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Flashcards in Exam 3 Deck (153):
1

EDIA

E - Empathy statement. Ex. “I can see you’re very busy.”
D = Description of another’s behavior or situation (NON-BLAMEFUL). Ex. “I ordered my steak medium but it’s well-done.”
I - An “I” message (influence it has you you). Ex. “I can’t eat a well-done steak.”
A - Action Statement - What is it you want to happen? Ex. “Would you please exchange this for another, medium-cooked, steak?”

2

QUALITIES OF ASSERTIVENESS

Assertiveness is a characteristic of behavior, not persons.
-Assertiveness is person-centered and situation-specific, not a universal characteristic.
-Can’t apply same situations across the board; every situation is different (no cookie cutter approach that can be applied to all situations); need to express what you feel
-Assertiveness must be viewed in a cultural context as well as in terms of situational variables.
-Assertiveness is predicated on the ability of the individual to freely choose an action.
-I can be assertive and ask but I don’t get to choose
-Assertiveness is a characteristic of socially effective, non-hurtful behavior.
-Not having hurt feelings isn’t the goal but framing it where you have mutual respect is the goal

3

How we learn assertiveness:

1) Instruction – difference between selfish and self interest
2) Behavioral modeling
3) PRACTICE
4) Feedback

4

Ventilation:

Process of moving gases into and out of the lungs.
Requires coordination to muscular and elastic properties of lungs and thorax).

5

Perfusion:

CV system pumping oxygenated blood to the tissues and return deoxygenated blood to the lungs. (using concentration gradients to move respiratory gases.)

6

Inspiration

active process stimulated by chemical receptors in aorta

7

expiration

passive process depends on elastic recoil of lungs

8

Surfactant

chemical produced in lungs to maintain surface tension and keep alveoli from collapsing

9

Atelectasis

collapse of alveoli prevents normal gas exchange

10

What can lung volume be determined by?

age, gender and height

11

tidal volume

air exhaled after deep breath in.

12

purpose of the Pulmonary circulation

moving blood to and from alveolar capillary membrane for gas exchange.

13

Diffusion

process of the exchange of gases in the alveoli and capillaries of the body tissues

14

What does the oxygen transport consist of?

lungs and CV system

15

key carrier for oxygen and transports 97% of the body’s O2?

hemoglobin

16

What controls the regulation of respiration?

The CNS (neural) and chemical regulators. (CNS: Resp rate, depth and rhythm) (chem
reg: maintain depth and rate based on changes in CO2, O2, H and pH in the blood)

17

4 factors that influence oxygenation

physiological, developmental, lifestyle and environmental

18

conditions that affects cardiopulmonary functioning directly affects the body’s ability
to meet O2 demands.

-Hyper/hypo-ventilation
-hypoxia
-decreased O2 carrying ability
-hypovolemia
-decreased
-inspired O2 concentration
-increased metabolic rate
-conditions affecting chest wall movement (IE: pregnancy, trauma, musculoskeletal abnormalities etc)

19

hypoventilation

Retaining CO2 (determined by ABG-arterial blood gas tests that are drawn)

20

When does hypoventilation occur and what are the S/S?

Occurs when alveolar vent. is inadequate to meet O2 demand of body or rid enough CO2.
S/S: mental status change (drunk walking), dysrhythmias, potential cardiac arrest.

21

Hyperventilation

Removal of CO2 faster than it is produced.

22

What can hyperventilation be caused by and its S/S?

Caused by anxiety, drugs, acid/base imbalance, fever or chemically can induce
S/S: rapid RR, sighing breaths, numbness/tingling of hands/feet, light-headedness, loss of
consciousness, maybe Kussmaul’s breathing.

23

hypoxia

Inadequate tissue oxygenation at CELLULAR level.

24

What can cause hypoxia?

Caused by:
-decreased Hb
-diminished inspired O2 (high altitudes)
-inability to extract oxygen from blood
-decreased diffusion of oxygen from alveoli to blood (pneumonia),
-poor tissue perfusion (shock), and impaired ventilation (rib fx, chest trauma).

25

Two earliest S/S of hypoxia?

Apprehension, restlessness.

26

Later S/S of hypoxia

Some other S/S are: inability to concentrate, decreased consciousness, dizziness,
behavioral changes,cyanosis, increased pulse and depth of respiration.

27

What are some cardiac/respiratory changes that occur with aging?

-chest wall/airways become rigid and less elastic
-amount of air exchanged decreases
-cough reflex decreases
-mucous membranes dry and are more fragile
-decrease in muscle strength/endurance, and efficiency of immune system
-increased risk for respiratory infection!!

