112A prelims.pdf

ECG/ Diana Kris L.Ngayawon Rn Electrocardiogram Instructor  It provides information about your heart rate and rhythm, and shows if there is enlargement of the heart due to high blood pressure (hypertension) or evidence of a previous...

ECG/ Diana Kris L.Ngayawon Rn Electrocardiogram Instructor  It provides information about your heart rate and rhythm, and shows if there is enlargement of the heart due to high blood pressure (hypertension) or evidence of a previous heart attack (myocardial infarction).  You may need an ECG if you have any of the following signs and symptoms: Chest pain Dizziness, lightheadedness or confusion Heart palpitations Rapid pulse Shortness of breath Weakness, fatigue or a decline in ability to exercise.  Sample of cardiac Telemetry: If your symptoms tend to come and go, they may not be captured during a standard ECG recording. In this case your doctor may recommend remote or continuous ECG monitoring. There are several different types. 1.Holter monitor 2.Event monitor 3 lead and 5 lead ECG: 12 LeaD ECG  Edit Edit Edit Edit Edit 12-lead Precordial lead placement: V1: 4th intercostal space (ICS), RIGHT margin of the sternum V2: 4th ICS along the LEFT margin of the sternum V4: 5th ICS, mid-clavicular line V3: midway between V2 and V4 V5: 5th ICS, anterior axillary line (same level as V4) V6: 5th ICS, mid-axillary line (same level as V4)  Edit Edit Edit Edit Edit RIGHT AXIS LEFT AXIS: Parts of the ECG: SEQUENCE METHOD:  Edit Edit Edit Edit Edit  ECG - Risk An electrocardiogram is a safe procedure. There is no risk of electrical shock during the test because the electrodes used do not produce electricity. The electrodes only record the electrical activity of your heart. You may have minor discomfort, similar to removing a bandage, when the electrodes are removed. Some people develop a slight rash where the patches were placed. Referrences: End of Discussion: THANK YOU😘☺฀…  THE RESPIRATORY SYSTEM nasal cavity pharyn x larynx trache a  left main primary bronchus bronchi right main primary bronchus Carina of trachea right lung  Nebulizer Nebulization  Nebulizer Nebulization (PURPOSE)  Nebulizer Nebulization (PURPOSE)  Nebulizer Nebulization (PURPOSE)  History The first "powered" or pressurized inhaler was invented in France by Sales-Girons in 1858. This device used pressure to atomize the liquid medication. The pump handle is operated like a bicycle pump. When the pump is pulled up, it draws liquid from the reservoir, and upon the force of the user's hand, the liquid is pressurized through an atomizer, to be sprayed out for inhalation near the user's mouth.  History In 1864, the first steam-driven nebulizer was invented in Germany. This inhaler, known as "Siegle's steam spray inhaler".  History The first electrical nebulizer was invented in the 1930s and called a Pneumostat. BERNOULLI’S PRINCIPLE  BERNOULLI’S PRINCIPLE no such machine would have been invented if not for the discovery of the Bernoulli Principle. Daniel Bernoulli that when water hits a rock it creates a mist that can be inhaled. He published a book in 1738 where he described that a similar effect could be created by forcing water through a narrow tube  His concept was based on the fact that the faster water flows through a tube, the less the lateral pressure will be. A decreased lateral pressure is also referred to as a negative side stream pressure. If there is a hole in the side of the tube, the negative pressure will force water into the stream. This same concept was used in creating the first nebulizers. only using air. Air is forced through a tube, and a hole in the Cube is connected to a container with a solution in it that contains the medication. The fluid is basically sucked in due to the negative sidewall pressure, and turned into a spray or mist  TYPES OF NEBULIZER inhaler or metered dose inhaler ultrasonic nebulizer jet nebulizer A nebulizer is a device that uses a small compressor to convert liquid medication into tiny droplets of mist that can be inhaled directly into the lungs. the medication goes straight to the lungs, onset of the medication's action often takes place rapidly. equipments 9. THANK YOU CHEST PHYSIOTHERAPY/ CPT Introduction The goal of respiratory care interventions is to improve air flow and gas exchange. Standard nursing care for all clients includes independent nursing measures to promote pulmonary dysfunction helps the nurse to individualize care planning and to evaluate the client's response to care measures. Introduction Crackles (fizzing or popping sounds) heard at the end of inspiration indicate hypoventilation of alveoli- signals the need for deep breathing and turning Clinical Manifestation of Inadequate Ventilation Wheezes are musical sounds heard on inhalation or exhalation. They indicate secretion retention or airway spasm.-Interventions that promote airway clearance and pharmacologic bronchodilator therapy can help to reestablish unobstructed airflow. Clinical Manifestation of Inadequate Ventilation Crackles at the end of inspiration, usually heard on independent lung areas Dyspnea-difficulty in breathing; the client's sensation of being short of breath Restlessness or loss of muscle coordination Use of accessory muscles for breathing Change in cognition or level of response Clinical Manifestation of Inadequate Ventilation Tachycardia-heart rate over 100 beats per minute Tachypnea-breathing rate over 24 breaths per minute Increased blood pressure Cyanosis-bluish discoloration of mucous membranes (Po2 < 60 mm Hg or Spo2 < 85 percent) Measures to Support Respiratory Function 1. Adequate hydration 2. Assist the client to a comfortable Fowler position with pillows supporting the arms to promote optimal ventilation. 