is surgically closed
- Ureterostomy: Both ureters are brought to abdominal wall, two stomas
- Transureterouterostomy: one ureter connected to other, one stoma, more complications
66
Q
Stoma Management
A
- Assess: color (no dusky/brown/black/pale), moisture, size
- Skin around: keep dry for adhesive to reduce risk of yeast infection, use mild soap when cleaning
- Monitor peristalsis, mucous shreds in urine, I&O
- Measure stoma weekly 8 weeks after surgery
- Contact provider if having stool changes, breakdown of skin, skin irritation, not getting a good seal, see hernia, narrowing, separation of stoma from abdomen, cuts in stoma
67
Q
Ostomy Pouch
A
- May be disposable or reusable, one piece or two pieces
- What has best adhesive, best skin protection, stoma location, consistency of drainage, abdominal shape, coordination of patient
- Closed End: one time use, for Sigmoid, have filter for odor
- Open End: multi use for ascending or transverse
- Two Piece: Wafer and then bag clips on for frequent pouch changes, minimizes skin breakdown
68
Q
Changing Ostomy Bag
A
- Begin on one corner and slowly pull off
- Can use adhesive removal wipe
- Always do patch test
- Remove if feeling itching and drainage, skin breakdown, rash
- Cut 1/8 inch wider
69
Q
Documentation
A
- Stoma appearance
- Condition of skin
- Amount, color, characteristics, I and O
- Pt reaction and tolerance
- Psychosocial