28

What are some lifestyle factors that increase the risk for heart disease which affects Resp?

Nutrition, exercise, smoking, substance abuse, and stress.

29

Environmental Factors that increase the risk for respiratory diseases:

Location: Altitude (mountains vs. plains), heat, cold, air pollution (smog, second hand smoke) air quality, second hand smoke, hot air and extremely cold air harder to breath.

Workplace: Asbestos, talcum powder, dust, airborne, fibers (breathing in these substances in can affect the lung tissue, increased risk of developing respiratory issues)

30

Airway assessment: what are we looking for?

-pain
-fatigue
-Cough and hemoptysis
-Wheezing
-environmental and geographic exposures
-smoking
-respiratory infections
-allergies
-health risks
-medications

31

Assessment of breathing patters: what are we looking for?

-tachypnea
-bradypnea
-apnea
-orthopenea
-dyspnea
-kussmal's breathing
-cheyne stokes
-biots

32

tachypnea

seen with fevers, metabolic acidosis, pain, hypoxemia; rapid/fast breathing

33

bradypnea

seen with certain medications, metabolic alkalosis, or intracranial pressure; slower/depressed breathing

34

apnea

absence of breathing; during sleep

35

orthopnea

seen with heart failure and obesity; have to sit up to breath

36

dyspnea

seen with asthma, pneumonia, anxiety, CHF; difficult/uncomfortable breathing

37

Kussmaul’s breathing:

seen with metabolic acidosis; deep/labored breathing

38

Cheyne stokes

seen with chronic diseases, increased intracranial pressure or drug overdose.; rhythmic/deep pattern of very deep breaths then very shallow breaths and then no breaths and then the body kicks back in again to that original pattern

39

Biots (cluster) respirations

seen in patients with CNS disorders; short shallow breaths with periods of apnea (no deep breathing pattern)

40

Physical Examination: Assessment of the thorax

-inspection, palpation, percussion, auscultation
-observe the rate, depth, rhythm, and quality of respirations
-note the position the client assumes when breathing
-monitor patient’s oxygen saturation (SaO2) by using a pulse oximeter (place on the pt finger - be aware of cold, shaking hands or fingernail polish, can place in other areas to read the pt o2 level)
-shooting for 95%; anything below will be monitored; anything below 90% requires intervention - administer oxygen, deep breathing etc.

41

diagnostic studies re: airway

-Arterial Blood Gas
-Pulmonary function test
-Peak expiratory flow rate
-bronchoscopy
-lung scan
-thoracentesis
-sputum specimen
-chest xray

42

ABG

provides info on pt respiratory and metabolic status; will include acid-base imbalances; drawn from either the radial, brachial or femoral arteries

43

Pulmonary function test

group of tests put together to check the pt pulmonary status (breath/measure, exercise/measure, ABG)

44

peak expiratory flow rate

reflect changes in airway sizes; measure rate and note any changes

45

bronchoscopy

take a little tube with a camera on the end and go down pt mouth and look into the lungs looking for any masses; can take samples/sputum culture; can also remove foreign bodies and mucous plugs

46

lung scan

Nuclear scanning; go in if a mass has been identified on a chest x-ray; will allow to get a better image of mass; also used to identify blood clots

47

thoracentesis

surgical procedure that uses a needle and goes through the chest wall and pull back out extra fluid that is on the lung; used to get samples to send to the lab for testing for infection/cancer

48

sputum specimen

have pt cough up sputum and send to lab for culture/sensitivity; or for cytology purposes

49

chest xray

most basic image of chest

50

Acute care interventions re: respiration

Try to manage whatever is causing the problem
-dyspnea management
-airway maintenance
-hydration
-humidification
-nebulization
-coughing deep breathing
-chest physiotherapy
-postural drainage
-promoting lung expansion
-position
-incentive spirometry
-noninvasive ventilation

51

hydration

1500-3000 mL per day unless contraindicated; keeps mucous loose, thin and flowing

52

Humidification

adding water to gas; anything greater than 4 L

53

Nebulization

adding liquid to medication

54

coughing/deep breathing

cascade (cough, cough, cough, cough)

huff(saying huff with the cough)

quad coughing (spinal cord injury - press abdomen in and up);

deep breathing to help expand the lungs

55

chest physiotherapy

group of therapies that are going to be put together to help mobilize those secretions (percussion, vibration)

56

Postural drainage

semi to high fowler’s best position to help drain; have good lung go down if infection is only in one lung. High fowler’s best position for lung expansion

57

Promoting lung expansion

Ambulation - encourage early ambulation to promote lung expansion; get them moving; 1 week bed rest can cause up to 20% decrease in muscle