3. Turning clients and encouraging deep breathing. According to Study Deep breathing >is the most effective way to prevent postoperative pulmonary complications According to Study Encouraging clients to cough while splinting operative sites helps remove retained secretions that increase airflow resistance and lessens the risk of nosocomial infection. According to Study Range of motion exercises (passive or active) stimulate both the rate and depth of breathing. Early ambulation promotes greater air exchange (tidal volume) and reduces the risk of other complications of immobility that negatively impact pulmonary function (e.g., pulmonary embolism). According to Study Bronchopulmonary hygiene chest physiotherapy, sometimes called pulmonary toilet, includes postural drainage, percussion, and vibration. These medically prescribed therapies are indicated when the client has excessive amounts of thick secretions that become difficult to mobilize. ASSESSMENT Assess client's ability to perform breathing exercises. Evaluate client's operative pain before breathing exercises are encouraged. Identify if client is able to independently continue breathing exercises at regular intervals. Assess client's breath sounds for improvement following breathing interventions. Deep Breathing and Coughing GOALS 1. Improve ventilation 2. Increase the effectiveness of cough and promote airway clearance 3. To prevent post operative pulmonary complications 4. To improve the strength endurance coordination of the muscles of ventilation GOALS Maintain and improve chest and thoracic spine mobility Promote relaxation and relive stress To teach the patient how to deal with episodes of dyspnea Assist in removal of secretions. Diaphragmatic Breathing Diaphragmatic breathing is a deep breathing exercise that fully engages the diaphragm and increases the efficiency of the lungs. Refers to a flattening of the dome of the diaphragm during inspiration, with resultant enlargement of the upper abdomen as air rushes in expiration abdominal muscles contraction expiration How to Perform Deep Breathing and Coughing 1. With client sitting upright, instruct client to breathe in slowly through nose to expand chest and abdomen, and to hold sustained inspiration for 3 to 5 sec, then exhale slowly through mouth. 2. After several deep breaths, instruct client to inhale deeply, hold breath for several seconds, lean forward, and cough rapidly through an open mouth, using abdominal, thigh, and buttock muscles. 3. Instruct client with pulmonary condition to exhale through pursed lips and to cough throughout exhalation in several short bursts (not at end of deep inhalation). How to Perform Deep Breathing and Coughing 4. Instruct client with abdominal incision to cross arms over pillows as abdominal muscles contract during cough. 5. Instruct client to use manual pressure on wound, or support incision with palms of your hands. 6. Assess client regularly and provide positive reinforcement. Encourage client to repeat deep breathing exercises several times hourly. 7. Repeat cough only if it is productive of secretions. Coughing 1. Lean forward slightly from a sitting position in bed, interlace your fingers together, and place your hands across the incision site to act as a splint for support when coughing. 2. Breathe with the diaphragm as described under “Diaphragmatic Breathing.” 3. With your mouth slightly open, breathe in fully. 4. “Hack” out sharply for three short breaths. 5. Then, keeping your mouth open, take in a quick deep breath and immediately give a strong cough once or twice. This helps clear secretions from your chest. It may cause some discomfort but will not harm your incision What to Remember while Doing Deep Breathing and Coughing Breathe slowly and rhythmically to exhale completely and empty the lungs completely. Inhale through the nose to filter, humidify, and warm the air before it enters the lungs. If you feel out of breath, breathe more slowly by prolonging the exhalation time. Keep the air moist with a humidifier.  Film Viewing on Deep Breathing and Coughing How to Perform Diaphragmatic Breathing 1. Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing. 2. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. 3. Breathe out through pursed lips while tightening (contracting) the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. 4. Repeat for 1 minute; follow with a rest period of 2 minutes. Gradually increase duration up to 5 minutes, several times a day (before meals and at bedtime). Pursed-Lip Breathing Goal: To prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance How to Perform Purse Lip Breathing 1. Inhale through the nose while slowly counting to 3—the amount of time needed to say “Smell a rose.” 2. Exhale slowly and evenly against pursed lips while tightening the abdominal muscles. (Pursing the lips increases intratracheal pressure; exhaling through the mouth offers less resistance to expired air.) 3. Count to 7 slowly while prolonging expiration through pursed lips— the length of time to say “Blow out the candle.” 4. While sitting in a chair: Fold arms over the abdomen. 5. Inhale through the nose while counting to 3 slowly. 6. Bend forward and exhale slowly through pursed lips while counting to 7 slowly. 