1. of a disease process

2. of a trauma to GI tract

3. congential defects

They can be temporary or permanent!

RLQ! Ileum,small intestine.

Liquid, fecal material. Constant output.

Can't be regulated/controlled.

Has digestive enzymes, damaging to skin!

Very little odor. (not as much bacteria)

Fluid and electrolyte imbalance possible!

Don't have to wear appliance.

Use catether to empty.

Empty 3-5 times.

It's surgically inserted.

RUQ Usually temporary.

Liquid stool. Can't be regulated.

Digestive enzymes present (skin irritation possible)

Odor more present than ileostomy.

Usually temporary to allow distal portions to rest.

Near middle abdomen

Almost always temporary.

Semi liquid/soft stool.

Odor is a problem!

Enzymes a little less.

Most common!

LLQ Permanent.

Solid stool.

Can be regulated through diet and irrigation.

Don't always have to wear appliance.

Odor present!

Stoma is oblong/irregular.

Common in emergency/temporary.

Two parts: 1 draining, 1 resting.

They leave the bottom wall of the intestine intact.

Two Separate stomas

Intestine is entirely cut.

One side drains and one side rests.

Most Common!

Permanent

Bring intestine on abdominal wall.

May remove distal portion depending on diagnosis.

Always need a beefy red appearance!

If it's pale, purple, or black it's not getting blood flow there.

Look at size of stoma. Edema at first then will shrink in 4-6 weeks.

1/2-1inch protrudes above skin surface!

While cleaning it might bleed b/c of capillaries.

Cleanse with clear water and lotion free soap.

If there's a burning sensation there's skin irritation.

Measure the output, color, and consistency.

New ileostomy (liquid) will drain in 24-48hrs

New Colostomy will drain in 2-5 days

Empty when it's 1/3 to 1/2 full.

Is ONLY done if patient choose to have control.

It's installing into stoma.

Ileostomy almost never irrigated. It can cause perforation and cramping, and possible blockage.

Blockage-^in output, cramping.

LPNs CAN'T! irrigate!

Then lots of fiber (to form stool)& Lots of fluids to prevent blockage.

Limit gas forming foods: veggies, milk, carbonated beverages, alcohol.

Cheese, beans, onions, fish, and eggs cause extra odors.

Cranberry juice, buttermilk, parsley, and yogurt REDUCE odors!

Change every 3-7days!

1/3-1/2 inch left in between stoma and skin so it's not too tight to cause irritation.

1. Malignacy of urinary tract

2.radiation damage

3. birth defects

4.neurogenic bladder dysfunction

5. trauma

6.obstruction

7.pyleonephreitis

tube directly into kidney. 

Usually temporary (can be permanent)

HIGH RISK OF INFECTION!

two sources of output

STERILE TECHNIQUE! 

Make sure tube is patent. Only irrigated with 5ML

Right into bladder. 

Also called superpubic catheter.

For pts who don't tolerate a foley well.

permanent/temporary.

STERILE!

30ml/200ml for irrigating.

Section of ileum taken totally out of GI tract. Ureters put into it to make a pipeline and create a stoma.

Continuous drainage.

Permanent.

*mucuous in urinary output b/c of ileum.

They need appliance.

Take ureter and bring it to skin's surface to make a stoma.

Can be unilateral or take both out.

STERILE!

Have appliance.

Unilateral-2nd output

Bilateral-one output (bladder usually removed)

Ureters moved to sigmoid colon.

Makes stool liquid!

Urine flows out of rectum.

*Increase risk for infection

HIGH RATE FOR COMPLICATIONS!

Moved bladder forward to create stoma.

hard to get appliances to fit right.

Easily reversed.

Temporary.

Continent-insert cathether to empty!

Transplant ureters to part of small bowel. 

Pouch on abdominal wall.

Permanent.

Pt doesn't have to wear appliance. Empty 3-5 times

Diverts urine flow.

