ANS CH-36,27,28 1 PDF

ANS CHAPTER 36 IV Therapy: - IV’s are given when:. Drugs/substances cannot be taken orally/rectally - IV’s Supply body with:. Fluids & Electrolytes (dehydration). Blood products (anemia). Medications (low blood pressure). Nutritional components (TPN) - IV’s must be Sterile….du...

ANS CHAPTER 36 IV Therapy: - IV’s are given when:. Drugs/substances cannot be taken orally/rectally - IV’s Supply body with:. Fluids & Electrolytes (dehydration). Blood products (anemia). Medications (low blood pressure). Nutritional components (TPN) - IV’s must be Sterile….duh Watch for Fluid overload!!! - The average adult needs 1500 to 2000 mL of fluids per day to replace those eliminated by the body - How does a person lose fluid?. Hemorrhage. Dehydration. N/V. Diarrhea. Profuse Perspiration. Fever. Drainage from wounds - Monitor Accurate I’s & O’s - Monitor Electrolyte Levels (Sodium, Potassium, Chloride). Sodium= 135-145. Chloride= 96-106. Potassium= 3.5-5.0 However, all nurses MUST monitor flow rates in IV therapy  Types of IV Solution with Solutes:. Glucose. Saline. Electrolytes. Vitamins. Amino Acids. Blood Products - IV Fluids orders should have:. Solution Type. Amount To Be Infused. Rate Of to Infuse - Hypertonic=Shrunk - Isotonic= Normal - Hypotonic= Swollen - Very Hypotonic= Lysed Types of IV Solution: ISOTONIC “The Lane Driver” - Think… “it STAYS where I put it”. SAME concentration as blood. Fluid does NOT cause cells to change in size - Use:. E X P A N D the fluid volume of the body - Examples:  0.9 Normal Saline  5% Dextrose in water (D5W)  Ringer’s Lactate (LR) Types of IV Solutions: HYPOTONIC “The Wanderer” - Think of Hippo because the cell gets bigger & swells. DIFFERENT concentration as blood. Contains LESS solute than extravascular fluid. Desires to go “wander” to find cells to move its fluid into. Cells DO change in size. Fluid moves INTO the cells & SWELLS *Danger to children* - Use:. Cellular Dehydration - Examples:  0.45% Normal Saline (1/2 NS)  Types of IV Solutions: HYPERTONIC “The Drainer” - Think “They are a very active person & they need water to drink” so they are going to pull all the water from all the surrounding cells, which shrinks the cell and makes the cell smaller.. DIFFERENT concentration as blood. Contains GREATER solute than blood. Cells DO change in size. “Drains” the cells of their fluid causing them to SHRINK - Use:. Replaces Electrolytes. Reduces Edema - Examples:  10% dextrose in water (D10W)  5% dextrose in 0.9% saline (D5 in 0.9 NS)  5% dextrose in 0.45% saline (D5 in.45 NS)  5% dextrose in Ringer’s lactate (D5LR) - IV solution containers must be sterile, check expiration dates, check for clarity. Administration Sets: - Primary Sets: (Main Line). Solution, tubing, needleless connector, IV stand - Secondary/Piggyback Set: (Antibiotics). Medications given IV & added to existing IV line - Parallel IV Set: (Blood). Y-Typed administration set (used to infuse blood products) - Controlled Volume Set: (Pediatric Safety Feature). Controls volume for safety IV Tubing:. Label IV tubing. Verify with another nurse with high-risk meds. (Dual sign off). Monitor signs of over infusion & under infusion. Change set every. 96 hours. Reduce infection. Always assess and follow prescribed IV flow rates of infusion IV Tubing Sizes:. Regular drops 10-20 gtt/mL (most common for adults). Macro drops 10-15gtt/mL (for viscous “thick” or sticky fluids) (blood). Micro drops 60 gtt/mL (for small amts of fluid or when exact amts need to be given) Pediatrics Fragile Veins  Second/Piggyback Tubing:. To hang IV antibiotics, antineoplastics (chemotherapy). Placed higher than primary line-uses gravity. Once piggyback is completed primary IV begins. Always use needleless system!. Make sure clamps are open. Side and roller. Both on primary and secondary - Assess for:. Adverse or side effects from medications. Drug incompatibility with primary IV solution (Signs-white precipitates in tubing). Very dangerous!. Always "SCRUB THE MF HUB". Scrub the hub of ports with sterile alcohol swab prior to inserting. Parallel or Y-Tubing:. MUST be used to administer BLOOD. Consent MUST be signed by the patient. Always have BOTH blood & 0.9 NS *Start the saline to keep IV access open, for emergency drugs.. 0.9 NS is clamped once blood is started. Once blood is done, tubing is flushed with 0.9 NS *Blood products are never infused into the same IV line as medications or other fluids *Use a large IV cath to ensure cells are not damaged (18 Gauge) Nurse care for patients receiving blood:. Watch for adverse reactions. Vital Signs (Timed intervals). Chest Pain. Shortness of Breath. Itching. Back Pain IF reaction from blood happens… STOP INFUSION!!! Controlled Volume Set: - Uses:. Controls volume of diluted medications. Backup safety method-prevents free flow of fluid to client. Small amount of fluid to be infused over a long period of time  - Can use for risk of fluid overload:. Pediatric patients. Older adults - Burette:. Tube like chamber. Holds 150ml of fluid (Roller clamp regulates flow) Intermittent IV (Saline or PRN lock): - Use: Intermittent IV access. Antibiotics. Heparin. Corticosteroids. Apply Luer-lock cap or an extension set to the IV cannula - Nursing Action:. Check the lock for patency BEFORE & AFTER administering meds.. Since there Is no infusion site may form a blood clot (DVT). Reduce risk order to flush *Diluted Heparin *Do NOT use full strength or concentrated dose heparin, it could cause death! IV Filters:. Traps small particles-precipitated from solution. Prevent particles from entering vein. 0.22-micron filter-most common. 