TUBES , SUCTIONING/PROCEDURES Flashcards
What size tube is used in PEDIATRIC PT’s FOR RESPIRATORY SUCTIONING ?
- French 8 - 10
SIZE TUBE FOR ADULTS ?
French 14 - 16
How long can you suction the patient ?
- SUCTION (NO > than 10 SECONDS)
- SUCTION FOR about (5 - 10 Sec)
What is the purpose of Respiratory Suctioning ?
- Remove secretions that is OBSTRUCTING AIRWAY
- FACILITATE RESPIRATORY VENTILATION
- OBTAIN SECRETIONS FOR DIAGNOSTIC PURPOSES
- PREVENT INFECTION THAT MAY RESULT FROM ACCUMULATED SECRETIONS
Indication of need for respiratory suctioning
- RESTLESSNESS
- GURGLING SOUNDS DURING CHEST AUSCULTATION
- CHANGE IN LEVEL OF CONSCIOUSNESS
- SKIN A MUCOUS COLOR
- RATE
- DEPTH
- PATTERN OF RESPIRATIONS
- CHANGE IN THE VITAL SIGNS
PULSE RATE AND RHYTHM
EFFECTS OF SUCTIONING
- HYPOXEMIA
- CYANOSIS
- INITIALLY MAY CAUSE TACHYCARDIA to BRADYCARDIA
- MAY INCREASE INTRACRANIAL PRESSURE (ICP)
- CARDIAC DISRHYTHMIAS and HYPOTENSION
Nasal Cannula or Prongs ( O2 Administration)
- SIMPLE & COMFORTABLE DEVICE FOR DELIVERING OXYGEN TO A CLIENT
- 1-6L/min
Does oxygen need a doctor’s order ?
YES, it is a DRUG and should NOT BE ADJUSTED WITHOUT MD ORDER
Nursing Intervention for Nasal Cannula or Prongs
- Assess the latency of nostril
- Apply water solvable jelly to nostrils every 3-4 hrs to PREVENT SKIN BREAKDOWN
- Provide good oral hygiene
- ABGs if indicated is taken 10-15 min after initiating oxygen
- USE IN CAUTION FOR PATIENT’S WITH COPD to (1-2L)/NC, EXCESSIVE OXYGEN CAN SUPPRESS RESPIRATORY DRIVE
Face Mask
- SHAPE TO FIT SNUGLY OVER THE CLIENT’S MOUTH AND NOSE
- SECURED IN PLACE WITH A STRAP
- Has a metal strip to mold the mask to the nose and multiple oxygen ports
- 5 - 10L/min
Nursing Intervention for Face Mask
- Provide emotional support to decrease feeling of claustrophobia
- OBSERVE FOR APPREHENSION & ANXIETY
- CONTRAINDICATED TO COPD (RETAINS CO2)
Partial Rebreather Mask ( MASK WITH RESERVOIR )
- Indicated for SEVERE HYPOXIA
- IT DIFFERS FROM NRBM IN THAT THERE IS NO ONE-WAY FLAP VALVES BETWEEN THE BAG AND THE EXHALATION PORTS
- 6-15L/mL
Nursing Intervention for Partial RM
- Make sure that the reservoir is COMPLETELY EXPANDED
- ADJUST O2 FLOW TO KEEP RESERVOIR BAG 2/3 Full
Non- Rebreather Mask
- Delivers MEDIUM to HIGH CONCENTRATIONS OF O2
Nrsg Intervention (NRBM)
- FiO2 of 60 - 100% at a rate flow that maintains the bag 2/3 full
- RESERVOIR SHOULD FILL ON EXHALATION AND BAG DOES NOT COLLAPSE MORE THAN HALF ITS FULL POSITION
- Observe for PRESSURE NECROSIS with TIGHTLY FITTING MASK
NRBM
- Adjust airflow rate to keep the reservoir bag inflated. KEEP MASK SNUG ON FACE
- REMOVE MUCUS AND SALIVA FROM MASK
- PROVIDE EMOTIONAL SUPPORT TO THOSE WHO FEEL CLAUSTROPHOBIC
- ENSURE THAT THE VALVES AND FLAPS ARE INTACT AND FUNCTIONAL DURING EACH BREATH
- ( Valves should OPEN ON EXPIRATION AND CLOSE ON INHALATION)
- MAKE SURE RESERVOIR BAG DOES NOT TWIST or KINK
- ## MAKE SURE IT DOES NOT DISCONNECT (CLIENT WILL SUFFOCATE)
Venturi Mask (Venti Mask)
- KEEP ENTRAPMENT PORT FOR THE ADAPTOR OPEN AND UNCOVERED TO ENSURE ADEQUATE OXYGEN DELIVERY
- KEEP SNUG ON FACE
- MAKE SURE TUBING IS FREE OF KINKS FiO2 I altered if kinking occurs or if the mask fits poorly
- CHECK NASAL MUCOSA FOR IRRITATION
- HUMIDITY or AEROSOL CAN BE ADDED TO THE SYSTEM AS NEEDED
How many L/min for Venturi Masks ?