58

Incentive spirometry

5-10 breaths per session every hour while awake; focus is big deep breath in; (getting ready to blow out birthday cake) focus on expansion

59

Noninvasive ventilation

CPAP (continuous) provides air under pressure during inhalation and exhalation so that the airway is kept open and cannot collapse; BiPAP (bi-level) pressure delivered during exhalation is less than the pressure delivered during inhalation. (pt with sleep apnea, heart failure)

60

Suctioning

necessary when patient is unable to clear their airway secretions

61

Techniques of suctioning

oropharyngeal/nasopharyngeal: used when the patient is able to cough effectively but unable to clear secretions; apply suction after the patient has coughed

orotracheal/nasotracheal: necessary when pulmonary secretions can’t be managed by coughing and no artificial airway is present.

tracheal suctioning

62

what technique of suctioning is sterile?

oropharynx and trachea

63

each pass of airway suctioning can be no more than

10-15 seconds. Hold your breath

64

Negative airway pressure

(120-150 mmHG - some books say 100-150; important to know that greater than 150 can cause damage) during the withdrawing of the catheter; never on insertion, and apply intermittent suction and rotate the catheter when withdrawing catheter and use the smallest catheter possible to remove secretions; use the smallest catheter possible; give pt breaks between passes; allow them to breath; hyperoxygenate.

65

when should you suction?

Indicated when audible on auscultation or visible secretions (when you should do it); can hear the gurgling; may have secretions dripping out of their trach or running out of their mouth; pt may request it themselves

66

Trach Care/Suctioning

make sure wearing gown and face mask

-Nurses role is to maintain patency(make sure cannula not occluded) and reduce the risk for infection
-Includes suctioning the patient
-Most serious trach complication is airway obstruction which can lead to a cardiac arrest
-Important to always have a spare at the bedside in case it becomes occluded.

67

Oral airway artificial airways

~Prevents obstruction of the trachea by displacement of the tongue into the oropharynx
~Extends from teeth to oropharynx and maintains the tongue in a normal position
~Size is determined by measuring from patient's earlobe to their mouth
~Maintained/inserted using clean technique
~Good for unconscious patient
-Drunk patients

68

Endotracheal(ETT)

~Short term artificial airway to administer mechanical ventilation, relieve upper airway obstruction, protect against aspiration or clear secretions
~Inserted by physician
~Tube passed through patient’s mouth, past the pharynx and into the trach
~Most often removed within two weeks but can be used for longer
-May need a trach inserted if needed for longer than 2 weeks
~Can be used with a ventilator
~Must be maintained using sterile technique

69

Tracheostomy

~Used for long term assistance from an artificial airway
-If not permanent, hole will heal on own after removal
~Surgically inserted by a physician
~Consists of a small plastic tube that fits inside of a large tube that can be removed and cleaned or replaced
~Monitor for build up of respiratory secretions, suction as often as needed to clear secretions
~Patients cannot speak because the tubes are inserted below the level of the vocal cords
~ Can be used with a ventilator

70

CHEST TUBES

~ Catheter that is inserted through the thorax to
- Remove air and fluids from the pleural space
- Prevent air or fluids from re-entering the pleural space
- Reestablish normal intrapleural and intrapulmonic pressures
~ Common after surgery, trauma and used for treating pneumothorax or hemothorax to promote lung expansion

71

pneumothorax


~ Collection of air in the pleural space resulting from trauma, surgery, mechanical ventilation

72

hemothorax

~ Accumulation of blood and fluid in the pleural cavity usually resulting from trauma
~ Can also be from pneumonia, TB

73

chesttube maintenance

~ After insertion chest tube is attached to a drainage system that has three chambers for collection, a water seal and suction control
- Chamber is not emptied. RN marks location and initials collection point at end of shift

74

Handling the chest tube system

- Keep system closed and below the level of the chest
- Watch for steady bubbling in the suction control chamber and keep filled with sterile water
- Monitor for bubbling in the water seal chamber indicates a leak
- Make the level of drainage on the chamber every shift, record patency, type and amount of drainage, presence of fluctuations, dressing status, amount of suction or water seal and pain level
- Keep tubing from kinking and do not milk or clamp the chest tube
→ Can cause a change in lung pressure
- Encourage use of IS
- Maintain an airtight dressing over the insertion or puncture site
- Assess the patient’s vital signs, oxygen saturation and respiratory status, check the breath sounds bilaterally