1.2-micron filter-for solution containing lipids or albumin. Special filters are used for blood components Infusion Pumps:. Regulate the flow of routine IV fluids. Programmed by nurse. Use alarms for safety. IVF is complete. Occlusion in line - REMEMBER:. Pump is a tool for safety-nurse is the first line of deterring safety risk - Use is mandatory when patients receive: Medications requiring critical accuracy Total parenteral nutrition (TPN) Heparin Insulin Labor inducting - Potassium IV fluid, chemotherapy, cardiac meds (DANGEROUS) - NEVER IV push Potassium or infuse at too fast of rate….unless you don’t like yo baby daddy.. then feel free to DC him to JC.  PCA Pumps:. Allows patient to regulate administration of IV pain meds.. Settings provide pain relief without over medicating your patient.. May have a PRN dose. Infused at a “Basal (continuous) rate. Patient is the ONLY one allowed to press the button IV Cath Sizes: - 18 Gauge:. Blood Transfusions. The large gauge keeps from damaging the cell when transfusing. Used in trauma if needing a rapid infusion - 24 Gauge:. Fragile Vein. Geriatric. Small Vein. Pediatrics - Winged-Tip Butterfly needle:. Meant for short-term therapy Supplied in odd-numbered gauges (17, 19, 23, and 25) Pediatric & older population - Over the needle Caths:. Consist of a needle with a catheter sheath over it The needle is removed, leaving the flexible catheter in the vein 18, 20, 22, 24, 26... gauge needles Blood administration requires at least 18 g IVF solutions: 20, 22 gauge Fragile veins: 24 gauge - Through the needle Caths:. Used for midline catheter insertion for long term peripheral use. Central lines, PICC lines Peripheral IVs: - Consider:. freedom of movement, vein size, client preference. IV trauma can occur *Start distal...then proximal!. Antecubital veins (AC) -restrains movement of patients and can cause Distal Occlusions in your IV.. Feet veins- rarely used for adults (often require order). Scalp veins-used for infants Types of IV therapy infusions:. Continuous. Intermittent. PCA. Direct Injection (IV Push) - Factors that can affect the flow:. change in cannula position. height of solution. patency of cannula Direct IV Push:. MUST be slow (1-10 min). Provides RAPID effect. Dangerous if NOT given correctly. Use drug references to determine the safe amount of time to administer medication - IV push is NOT within the scope of the LVN Heparin Infusions: - Reduce harm associated with anticoagulant therapy. - Heparin infusion rates are adjusted by the RN. Based on the partial thromboplastin time (PTT) Nursing students should not:. Adjust the dosage. Change the pump settings of heparin infusions Monitor for signs of bleeding: ◦ Bruising ◦ Bleeding of gums ◦ Blood in the stool Central Venous Catheters:. Ends in superior vena cava or right atrium. When peripheral sites cannot be placed. Delivers all type of solutions, medications, blood, blood products, irritant medications. May be left in place for 6-8wks. May be tunneled or non-Tunneled. Correct placement is verified by X-Ray - Central lines can have:. One-three lumens in catheter. One or more port chambers. Each lumen exit-called a tail Multi-Lumen Allow:. Simultaneous administration of solutions. Preventing mixing or incompatible solutions Central Venous Access Device Types:. Non-Tunneled Central Catheter. Tunneled Catheter. PICCs. Ports. Hypodermoclysis Non-Tunneled: - Accessed directly into the vessel. Inserted DIRECTLY into the Jugular, Subclavian, or Femoral vein. Used short term (7 days- few weeks). Can be inserted at bedside or in an outpatient setting Tunneled: - Accessed away from vessel and “tunneled” under the skin to the vessel. Used long term (months-years). Placed in the Superior Vena Cava. Device has cuff-anchors in place (to prevent bacteria migrating to cath tip). Catheter breaks can be repaired. Requires WEEKLY site care. Can affect a patient’s body image. Cost maintenance supplies Portacaths: - Reservoir surgically implanted in pocket. created under skin. usually in upper chest. catheter is attached to reservoir. tunneled under skin. can be placed in the Superior Vena Cava. can be left unused for long periods of time - Used For:. Chemotherapy. Antibiotics - RNs usually access these - REQUIRES a Hubert Needle (Non- corning needle) PICC Line: - Inserted into Basilic or Cephalic Vein of upper arm advanced as far as the Superior Vena Cava.. can be tunneled or non-tunneled. used for therapy lasting more than 2 weeks. often used in children or adults requiring high flow of blood or home IV therapy. be sure to put a LIMB RESTRICTION indicator on whichever arm the PICC is on. Do NOT take Blood Pressure on arm with PICC Hypodermoclysis: - Administration of fluids in subcutaneous tissues.. Absorbs by capillaries & lymphatic system. can be used to treat hydration. usually used in pediatrics, palliative & hospice  - Locations:. Abdomen. Thighs. Upper Arms. Cheek. Scapula − Administration rate is approximately 1ml/min Complications of IV therapy:. Hematoma. Phlebitis. Infiltration. Extravasation Hematoma: - Signs & Symptoms:. Swelling. Resistance during flushing the IV. Ecchymoses (discoloration of the skin from bleeding, bruising) - Treatment:. Remove IV. Elevate extremity. Apply cold compress *Do NOT massage site!! *Do NOT apply warm compress!! Phlebitis: - Hardness of the Vein - Signs & Symptoms:. Redness. Warmth. Swelling. Pain - Treatment:. Remove the IV. Apply COLD compress initially than WARM. Consult RN & Provider P.S. I am tired