- 4 - 10L/min
- Entrapment ports are adjustable to permit regulations of FO2 from 24% - 50%
In suctioning a conscious Pt via nasal the neck should be ?
HYPEREXTENDED
In suctioning a conscious patient via mouth the head must be ?
TURN TO ONE SIDE
Tracheal Suctioning (Conscious Pt)
HYPEREXTEND THE HEAD, CLIENT MAY ASK TO EXTEND TONGUE
Left Bronchus (Conscious Pt)
Turn head to EXTREME RIGHT, CHIN UP
Right Bronchus (Conscious Pt)
Turn head to EXTREME LEFT, CHIN UP
Suctioning (Unconscious Pt)
- Pt in Lateral Position to drain secretions from pharynx ( Helps PREVENT ASPIRATIONS)
- This position will help with the tongue to fall forward to easily insert the catheter
How do you measure a catheter before inserting into the nose ?
- Tip of nose to tip of earlobe (about 13cm or 5 inches)
Use lubricant (water soluble jelly ) when suctioning nasopharyngeal ?
Yes
Never force the catheter against an obstruction, if one nostril is obstructed, try the other.
YES
Do you apply catheter suction on insertion ?
- No, because you will cause trauma to the mucous membrane
- Allow for 20-30 second intervals between suctioning
How long should you suction the Pt ?
5- 10 seconds and should ONLY LAST 5- 10 seconds
How long all together should you be suctioning the Pt ?
- Limit suction to a total of 5-10 min
- No more than 2-3 suction passes should be made per suction episode
What should you do in between suctions ?
- FLUSH
- Suction catheter, tubing, and suction bottle at least once a day
If you have to suction both the nose and mouth, which will you suction first ?
NOSE
Tracheostomy (Explain how to wash/remove inner cannula) is this a clean or aseptic technique ?
- Aseptic Technique is used for both Tracheostomy and Endotracheal
- Suction patient no more than 10 seconds (Pre-oxygenation may be required beforehand)
- Sitting position if possible (Promotes lung expansion and with each feeding)
- Unlock inner cannula by turning the lock LEFT (90 degrees), Pull slightly upward and toward you
- Soak inner cannula with (Hydrogen Peroxide) then rinse thoroughly with sterile water or saline
How often should tracheostomy care be performed and how often should ties be changed ?
- Trach care should be performed ever 8 Hrs
- Trach ties should be changed every 24 Hrs or as needed when soaked
- If trach tie has to be changed, ask another nurse to secure tracheostomy tube in place
What kind of gauze is used for tracheostomy ?
Pre-cut gauge, cutting gauge would cause shredding, may cause aspiration
Which Pt’s use cuffed trach’s ?
Clients on mechanical vents or CPAP
For Pt’s awake, alert, and able to protect air away, is the cuff inflated or deflated ?
Deflated
What should always be at the head of bed next to trach Pt ?
Tracheostomy obturator attached with seated tracheostomy set
What are water seal chest drainage systems used for ?
- For either pneumothorax or hemothorax or both
- It is a closed drainage system to remove fluid/air or both from pleural space
Are nursing able to insert chest tubes ?
NO, physician does insertion with the assistance of the nurse
In a PNEUMOTHORAX where is the chest tube inserted ?
2ND or 3RD intercostal space (Think lungs are higher up and can easily fill with fluid)
In a HEMOTHORAX where is the chest to tube inserted ?