Contraindicated for compromised renal function and poor compliance

Hematuria right after surgery.

Watch for encrustations-whitish crystals in and around stoma. Means urine is too alkaline. Can lead to stone formation.

Urinary applicances can be hooked up to a foley at night.

Remember to empty at 1/3-1/2 full.

Complication

Shrinking of stoma

Results from alkaline urine. 

Give pt cranberry juice and vitamin C

Complication of urinary diversion

Aseptic techniquie...STERILE!

pts don't necessarily have to b/c it's their own organisms

Very small catheters up into ureters.

can be unilateral/bilateral

Used to make sure urine drains from kidneys.

Keep patent!

They are internal and surgically inserted.

Artificial semipermeable membrane that acts like the kidney. It's a filter. 

Pts arterial blood circulates through while chemical wastes and extra fluids are drawn out.

Diaylsate: solution that pulls out b diffusion in b/w fibers

Diaylzer: Acts as an artifical kidney that gets rid of wastes

Takes 3-4hours

3-4 times a week

Most ideal to dialize with arterial blood, but can be done with venous blood.

Check patency!!!

Hear the bruit, feel thrill!!!

Artery and vein hooked together. Diverts blood.

Raised area.

Fistulas need 6-8 weeks to mature. In the meantime use venous blood!

Synthetic material. Diverts blood flow into vein.

Grafts last 3-5 years.

Dialysate infused into peritoneum cavity. Blood doesn't go into machine.

Catheter implanted. Instilled and stays in for a period of time. (Dwell time approx 4-10 hrs)

Always dialysate in peritoneum, exchange always taking place.

Able to ambulate and move around.

Need to monitor I&O

Should have more coming out! b/c you're drawing out fluid

Peritonitis is a BIG RISK! STERILE TECHNIQUE!

Hook up and instill WARM soln!

Fluid coming out from peritoneal dialysis.

Should be crystal clear, pale yellow.

If it's cloudy-first sign of infection

pt might complain of abd pain

Sodium and fluid restrictions (not as tight on peritoneal)

Watch phosphorus intake-take meds to remove for peritoneal!

Artificial Airways

Used to:

1. Relieve mechanical airway obstruction

2. Provide mechanical airway ventilation

3. Permit easy access for secretion removal

4. Protect airway from aspiration due to impaired cough/gag reflexes

Usually temporary.

Very thick, heavy tube.

If problem persists more than 2-3 weeks perform tracheostomy.

Tube is too irritating. (which is why it's usually temp)

Incision into trachea just below 1st/2nd trachea cartilage

Can be temporary/permanent.

Permanent (disease, stroke, burns, things that affect the brain stem)

They have either 2/3 pieces

*All have obturator!!!

ALL TRACHS HAVE!!!

Fits in outer cannula and extends past end to make it round.

The minute the trach is in it comes out and is discarded.

USED FOR INSERTION ONLY!

NOT ALL TRACHS HAVE!

It clicks/Snaps in

Stays in place except when cleaning.

Some are disposable.

Anchor trach in place.

Create a seal so pts cannot aspirate secretions

Prevents leakage of air.

*Anyone on ventilator has to have a cuffed trach!

Alternating inflation so necrosis doesn't occur.

High pressure.

Doctor's order how much air and how often you alternate.

Hole on either side so air can go up to vocal cords

Permits them to talk.

1. Can't speak unless special design (fenestrated)

2. Lose cough reflex

3. Lose upper respiratory passage functions 

Obstruction b/c of secretions

Expulsion Emergency! -cough tube out

Hemostat needs to be kept in room to keep airway open!

Hemorrhage

Fistulas (b/w trachea & esophagus)

Aspiration

Ischemia-necrosis of tissues

New trach q15min! Pt will have lots of secretions b/c of inflamm

Otherwise use your judgment

Pt will be restless and have ^HR

STERILE!!! 100-120 for suction

Possible to irritate mucousa

Hyperoxgenate FIRST!