as hell yall... just letting yall know I’m eating an entire can of BBQ pringles Infiltration: - Occurs when the infusion fluid is outside the vein, and is leaking into tissues - Signs & Symptoms:. Edema. Skin Blanching. Skin cool. Swollen. Could have fluid leaking from site - What to do when this shit happens:. Get mad… and annoyed bc wtf…... STOP infusion and find a new site to start another damn IV. Fluid usually reabsorbs within 24 hours Extravasation: - Caused from Infiltration. Damage can result in infection - Signs & Symptoms:. Pain. Edematous. Cool to touch - Treatment:. STOP the infusion IMMEDIATELY… RUN FORREST RUUUUNNN. Notify Provider & RN. Do NOT remove the IV because may need to administer an antidote into tissue. Be cautious of meds that have irritating properties Potassium Infusion:. Potassium is ALWAYS diluted in fluid. Potassium is ALWAYS given carefully controlled infusion. Potassium is NEVER given as a bolus!!! (Unless it’s to joe). Incorrect administration of potassium can be fatal!! Joe.. take yo ass on to a nursing home my guy … Joe will 1000% forget all that Complications of IV therapy:. Septicemia- Occurs when pathogens are introduced into the blood stream. Circulatory (fluid) Overload- Occurs when too much fluid is entering the body. Catheter Embolism- Occurs when a piece of the catheter breaks off, and travels in the vein until it lodges.. Air Embolus- Caused by gas bubbles in bloodstream, stops flow of blood, causing lack of oxygen and death. Speed Shock- Occurs when fluid is administered too rapidly. Drug-Solution Incompatibility- White precipitates in the tubing Septicemia: Blood stream infection. Can occur from breaks in sterile technique during cannula insertion or time system is opened to change the bag or tubing - Signs and symptoms:. fever, chills, pain, headache, nausea, vomiting, extreme fatigue - At site: ◦ Warmth ◦ Redness ◦ Painful ◦ Vein is NOT hard or swollen - Blood cultures ordered, and aggressive antibiotic therapy is started - IMMEDIATELY remove IV Circulatory Overload (Fluid Overload): - Signs & Symptoms:. Dyspnea. Crackles. Tachypnea. Moist cough - Cardiovascular complications:. Tachycardia. Increased BP. Distended neck veins. Dependent Enema - Fluid overloaded in older patients:. Reduce IV to a minimum drip rate of 1ml per min. do NOT remove IV. position patient to maximize lung expansion. monitor vitals. monitor fluid output. ask doctor about getting a diuretic to get the fluid off the patient (Lasix) Embolus:. CALL FOR HELP, CALL A RAPID!. Place patient in Trendelenburg on left side. Administer Oxygen. Monitor VS. Notify provider immediately. IF patient crashes start CPR. High flow oxygen (hyperbaric chamber). Surgical aspiration into right atrium Speed Shock: - Signs & Symptoms:. Dizziness ◦ Tightness of chest ◦ Flushed face ◦ Irregular heartbeat ◦ Loss of consciousness, shock, cardiac arrest - Treatment:. CALL FOR HELP!. Stop infusion IMMEDIATELY. Give Antidote or Emergency meds as ordered. Notify HCP Drug Solution Incompatibility:. look for white precipitations in tubing. stop infusion. flush line with sterile saline. contact provider Nurse Knowledge for assessing and managing IVs: - Assess:. Rate of the infusion-very important!. Insertion site. Every 1-2 hours during a shift. Patency. Absence of complications. Prescribed rate. Infection. Complaints from the patient. Level of the fluid remaining in the bag. When less than 50 ml are left hang a new bag Nursing process: Planning. IVF enters circulation immediately. Adult adapts best at a steady rate 80 to 250 mL/hour. Large amounts of fluid increase the work of the heart. Fluid overload can cause CHF. When provider orders fluids its typically 1000ml over 8,10,12-hour periods.  Evaluation:. check for good skin turgor. monitor Is & Os. when giving TPN assess patients weight gain and blood sugar levels. when giving blood watch lab values to see if they improve. documenting of IV meds is done in the MAR. Iv site is assessed every 1-2 hours according to facility. IV assessments are charted on flowsheets or notes CHAPTER 27 Goals of nutritional therapy: - Treat & manage disease - Prevent complications - Restore/maintain health - Diets are prescribed by providers Patients needing feeding assistance (FEEDERS):. Paralysis of the arms. Problems breathing or swallowing. Older population is at risk for aspiration. Visual impairment. Weak and Visually impairment as well as confused patients. Post-op patient & nutrition: - Patients that come out of surgery could be on certain diets due to procedure. Some may be able to go back to just a regular diet. -. Full liquid diet -. Clear liquid diet -. Soft diet -. Regular diet -. Minced and Moist -. Pureed diet Post-op patient diets:. Clear liquid:. Started when bowel sounds return. bowel sounds (asculation). Goal is to have low residue diet to easily digest foods. Liquid diets decrease risk of abdominal discomfort & N/V. Encourage ice chips 4 hours before first mean - Clear liquid diet:. Short term-deficient in nutrients. Grape, apple, cranberry juices. Strained fruit juices. Vegetable broth. Carbonated water. Clear, fruit-flavored drinks. Tea, coffee. Gelatin and ices. Popsicles. Clear broth Full Liquid: Step between clear liquid and soft diet. Longer term than clear liquid. Used following surgery, or for patients that have difficulty swallowing or chewing. Milk and Milk beverages. Yogurt, eggnog, pudding. Ice cream. Pureed meat, vegetables in cream soups. Vegetable juices. Sweetened plain gelatin Soft diet: Recovering from surgical procedures