7. While walking: Inhale while walking two steps. Exhale through pursed lips while walking four or five steps.  Film Showing For Diaphragmatic Breathing STEAM INHALATION Also called steam therapy It involves the inhalation of water vapor. The warm, moist air is thought to work by loosening the mucus in the nasal passages, throat, and lungs. This may relieve symptoms of inflamed, swollen blood vessels in your nasal passages.  Film Showing for Small-Volume Nebulizer (Mini-Nebulizer) Therapy Chest Physiotherapy Chest physiotherapy (CPT) includes postural drainage, chest percussion and vibration, and breathing retraining. In addition, educating the patient about effective coughing technique is an important part of CPT. Goals of Chest Physiotherapy 1. Remove bronchial secretions 2. Improve ventilation 3. Increase the efficiency of the respiratory muscles. Postural Drainage Also called Segmented Bronchial Drainage Allows the force of gravity to assist in the removal of bronchial secretions The secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning Postural Drainage The nurse instructs the patient to inhale bronchodilators and mucolytic agents, if prescribed, before postural drainage, because these medications improve drainage of the bronchial tree. Postural Drainage force of gravity helps move secretions from the smaller bronchial airways to the main bronchi and trachea. lower and middle lobe bronchi drain more effectively when the head is down, whereas the upper lobe bronchi drain more effectively when the head is up. The secretions then are removed by coughing. POSITIONS FOR POSTURAL DRAINAGE Chest Percussion The physician has ordered that the patient receive percussion and vibration to help clear airway secretions. Where must the nurse place her hands? Chest Percussion 1. Cup your hands with thumbs and fingers closed. 2. Keep wrists loose and relaxed and rhythmically flex and extend wrists to clap over area 3. Alternate hands to percuss, and listen for hollow sounds with wrist movements 4. Percuss each area for 3 to 5 min. VIBRATION Can be done manually Can use vibration machine Can use inflatable vest attached to a machine by vibrating at high frequency VIBRATION 1.Place hands flat over area to be vibrated (may use one hand on top of the other). Keep arms and shoulders straight and wrists stiff. 2. Vibrate area for three to four exhalation 3.Instruct client to turn to other side, and then supine, repeating sequence of percussion and vibration in each position 4.Discard sputum container in biohazard receptacle, or send sputum specimen to laboratory if ordered.  Film Showing for Chest Physiotherapy 1. Percussion 2. Vibration 3. Postural Drainage END OF DISCUSSION:  INCENTIVE SPIROMETER DIANA KRIS NGAYAWON  >is a handheld medical device commonly used after surgery or with certain lung conditions such as chronic >Respiratory capacities are measured obstructive pulmonary disease (COPD), with a spirometer, wherein as a person pneumonia, or asthma to help keep breathes, the volumes of air exhaled your lungs healthy. The device helps can be read on an indicator, which retrain your lungs to take slow, deep shows the changes in air volume inside breaths, which following surgery or a the apparatus. COPD exacerbation, may be too painful to do on your own.  PURPOSE: Provides visual reinforcement for deep breathing by the patient It assists the patient to breathe slowly and deeply To sustain maximal inspiration/SMI while providing immediate positive reinforcement. Encourages the patient to maximize lung inflation and prevent or reduce atelectasis. Optimal gas exchange is supported and secretions can be cleared and expectorated. Sustained maximal inspiration:A deep-breathing maneuver that mimics the normal physiological sigh mechanism. An SMI is a slow, deep inspiration from the Functional Residual Capacity up to the total lung capacity, followed by ≥5 seconds breath hold. Types Of IS TEXT TEXT FLOW- ORIENTED IS AND VOLUME-ORIENTED IS  The parts of your incentive spirometer : Chamber Figure 1. Incentive Spirometer  INDICATION: Conditions predisposing a patient to the Presence of development of pulmonary atelectasis atelectasis. Presence of a restrictive lung Preoperative screening of defect associated patients at risk for with a pulmonary complications dysfunctional postoperatively: a baseline diaphragm or flow or volume may be involving the obtained to aid in assessing respiratory the patient’s postoperative musculature. function.  FREQUENCY: Evidence is lacking for a specific frequency for the use of incentive spirometry. Some suggestions have been made in clinical trials. Ten breaths every one (Rafea et al., 2009) to two (Bellet et al., 1995) hours while awake Ten breaths, 5 times a day (Renault et al., 2009) Fifteen breaths every 4 hours (Kundra et al., 2010)  CONTRAINDICATION: Patients who cannot be instructed or supervised to assure appropriate use of the device Patients in whom cooperation is absent or patients unable to understand or demonstrate proper use of the device Incentive spirometry is contraindicated in patients unable to deep breathe effectively due to pain, diaphragmatic dysfunction, or opiate analgesia. (Wilkins, 2005) Patients unable to generate adequate inspiration with a vital capacity You have a. >You have an (Ballooning of Blood Vessel) in the chest, abdomen, or brain.  ASSESSMENT: 1. Assess the patient for pain and administer pain medication as prescribed if deep breathing may cause pain 2. Assess the lung sounds pre- and post use to establish a baseline and to determine the effectiveness of incentive spirometry. 