ALWAYS DO FIRST when trach suctioning!!!

Use ambubag if not a lot of secretions!!!

Squeeze when they inhale 3-5 times

Turn up O2 source if lots of secretions

For a minute/two.

10 seconds!

Intermittant suctioning on way out & twist!

Prevents infection at site

Maintains patent airway

Prevents skin excoriation

STERILE!

When changing ties, never untie old one before new one is on!

Hemostat

Suction

Ambubag

Trach kit (extra one)

When doing CPR put bag over trach!

1. controlling their pain

2. allowing them to participate in decisions

3. have prescence of loved ones for support

1. loss of motion/sensation (gradual/usually extremities)

2. Decrease in activity in GI tract (diff swallowing/secretions buildup)

3. Reflexes gradually disappear. Incontinent (sphinchter relaxed) & mental alertness varies.

4. Body temp ^, skin cool & calmy (circulatory system shuts down)

5.Dusky/gray/pale skin/mottling/bruised look (bloods not getting to periphery)

6. BP drops, pulse weak, fast, irregular. Pupils dilated & fixed. Pt is restless.

7. Secretions rattle in throat. Cheynes-stokes-period of tachypnea then apnea. 

Neurological Death

Brain Dead

1. Pt must be unresponsive & unreceptive to external stimuli as evidenced by coma.

2. No muscle movement, ESPECIALLY BREATHING EFFORT.

3. no brain stem reflexes. No EEG activity for 24hrs.

*LPNs CANNOT pronounce someone dead

Rigor Mortis

(Post Mortem)

Muscles of the body have become contracted and joints are immobilized

ATP is not getting to muscles.

It happens within 2-4hrs

Lasts 36hrs!

Algor Mortis

(post mortem)

Post Mortem cooling because circulation has stopped.

Temp decreases 1C per hour until it reaches room temp.

Livor Mortis

Post Mortem

Tissue Softening

Post Mortem

Skin has lost it's elasticity.

Skin is soft b/c of bacterial action taking place.

Embalming stops bacterial action.

Make sure head is in semi fowlers.

For autopsy-DO NOT REMOVE ANYTHING, but still clean up.

Catheter inserted into large vein located centrally in body

Tip of catheter terminates (ends) in superior vena cava/R atrium

1. minimize vessel irritation, inflamm/sclerosis that can occur in smaller veins

2. Used in chronic diseases, long term tx, chemo, long term antibiotics.

3. To monitor central venous pressure (CVP) - hydration status.

4. For TPN (total parenteral nutrition) CANNOT be given peripherally.

5. to obtain blood samples/frequent blood draws.

Goes directly into vein

Jugular/subclavian

HIGH RATE OF INFECTION!

SHORT TERM USE!

Peripherally Inserted Central Catheter

PICC Line

Antecubital threaded into superior vena cava or R atria

Left in place longer

Bad placement restricts mobility!

Chest area

Tunnel through SubQ tissue into superior vena cava

For chemo pts usually

Some are totally implanted

Usually long term!

1. Infection-STERILE TECHNIQUE! Look for redness, swelling, tendering, and warmth

2. Clotting-especially if not used all the time. **LPNs cannot flush central lines!!!

3. Air embolism!-potentially lethal! Air in lungs/line. Make sure all the air is out and cap is on secure so air can't enter port!!! Usually pts have an air filter to capture air bubble.

4. Pneumothorax-Air in the pleural cavity. Chest tube can be inserted if a lot of air. If it's only a little the chest will absorb it.

5. Phlebitis-Percutaneous and PICC line complication!

Usually done by physician.

STRICT STERILE TECHNIQUE.

Verify placement with Xray!!! Blue tip is radiopaque.

Sterile!

maintain connections and ensure they're securely taped.

To prevent air embolism!

Dressing changes per insitution policy.