involving stomach or bowel.. Low in fiber. Foods are softened by cooking, mashing, chopping.. Eggs. Breads without seeds. Soups. Fruit. Juices. Tender meats Bulimia: (Binge eating). Patient may take laxatives & Diuretics to lose weight. Often feel ashamed. Esophageal & Peptic ulcers, depressed gag reflex, dental issues. Monitor for blood in output due to vomiting so much causing bleeding from gastric acid. - Treatment:. Nutrition counseling. Psychological Obesity: - Chronic diseases for obesity:. Cardiovascular. Stroke. Diabetes. Joint Disease. Gallbladder - Contributing factors:. Genetics. Poor eating habits. Meds.. Age/Gender - Long term weight management success rates are low Pregnancy: - Nutritional status before and during pregnancy can influence health status of mother and fetus - Nutritional counseling-important to reduce risk of low-birth weight infants, gestational diabetes, pregnancy induced hypertension - Emphasize management of maternal weight gain and taking prenatal vitamins Substance Abuse: - Interferes with food intake by:. decreases appetite. decreasing financial resources for food. replacing substance for food. may lead to impaired absorption of nutrients - Treatment:. Fluid & Electrolyte supplements. Vitamin & Mineral supplements (Particularly thiamine). High calorie, high carb diet. Dietary fat restriction if liver function impaired *Thiamine (Vitamin B1) deficiency is seen in alcohol abuse  Thiamine Deficiency:. Assist in generation of energy. Role in developing nerve impulses. Helps with Myelin Sheath maintenance. Affects the CV, Nervous, and immune system - Signs & Symptoms:. Anorexia. Irritability. Short- term memory - Prolonged symptoms:. Loss of sensation in the extremities. Symptoms of heart failure. Swelling of hands and feet. Chest pain related to demand ischemia. Feelings of vertigo/double vision. Memory loss - Describe to family members/friends that the patient may be more confused than normal and say things that does not make sense. But most likely will get better as their blood levels return to normal. Cardiovascular Disease: - Diseases such as:. Blood Vessels. Hypertension. Myocardial infarction. CHF. Atherosclerosis prevention (accumulation of fatty deposits ion blood vessel walls) - Focused on reduction of:. Fats. Sodium. Cholesterol 3 Types of Cholesterol: - High- Density Lipoprotein (HDL). “Good Cholesterol”. Cleanse vessel of fatty deposits - Low-Density Lipoprotein (LDL). Increases fatty deposits on vessel walls - Very-Low Density Lipoprotein (VLDL). Carrier for triglycerides in blood. Type of fat linked to Atherosclerosis & coronary artery disease (CAD) Cardiovascular Trans Fats: - Trans-fats. increases levels of triglycerides. risk for diabetes. fast foods & chips usually high levels of trans fats. low fat dairy vegetable oils, fish, poultry lowers cholesterol levels. vitamin D may help prevent CVD. decreasing inflammation Cardiovascular Sodium:. Causes fluid retention. Increased fluid with heart failure increases which causes your heart to work harder. Increases respiratory distress and edema. leads hypertension. diets with low sodium and high fruits can lower blood pressure. no added salt or sodium striction diets. salt substitutes and no salt seasoning may be used in cooking Diabetes Mellitus: - Type 1: Insulin Dependent - Type 2: Non- Insulin Dependent - High risk populations:. American Indians. Native Hawaiians. Pacific Islanders. African Americans. Mexican Americans. Asian American - Goal- Maintain serum glucose at 70-120 mg/dl - Diet of moderate complex carbohydrates. Pasta. Beans. Whole grains. Rice. Fruit - Disturbance carbohydrates throughout data. Avoid large amounts of carbohydrates in one meal - Encourage monitoring blood glucose. Blood sugar level 180 mg or below. usually dictates post-meals HIV/AIDS: - HIV wasting syndrome. 10% of body weight associated with diarrhea & fever. Muscle wasting- Due to treatment, infections, loss of appetite, GI disorders - Therapy:. Replacing of fluids & electrolytes. Vitamins & Minerals (Vitamin D) - Weight Gain:. Increase Calorie intake. Soft food when mouth is painful from lesions. Small frequent meals. Replacement of lost muscle mass. Protein intake. Maintaining the immune system  Dysphagia: - Signs of difficult swallowing:. Coughing while drinking. Drooling. Having food remain in mouth (Pocketing) - When someone aspirates, they may or may not show obvious signs of aspiration. - Aspiration may change voice or feeling food being stuck in the throat - Liquids can be thickened to prevent aspiration Tube Feeds: - Enteral:. Usually range from 240-360 ml per feeding. Daily amount of 2000ml if efficient. Providing nutrition directly into the digestive tract - Parenteral:. Providing nutrition through a vein. Administered into the BLOODSTREAM. Used in people who do NOT have a functioning GI tract Feeding Pumps: - Continuous feedings:. Effective for patients who cannot tolerate large amounts of fluids at one time.. Patients who cannot tolerate a large amount of fluid at once. Infused via a feeding pump. Check order for type and amount of formula. Wash hands, put on gloves. Assess for correct tube placement or residual before feeding. Keep HOB 30 Degree or higher- Prevents reflux, facilitates stomach emptying, and helps prevent aspiration. - Intermittent feedings:. Beneficial for patients able to feed themselves. Beginning to reintroduce oral feeding. Resembles regular mealtimes. Stimulates the feeling of hunger. Helps stomach to empty, prevents aspiration, and reflux. Verify with provider for type