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NURSING PROCEDURES

RESPIRATORY
OXYGENATION Purposes: a.) to reverse hypoxemia by improving tissue oxygenation b.) to decrease work of breathing in dyspneic clients c.) to decrease myocardial workload Humidified O2 delivered through nasal cannula/prong at 1-6L/min (2545%); Face Masks: simple O2 mask at 5-8L/min (40-60%); venturi mask at 410L/min(25-50%) COPD clients; partial rebreather mask (50-70%): nonrebreather mask 10-15L/min (80-90%) Positioning (fowlers) Diet: Small, frequent meals Health Teachings: Deep breathing (expands alveoli and mobilizes secretion) Pursed-lip breathing (allows a gradual decline in intrapulmonic pressure hence preventing lung collapse) Ensure adequate hydration (to maintain moisture of the respiratory tract) Safety Checks: Not to use woolen blankets as this may create static electricity No smoking sign No grease or oil that may spark Ceck for kinks in tubings, connections, as well as for bubbles in the humidifier Untoward s/sx: Retrolental fibroplasia (retinal damage leading to irreversible blindness due to exposure to 100% O2 in adults and to high O2 flow rate (40% or more) in neonates, especially premature (retinopathy of prematurity)

Considerations:

RR <12cycles/min (among those w/ COPD since CO2 levels CHEST PHYSIOTHERAPY

act as the hypoxic drive, stimulating respiration)

a.) done BEST 15 minutes after nebulization b.) before meals / feeding Contraindicated to clients who are pregnant, have rib or chest injuries, dizziness, pulmonary embolism and recent abdominal surgery Percussion produces mechanical wave of energy (striking the chest rhythmically w/ cupped hands) that is transmitted through the chest wall 1-2 minutes but if w/ tenacious secretions: 3-5 minutes Vibration is done w/ the use of hands placed on clients chest w/ rapid and vigorous vibration as client exhales (5x) Postural Drainage makes use of gravity to assist in the movement of secretion (mucus-filled segment of lungs should be higher to allow movement out of lungs); done 10-15minutes; usually performed 3-4x/day. LOCATION OF SECRETIONS Apex / Upper lobes Posterior section of upper lobes Right Lobe Lower Lobes SUCTIONING Using () pressure; purpose: to maintain patent airway and to collect specimen for diagnostic testing Its therapeutic effect can be maximized if done after nebulization or chest physiotheraphy. It is imperative that suctioning precedes feeding Materials/Equipment needed: Catheter size: F5-8 for infants; F8-10 for children; and F12-18 for adult smaller size for oral cavity; larger for ET or tracheostomy tube POSITIONING High Fowlers Side-lying Left Lateral w/ pillow under the chest wall Trendelenburg

for newborns: mouth first then nose Wall suction w/ pressure at 50-95mmHg for infants; 95-110 children; 100120 adults Sterile H20 1L and disposable gloves Ways to Hyperoxygenate: take several deep breaths; increase O2 flow rate; hyperventilate w/ ambubag; 100% O2 delivered through mechanical ventilator Hypertonic flushing w/ saline solution through ambubagging can help liquefy phlegm prior to suctioning Steps: lubricate tip first by immersing it in saline solution Advance catheter during inspiration (epiglottis is open, without suctioning yet) open port until you feel resistance Retract catheter by 1cm before suctioning Exert suction by closing the open port, withdrawing catheter in rotating motion within 5 to 10 seconds only Hyperoxygenate in between suctioning; encourage DBE Untoward s/sx: increased PR and decreased O2 Sat: <90% Auscultate lungs for presence of adventitious sounds and s/sx of respiratory distress before (assessment) and after (evaluation) High pressure alarm on MV and presence of ronchi and wheezes indicate increased respiratory secretions USE OF INCENTIVE SPIROMETER

Purpose: measures and shows the flow of air inhaled through the mouth piece, thus providing an incentive to breath deeply Steps: fowlers position slow deep breaths to elevate ball in the device hold breath for 2-6 seconds and note the height reached clean mouthpiece after use ARTIFICIAL AIRWAY CARE Purpose: to administer O2, suction secretions and bypass upper airway obstruction

Endotracheal tube inserted through the mouth into the trachea and ending just above the bifurcation of the trachea into the bronchi, passing through the epiglottis and glottis (the client cannot speak) Nursing Responsibility: a.) Focused assessment (always anticipate things you need to prepare for) b.) Intubation Set: ET tube, guide wire, laryngoscope, gloves, lubricant (KY jelly), xylocaine spray, trache tie, leucoplast, ambubag, suction apparatus b.) Check placement (if intact) and ET level (cm); moisten lips and perform oral care PRN Tracheostomy Tubes artificial aperture made through the neck into the trachea of patient needing long-term airway maintenance. A curved tube (plastic or metal) is inserted through the opening and into the trachea to keep airway with an air-filled cuff to prevent leakage of air and bronchial aspiration of foreign materials. PARTS: a. Outer Cannula (Main Shaft) has a flange at the external opening of the tracheostomy stoma. Cloth or tape is tied through the flange around the neck of the patient to keep it in place b. Inner Cannula fits into the outer cannula; removed during trache care c. Obturator inserted into the tube to guide the outer cannula during initial placement; kept at the bed side in case the outer cannula needs to be reinserted. Nursing Consideration: fowlers, sign language/picture boards; done sterile gloves; no movement of tubes (irritates the trachea) and maintains cleanliness of tubes use hydrogen peroxide; tie should not be too tight (jugular vein compression) and interferes w/ coughing. Do not cut gauze! Have obturator at bedside!