3. Assess vital signs and oxygen saturation to provide the baseline date to evaluate patient response. ◦Incentive spirometer ◦Stethoscope ◦Folded blanket or pillow for splinting of chest or abdominal incision, if appropriate ◦Lung volumes and lung capacities refer to the volume of air in the lungs at different phases of the respiratory cycle. The average total lung capacity of an adult human male is about 6 Liter of air. Tidal breathing is normal, resting breathing; the tidal volume is the volume of air that is inhaled or exhaled in only a single breath. The average human respiratory rate is 30–60 breaths per minute at birth, decreasing to 12–20 breaths per minute in adults. Inspiratory Capacity The inspiratory capacity is the total volume of air that can be inspired which is about 3600 ml. IC = TV + IRV LUNG CAPACITY: LUNG VOLUME: Setting up your incentive spirometer ◦ Before you use your incentive spirometer for the first time, you will need to set it up. First, take the flexible (bendable) tubing out of the bag and stretch it out. Then, connect the tubing to the outlet on the right side of the base. The mouthpiece is attached to the other end of the tubing. Using your incentive spirometer ◦ When using your incentive spirometer, make sure to breathe through your mouth. If you breathe through your nose, your spirometer will not work right. You can hold your nose if you have trouble. ◦ If you feel dizzy or lightheaded (like you’re going to faint) at any time, stop and rest. Try again at a later time.  Follow these steps to use your incentive spirometer. ◦ Repeat these steps each hour you’re awake. 1.Sit upright on the edge of your bed or in a chair. Hold the incentive spirometer at eye level. >If you had surgery on your chest or abdomen (belly), it may help to splint your incision (surgical cut). To do this, hold a pillow against your incision. This will keep your muscles from moving as much while you’re using the spirometer. It will also help ease pain at your incision. 2.Before you use the spirometer, breathe out (exhale) slowly and fully through your mouth. 3.Put the mouthpiece in your mouth and close your lips tightly around it. Make sure you do not block the mouthpiece with your tongue. 4.Breathe in (inhale) slowly through your mouth as deeply as you can. You will see the piston slowly rise inside the spirometer. The deeper you breathe in, the higher the piston will rise. 5.Try to get the piston to rise as high as you can. As the piston rises, the coaching indicator on the right side of the spirometer should also rise. It should stay between the 2 arrows. >The coaching indicator measures the speed of your breath. If it does not stay between the arrows, you’re breathing in either too fast or too slow. 1. If the indicator rises above the higher arrow, you’re breathing in too fast. Try to breathe in slower. 2. If the indicator stays below the lower arrow, you’re breathing in too slow. Try to breathe in faster 6. When you get the piston to rise as high as you can, hold your breath for at least 3- 5 seconds. You will see the piston slowly fall to the bottom of the spirometer. 7. Once the piston reaches the bottom of the spirometer, breathe out slowly and fully through your mouth. If you want, you can take the mouthpiece out of your mouth first and then breathe out. 8. Rest for a few seconds. If you took the mouthpiece out of your mouth, put it back in when you’re ready to start again. 10. Repeat steps 1 to 8 at least 10 times. Try to get the piston to the same level with each breath. After you have done the exercise 10 times, go on to step 10. 11. Try to cough a few times. As you’re coughing, hold a pillow against your incision, as needed. Coughing will help loosen and bring up any mucus in your lungs. 12. Use the marker on the left side of the spirometer to mark how high the piston rises. Look at the very top of the piston, not the bottom. The number you see at the top is the highest number the piston reached. Put the marker there. This is how high you should try to get the piston the next time you use your spirometer. >Write down the highest number the piston reached. This can help you change your goals and track your progress over time. ◦ Use your incentive spirometer 10 times each hour you’re awake. ◦ Cover the mouthpiece of your incentive spirometer when you’re not using it. DOCUMENTATION: The number of Document patient IS was used by the repetitions and the 01 02 teaching and patient patient average volume response reached 03 If productive cough is present, include the If the patient cough, characteristics of the 04 document whether the sputum including cough is productive or consistency, amount nonproductive. and color.  ◦ Educate patient how to use it and the importance of using it regularly ◦ Observing and encouraging patient to use it often Nurse’s role ◦ Monitoring lung sounds for improvement: For example, if the patient has atelectasis the lungs will sound diminished or bronchial breath sounds with an may be heard in the peripheral lung fields, or crackles. LISTEN TO ABNORMAL LUNG SOUNDS Incentive Wrong Ways to use an Incentive Spirometer? ◦ Blowing into the device (most devices will not Spirometer: work if this is done) ◦ Rapidly inhaling and exhaling off of the device ◦ Inhaling too fast or too slow off of the device and not allowing the piston to completely fall to baseline before repeating ◦ Not using it often (less than 2 -3 times per day) ◦ Not using the device in sets of 10 ◦ http://www.ceu.org/cecourses/981130/ch7b.htm ◦ https://www.guideline.gov/summaries/summary/34793 ◦ Basic Nursing Skills 7th Edition by Ellis and Bentz ◦ Taylor’s Clinical Nursing Skills by Pamela Lynn ◦ Photo Guide in Nursing Skills, Sandra Smith, Donna J. Duell, Barbara C. Martin ◦ Textbook of Medical Surgical Nursing 14th edition, Brunner and Suddarth ◦ Ctto: Ma’am Imelda payas handouts/powerpoint THANK YOU FOR BEING ATTENTIVE!!!.... 