and method of formula. Use a 30ml syringe to attach to feeding tube and pull formula into syringe and allow it to flow by gravity.. Formula is infused over 10 minutes or longer. Regulate the infusion rate by raising and lowering the syringe. Add formula to the syringe to keep the neck of the syringe filled (keeps air from entering stomach.. Using Gavage bag regulate the drip factor for the formula to run in over the desired amount of time. Flush with 30-60ml of sterile water after feeding Complications with Tube Feeds:. Patient not tolerating feeds (Stop the feed if pt. is not tolerating). Nausea. Having the shits.. biggest complication… for us anyways lol. WARNING tube feed shits SMELL HORRIBLE!!. Clogged tubes. Aspiration. HYPERGLYCEMIA. FLUID OVERLOAD. DEHYDRATION - If patient is not tolerating look for signs of Abdomen distention, increased residual, N/V/D, Abdomen pain. - Again… im repeating myself at this freakin point BUUUTTTTT.. Document type of formula given, amount given, verification of tube placement, amount of residual obtained, and any type of intolerance from feedings. NG Tube: - Placed through the nose into the stomach - Uses:. Decompression of the stomach before or after surgery. Obtaining gastric specimens for analysis. Gastric feeding or Lavage for patients with GI bleeding or for removal of Ingested toxins. Administration of meds - Nursing care for NG tubes:. Before insertion check airway and airway through the nostrils by closing one side of the nose and check airflow and then do the next nostril.. Position the patient with head of bed at 30-90 degrees, moving up the head of the bed enables the tube to move by gravity down the digestive tract. - Insertion:. Be sure you have patients consent. Assess gag reflex, lung sounds and bowel sounds. Traditional method is to Measure from the tip of the nose to the tip of the ear & then to the Xiphoid process.. Mark the distance ON the tube with Permanent marker or tape is preferred. This will be called the “traditional mark”. LUBRICATE the tip and insert it through the nostril with the BEST airflow.. IF you have to change out the NG tube, be sure to put it in the opposite nostril of the one before to prevent irritation of the tissue.. With the patient’s head hyperextended, aim the tube down and toward the ear.. Twist the tube slightly as you advance it. IF you encounter severe resistance, withdrawal the tube and assess the other nostril.. Forcing the tube could case tissue damage or bleeding.. Using the largest passageway for insertion decreases the tissue trauma. For easier insertion use water or water-based solution to lubricate to moisten the tip.. Do NOT use an oil-based lubricant because of the possibility of lipid aspiration. Hold down the patient’s tongue, and if the tube gets coiled up in the patient’s mouth withdrawal the tube.. When inserting have patient swallow while having their head bent forward and swallow.. Advance the tube each time the patient swallows, the tube advances easier when having esophageal movement.. Check placement and auscultate over the LUQ. Inject 20ml of air, using irrigation syringe into the tube. Stethoscope placed to the left of the xiphoid process you should hear a swooshing sound.. Observe for changes in the volume and appearance of the feeding tube aspirate. Tape gently to the patients nose after cleaning the nose with prep pad and secure it safely. THEN X-RAY WHEN YOURE DONE TO ENSURE PLACEMENT IS CORRECT!!!. Be sure to document the length from the nares to the end of the tube and to educate your patients on not to pull this tube out. - Documentation:. Date & time of insertion. Type and size of tube & Which nare. Depth of insertion. Post-procedure assessment. NEVER let go of the tube until you have secured it. Do NOT use until X-Ray is confirmed it is in correct spot - When NG tube enters the lungs instead of the stomach it could cause damage. - Signs you have it in the lung and NOT stomach:. Patient may become Cyanotic. Unable to make a verbal sound. Coughing spasmodically and uncontrollably. REMOVE IMMEDIATELY - Maintaining patency:. Check Provider order. Assess secretions and bowel sounds. Position HOB 30-90 degrees (semi-fowlers or higher). Wash hands and put on gloves. Verify proper tube placement. Fill the syringe with the correct amount and solution. 30 ml normal Saline or sterile water. Disconnect NGT from tube feed or suction. Attach the syringe to the end of the tube and instill the solution. Attach tube back to suction or tube feed. Remove gloves, wash hands.. Document, adding amount of fluid to Intake Removal:. Verify order. Assess secretions. Explain procedure. HOB 30 degrees. Wash hands. Put on gloves. Turn off suction/feed. Inject 20ml of water...followed by 20ml of air. Pinch off tube. Remove tape. Have patient hold his breath. Pull out tube quickly/gently. Mouth/nose care. Remove gloves/hand hygiene.. Document time removed, gastric drainage, toleration of procedure. Assess every 3 hours for nausea/vomiting, abdominal distention, bowel sounds. Holy tits that was a lot to type….. sorry guys lol NG tubes vs. NI tubes: - NG goes into stomach while NI goes into intestine. NG tube & NGI (Dubhoff) are used short time. PEG tube & J tube are used long term. An NGI tube small bore feeding tubes are ONLY used for tube feed and medication, administration CANNOT take suctioning.. An NGI is inserted using a guidewire or stylet. Placement must be verified by X-Ray prior to removal of guide wire PEG tubes (J-tube):. Continuous or Intermittent. Placement should be checked EVRY