Monitor for s/sx of infection.

Monitor for s/sx of air embolism.

S/SX

Air Embolism

SOB, tachycardia

Pallor, coughing

*substernal chest pain

Decrease in BP

Sterile! 

Even wear mask

Dressings are occulsive. If tape cover the entire gauze, but usually use transparent barrier.

Make sure to stabilize catheter to prevent displacement!

Tunneled Catheter Care

Check for:

SubQ Emphyzema

Press and check for crackling

Measures pressure of blood in R atrium which reflects R ventricular BP as well as ability of R side of heart to recieve and eject blood.

It helps up determine blood volume

Purposes of CVP readings

(Central Venous Pressure)

1. To assess hydration status

2. To monitor fluid replacement and determine specific fluid needs.

3. To evaluate blood volume.

Normal CVP 6-12cm of H2O.

Low CVP/High CVP

(central venous pressure)

Could mean:

Low: dehydrated, low blood volume, after hemmorhage

High: High blood volume, CHF, peripheral vasoconstriction

LPN can ONLY assist!!!

Maintain asepsis while D/Cing!!!

Pt placed in trendlenburg position (feet up/head down) to distend vein.

Valsalva maneuveur (bear down) to prevent air in vessel while removing catheter in central vein.

Occulsive dressing applied once removed!

NS, D5W, LR, .45NS, .45NaCl, .2NaCl, Sterile Water

Can hang subsequent bags of antibiotics, but cannot flush

Looks at pts response to care that has been given and to see if goals have been met.

Pts is the focus. Look at them and see what's changed. (similiar to the assessment)

1. Appropriateness of nursing action

2. Any need to alter interventions

3. Development of new problems/needs

4. Need for referrels to other resources (PT, OT)

5. Need to rearrange other priorities to meet changing demands of care.

If goals need revision after evaluating,

Ask these questions:

1. were goals realistic & appropriate for pt

2. was pt involved in setting goals

3. was important info overlooked in assessment phase

4. were all the interventions carried out properly

5. was there an incorrect nursing diagnosis

6. did new problems arise

Keep Maslow's Hierarchy in mind***

1. Physiological Needs

2. Safety

3. Love & belonging

4. Self esteem

5. Self actualization

Mucus secretion that comes from the respiratory tract.

NOT HEALTHY!!!

Can be a sign of upper respiratory inf, bronchitis, CF, TB

It interferes with gas exchange

Cilia doesn't work as well b/c it's held down by the mucus.

1. Airway obstruction

2. Problems with gas exchange

3. Hypoxia (deficient in O2)

4. Atelectasis (collapse of alveoli)

^fluids, cough & deep breath, turn and position

Chest Physiotherapy

CPT

Doctor has to order!

loosens the sputum from smaller airways into bigger airways to be coughed up or suctioned.

Pts with COPD, asthma, CF, TB (have this done), etc

Increased intracranial pressure

Spinal cord injuries

Abdominal Aneurysm Ressection

Some thoracic trauma

1. Postural Drainage (PD)

2. Percussion/Clapping (PD & C)

3. Vibration

Cough and deep breath after all done

Give break in b/w positioning!

Gravitational clearance of airway secretions from various lung segments.

Use one/more of a variety of body positions.

DONE BEFORE MEALS!!!

LISTEN TO LUNG SOUNDS BEFORE!!!

STAY IN POSTION 15MIN!

Watch tolerance, may have trouble breathing. Give pain meds first.

Forceful striking of the skin with cupped hands to loosen secretions in the lungs.

Strike right over affected area. NOT ON SKIN!

DO NOT CLAP OVER STERNUM, BREASTS, SPINAL CORD, AND KIDNEYS!!!

Clap for 5-7min!!!

Done 3-4 times/day

Done on EXHALATION ONLY!!!

Tell pt to slowly let it out and purse lips.

Lock arms and wiggle/vibrate over area.