1. WHAT ARE THE TWO TYPES OF Incentive Spirometer? 2. ____________________ 3. GIVE ATLEAST 3 EQUIPMENTS USED WHEN USING IS? PREPARE 4. ____________________ 5. ____________________ 1/4 6. _______________What is the normal breath of adults per minute? SHEET OF 7. IRV stand for_______________________? PAPER 8._______________ Refers to the maximal volume of air FOR A that can be expired following maximum inspiration? SHORT refers to the volume of air in the lungs at 9.______________ different phases of the respiratory cycle QUIZ: 10.SMI Stands for____________? Continuation of quiz! 11._______Give me the formula or computation of inspiratory capacity? 12. 4 Types of lung volume? 13. 14. 15. 16. Give me atleast 5 parts of Incentive Spirometer? 17. 18. 19. 20. HEMODIALYSIS By Nora Mongolnon  OVERVIEW  Haemodialysis is used for regular long term treatment of patients with chronic end stage renal disease, temporary support for patients with acute reversible renal failure, and less commonly, acute poisoning.  The procedure extract toxic wastes from the blood of patients in renal failure by removing blood from the body, circulating it through a purifying dialyzer, then returning it to the body  For a long term treatment, various access sites, including arteriovenous (AV) fistula, are used. CONTRAINDICATIONS Hypotension Active Bleeding EQUIPMENT For machine preparation  Hemodialysis machine with appropriate dialyzer  I.V. solution  Administration sets, lines and related equipment  Dialysate  Heparin  10-ml Syringe with needle, medication label, hemostats (optional) For Hemodialysis with a double lumen catheter  Povidone-iodine pads  Two sterile 4 “ x 4” gauze pads  Two 10 ml syringes  Tape  Heparin bolus syringe  Clean gloves Hemodialysis with an AV Fistula  Two winged fistula needles (each attached to a 10-ml syringe filled with heparin flush solution)  Linen – saver pad  Povidone-iodine pads  Sterile 4”x4” gauze pads  Tourniquet  Clean gloves  Adhesive tape Discontinuing haemodialysis with a double lumen catheter  Sterile 4”x4” gauze pads  Povidone-iodine pads  Precut gauze dressing  Clean gloves  Sterile gloves  Normal saline solution  Alcohol pads  Heparin flush solution  Luer-lock injection caps  Transparent occlusive dressings, skin barrier preparation, Discontinuing hemodialysis with an AV fistula  Clean gloves  Sterile 4”x4” gauze pads  Two adhesive bandages  Hemostats ESSENTIAL STEPS  Wash your hands before all procedures  Explain the procedure especially if the patient to undergo is his first time  Maintain strict sterile technique to prevent introducing pathogens into the patient’s bloodstream  Wear appropriate PPE as necessary throughout all procedures  Weigh the patient and compare his before weight to his weight after the last dialysis and his target weight to determine ultrafiltration requirements  Record baseline VS, taking BP while he’s sitting and standing: auscultate the heart for rate, rhythm and abnormalities; assess for edema; observe respiratory rate, rhythm and quality: and check his mental status  Assess the condition and patency of the access site  Check for problems since last dialysis: evaluate previous laboratory data  Help the patient into a comfortable position (supine or sitting in recliner chair with feet elevated)  Support the access site and rest it on a clean drape Beginning hemodialysis with a double-lumen catheter  If extension tubing isn’t already clamped, clamp it to prevent air from entering the catheter  Clean each catheter extension tube, clamp, and Luer-lock injection cap with povidone-iodine pads to remove contaminants  Place a sterile 4”x4” gauze pad under the extension tubing, and place two 5ml syringes and two sterile gauze pads on the drape  To remove clots and ensure catheter patency, remove catheter caps, attach syringes to each catheter port, open the clamp, aspirate 1.5 to 3 ml of blood, close the clamp, and flush each port with 5 ml of heparin flush solution  To gain patient access, remove the syringe from the arterial port and attach the line to it; administer the heparin according to protocol to prevent clotting in the extracorporeal circuit  Grasp the venous blood line and attach it to the venous port; open the clamps on the extension tubing and secure the tubing to the patient’s extremity with tape to reduce tension on the tube and minimize trauma at insertion site.  Begin hemodialysis according to your facility’s protocol Beginning dialysis with an AV fistula  Flush the fistula needles, using attached syringes containing heparinized saline solution, and set them aside.  Place a linen-saver pad under the patient’s arm  Using sterile technique, clean a 3” x 10” (7.5 x25 cm) area of skin over the fistula with povidone-iodine pads. If the patient is sensitive to iodine, use alcohol instead.  Discard each pad after one wipe  Apply a tourniquet above the fistula to distend the veins and facilitate venipuncture; avoid occluding the fistula.  Put on clean gloves  Remove the fistula needle guard and squeeze the wing tips firmly together.  