SHIFT BEFORE feeding and BEFORE administering meds.. Residual fluid in the stomach should be assessed BEFORE feeding and meds. Always reinstill aspirated content. IF residual is greater than ½ of the volume given at the last feed, hold the feeding.. Keep HOB elevated at least 30 for continuous feeds. This tube is placed in the stomach for long term use. Measure tube length from skin level to end of placement adapter for possible dislodgement. Compare previous measurements. Higher measurements indicate tube. migrated or dislodged. Notify Charge Nurse and Provider - Benefits of PEG tube:. Patient can administer their own feeding. Concealed. Easily removed - Nursing care:. Inspect skin around insertion site daily. Monitor for irritation, infection. Clean with soap and water, then dry, daily. Rotate external disk to prevent sticking to skin. Monitor for dislodged, abdominal distention, aspiration, pain, vomiting, respiratory distress. If occurs-notify Provider immediately. Assessing correct placement every shift. Before feeding or admin. medications. Measure amount of residual fluid. If residual is greater than 500 ml replace withdrawn fluids, document, notify RN or Provider.. Delay further feeding. Keep HOB 30 degrees. Cover with drain gauze, if needed. TPN & PPN:. High concentration of calories, carbohydrates, vitamins, minerals, electrolytes, lipids. Infused very slowly at first. Body can adjust to the high level of glucose in the solution. Do NOT increase the infusion rate of the solution too quickly. It can be harmful to the patient and lead to coma or death.. MUST also be weaned slowly before stopping TPN. Solution is usually started slowly to allow the body to adjust to solutions high glucose concentration & hyperosmolality.. Usually 1000-2000mls are administered in the first 24hrs, and the infusion is increased until the desired volume is met Nutrition:. Delivers total nutrition through intravenous central line. Subclavian vein, port, jugular, PICC. Used for long term therapy. Unable to tolerate feedings through the gut. Unable to maintain adequate calories - Patients that may need TPN:. Burn patients. Intestinal obstruction. Inflammatory bowel disease. AIDS. Cancer patients. Can be used in addition to tube or oral feedings PPN (Peripheral Parenteral Nutrition):. Have some oral intake but not enough calories. Administered through a peripheral IV site. Used for a very short amount of time. Monitor infusions closely and NEVER attempt to catch up if the rate has been slowed. Monitor IV site every 4hrs. Vital Signs every 4-8hrs. Monitor Flow rate of pump every 4 hours. Monitor Patients tolerance/response EVERY shift. Monitor Is & Os. Check patients blood sugars (Q-4, Q-6, Q-8). Weigh daily or weekly. Lab work Daily (Lab or Nurse may draw from PICC or IF doctor gives the order to do so) - Complications:. Infection can occur at the site of Central line (keep an eye on your IV dressings and keep clean). Leads to sepsis. Bacterial and fungal infections can develop in the solution if it is left unrefrigerated for over 24 hours. Check other IVs that patient may have and ensure they are not infiltrated or occluded (DVT can appear if you keep lines in that are infiltrated). ALL bags MUST be changed EVERY 24hrs CHAPTER 38 Closed & Open wounds: - Closed wounds without break in skin:. Contusion/Bruise- tissue injury, normally seen on skin. Hematoma- tissue injury with damage to the blood vessel. Sprain- twisting of joint partial rupture of ligaments, causes swelling - Open wounds-break in skin:. Incision- surgically made, clean smooth edges. Laceration- traumatic, torn edges. Abrasion- traumatic scraping away of the skin layers. Puncture- made by sharp, pointed objects through skin or membranes. Penetrating- made by penetrating objects such as bullets, metal ect. (Extends deep). Avulsion- tearing away of structure or part, such as fingertip. Ulceration- excavation of tissue from injury or necrosis. Perforation- internal organ or body cavity open, due from infection or penetrating wound.. Crush- compressed tissue Wound thickness: - Partial thickness:. Superficial. Heals more quickly. Fibrin clot framework - Full thickness:. No dermal layer except margins. Necrotic tissue must be removed for granulation fill Healing by Regeneration:. Body uses SAME type of cells to heal. Partial thickness wounds-same tissue. Original function and strength remain - Types of cells that can regenerate:. Skin. Mucous membranes. Bone. Muscle. Liver. Kidney. Lung - Replacement (or combination):. Body uses DIFFERENT types of cells to heal. Full thickness wounds-scar tissue. Original function and strength may not remain - Types of cells that use replacement:. Heart m muscle. Central spinal nerve cells - Wounds may be CLEAN and free of microorganisms - Dirty wounds contain microorganisms from contaminated object and from an infected wound.  Yaaallll be ready because them unstageable sacral wounds STAAAAANKKKKKK 3 phases of wound healing: - Inflammatory Phase (1st phase):. Begins AFTER injury when wound is FRESH. Last 3-4 days Stage includes: - Hemostasis:. Constricts blood vessels. Platelet clumping. Fibrin formation. Clot & Scab forms. 