75

OXYGEN THERAPY

~ Oxygen therapy is widely available and used in a variety of setting to relieve or prevent tissue hypoxia
~ Therapeutic gas and must be prescribed and adjusted with a health care providers order
~ Highly combustible gas and can cause a fire if it contacts a spark
~ Supplied either by tank of by wall piped system
~ Regulators control the amount of oxygen delivered, common type is a flowmeter

76

Education

- Keep away from open flames
- Secure tanks so they don’t fall over
~ Check portable cylinders before use to make sure that there is enough oxygen

77

METHODS OF OXYGEN DELIVERY

-nasal cannula
-oxygen masks
-venturi mask

78

types of oxygen masks

-simple face mask
-face mask with reservoir bag
-partial rebreather-bag
-nonrebreather bag

79

Breathing exercises

pursed lip breathing
-diaphragmatic breathing

80

pursed lip breathing


~Deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse
~Instruct the patient to sit up, take a deep breath and exhale slowly as if they are breathing through a straw

81

diaphragmatic breathing

~ Useful for patients with pulmonary disease, post op patients and women in labor
~ Relaxing intercostal and accessory respiratory muscles while taking deep inspirations
~ Place one hand on the breastbone and the other hand on the abdomen
~ Inhale slowly making the abdomen push out, exhale and the abdomen should go in
~ Can be used with pursed lip breathing

82

simple face masks

- Used for short term oxygen
- Fits loosely and delivers oxygen concentration between 35-50% FiO2
- Flow should be 5L or more to avoid rebreathing CO2

83

face mask with reservoir bag

- Capable of delivering high levels of oxygen
- Can be used as a non rebreather or partial rebreather

84

partial rebreather bag

should be 1/3 to half full with a flow rate of 6-10L and delivers 40-70% FiO2

85

Non rebreather-bag

should be inflated, flow minimum of 10 L, and 60-80% FiO2

86

Venturi Mask

- Delivers higher level of oxygen concentrations of 24-60% FiO2 with oxygen flow rates of 4-12 L

87

A patient has thick respiratory secretions. What should the nurse do to best help liquefy the patient’s respiratory secretions

Encourage the patient to drink more fluid

88

What client statement informs the nurse that the teaching about the proper use of an incentive spirometer was effective?

I should inhale slowly and steadily

89

Nasogastric Tubes types

-Large-bore nasogastric tube
-Salem sump tube
-Small-bore nasogastric tube (Dobhoff)

90

stomach tubes

Gastric tube (G-tube)
Percutaneous Endoscopic Gastrostomy (PEG) tube

91

Large-bore nasogastric tube

-Gastric decompression for intestinal obstruction or ileus
Removal of gastric secretions post GI surgery to allow -wound healing
-To obtain gastric content samples for analysis
-Lavage stomach to remove ingested substance
-Monitor quantity of gastric bleeding
-This is primarily used to suction. however, you may turn suction off and administer feedings or medication through this tube as well.

92

Salem Sump Tube

-Use large bore nasogastric tube with double lumen
Large bore primary lumen
-Blue air lumen vent
-Primary lumen is attached to suction (sump pump)
-Blue air lumen is kept above level of stomach and allows atmospheric air to enter stomach, reducing negative suction that can damage wall of stomach
be sure to use intermittent suction so you don’t damage stomach
-use an X-ray to determine placement
-Faye says the Salem Sump Tube and Large Bore are “essentially the same”
-Both are used to DECOMPRESS stomach

93

Small Bore Nasogastric Tube

Used for long term feedings – less irritating
-Tube is placed in small bowel requiring at least 40 inches to be inserted and carried into small bowel (tungsten weighted tip is radiopague)
-Inserted using metal stylet to stiffen tube
-Difficult to aspirate stomach contents as tube tends to collapse, use large syringe
-Placement must be verified by radiograph
-Continuous feedings usually administered rather than bolus due to size of lumen
-Medications can be administered through tube

Notes from class:
-This tube is used for FEEDING and medication admin (not suctioning)
-this is done only by a physician using a guide wire
-it is a weighted tube so that it doesn’t float up to a place it’s not supposed to be
-Aspirate to check the pH of the small bowel
-Placement must be checked on an X-ray
-“nasogastric” means in through the nose, to the gastric area

94

Equipment needed for Insertions

-Personal protective equipment
-NG/OG tube
-Catheter tip irrigation 60ml syringe
-Water-soluble lubricant, preferably 2% Xylocaine water soluble jelly
-Adhesive tape
-Stethoscope
-Cup of water (if necessary)/ ice chips
-Emesis basin
-pH indicator strips
-Tube placement should be indicated by pH strips-- different parts of the bowels have different pH’s