Insert the arterial needle at least 1” (2.5 cm) above the anastomosis, being careful not to puncture the fistula  Release the tourniquet and flush the needle with heparin flush solution to prevent clotting  Clamp the arterial needle tubing with a hemostat, and secure the wing tips of the needle to the skin with a adhesive tape to prevent it from dislodging  Flush the venous needle with heparin flush solution  Clamp the venous needle tubing, and secure the wing tips of the venous needle and secure with tape  Remove the syringe from the end of the arterial tubing, uncap the arterial line from the haemodialysis machine and connect the two lines  Tape the connection securely to prevent separation during the procedure  Remove the syringe from the end of the venous tubing, uncap the venous line from the haemodialysis machine and connect the two lines  Tape the connection securely  Release the hemostats and start hemodialysis Discontinuing hemodialysis with a double-lumen catheter  Clamp the extension tubing to prevent air from entering the catheter  Clean all connection points on all lines and clamps to reduce risk of infection  Place a clean drape under the catheter and place two sterile povidone-iodine soaked 4”x4” gauze pads on the drape beneath the catheter lines  Prepare the catheter flush solution with NSS or heparin flush solution as ordered  Put on clean gloves  Grasp each blood line with a gauze pad and disconnect each line from the catheter  Flush each port with saline solution to clear extension tubing and catheter of blood  Administer additional heparin flush solution as ordered to ensure catheter patency. Attach Luer-Lock injection caps to prevent air entry or loss of blood  Clamp the extension tubing  Redress catheter insertion site; also redress it if its occluded, soiled, wet  During dressing change, put a patient in a supine position with his face turned from the insertion site so he doesn’t contaminate the site by breathing on it  Set up sterile field, and observe the site for drainage; obtain a drainage sample for culture if necessary  Notify the physician if the suture appears to be missing  Put on sterile gloves and clean the insertion site with an alcohol pad  Clean the site with a povidone-iodine pad and allow it to air dry  Place a precut gauze dressing under the catheter and another gauze dressing over the catheter  Apply a skin barrier preparation and cover the gauze and catheter with a transparent occlusive dressing  Apply a 4” x 5” piece of 2” tape over the cut edge of the dressing to reinforce the lower edge.  Turn the blood pump on the hemodialysis machine to 50 to 100 ml/minute  Put on clean gloves and remove tape from the connection site of arterial lines  Clamp the needle tubing with the hemostat and disconnect the lines. The blood in the machine’s arterial line will continue to flow toward the dialyzer, followed by column of air. Just before the blood reaches the point where the NSS enters the line, clamp the blood line with another hemostat  Unclamp the NSS to allow a small amount to flow through the line  Unclamp the hemostat on the machine line to allow all blood to flow into the dialyzer where it passes through the filter and back to the patient through the venous line  After the blood is retransfused, clamp the venous needle tubing and the machine’s venous line with hemostats and turn off the blood pump  Remove tape from connection sites of the venous lines and disconnect the lines  Remove the venipuncture needle and apply pressure to the site with a folded 4”x4” gauze pad until all bleeding stops usually within 10 minutes  Apply an adhesive bandages  Repeat the procedure on the arterial line  Disinfect and rinse the delivery system according to manufacturer’s instructions  Hemodialysis requires vascular access. The site and type of access depends on expected duration dialysis, surgeon’s preference and patient’s condition  SUBCLAVIAN VEIN CATHETERIZATION  Using the Seldinger technique, the surgeon inserts an introducer needle into the subclavian vein. He then inserts a guide wire through the introducer needle and removes the needle. Using the guide wire, he threads a 5” to 12” plastic or teflon catheter into the patient’s vein  FEMORAL VEIN CATHETERIZATION  Using the Seldinger technique, the surgeon inserts an introducer needle into the left or right femoral vein. He then inserts a guide wire through the introducer needle and removes the needle. Using the guide wire, he threads a 5” to 12” plastic or Teflon catheter with a Y-hub or two catheters, one for inflow and the other placed about ½ distal to the first outflow.  ARTERIOVENOUS FISTULA  To create a fistula, the surgeon makes an incision in the patient’s lower forearm, then a small incision in the side of an artery, and another in the side of the vein. He sutures the edges of the incision together to make a common opening 1/8” to ¼” long.  