48hrs epithelial tissue forms over wound. Phagocytes removed debris & protect against infection. Edema to injured part. Redness resulting from the increased blood supply (Erythema). Heat or increased temperature at the site. Pain stemming from pressure on nerve receptors. Possible loss of function resulting from all these changes - Clinical signs of Inflammation:. Edema. Erythema. Warmth. Pain - Proliferation wound healing (2nd stage):. Begins on 3rd-4th day. Lasts 2-3wks. Wound filled new connective tissue (Scar begins to form). Macrophages-clean wound of debris, stimulating fibroblasts... causing collagen (protein in connective tissue). Capillary networks formed-provides oxygen/ nutrients...for collagen & granulation tissue. Tissue is deep pink. Full thickness wound closes with scarring  - Maturation (3rd Phase):. FINAL stage of healing. Begins approximately 3wks after injury. Scar maturation and remodeling is the process of collagen Lysis. Macrophages refine collagen gives scar strength. Scar slowly thins and lightens. Scar finally is firm & inelastic Contracture:. Abnormal shortening muscle tissue from scaring. When it occurs around joints it restricts joint extension. Overgrowth of collagen which is frequent in dark pigmented skin a KELOID appears. (fun fact I have one of these and it itches like a mf ) Adhesions:. Fibrous bands holding tissues together normally separated. Interferes with function of internal organs Healing intentions: - Primary: A wound with little tissue loss, such as a surgical incision heals by Primary intention.. Partial-Full thickness. Edges approximate (meet). Slight chance of infection - Secondary intention: A wound with tissue loss such as a pressure injury or severe laceration typically heals by secondary intention.. Partial-Full thickness. Edges DO NOT approximate. Fills with scar tissue. The wound is left open. Chance of infection is higher - Tertiary Intention: Also known as delayed closure. This occurs when there is delayed suturing of a wound.. Wound left open then later sutured. Higher chance of infection. Suture after granulation tissue begins to form and if there is no infection present EX: Abdominal wound left open for drainage and then later closed is an example of healing by tertiary intention  Factors affecting wound healing:. Age- Children & adults heal more quickly than elderly. Peripheral Vascular Disease (PVD)- Impairs blood flow, which makes healing harder. Decreased immune system function- Antibodies & Monocytes necessary for wound healing. Reduced liver function- Impairs the synthesis of blood factors. Decreased lung function- Reduces available oxygen needed for synthesis of collagen and the formation of new epithelial cells.. Lifestyle- Not smoking & exercising regularly will help with wound healing. Medications- Steroids & anti-inflammatories, heparin, and antineoplastic agents interfere with healing process. Infection- Bacterial infections often cause a decrease in the healing process wound drainage, assess color, consistency, & odor. Chronic illnesses- Diabetes, cardiovascular disease, immune system disorders may slow wound healing Wound Complications:. Hemorrhage- Risk is greatest during first 48hrs after surgery. Its considered an EMERGENCY! - Signs & Symptoms of Hemorrhage:.  in BP.  pulse rate & Respirations. Restlessness. Patient may have an  in temp.. Diaphoresis (cold, clammy skin). Swelling in the wound area. Sanguineous drainage in surgical drain - When assessing a dressing always look & feel beneath the patient for pooled blood - Can be caused by Slipped suture, clot, trauma to the site. - Apply pressure using sterile towels, monitor VS & notify MD.. Infection- MOST common type of wound complication. Wound may be infected during surgery or post-op. Traumatic wounds are more likely to become infected. An accumulation of pus from debris Localized infection in an abscess - Infection Signs & Symptoms:. Increased pain. Redness. Warmth in the surrounding tissues & purulent exudate (fluid containing cellular debris) - Labs:. Culture & Sensitivity. WBC (will most likely be elevated). Taken from the wound exudate (fluid/drainage). Determine what type of organism is growing and what ABX can treat - Microorganisms:. Discharge (white, yellow, pink, green). Staphylococcus aureus. E. Coli. MRSA (methicillin-resistant staphcoccus aureus). Pseudomonas aeruginosa Complication from infection:. Cellulitis- Inflammation of tissue surrounding with redness and induration (skin hardening). Fistula-abnormal passage formed between 2 internal organs. Sinus-fistula leading from infected cavity to outside of body - Dehiscence- Spontaneous opening of an incision. GREATEST risk for wound dehiscence is on 4-5 post-op day (before extensive collagen has been built). Straining could cause dehiscence. poor nutrition & dehydration can cause dehiscence. Being unhealthy & suture failure can cause dehiscence as well - Evisceration- Protrusion of an internal organ through the incision. Can lead to NECROSIS of intestines or Sepsis. Patient will express that they feel like something split open. Could have wound drainage before tearing - IMMEDIATE CARE:. Supine. Place a LARGE STERILE dressing over the viscera. SOAK the dressing in Sterile normal saline. NOTIFY the surgeon immediately. Prepare the patient for return to surgery Wound Closures: - Sutures:. Hold the edges of the wounds together until it can heal. Suture that are used to attach tissues beneath the skin are absorbed and not removed. When sutures are removed use STERILE technique. Inspect for intactness after removal. Made from silk, cotton, linen, wire, nylon, or Dacron - Retention Sutures:. Used to take some of the pressure off other sutures. Wound does not pull open as it is healing. Usually used after abdominal surgeries in patients who are overweight or who may suffer from a distention of the abdomen due to swelling or disease - Steri-Strips:. Small reinforced adhesive