95

Steps for NG Insertion

-Gather equipment
-Don non-sterile gloves
-Explain the procedure to the patient and show equipment
-If possible, sit patient upright for optimal neck/stomach alignment
-Examine nostrils for deformity/obstructions to determine best side for insertion
-Measure tubing from the tip of nose to earlobe, then to the end of the sternum
-Mark measured length with a marker or note the distance
Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine)..
-Pass tube via either nare posteriorly, past the pharynx into the esophagus and then the stomach.
-Instruct the patient to swallow (you may offer ice chips/water) and advance the tube as the patient swallows. Swallowing of small sips of water may enhance passage of tube into esophagus.
-If resistance is met, rotate tube slowly with downward advancement toward closes ear. Do not force.
-Withdraw tube immediately if changes occur in patient's respiratory status, if
-tube coils in mouth, if the patient begins to cough or turns pretty colors
-Advance tube until mark is reached
-Check for placement by attaching syringe to free end of the tube, aspirate sample of gastric contents.
-Also use an X-ray to check placement before starting feedings

96

Stabilizations of Tubes

-Use either commercial tape product or adhesive tape split half way up and placed on nose and then wrapped around tube
-Also need to pin to gown to reduce tension on nose.
-Loop piece of tape around tube and pin “tail” to gown.
-Check patency of tube each shift to make sure tube does not fall out
needs to be clear each shift
-Document what number is at the nose at the end of each shift (to know whether it’s been moving or not)

97

GASTRIC TUBE

-Used for long term enteral feeding
-Surgically placed directly through wall of stomach or jejunum
-Tube is not visible under clothes
-Esophageal irritation is avoided
-From Study Guide questions: a Gastronomy Tube is inserted surgically and is held in place by sutures

98

PEG TUBE

-PEG tube placement can generally be performed under local anesthesia rather than general anesthesia.
-An endoscope is passed into the mouth, down the esophagus, and into the stomach so that the surgeon can see correct placement for tube
-The surgeon can then see the stomach wall through which the PEG tube will pass.
-Under direct visualization with the endoscope, a PEG tube passes through the skin of the abdomen, through a very small incision, and into the stomach.
-A balloon is then blown up on the end of the tube, holding in place.
-PEG gastrostomy tubes avoid the need for general anesthesia, take about 20 minutes, eliminate need for a large incision.
-Held in place by the design of the balloon

-The PEG tube extends from the interior of the stomach to outside the body through a small incision only slightly larger than the tube itself in the abdominal wall.
-Removal of the tube involves deflating the balloon section of the tube allowing it to slip easily from the stomach.
-About three inches of tubing will protrude from the incision area.

99

STOMA CARE

-The area around the wound must be kept clean and covered with clean, gauze.
-The incision area must be observed daily for redness, swelling, necrosis or purulent drainage
-Apply antibacterial ointment such as Neosporin to the insertion site after cleaning to help prevent infections (check hospital policy first).
-Excessive tension on the tube may also result in pressure necrosis of the interior abdominal wall.
-Excess tension on outside of abdomen by plastic disk can cause pressure sore on abdominal skin.

100

BOLUS FEEDING

-Provides nutrients to clients who are unable to normally ingest food (comatose, obstructive lesions, aphagia post stroke)
-Provide supplemental nutrition to clients with protein or calorie malnutrition.
-Provide supplemental nutrition to clients with high metabolic requirements.
-Provide specialized dietary supplementation.
-Maintain fluid and electrolyte balance. *** This one is really important***

101

CHECK PLACEMENT AND RESIDUAL: - THIS SHOULD BE DONE BEFORE ANY FEEDINGS OR ADMINISTRATION OF MEDICATION

•Check placement!!!
Assess abdomen for distension
Assess abdomen for bowel sounds
Check gastric contents PH should be

102

The patient is receiving a continuous enteral feeding. What assessment finding would require follow-up?

A residual of more than 100 mL is considered excessive. The nurse should stop the feeding, notify the physician, keep the patient in high-Fowler’s position, and recheck residual in 1 hour. Normal residual is in the 10 mL or less range. Bowel sounds in all 4 quadrants and pH of 5.0 in gastric contents is normal for a patient who is receiving continuous enteral feeding.

103

The nurse is going to administer an intermittent tube feeding. Since the patient's feeding tube has been in place for 3 days, what should the nurse do prior to administering the feeding?

Aspirate gastric contents and test on a pH strip.Ongoing verification of tube placement is made by pH testing of aspirate. Verification by x-ray is necessary upon feeding tube insertion and if tube migration is suspected. Auscultation is no longer considered a reliable method for determining feeding tube placement. The tube can migrate without moving at its externally taped location.