Do it for 2-4 breathes.

Done 3-4 times/day

Listen to lung sounds after. Note what comes up and evaluate respiratory rate.

To remove secretions from upper respiratory tract thereby maintaining a patent airway if this person is not able to do so on their own.

Indications: If they can't expectorate/swallow. When you hear audible rattling from secretions accumulating. Pt might have weakened muscle tone.

Freq: As often as needed. Order will be PRN.

But you do NEED an order to suction!

Point at which bronchi split.

Cough receptors are located here.

When suctioning hit those to stimulate a cough.

Don't stop suctioning if coughing occurs!!!

Explain to pt it won't hurt it'll just be uncomfortable and that they'll feel better after.

Position them in at least semi fowler's.

Med setting suction. 80-120ml/Hg

If it's on high it can cause mucuousal irritation.

STERILE TECHNIQUE! (except oralpharyngeal)

Orapharyngeal

&

Nasapharyngeal

Both 5in

Tip of nose to earlobe

Ora-lots of gagging, NOT sterile

Nasa-STERILE!

Do not exceed 10-15 seconds!!!

If you need to repeat clear with normal saline first!!!

One time only use!!!

Can do nasal then oral (NOT VICE VERSA)

Same as Nasalpharynx except deeper.

About 8inches.

Tip of nose around ear to adams apple.

10 seconds ONLY!!!

Intermittant suctioning.

STERILE!!!

NOT STERILE!

Can be used for 24hrs!

Orally only!

One size (except peds sizes)

GET IN THE AM!

Cough and spit into cup.

Also can use luken's trap

(self contained)

TIME FACTOR!

Should be intermittant.

It's preveting gas exchange!

Help determine adequate gas exchange at alveoli level. 

Determine acid base balance and detect hypoexemia.

Has to be done on ARTERIAL BLOOD!

Can't be done on venous blood (has too many changes)

ABGs-do not detect disease/distinguish cause of imbalance!

pH 7.35-7.45 acid/alkaline

pO2 80-100 amt of O2 in blood

pCO2 35-45mmHg amt of carbon dioxide in blood

SaO2 94-100% amt of hemoglobin bound to oxygen

HCO3 (bicarbonate) indicator of acid base balance

Occur in pts whose respiratory function is impaired to the point where lungs cannot remove carbon dioxide.

(COPD)

pH down, pCO2 ^

Example: hyperventilating

Opposite of acidosis

pH ^, pCO2 down

If a person has good oxygen saturation they can still have hypoxemia. Have to draw ABG!

S/SX: restlessness, confusion

Drawn by physician/specially trained RN/respiratory therapist

Most common place: radial (safest, most accesible)

Femoral (emergency, harder to stabilize, likely to cause infection)

Brachial (last resort, hard to find & stabilize)

*STERILE!

Glass syringe coated with heparin so specimen doesn't clot.

Put on bag of ice also to decrease chance of clotting.

TAKE IMMEDIATELY TO LAB!!!

Explain to pt that it HURTS!!! ouch :(

Remind them not to hold breath!

Apply pressure 3-5min!!!

If only blood thinners you need to hold longer!!!

Check site after. Check circulation DISTAL to puncture.

Results come fast.

Bronchial 

Breath Sounds

Top

Created by air moving through trachea

Loud & hollow sound

Short insp, Longggggg exp

Heard anterior (front) over trachea

Bronchovesicular

Breath Sounds

Created by air that's moving through larger airways

(such as the bronchi)

Medium pitch/Blowing sound

Inspir=exp phase

Heard best posterior (back) b/c scapula

Anteriorly lateral at about 1st and 2nd intercoastal space.

Vesicular

Breath Sounds

Created by air moving through bronchioles & alveoli

Soft, breezy sounds

Low pitch

Inspir phase 2-3x longer than exp phase

Heard over periphery of lungs & bases

Expand on inspiration

and

Collapse on expiration!