strips that hold the wound edges together. Often applied after sutures/staples are removed - Staples:. Hold edges of the wound together. Typically removed after 7-14 days - Dermabond (surgical adhesive):. Noninvasive glue. Provides a seal without needing a dressing. Used in place of sutures.. Comes off in 7-10 days.. Do NOT use on mucous membranes Open wound colors:. RED: Clean & ready to heal (protect the wound). YELLOW: Layer of yellow fibrous debris or exudate, needs to be cleaned often, natural shedding of dead tissue may cause drainage, dressing needs to absorb drainage. (Watch for infection). BLACK: Needs debridement, eschar (dead tissue), won’t heal until debrided Drains and Drainage devices: - Passive drain: (Penrose). Has no suction device attachment. It works by the increased pressure in the wound. Drains with GRAVITY & capillary action to pull out any fluid build up - Active: (Hemovac, devol, & Jackson-Pratt). An active drain is attached to wound suction device to remove any accumulated drainage.. An active drain works by compressing device - Nursing care for drains:. Empty Drains EVERY end of shift. If drain is 1/2 -2/3 full go ahead and empty out or it will NOT suction. Document intake and output EVERY shift (clean spout & plug with alcohol pad) - When a patient needs to have a wound debridement, NECROTIC tissue is being removed and when it’s removed the goal is to keep it dressed and clean  - Change dressings per doctors’ orders - Mechanical debridement:. Irrigation or hydrotherapy Whirlpool or ultrasound mist Microscopic bubbles, sound waves Wet to dry dressing. Tissue sticks to dressing Cells are pulled off Not recommended any longer - Autolytic Debridement:. Longer process Uses body’s own enzymes break down the tissue Use on small, uninfected wound- - Dressings that promote moist environment:. Hydrogels. Hydrocolloids - transparent films: support moisture retention and assist in debridement - Chemical debridement:. Use when necrotic is NOT responding. Dakin solution or sterile maggots (Bleach & peroxide) Dressings & dressing changes:. Set up sterile field - Clean wound:. Saline or wound cleanser (not cold). Clean grossly infected wounds each change. Do NOT use cotton balls-cotton fibers can embed. Clean from center outward to avoid pulling microorganisms from skin to wound-do not use circular motion - Occlusive dressings:. Occlusive dressings keep wounds moist while protecting from contamination. Occlusive dressings are used for chronic hard to heal wounds - Transparent film dressings:. Clean wounds without drainage or infection. Can be used for IV dressings. In place for 3-7 days EX: Tegaderm - Hydrocolloid:. NOT to use on infected wounds. Keeps moist wounds moist. DON’T USE on heavily draining wounds. In place 3-5 days. Facilitates autolytic debridement. Provides insulation EX: DuoDERM Secure dressings: - Binders:. Decrease tension around wound or suture line. Adds comfort. Holds abdominal dressings in place. Helps apply pressure to site Negative Pressure Wound Therapy: - Wound Vac:. Suction device creates negative pressure drawing edges together. Stretches cells increasing cell and tissue growth. Removes fluid from wound. Increases blood flow-increases oxygen and nutrients to wound. Keeps wound moist - Dressing changes: Infected wound- every 12-24 hours Clean wound- 3 times a week - Do not use: Bleeding, exposed organs, exposed blood vessels or nerves, malignant tissue Cleaning ulcers or pressure injuries:. Clean at each dressing change. Irrigate with Syringe & water, saline.. Do NOT damage the new granulation that is forming over the wound. Document detailed wound care Pressure injuries stages: Nursing Process: - Assessment:. Document the location & appearance of the wound DAILY - Things to document from your assessment:. Amount of drainage on the wound. Scant, small, moderate, large. Color of the drainage. Swelling. Odor. Pain. Approximation (degree of closure). Warmth. Signs of infection (Elevated WBC, malaise). Acute= 8hrs. Chronic= 24hrs. Measure wounds. Measure Depth of wounds with a sterile cotton-tip. Also check for sinus tract. Type of dressing applied. Appearance around skin - Planning:. Must have an order - change Dressing or irrigate. If ordered not to change-draw a circle with a pen around the drainage on the dressing. Determine when last dressing change or irrigation was. Date/time/initial after dressing change. If large amount of drainage, reinforce the dressing and notify the MD - Implementation:. Sterile=touching open or fresh surgical wound. Nonsterile= wound is closed. Clean. Water. Normal saline. Antimicrobial cleaner. If solution is refrigerated, bring to room temperature. Cold solution lowers wounds temp & slows healing Packing wounds:. Do NOT use on infected wounds. Facilitates wound healing from the inside out, granulation tissue. Wet to damp dressing. Moist gauze is placed in the wound and changed before it dries out. Performed every 4-6 hours. Painful Eye, ear & vaginal irrigations: - Eye irrigations:. May be performed when injury is involved and debris or a caustic substance is present in the eye - Ear irrigations:. Used to remove cerumen or foreign substances - Vaginal irrigations:. May be ordered for infections or surgical preparation - HOT & COLD applications:. can be dry or moist. usually requires Physician’s order. HOT application help reduce inflammation. COLD application decreases swelling and pain. For joint injuries or areas requiring decreased blood flow OKAY IM FREAKING DONE… I CAN’T LOOK AT THIS ANYMORE. THE FREAKING END!!