ARTERIOVENOUS SHUNT  To create a shunt, the surgeon makes an incision in the patient’s lower forearm or ankle. He inserts a 6” to 10” transparent Silastic cannula into an artery and another into a vein. Finally, he tunnels the cannulas out through stab wounds and joins them with a piece of Teflon tubing  ARTERIOVENOUS GRAFT  To create a graft, the surgeon makes an incision in the patient’s forearm, upper arm or thigh. He then tunnels a natural or synthetic graft under the skin and sutures the distal end to an artery and the proximal end to a vein SPECIAL CONSIDERATION  Obtain blood samples from the patient as ordered usually before beginning haemodialysis  ALERT: To avoid pyrogenic reactions and bacteraemia with septicaemia, use strict sterile technique while preparing machine  Immediately report any machine malfunction or equipment defect  Avoid unnecessary handling of haemodialysis tubing  Assess the catheter insertion site for signs of infection, such as purulent drainage, inflammation, and tenderness  ALERT: Complete each step of dialysis correctly to avoid unnecessary blood loss or inefficient treatment from poor clearances or inadequate fluid removal. Failure to perform haemodialysis properly can lead to patient injury and death  If bleeding continues after you remove an AV fistula needle,  Monitor V/S throughout hemodialysis at least hourly or as often as every 15 minutes  After dialysis, assess patient’s weight, V/S, and Mental status; compare findings with your predialysis assessment  The patient may have a light meal during treatment  Give necessary drugs during dialysis unless the drug would be removed in the dialysate COMPLICATIONS  Dialysis Disequilibrium Syndrome  Hypovolemia, Hypotension, Hyperglycemia  Hypernatremia, Hyperosmolarity  Cardiac arrhythmias, Angina  Air embolism  Hemolysis  Hyperthermia  Exsanguination PATIENT TEACHING  Teach patient how to care for the vascular access site at home  As needed advise the patient how to perform hemodialysis at home-usually a complex process requiring 2 to 3 months to feel comfortable and be competent  Provide the telephone number of the dialysis center  Provide emotional support DOCUMENTATION  Note the time treatment began and ended  Record problems with treatment  Document VS and Weight before, during and after treatment  Note time blood specimens were taken for testing, test results, and treatment for complications  Document patient’s response to treatment  Note condition of vascular access site and site care.  WAY-YAS,URANY MARIE S. CLINICAL INSTRUCTOR PEAK FLOW METER and NEB PROCEDURE  Peak expiratory flow A peak flow meter issued in Europe. Peak flow meter (made in USA) MeSH D010366 A peak flow meter is a small, handheld device used to measure how fast you can push air out of your lungs when you exhale as hard and as fast as possible. It is used to assess lung function and can help determine the severity of asthma attacks or monitor treatment response during acute episodes The peak expiratory flow (PEF), also called peak expiratory flow rate (PEFR) and peak flow measurement, is a person's maximum speed of expiration, as measured with a peak flow meter, a small, hand-held device used to monitor a person's ability to breathe out air. It measures the airflow through the bronchi and thus the degree of obstruction in the airways. Peak expiratory flow is typically measured in units of liters per minute (L/min). Peak flow readings are higher when patients are well, and lower when the airways are constricted. From changes in recorded values, patients and doctors may determine lung functionality, the severity of asthma symptoms, and treatment. Measurement of PEFR requires training to correctly use a meter and the normal expected value depends on the patient's sex, age, and height. It is classically reduced in obstructive lung disorders such as asthma. Due to the wide range of 'normal' values and the high degree of variability, peak flow is not the recommended test to identify asthma. However, it can be useful in some circumstances. A small portion of people with asthma may benefit from regular peak flow monitoring. When monitoring is recommended, it is usually done in addition to reviewing asthma symptoms and frequency of reliever medication use. When peak flow is being monitored regularly, the results may be recorded on a peak flow chart. It is important to use the same peak flow meter every time.  Zone Reading Description 80 to 100 percent of A peak flow reading in the usual or normal the green zone indicates Green Zone peak flow readings that the asthma is under are clear. good control. Indicates caution. It may 50 to 79 percent of mean respiratory airways Yellow Zone the usual or normal are narrowing and peak flow readings additional medication may be required. Indicates a medical emergency.Severe airway Less than 50 percent narrowing may be of the usual or occurring and immediate Red Zone normal peak flow action needs to be taken. readings This would usually involve contacting a doctor or hospital. Peak flow readings are often classified into 3 zones of measurement according to the American Lung Association; green, yellow, and red. Doctors and health practitioners can develop an asthma management plan based on the green- yellow-red zones. The measurement of peak expiratory flow was pioneered by Martin Wright, who produced the first meter specifically designed to measure this index of lung function. Since the original design of instrument was introduced in the late 1950s, and the subsequent development of a more portable, lower cost version (the "Mini-Wright" peak flow meter), other designs and copies have become available across the world. Variables and formula The above calculator estimates the (predicted) peak expiratory flow based on the patient’s age, gender and height: Age – the PEFR has a specific estimation formula for pediatric patients; Gender – women tend to have a lower PEFR than men; Height – tall individuals tend to have a higher PERF. The calculator allows input in either cm or inches, however, inches are transformed in cm that are used in the formula. Peak expiratory flow rate (PEFR) is estimated via one of these equations: Children PEFR = ((Height in cm - 100) x 5) + 100 Adult Men = (((Height in m x 5.48) + 1.58) - (Age x 0.041)) x 60 Adult Women = (((Height in m x 3.72) + 2.24) - (Age x 0.03)) x 60 If a measured peak flow value is available, the estimated one is compared to that and a percentage is extracted. This reflects the difference between the predicted (normal for age, gender and height) and the real value. EXAMPLE :ADULT MALE PEFR 6 FEET MALE,20 YEARS OLD ( Ht. in METERS X 5.48 )+ 1.58 – (AGE x 0.041) x 60 1.8288 x548 + 1.58 – 20y/o x 0.041 x 60 10.021824 + 1.58 – 0.82 11.60- 0.82 10.78 x 60 CONVERSION: 646.8 L/min 1 FOOT=0.3048 meter 1 FOOT= 30.48 cm 1 INCH= 2.54 cm  COMPLIANCE Is the BEST Medication.. THE END References 1.