104

INSTRUCTION ON ADMINISTERING MEDICATION through GI tube

-1st - Pinch tube and open the stopper. Pinching the tube prevents excess air entering the stomach when the stopper is removed
-2nd- Connect syringe to tube.
-3rd- Pour 20-30 mls of lukewarm water into the syringe to check for blockage - the water must flow smoothly. This will also moisten the tube so that feeding will not stick
Next, fill syringe with feeding
-4th - Hold syringe upright to let feed flow into the stomach slowly, by gravity. Raising or lowering the syringe will cause the flow to go faster and slower respectively. It is not advisable to have a fast flow as this will distend the stomach quickly and may cause discomfort.

105

Medication through enteral tube

-Check medication against MAR
-Check for drug allergies
-Avoid interruption of NG feedings, try to group medications at one time
-Before crushing pill make sure the pill is crushable
-Never add medication directly to tube feeding
-Determine if medications interacts with feeding or any other medication ordered
-Check residual and placement (PH)
-Return residual if less than 100 ml
-Crush medication and dilute with 15-30 ml water
-Give according to medication policy including three checks of medication
-Flush with 10 ml between medications

106

The student nurse is preparing to administer medication through a feeding tube, what things would you need to keep in mind about medication administration through a feeding tube?

Flush with water prior to administering the medication to check for tube patency. Flush with 10 mL of tap water after each medicine and with 30-60 mL of water after the last medication

107

Ostomy

Temporary or permanent surgical opening created where the ends of the intestine are brought through the abdominal wall to create a stoma.

used for pooping

The Stoma is simply the opening itself in the abdominal wall, it should always be placed in the abdominal rectus muscle. It can either be temporary or permanent. Stoma management problems are most commonly related to a stoma that is too long/short, unusual stoma configuration, location of stoma, the presence of devices, and skin problems associated with it. A stoma bag should be changed every 3-5 days.

108

3 ostomy locations

-ileostomy
-Colostomy
-Urostomy

109

iliostomy

-An ileostomy is a temporary or permanent opening in the belly (abdominal wall) that's made during surgery. The end of the ileum (the lowest part of the small intestine) is brought through this opening to form a stoma, usually on the lower right side of the abdomen.

- The Salt output from an ileostomy is very high. A normal functioning colon would excrete almost no salt. Therefore salt intake of these patients is very important and must be monitored to avoid electrolyte imbalances. The body makes up a little of the salt loss by discharging less salt than normal through urine or perspiration. Too much salt intake will increase ileal output. It is advisable for these patients to intake above normal water intake so that urine output is increased decreasing the possibility of kidney stone development.


110

indications for an iliostomy bag

Crohn’s Disease, Ulcerative Colitis, Cancer, Familial Polyposis

111

colostomy

-Surgical opening in the colon in which an opening (stoma) is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall and suturing it into place.
o Colostomies take the name of the portion of the colon from which they are formed. (ascending, decending, sigmoid)
- The colostomy pouching system is designed to contain stool, manage flatus, prevent leakage, compatible with self-care, suitable to patients lifestyle, and provide physical/psychosocial security.

112

indications for a colostomy

cancer, diverticulitis, congenital conditions, stab/gunshot wound

113

Urostomy

Surgical opening in the ureters that creates an opening for the urinary system.

114

3 categories of stomas

-Loop:Temporary and large, transverse colon, two openings are created through ONE stoma. It is usually done on elderly patients because it’s a faster procedure shortening their time under anesthesia.

-End: One stoma formed from proximal end of bowel. The distal end of the GI tract is removed or sewn together.


-Double Barrel: Surgically severed colon, two ends brought out to abdomen, two stomas.

115

2 alternative ostomies

-Kock or Indiana Pouch: Internal reservoir connected to small intestine, continent stoma that needs to be manually drained with a catheter. IT HAS A STOMA. It does not drain however, it needs siphoned.

Ileoanal Pouch Anastomosis: The colon is removed, a pouch is created out of the small intestine and attached to the anus. NO STOMA.

116

Stoma assessment

o Color: A good stoma should ALWAYS be REDISH PINK and MOIST
o Swelling
o Trauma
o Healing
o Protrusion
o Measure Stoma
o Observe effluent: Describe color, odor, consistency, frequency, amount, shape, consituents
o Assess skin for irritation
o Contour of abdomen, scars, incisions

117

stages of psychosocial adjustment upon hearing they need an ostomy

shock
defensive retreat
acknowledgement
finally adaptation and resolution.