7TH or 8TH intercostal space
What to be alert for in a water seal
- Air leak in the water seal
- Excessive or constant bubbling due to leak, can result to tension pneumothorax
- Fluctuations or Tidaling means Pt is progressing, it is normal
When do fluctuations stop ?
- When lung is re- expanded
- Tubing is obstructed by blood or clot
- Development of loops
What to look for when assessing fluctuation or tidaling ?
- Fluid in the water seal
- Rises on inspiration/Falls on expiration
What does intermittent bubbling in the water seal indicate ?
Air is exiting the plural space, consistent with resolving pneumothorax
What does rapid, vigorous bubbling in the water seal indicate ?
- Large air leak consistent with a teat in the pleura, bronchopleural fistula, or a crack or leak in the drainage system
Set Up for Chest Tubes
- Equipment
Chest Tube Tray
Water seal drainage (Atrium or Pleur-a-Vac), Elastoplasts, Sterile 4X4 gauze, 50-ml syringe, kelly forceps, povidone- iodine (Betadine), gloves
Fill water chamber with sterile water (2cm level or up to the line)
Fill suction chamber with sterile water to the prescribed level (usually 20 cm water suction)
Documentation for water seal drainage
- Consent is obtained prior to procedure
- Observe UNIVERSAL PROTOCOL ( TIME OUT prior to the procedure)
Documentation for chest tubes continued
- Collection Chamber: Amount and appearance of drainage
- Water Seal Chamber: Water level, bubbling, and fluctuations of tidaling, fill (Sterile Water) 2cm level
- Suction Chamber: Water level
- Monitor chest tube drainage every 2 hrs
More frequently in the immediate post op period (Every 30 min during the first 2 hrs after the insertion - Mark output every 8 hrs and document amount and color
- Make sure that a chest X-ray is completed after the insertion to confirm the position of the tube
Trouble Shooting and what to check for
Patient suddenly experiences of trouble breathing
- Check for occlusion/kinking of tube and integrity of the line
- Ensure that suction control stopcock is in ON position
If there is constant bubbling in the water seal what do you monitor for ?
- Assess for leaks in the system (location of leak)
- Intermittently occlude for a moment (< 1 min) Chest tube or drainage tubing beginning at insertion site of progression to chest drainage unit
What to check for in a tubing obstruction
- Scan length of tubes for signs of mechanical obstruction
- If clots are there CALL MD
- Milking/Stripping of chest tube is only performed with a specific MD order
Nurse alert
- Ensure that tubing is patent and free of dependent loops (drainage accumulating in dependent loops obstructs chest drainage into the collecting system and increases pressure within the lung )
- Assess for air leaks in the system as indicated by consultant bubbling in water seal chamber
- Assess for patent system (NOTE: Fluctuations or tidaling of water in the water seal chamber. Gentle bubbling only)
- DO NOT TURN OFF SUCTION control stopcock OFF when transporting patient (to prevent tension pneumothorax)
- Dislodgment of chest tube/drainage system (put end of chest tube into a glass of water to maintain water seal)
AT INSERTION SITE INSTRUCT PATIENT TO TAKE A DEEP BREATH AND HOLD UNTIL SITE IS SEALED. IMMEDIATELY COVER WITH VASELINE GAUZE AND STERILE 4X4 DRESSING AND TAPE IN PLACE - If accidentally tipped over, immediately return it to the upright position
How long will a chest tube remain in place and for how many days ?
Chest tube will remain in place for a minimum of 24 hrs and maximum of 7 days due to risk of infection from the site
Indication of chest tube removal
- Improvement of respiratory status (first sign)
- Breathing is evenly, unlabored, and not having shortness of breath
- Symmetrical breathing on inspiration
- Respiratory date of less
- Output of less than 100ml in 24hrs
Chest tube discontinuation
- Removal of sutures while holding chest tube steadily in place
- Teach patient to perform valsalva maneuver by taking a deep breath (inhalation) and hold till the chest remove has already been pulled out
- Withdraw chest tube quickly simultaneously covering entry side with Vaseline gauze
- Obtain chest x-ray post removal of tube
Observe and document the following
- Respiratory rate and breathing pattern
- Chest auscultation and chest excursion
- Vital signs and pulse oximeter readings