^ "Peak Flow Measurement". www.hopkinsmedicine.org. 2019-08-14. Retrieved 2023-06-22. 2.^ National Asthma Council of Australia 3.^ Nunn, A. J., and I. Gregg. 1989. New regression equations for predicting peak expiratory flow in adults. Br. Med. J. 298: 1068-1070. Adapted by Clement Clarke for use in EU scale - see Peakflow.com > Predictive Normal Values (Nomogram, EU scale) 4.^ Martin R. Miller (June 2004). "Peak expiratory flow meter scale changes: implications for patients and health professionals" (PDF). The Airways Journal. 2 (2): 80. Archived from the original (PDF) on 2006-06-25. Retrieved 2006-06-06. 5.^ Nunn A, Gregg I (1989). "New regression equations for predicting peak expiratory flow in adults". BMJ. 298 (6680): 1068–70. doi:10.1136/bmj.298.6680.1068. PMC 1836460. PMID 2497892. - Predicted peak expiratory flow in normal adults using Wright-scale 6.^ Godfrey S, Kamburoff PL, Naim JL (1970). "Spirometry, lung volumes and airway resistance in normal children ages 5 to 18". Br J Dis Chest. 64 (1): 15–24. doi:10.1016/S0007-0971(70)80045-6. PMID 5438753. - Predicted peak expiratory flow in normal children using Wright-scale 7.^ Clement Clarke International (2004). "Predictive Normal Values (Nomogram, EU scale)". Clement Clarke International. Archived from the original on 2020-07-10. Retrieved 2006-06-06. - Downloadable PDF charts for adults and children using EU scale 8.^ J.L. Hankinson, J.R. Odencrantz, and K.B. Fedan, Spirometric Reference Values from a Sample of the General U.S. Population. Am J Respir Crit Care Med, Vol 159, pp. 179-187, 1999. 9.^ Clement Clarke International (2004). "Mini-Wright Peak Flow Meter - Wright to EU (EN13826) converter". Clement Clarke International. Archived from the original (EXE macromedia flash) on September 30, 2007. Retrieved 2006-06-06. 10.^ Knudson, RJ (1983). "Changes in the normal maximal expiratory flow-volume curve with growth and aging". Am Rev Respir Dis. 127 (6): 725–34. doi:10.1164/arrd.1983.127.6.725 (inactive 31 January 2024). PMID 6859656. 11.^ Scottish Intercollegiate Guidelines Network; The British Thoracic Society (July 2007). "British Guideline on the Management of Asthma - Annex 8: Personal Asthma Action Plan" (PDF). Thorax. 58: Suppl I. doi:10.1136/thx.58.suppl_1.i83. S2CID 220143006. Archived from the original (PDF) on 2009-01-17. Retrieved 2011-10-27. - for recording chart of PEFR readings 12.^ American Lung Association. "How can I determine a normal peak flow rate for me?". Archived from the original on 2007-11-03. 13.^ WRIGHT BM, McKERROW CB (November 1959). "Maximum forced expiratory flow rate as a measure of ventilatory capacity: with a description of a new portable instrument for measuring it". Br Med J. 2 (5159): 1041–6. doi:10.1136/bmj.2.5159.1041. PMC 1990874. PMID 13846051. References 1. Balasubramanian S, Ravikumar NR, Chakkarapani E, Shivbalan SO. Peak expiratory flow rate in children--a ready reckoner. Indian Pediatr. 2002; 39(1):104-6. 2. Knudson RJ, Lebowitz MD, Holberg CJ, Burrows B. Changes in the normal maximal expiratory flow-volume curve with growth and aging. Am Rev Respir Dis. 1983; 127(6):725-34. 3. Radeos MS, Camargo CA Jr. Predicted peak expiratory flow: differences across formulae in the literature. Am J Emerg Med. 2004; 22(7):516-21. 4. Knudson RJ, Lebowitz MD, Holberg CJ, Burrows B. Changes in the normal maximal expiratory flow-volume curve with growth and aging. Am Rev Respir Dis. 1983; 127(6):725-34. NEBULIZATION Nebulization is a form of respiratory care. It is the medical process of administering medication directly by inhalation, with the help of a nebulizer that converts liquid medicine into mist, which is then given to the patient with the help of a breathing mask. A nebulizer or nebuliser is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. Nebulizers are commonly used for the treatment of asthma, cystic fibrosis, COPD and other respiratory diseases or disorders. Indications of nebulization treatment in pre-hospital first aid. If symptoms or signs of airway hyper reactivity is indicated, the nebulization treatment is recommended: Patients with respiratory symptoms such as dyspnea, coughing, expectoration, or chest tightness. A nebulizer treatment may help reduce inflammation in the lungs and/or open airways, especially in the case of respiratory illnesses like asthma. People with other respiratory diseases like COPD who have lung-related complications from a cold or flu may also benefit. What are the complications of nebulization? The most common side effects of nebulizer treatment are rapid heartbeat, jitteriness and anxiety. Less frequent side effects may include headache, nausea, vomiting or throat irritation. Serious reactions to nebulizer treatment are also possible and should be immediately reported to the prescribing physician. EQUIPMENTS NEEDED THE END