118

stoma issues

-stoma retraction
-flush stoma
-stoma prolapse
-stomal prolapse
-oval stoma
-mushroom shaped stoma
-stoma in skin fold
-peristomal hernia
-pseudoepithelial hyperplasia
-allergic reactions/appliance
-Irritant dermititis
-pressure ulcer

119

ostomy tips

· If the patient c/o itching, change the appliance.
· Never tape up an ostomy
· If patient is put on antibiotics for any reason, this makes them susceptible to yeast and yeast infections around site. Think preemptively and get doctor to order yeast powder to put around site.

120

stoma things to report to the doc

· Severe watery discharge lasting more than 4-5 hours. This diarrhea can lead to dehydration.
· No stoma output, may be a blockage associated with one of the following
o Abdominal Cramps lasting 3-4 hours
o Distended abdomen

121

stoma things to report to ET nurse

· Excessive/persistent stomal bleeding
· Swelling or elongation of stoma
· Changes in stoma color
· Cuts or ulcerations of the stoma
· Skin irritants around stoma
· Bulging of skin around stoma
· Persistent burning or itching
· Severe odor

122

physical factors that can affect pooping

-Age (Stomach size, peristalsis slows down with age, esophageal reflux isn’t as good - acid reflux is more common.
-Diet
-Fluid intake (not enough water, things aren’t going to move)
-Physical activity (mobility increases motility)
-Personal habits
-Position during defecation (squatting is the best)
-Pain (it shouldn’t hurt to poop; pain can be caused by hemorrhoids or Crohn's disease)
-Pregnancy (can slow things down, there is something else taking up space in the abdominal cavity)
-Surgery and anesthesia (slows movement, pain meds can slow things down as well)
-Medications (can help to move things)
-Diagnostic tests (colonoscopy requires prep work)

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Constipation

can't poop

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Impaction

caused by severe constipation. Not passing any stool - if you suspect that your patient is impacted and you wipe and wipe and wipe and you get brown, then they are impacted.

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diarrhea

watery stool

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Incontinence:

muscle walls relax, unable to hold stool to get to the bathroom. Leads to a lot of social issues. Incidence increases with age.

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Hemorrhoids

can be internal or external; very painful.
Swollen veins in the anal canal.
You can have internal and external hemorrhoids at the same time.
Straining or sitting on the toilet for long periods of time will cause pressure to build in vessels that normally fill with blood to help control bowel movements. This prolonged straining will cause the veins to fill with blood and stretch, creating a hemorrhoid.

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common causes of hemerrhoids

Straining to go: diarrhea or constipation
Being overweight
Pregnant women, primarily in the last 6 months

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Poop assessment

Color - Brown. Any other color is an abnormal color
Odor - It should be a little stinky. C. diff and blood in stool have very distinct smells.
Consistency - Should be nice and formed, soft
Frequency - Should be going daily or every 2-3 days.
Amount - This is going to depend on the patient. Cassie mentioned in the class that a rule of thumb is 150 grams daily.
Shape - The goal is to be type 4, type 3 is ok too. Everything else is not awesome.

Constituents - What’s in it?! Undigested food and bacteria are normal. Fatty pockets, worms, and blood are examples of abnormal fecal constituents.

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Things that help normal pooping

-sitting/squatting position
-privacy
-normal routine
-proper diet and fluids
-give them adequate time... not too short, not too long

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bedpan tips

Lower the head of the bed when positioning
-Don’t push the pan under the buttocks
-Raise head of bed to position of comfort when patient is attempting to use bedpan
-If patient left alone to attempt use, place call light within reach
-Lower the head of the bed when removing the pan
-Watch out for pressure ulcers
-Assist with cleaning the patient if necessary
-The easiest time to help wipe is when the patient is on their side. Even if the patient is able to clean themselves, it’s important to double check that the patient is clean.
-Baby powder on the rim will make it easier to pull out from under your patient.

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pooping interventions

-Cathartics and Laxatives
-Antidiarrheals
-enemas
-suppositories

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antidiarrheal agents

Used to stop diarrhea, especially if it’s been going on for more than 2 days
If the patient has diarrhea 2+ days, send a sample to the lab to figure out what’s going on

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enema types

tap water, soap suds, oil retention, hypertonic, normal saline, medicated, carminative (accelerates defecation)

the doc will order the type of enema that you should give the patient

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Prior to administering enema it’s important to assess

The last bowel movement
-Normal bowel patterns
-Hemorrhoids, look and watch out to be careful about how you administer them
-Mobility
-Abdominal pain
-External sphincter control, can the patient hold it in or is it coming right back out - talk to the patient to assess control