GASTROINTESTINAL
NASOGASTRIC TUBE INSERTION Purposes: a.) Gastric Gavage (feeding) b.) Gastric Lavage (irrigation) c.) Decompresssion d.) Medication and Supplemental Fluid Administration Assessment: cipipi gained weight BEFORE Insertion Consciousness Presence of nasal polyps, deviated septum or nasal trauma Inability to swallow, cough or gag Presence of nausea and vomiting Impaired integrity of nasal and oral mucosa (infection, burn) AFTER Insertion Gastric distention Aspiration Improper placement into the lungs Nasal erosion Electrolyte imbalance Dehydration Principles: Position: high-fowlers (first is hyperextension followed by flexion) Length of tube to be inserted measure from tip of the nose to earlobe and down to the xyphoid process (apporoximately 50cm) Lubrication: tip with water-soluble lubricant (no fat-soluble which can cause lipid PNA) Encourage client to tilt or bend forward (closes epiglottis and trachea) and drink or swallow as tube advances

If tube meets resistance, withdraw it, relubricate and insert in other nostril.

Remember to stop and remove if client cannot talk; is coughing, tachypneic or cyanotic If not tolerated and contraindicated, place in right side-lying position with head elevated 45O to prevent aspiration Placement Aspirating 20-30mL of gastric secretions (green, off-white or tan) and measure the pH (0-4 due to presence of HCl); if 100mL or more than half of last feeding is the residual gastric content reported, reinstall and next feeding is withheld. Auscultate for a whoosing sound (tube in the airway not GI tract) Inject a small amount of air to the tube using asepto syringe and Immerse tip of NGT into water and observe for bubbling (which XRAY confirms proper placement

listening for gurgling sounds in the epigastrium (not very reliable) means it is in the lungs)

Type of Feedings a. Bolus Intermittent delivered into the stomach by means of gravity or a syringe b. Continuous delivered at an even rate by an infusion (kangaroo) pump over 24 hours c. Cyclic continuous feedings administered <24 hours, often at night. The client may eat regular meals throughout the day. d. Intermittent formula is administered preferably six times a day (or every 4 hours) Principles

feeding

Monitor bowel sounds and aspirate residual before each Check patency of tube prior to feeding Remember: Height of container = 12 Temperature of OF = lukewarm Duration of Delivery = not <15minutes (to prevent abdominal cramping) clamp tube for 30 minutes if cramping occurs Complications of Gastroenteral Feedings either through NGT or PEG Dumping Syndrome (to prevent, low fowlers position 30mins post OF) Obstructed tubing Nausea and vomiting Tubing inadvertently pulled-out Diarrhea Aspiration Pneumonia Stoma and skin infection or breakdown Hyperglycemia INTESTINAL OSTOMIES Purposes: a.) Provides an alterative feeding route b.) Elimination of feces or urine Types: 1. Gastrostomy an opening through the abdominal wall into the stomach 2. Jejunostomy an opening through the abdominal wall into the jejunum 3. Ileostomy an opening in the ileum (small bowel) for draining fecal material *no irrigation needed, wet fecal material, appliance needed all the time, meticulous skin care is necessary to prevent skin breakdown; bag is emptied if it is half-full 4. Colostomy an opening in the colon (large bowel) for excreting feces * solid fecal material comes out; can be irrigated; can be bowel trained

Assessment Stomal characteristics- red, initial slight bleeding normal, no irritation, 25 inches surrounding the area has no burning sensation Pale or dark-colored implies impaired circulation to the area) Size, shape and stomal bleeding Peristomal Skin each time the appliance is changed Amount and type of feces

Complication

Fluid and electrolyte imbalance Infection Constipation Stomal prolapse or retraction Skin breakdown feeding) Avoid lifting or contact sports Monitor I & O Burning sensation under the faceplate may indicate skin breakdown Laxatives and enemas may cause severe fluid and electrolyte Apply a barrier (Karaya Powder/Gum) over the skin around the Control odors: (Y? ABCD) A green leafy vegetable Bismuth Charcoal Deodorizer Nursing Considerations: Placement of ostomy determines its function Avoid gas-forming foods and nuts, but can have any food as

tolerated after 6 weeks(except for those whose chief purpose is enteral

imbalance stoma to prevent contamination with excreta Yogurt