Are heard IN ADDITION to normal sounds!

If you hear nothing, no gas exchange occuring.

Possible lung collapse!

Caused by air that is passing by fluid/mucus

Smaller airways (bronchioles/alveoli)

Heard on inspiration/exp

High/low pitched

May clear with coughing, but usually do not!

Caused by air trying to get through fluid mucus

Larger airways

Deeper/rumbling sound

Heard more on expiration

Coughing CAN clear it up!

Caused by air trying to get through a constricted bronchi

The constriction can be from swelling, fluid/secretions, or bronchospasms (COPD)

Whistling sound (can be heard w/o stethoscope sometimes)

All over lung sound-heard on insp & exp

Caused by rubbing together of inflammed pleural surfaces.

Creaking sound

Heard best on insp (can be heard on exp)

Cough has NO effect!

Anterior & lateral heard best!

In pleural cavity in a healthy person

If air, blood, fluid, gets in chest cavity it changes negative pressure and can lead to lung collapse.

pt has trouble breathing if above occurs.

Gets rid of things in chest that aren't supposed to be there. 

Reestablishes negative pressure.

Where it's placed determines type of drainage.

All tubes placement confirmed by xray!!!

All prevent backflow!

Air in chest.

Higher in chest cavity

2/3rd intercoastal space

*air rises

Not really any drainage!

Blood in cavity

5/6th intercoastal space

More lateral

Drainage: sanguinous

Tubes often hooked up to suction

Buildup of fluid

5/6th intercoastal space

More Lateral

Drainage: Serous (yellow)

Tubes often hooked up to suction

Common after open heart surgery

Placed just below sternum

Connected to drainage system (suction)

Keeps fluid away from heart

Sterile Water

No suction

Single bottle/chamber

ALWAYS below chest level

Drains by GRAVITY!

3 bottles/chambers

Water seal

Recieving chamber

Suction

Do not empty when full. Mark line each time when measuring.

Water volume rises up tube and when exhaling it goes back down.

When tidaling stops lung has reexpanded!

Have 2 rubber hemostats (clamps)

Sterile vasoline gauze (in case tube gets dislodged to cover opening)

Have another drainage system on unit

Units need to be kept BELOW chest level!

It's a closed system (can be kept on the floor)

Maintain patency! Tube coiled on bed to prevent backflow!

Milk the Tube

& 

Stripping the Tube

If a clot in the tube (drainage stuck) milk the tube (pinch and quickly release) Do not need doctor's order.

Stripping the tube NEED DOCTOR'S ORDER!!!

Squeeze the tube to increase pressure in chest cavity.

Will see tidaling.

If you don't see tidaling then there's either

1. occulsion

2. the lungs have reexpanded

Check by listening to lung sounds!

if there's suction you have to temporarily turn off suction to see tidaling b/c suction keeps negative pressure.

Sudden gush of drainage - could indicate hemmorhage (100ml or more) right after surgery there will be a lot of drainage.

Hemothorax - sanginous

Pleural Effusion - yellow/serous

DON'T EMPTY JUST MARK!

ONLY clamp when looking for air leaks and when switching out the system or if the system accidentally disconnects.

Do this to prevent air from rushing into chest cavity.

If the tube is dislodged/pulled out put vasoline gauze over site STAY WITH PT!!! and call for help!

Vasoline is occulsive. Pt might struggle to breathe.

If trouble breathing release hand for short period of time.

Avg time left in 5-7 days

Before removing need xray, check lung sounds & make sure there's no tidaling.

Drainage should be tappering off. Less than 50ml/24hrs

Clamped for trial period to test respiratory function.

Pt sitting up for removal. Deep breath & hold it.

Valsalva manuever(bare down) slide it out. 

Vasoline gauze over site.

Monitor vitals ESP RESP STATUS AFTER!

Jo

Ratner

Someone who's going to kickbutt on the procedures test

:D