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cleansing enemas

-Promotes complete evacuation of feces from the colon
stimulate peristalsis through infusion of large volume of solution or irritation of colon’s mucosa
-Types include: tap water, NS, soapsuds, hypertonic saline
-The maximum volume is 1000 mL (this is a very large bag)
-If you administer 1000 mL and you are still having bowel come back, you need to let the doc know.
-Used for: surgical procedures, diagnostic procedures (colonoscopy), beginning bowel training (creates a clean slate for monitoring)

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To administer a cleansing enema

Use a warm solution
-Too hot and you will burn your patient
-Too cold and you will cause them to have a lot of cramping
-Patient should be in the Sims position

There should be at least one waterproof pad under them - Cassie recommended that we use 4-5 in addition to having towels on the floor to mop up any spills
-Make sure that the bedpan or commode is nearby
-Lubricate the end of the tubing if it is not pre-lubed

Slowly insert 3-4 inches (adults), directed angle pointed toward the umbilicus
-Introduce solution slowly over a period of 5 to 10 minutes
-If they can’t tolerate it, slow down
-If they can’t tolerate the slower pace, stop and have the patient hold for as long as they can, eliminate and continue until you’re done with the solution
-Remove the tubing
-Hold the solution in until they can’t hold it anymore
-Take the patient to the bathroom and help them get cleaned up

Document
-What does the fluid look like (contains stool particles, if it was ordered to do until clear then you need to be documenting that)

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Assessment after a cleansing enema

Assess patient for abdominal cramping, rigidity, bleeding or distention of abdomen (these are all bad things)
-Inspect the color and consistency of the stool
-Estimate/measure the amount of stool and fluid passed
-Assess amount of flatus expelled (good)
-Gas means that everything is moving
-Document if they are passing it or not

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suppositories

Used to administer medications (when other routes are not available)

Examples: fever, nausea, vomiting, pain - if the patient can’t take anything my mouth. May be used to administer a laxative overnight.

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To administer a suppository

-Patient is in Sims position or standing
-Lubricate suppository
-Insert past internal sphincter, 4 inches in adults and 2 inches in children
-Patient should lay flat for 5 minutes
-Be sure not to embed in fecal mass
-Make sure call light is within reach of patient
-Be aware that if you patient is passing the suppository right back out after you insert it, it’s not going to work.

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Digital removal

THIS IS YOUR LAST RESORT
You MUST HAVE a doctor’s order in order to do this
The nurse breaks up/removes the stool with their fingers
Very uncomfortable and risky - can stimulate the vagus nerve and can cause a sudden drop in blood pressure.
When it comes to the point where you have to digitally remove stool from your patient, they are so uncomfortable that they don’t really care what you do to get them moving again.

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Phlebitis Scale

**Looking for signs of inflammation that follow the path of the vein.
0: No symptoms
1: Erythema at access site with or without pain
2: Pain at access site with erythema and/or edema
3: Above with streak formation; palpable venous cord
4: Above with greater than 1in length; purulent drainage

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Types of IV methods

-Peripheral IV
-Central Line catheters (implanted by surgeons and sterile procedure when changing)
-PICC lines (peripherally inserted)
-Imported Ports (implanted by surgeons)

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Peripheral IVs

short term, increased complications, RN can place

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Central Line IVs

long term, DTR/AP nurse

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PICC

long term, can be placed at bedside by special trained RN

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Port System IV

long term, surgery, less maintenance than above

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IV sites to avoid

-Any signs of infection, infiltration, or thrombosis
-----IV can be used in these areas again only after they're completely healed
-Extremities on same side as a mastectomy may not be used. Use alternate side.
-Makes it difficult for a patient with bilateral mastectomy
-Extremities that are flaccid
-Extremities with vascular graft/fistula

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Maintaining IV

-Monitor IV for patency
-----no complications like infiltration, phlebitis
-Keep the system sterile and in tact
-----changing IV fluid containers, tubing, and contaminated site dressing as ordered or as needed
-Assessment can't be delegated to the aide
-Prevent and assess for complications (check hourly)
—Infiltration
—Phlebitis
—Local Infection
—Bleeding (leakage)

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Saline Lock

-Able to administer meds or fluids without having to have IV tubing connected at all times. Also maintains venous access in the event you need to give IV meds later.
-This gives pts increased mobility, safety , and comfort.
-Must be flushed regularly to maintain patency.

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Isotonic fluids

Same osmolarity as body

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Hypotonic

lower osmolality, moves H2O into cells…1/2NS

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Hypertonic

greater osmolality, pulls H2O out of cells…D5 Lactated Ringers