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CHAPTER 20 Selected Nursing Skills Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 1 Standard Steps in Selected Skills • All nursing skills must include basic steps for the safety and well-being of the patient and the nurse. • Before the Skill Refer to medical record, care plan, or Kardex for special interventions. Introduce yourself; include your name and title or role. Identify patient by checking arm band and requesting patient to state his or her name. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 2 Standard Steps in Selected Skills • Before the Skill (continued) Explain the procedure and the reason it is to be done in terms the patient can understand, and give the patient time to ask questions. Advise patient of any unpleasantness that might be experienced. Assess need for and provide patient teaching during procedure. Assess patient. Wash hands and don clean gloves according to agency policy and guidelines from the CDC and OSHA. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 3 Standard Steps in Selected Skills • Before the Skill (continued) Assemble equipment and complete necessary charges. Prepare the patient for intervention. • Close door/pull privacy curtain. • Raise bed to comfortable working height; lower side rail on side nearest the nurse. • Position and drape patient as necessary. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 4 Standard Steps in Selected Skills • During the Skill Promote patient involvement as possible. Assess patient’s tolerance, being alert for signs and symptoms of discomfort and fatigue. • Completion of Procedure Assist the patient to a position of comfort and place needed items within easy reach. Be certain patient has a means to call for assistance and knows how to use it. Raise the side rails and lower the bed to the lowest position. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 5 Standard Steps in Selected Skills • Completion of Procedure (continued) Remove gloves and all protective barriers. Store or remove and dispose of soiled supplies and equipment according to agency policy and guidelines from CDC and OSHA. Wash hands after patient contact and after removing gloves. Document patient’s response, expected or unexpected outcomes, and patient teaching. Report any unexpected outcomes. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 6 Standard Steps: Step 14 (From Potter, P.A., Perry, A.G. [2003]. Basic nursing: essentials for practice. [5th ed.]. St. Louis: Mosby.) Removing disposable gloves. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 7 Skills for Sensory Disorders • Irrigations Eye Irrigations • Relieve local inflammation of the conjunctiva, apply antiseptic solution, or flush out exudate or caustic solutions. • Warm saline and small syringe or eyedropper are usually used to instill a few hundred milliliters of solution. • Irrigation should always be done from the inner canthus to the outer canthus. • Never allow the syringe tip to touch the eye. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 8 Skills for Sensory Disorders • Irrigations (continued) Eye Irrigations (continued) • At home, eye irrigation can be performed with an eye cup. • A copious irrigation of the eye may be accomplished with the use of intravenous tubing and bag connected to a Morgan Therapeutic Lens. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 9 Skills for Sensory Disorders • Irrigations (continued) Ear Irrigations • Using a small syringe and solution at body temperature, the nurse can cleanse a patient’s external auditory canal of excess cerumen or exudate from a lesion or an inflamed area. • Slow, gentle irrigation works best. • Irrigation is contraindicated when a vegetable foreign body obstructs the auditory. • Irrigation is contraindicated if the patient has a cold, a high temperature, an ear infection, or an injured or ruptured tympanic membrane. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 10 Skills for Heat and Cold Therapy • The nurse should Understand the normal responses to local temperature variations Assess the integrity of the body part Determine patient’s ability to sense temperature variations Ensure proper operation of equipment Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 11 Skills for Heat and Cold Therapy • The body can tolerate wide variations in • • • • • temperature. Normal skin temperature is 93.2° F. Temperature receptors usually adapt quickly to local temperatures between 113° and 59° F. Pain develops when local temperatures exceed these limits. Excessive heat causes a burning sensation. Cold produces a numbing sensation before pain. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 12 Skills for Heat and Cold Therapy • Local Effect of Heat and Cold Effects of Heat Application • Heat improves blood flow through vasodilation to an injured part. • However, blood flow is reduced by vasoconstriction as the body attempts to control heat loss from the area. • Periodic removal and reapplication of local heat restores vasodilation. • Continuous exposure to heat damages epithelial cells. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 13 Skills for Heat and Cold Therapy • Local Effect of Heat and Cold (continued) Effects of Cold Application • Exposure of the skin to cold results in vasoconstriction. • The cell’s ability to receive adequate blood flow and nutrients results in tissue ischemia. • The skin initially takes on an erythematous appearance, followed by a bluish-purple mottling with numbness and a burning type of pain. • The skin’s tissue can freeze on exposure to extreme cold. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 14 Skills for Heat and Cold Therapy • Assessment Assess patient’s physical condition for signs of potential intolerance to heat and cold. Observe the area to be treated for impairment of skin integrity. Identify conditions that contraindicate heat or cold therapy. • Warm applications are contraindicated when the patient has an acute localized inflammation; cardiovascular problems; or active bleeding. • Cold applications are contraindicated if the site of injury is edematous or the patient has impaired circulation or is shivering. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 15 Skills for Heat and Cold Therapy • Patient Safety Before heat or cold treatment is applied, the patient should understand its purpose, the symptoms of temperature exposure, and precautions taken to prevent injury. • Physician's Order A prerequisite to heat or cold application is a physician’s order, which should include body site and the type, frequency, and duration of application. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 16 Skills for Heat and Cold Therapy • Moist or Dry Applications Heat and cold applications can be administered in dry or moist forms. The type of injury, the location of the body part, and the presence of drainage or inflammation are factors to be considered. • Hot, Moist Compresses For open wounds, sterile, hot, moist compresses improve circulation, relieve edema, and promote consolidation of purulent exudate. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 17 Skill 20-4: Step 4 (From Ignatavicius, D.D., Workman, M.L. [2002]. Medical-surgical nursing across the health care continuum. [4th ed.]. Philadelphia: Saunders.) Assess condition of exposed skin and wound on which compress is to be applied. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 18 Skills for Heat and Cold Therapy • Warm Soaks Immersion of a body part in a warmed solution Promotes circulation Lessens edema Increases muscle relaxation Can provide a means to debride wounds and apply medicated solution A soak can also be accomplished by wrapping the body part in dressings and saturating them with warmed solution or by whirlpool treatments. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 19 Figure 20-1 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Whirlpool moist heat therapy. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 20 Skills for Heat and Cold Therapy • Paraffin Baths Bath consists of a mixture of heated paraffin wax and mineral oil. Patients with painful arthritis or other joint discomforts of the hands and feet benefit most from these baths. • Aquathermia (Water-Flow) Pads This is used to treat muscle sprains and areas of mild inflammation or edema. This consists of a waterproof plastic or rubber pad connected by two hoses to an electrical unit that has a heating element and motor. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 21 Figure 20-2 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Aquathermia pad. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 22 Skills for Heat and Cold Therapy • Commercial Hot Packs Commercially prepared, disposable hot packs apply warm, dry heat to an injured area. Sticking, kneading, or squeezing the pack mixes the chemicals and releases the heat. • Electric Heating Pads Pad consists of an electric coil enclosed within a waterproof pad covered with cotton or flannel cloth. The pad is connected to an electric cord that has a temperature-regulating unit for a high, medium, or low setting. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 23 Skills for Heat and Cold Therapy • Cold Moist and Dry Compresses Cold compresses should be applied for 20 minutes at a temperature of 59° F to relieve inflammation and edema. Commercially prepared cold packs are available for dry application. The nurse should observe for burning or numbness, mottling of the skin, erythema, extreme paleness, or cyanosis. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 24 Figure 20-3 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Commercial cold pack used for therapy. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 25 Skills for Heat and Cold Therapy • Ice Bags or Collars For a patient who has muscle sprain, localized hemorrhage, or hematoma or who has undergone dental surgery, an ice bag is ideal to prevent edema formation, control bleeding, and anesthetize the body part. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 26 Skills for Administering Parenteral Fluids • The overall goal of fluid IV administration is to correct or prevent fluid and electrolyte imbalances. • Indications for IV Therapy Poor tissue absorption Inadequate GI tract function Need to maintain mediations at optimum levels Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 27 Skills for Administering Parenteral Fluids • The nurse should will observe for the following guidelines: Monitor the solution drop rate at the ordered infusion rate. Infuse the amount of prescribed solution. Maintain the patency of the IV catheter. Monitor site every 1 to 2 hours; IV line should be assessed every 4 hours. During parenteral therapy, the patient’s I&O should be recorded. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 28 Skills for Administering Parenteral Fluids • Intravenous Therapy/Venipuncture Before the procedure, assemble and make ready the equipment. Assess the patient’s veins. Select and clean a puncture site. Perform venipuncture. Begin infusion. Teach the patient about the signs and symptoms of problems and ways to perform activities while on IV therapy. Follow strict aseptic principles. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 29 Figure 20-4 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Common intravenous sites. A, Dorsal surface of the hand. B, Inner arm. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 30 Figure 20-5, A (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Apply tourniquet. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 31 Figure 20-5, B (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Select intravenous site. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 32 Figure 20-5, C (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) C, Cleanse site for venipuncture. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 33 Figure 20-5, D (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) D, Pull skin taut as catheter is inserted. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 34 Figure 20-6, A (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Close valve. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 35 Figure 20-6, B (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Remove insertion port cover. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 36 Figure 20-6, C (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) C, Insert spike. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 37 Skills for Administering Parenteral Fluids • Intravenous Therapy/Venipuncture (continued) Tubing is selected based on the patient and type of infusion to be initiated. The valve is closed. The tubing spike is inserted into the insertion port on the correct fluid bag. The fluid bag is held upright, and the tubing drip chamber is gently squeezed to partially fill it with fluid. The valve is slowly opened to permit the flow of fluid down the tubing. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 38 Skills for Administering Parenteral Fluids • Intravenous Therapy/Venipuncture (continued) The venipuncture needle and catheter should be selected according to the solution to be infused and the size and condition of the patient’s veins. Plastic IV catheters are flexible and have blunt tips that reduce infiltration and allow the patient to move. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 39 Skills for Administering Parenteral Fluids • Intravenous Therapy/Venipuncture (continued) Intravenous Monitoring • Patency A condition of being opened and unblocked • Flow rate is ordered by the physician. • Assess tubing for kinks or obstructions. • Inspect and palpate the site for edema, erythema, induration, heat, and discomfort. • Assess for signs and symptoms of fluid overload. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 40 Skills for Administering Parenteral Fluids • Intravenous Therapy/Venipuncture (continued) Infiltration • Edema that does not subside generally indicates that the catheter is out of the vein. • Discomfort and dysfunction may also indicate that the solution has infiltrated. • An infiltrated arm will feel cool, and the skin may have a blanched appearance. • The solution is discontinued and another site is used to continue therapy, preferably in the opposite extremity. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 41 Skills for Administering Parenteral Fluids • Intravenous Therapy/Venipuncture (continued) Phlebitis • This results from mechanical irritation (the needle moving in the vein), the low pH of some IV solutions, and highly concentrated additives. • Classic Signs Erythema, warmth, edema, and discomfort • Applying warm compresses to the inflamed area lessens discomfort. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 42 Skills for Administering Parenteral Fluids • Intravenous Therapy/Venipuncture (continued) Septicemia • A systemic infection occurs from pathogens introduced into the circulating bloodstream. • Signs and Symptoms Fever, chills, prostration, pain, headache, nausea, and vomiting • Antibiotic therapy is vigorously initiated if blood cultures verify a septicemic condition. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 43 Skills for Administering Parenteral Fluids • Blood Transfusion Therapy This is most commonly used to replace blood loss. Individuals may store their own blood before anticipated surgery for infusion during hospitalization. The fear of HIV infection has led some patients to refuse blood products. Plasma expanders (Plasmanate, Dextran) can be used for patients who refuse blood transfusions because of personal or religious beliefs. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 44 Skills for Administering Parenteral Fluids • Blood Transfusion Therapy (continued) Autologous Blood Transfusion • A process of collecting a patient’s lost blood during surgery or after a traumatic injury and infusing it intravenously into the patient. • It is used in cardiac thoracic surgery or after traumatic chest injury. • Suction drainage device collects blood in a special bag. • The blood should be administered immediately or not more than 6 hours after initial collection. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 45 Skills for Administering Parenteral Fluids • Blood Transfusion Therapy (continued) Initiating a Blood Transfusion • Nurse is responsible for assessing and monitoring the patient before, during, and after transfusion. • Obtain informed consent. • An infusion of 0.9% or 0.45% normal saline is initiated. • Follow established protocol for obtaining the blood, double-checking the compatibility of the blood with the patient’s blood and identifying the patient. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 46 Figure 20-7, A (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Opened blood administration set and tubing primed with normal saline 0.9%. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 47 Figure 20-7, B (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Attached blood product to the normal saline 0.9%. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 48 Skills for Administering Parenteral Fluids • Blood Transfusion Therapy (continued) Initiating a Blood Transfusion (continued) • Baseline vital signs are taken and recorded. • Prime the special blood filter administration tubing and piggyback it into the primary infusion line. • Remain with the patient while slowly infusing the first 50 ml of blood. • Assess the patient’s response and monitor vital signs. • The nurse must know the symptoms of blood transfusion reaction and interventions to initiate for them. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 49 Skills for Administering Parenteral Fluids • Blood Transfusion Therapy (continued) Blood Transfusion Reactions • If the infused blood is not compatible with the patient’s blood type, a reaction will occur. • A transfusion reaction is an emergency. • Signs and symptoms Statement of “not feeling right” Chills, fever, low back pain, pruritis, hypotension, nausea and vomiting, decreased urine output, chest pain, dyspnea Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 50 Skills for Administering Parenteral Fluids • Blood Transfusion Therapy (continued) Blood Transfusion Reactions (continued) • If a transfusion reaction is suspected Stop the infusion. Keep the vein open with 0.9% or 0.45% sodium chloride solution. Notify the physician and the blood bank Monitor vital signs and urine output every 15 minutes. Reassure and support the patient. Send remaining blood to the blood bank for analysis. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 51 Skills for Administering Parenteral Fluids • Changing the Tubing This is most easily accomplished when a new container of solution is added. Connect and prime the new solution container and tubing. Carefully remove the tape, securing the old tubing to the IV catheter hub while gently stabilizing the catheter and site. Working carefully but quickly, turn off the flow valve of the old tubing, remove the old tubing from the catheter hub, insert the new tubing into the catheter hub, and open the flow valve. Secure with tape. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 52 Skills for Administering Parenteral Fluids • Discontinuing Intravenous Therapy Intravenous infusions are discontinued when • The prescribed amount of solution has infused • There are signs of infiltration • The patient has developed phlebitis or other complications Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 53 Skills for Administering Parenteral Fluids • Discontinuing Intravenous Therapy (continued) Steps for discontinuing an IV infusion: • • • • • • Assemble supplies. Wash hands. Explain procedure to the patient. Don gloves. Turn IV flow regulator to the “off” position. Gently remove tape and dressing from site while carefully stabilizing the needle or catheter. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 54 Skills for Administering Parenteral Fluids • Discontinuing Intravenous Therapy (continued) Steps for discontinuing an IV infusion (continued): • Place dry gauze pad over needle insertion site. • Swiftly withdraw needle or catheter from the site while applying gentle pressure over the site. • Hold site above heart level while continuing to apply direct pressure for about 45 seconds to 1 minute. • Assess for bleeding from the site. • Apply a bandage or sterile dressing according to agency policy. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 55 Skills for Administering Parenteral Fluids • Discontinuing Intravenous Therapy (continued) Steps for discontinuing an IV infusion (continued): • Gather soiled supplies, remove gloves, and discard in appropriate containers. • Wash hands. • Document promptly and accurately. • Reevaluate site in 10 to 15 minutes. • Instruct patient to report any redness, pain, drainage, or swelling. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 56 Skills for Administering Parenteral Fluids • Maintaining an Intravenous Site Change catheter dressings when loose, wet, or soiled. Gauze dressings should be changed every 48 hours. Fluid containers may be changed frequently depending on the rate of infusion and the volume of the container. Change infusion tubing according to facility policy. Infusion tubing should not be disconnected to change a gown or clothing. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 57 Skills for Respiratory Disorders • Oxygen Therapy Goal or oxygen therapy is to prevent or relieve hypoxia. Any patient with impaired tissue oxygenation can benefit from controlled oxygen administration. Oxygen is not a substitute for other treatments and should be used only when indicated. Oxygen should be treated as a drug. Oxygen is expensive and can have dangerous side effects. The dosage or concentration of oxygen should be ordered and continuously monitored. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 58 Skills for Respiratory Disorders • Oxygen Therapy (continued) Oxygen is a colorless, odorless, and tasteless gas that will not burn or explode. If combined with other factors, such as an electrical spark or fire, it will support combustion and ignite. Oxygen therapy is frequently initiated by a respiratory therapist, who is a health care professional licensed to deliver treatment that will improve a patient’s ventilation and oxygenation needs. The signs and symptoms manifested by patients who might require oxygen will vary according to the degree of oxygen deficiency. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 59 Skills for Respiratory Disorders • Oxygen Therapy (continued) Transtracheal Oxygen Delivery • A newer method of oxygen delivery is the transtracheal catheter, which is inserted directly into the trachea between the second and third tracheal cartilages. • Delivery does not interfere with drinking, eating, or talking. • Oxygen is delivered throughout the respiratory cycle. • It is recommended for patients with heart failure or chronic obstructive pulmonary disease. • The transtracheal opening should be inspected and cleaned regularly. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 60 Figure 20-9 A transtracheal catheter may be inserted into the trachea between 2nd and 3rd tracheal cartilages. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 61 Skills for Respiratory Disorders • Oxygen Therapy (continued) Care of the Tracheostomy • A tracheostomy is an artificial opening made by a surgical incision into the trachea. • It is performed to provide the patient with a patent airway. • After the surgical procedure is performed, the physician inserts a tracheostomy tube and secures it in place with cotton tape around the patient’s neck. • Sterile gauze is placed around the opening under the flange of the outer tube for skin protection. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 62 Skills for Respiratory Disorders • Oxygen Therapy (continued) Care of the Tracheostomy (continued) • It is essential that nursing interventions be consistently implemented that Minimize infection risk Minimize sensory deprivation Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 63 Skills for Respiratory Disorders • Oxygen Therapy (continued) Care of the Patient with a Tracheostomy Collar and TPiece/Tube • This requires constant humidification to the airway. • The T-piece/tube is a T-shaped device with a 15 mm connection with large-lumen tubing. • A tracheostomy collar is a curved device with an adjustable strap that fits around the patient’s neck; an exhalation port remains open at all times and another connects to large-bore tubing. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 64 Figure 20-11, A (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Trach tube (fenestrated) with inner cannula removed and cap in place to allow speech. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 65 Figure 20-11, B (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Trach tube with obturator for insertion and syringe for inflation of cuff. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 66 Figure 20-12 T-piece/tube. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 67 Figure 20-13 Tracheostomy collar. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 68 Skills for Urinary or Reproductive Tract Disorders • Urinary Elimination This is a natural process that individuals take for granted until it is altered by some uncontrollable physiological factor. Patients may require physiological and psychological assistance from the nurse. Physiological support may require the use of an invasive procedure, such as insertion of a urinary catheter into the bladder. Psychological assistance may be needed to help the patient adjust to a visible urine collection drainage bag. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 69 Skills for Urinary or Reproductive Tract Disorders • Urinary Elimination (continued) Catheter • This is a flexible tube that can be inserted into a vessel or cavity of the body to withdraw or instill fluids. • Most catheters are made of soft plastic or rubber. • Catheters may be used for treatment or diagnosis. • Catheterization of the bladder involves introducing a urinary catheter through the meatus and urethra and into the urinary bladder. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 70 Skills for Urinary or Reproductive Tract Disorders • Urinary Elimination (continued) Maintaining adequate urinary drainage • Urinary catheters are used to Maintain urine flow Divert urine flow to facilitate healing postoperatively Introduce medications via irrigation Dilate or prevent narrowing of some portions of the urinary tract May be used for intermittent or continuous drainage Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 71 Skills for Urinary or Reproductive Tract Disorders • Urinary Elimination (continued) Maintaining adequate urinary drainage • Urinary catheters may be introduced into the bladder, ureter, or kidney. • The type and size of urinary catheter used are determined by the location and cause of the urinary tract problem. • Catheters are measured by the French system (Fr). • Urethral catheters range in size from 14 to 24 Fr for adult patients. • Ureteral catheters are usually 4 to 6 Fr and are must be inserted by a physician. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 72 Skills for Urinary or Reproductive Tract Disorders • Types of Catheters Coudé Catheter • Selected for ease of insertion when enlargement of the prostate gland is suspected Foley Catheter • Designed with a balloon near the tip so that the balloon may be inflated after insertion, holding the catheter in the urinary bladder for continuous drainage Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 73 Skills for Urinary or Reproductive Tract Disorders • Types of Catheters (continued) Malecot, Pezzer, and Mushroom Catheters • Used to drain urine from the renal pelvis of the kidney Robinson Catheter • Has multiple openings in its tip to facilitate intermittent drainage Ureteral Catheter • Are long and slender to pass into the ureter Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 74 Figure 20-14 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Different types of commonly used catheters. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 75 Skills for Urinary or Reproductive Tract Disorders • Types of Catheters (continued) Whistle-tip catheter • Has a slanted, larger orifice at its tip to be used if there is blood in the urine Cystostomy, vesicostomy, or suprapubic catheters • Introduced through the abdominal wall above the symphysis pubis • Used to divert urine flow from the urethra to treat injury to the bony pelvis, urinary tract, or surrounding organs; strictures; or obstructions • Inserted via a surgical incision or puncture of the abdomen and bladder walls with a trocar Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 76 Skills for Urinary or Reproductive Tract Disorders • Types of Catheters (continued) Condom catheters • This device is not a catheter but a drainage system connected to the external male genitalia. • It is used for the incontinent male to minimize skin irritation from urine. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 77 Figure 20-15 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Condom catheter. B, Condom catheter attached to leg bag. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 78 Figure 20-17 (From Potter, P.A., Perry, A.G. [2003]. Basic nursing: essentials for practice. [5th ed.]. St. Louis: Mosby.) Drainage system must be below the level of the bladder. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 79 Skills for Urinary or Reproductive Tract Disorders • Self-Catheterization This is used for the patient who experiences spinal cord injuries or other neurological disorders that interfere with urinary elimination. Intermittent self-catheterization promotes independent function for the patient. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 80 Skills for Urinary or Reproductive Tract Disorders • Routine Catheter Care Perineal care and the cleansing of the first 2 inches of the catheter every 8 hours are expected at minimum. The use of powders or lotions on perineum is contraindicated. Assess the urethral meatus and surrounding tissues for inflammation, swelling, and discharge. Note amount, color, odor, and consistency of discharge. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 81 Skills for Urinary or Reproductive Tract Disorders • Routine Catheter Care (continued) The urinary tubing and collection bag should be changed only if there are signs of leakage, odor, or sediment buildup. Check the drainage tubing and bag to ensure that no tubing loops hang below the level of the bladder, that the tube is coiled and secured onto the bed linen, and that the tube is not kinked or clamped. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 82 Figure 20-18 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Empty and record urine output from Foley catheter into clean graduated container. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 83 Skills for Urinary or Reproductive Tract Disorders • Bladder Training Involves developing the use of the muscles of the perineum to improve voluntary control over voiding; may be modified for different problems. In preparation for the removal of a urethral catheter, the physician may order a clamp/unclamp routine to improve bladder tone. For the patient with stress incontinence, instruct to perform Kegel exercises. For habit training, a voiding schedule is established. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 84 Skills for Urinary or Reproductive Tract Disorders • Managing Incontinence Urinary incontinence occurs because pressure in the bladder is too great or because the sphincters are too weak. Kegel exercises Bladder training Credé’s method Disposable adult undergarments or underpads Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 85 Skills for Urinary or Reproductive Tract Disorders • Discontinuing an Indwelling Catheter An indwelling catheter must be removed or changed after a certain period of time. It may be removed and replaced by a new catheter or removed and the patient allowed to excrete urine via the normal route. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 86 Skills for Gastrointestinal Disorders • Inserting and Maintaining Nasogastric Tubes Nasogastric tube is a pliable tube that is inserted through the patient’s nasopharynx into the stomach. The tube allows for removal of gastric contents and introduction of liquids into the stomach. The primary purpose is decompression or removal of flatus and fluids from the stomach. Nursing challenges: patient comfort and maintaining patency of the tube Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 87 Figure 20-20 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Small-bore feeding tube. B, Salem sump tube. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 88 Skills for Gastrointestinal Disorders • Bowel Elimination Elimination of bowel waste (defecation) is a basic human need and is essential for normal body function. Normal bowel elimination depends on several factors: a balanced diet, including high-fiber foods; a daily fluid intake of 2000-3000; and activity to promote muscle tone and peristalsis. Normal stool (feces) is described for documentation as moderate in amount, brown, and soft in consistency and is expelled every 1 to 3 days. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 89 Skills for Gastrointestinal Disorders • Care of the Patient with Hemorrhoids The patient with hemorrhoids has pain when hemorrhoidal tissues are directly irritated from the passage of hard stool. The primary goal for the patient with hemorrhoids is soft, formed stools. Proper diet, fluids, and regular exercise improve the likelihood of soft stools. Local heat provides temporary relief to swollen hemorrhoids; sitz bath is the most effective means of heat application. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 90 Skills for Gastrointestinal Disorders • Flatulence This is the presence of air or gas in the intestinal tract. It may occur when a person consumes gas-producing liquids and foods, such as carbonated beverages, cabbage, or beans; swallows excessive amounts of air; or has constipation. In hospitalized patients, flatulence is often caused by decreased peristalsis, abdominal surgery, some narcotic medications, and decreased physical activity. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 91 Skills for Gastrointestinal Disorders • Flatulence (continued) May cause distention of the stomach and abdomen and mild to moderate abdominal cramping and pain One of the most effective measures to promote peristalsis and passage of flatus is walking Rectal tube may be used Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 92 Skills for Gastrointestinal Disorders • Administering an Enema This involves the instillation of a solution into the rectum and sigmoid colon. Primary reason for an enema is promotion of defecation. The volume and type of fluid instilled can lubricate or break up the fecal mass, stretch the rectal wall, and initiate the defecation reflex. Patients should not rely on enemas to maintain bowel regularity because enemas do not treat the cause. Frequent enemas disrupt normal defecation reflexes, resulting in dependency on enemas for elimination. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 93 Skills for Gastrointestinal Disorders • Fecal Incontinence The first step in care of the patient with fecal incontinence is to assess whether fecal impaction is the cause. An impaction involves the presence of a fecal mass too large or hard to be passed voluntarily. Either constipation or diarrhea can suggest the presence of an impaction. An oil retention enema lubricates the rectum and colon, softens the feces, and facilitates defecation. It can be used alone or with manual removal of a fecal impaction. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 94 Skills for Gastrointestinal Disorders • Ostomies Colostomy • A surgical creation of an artificial anus on the abdominal wall formed by incising the colon and bringing it out to form a stoma on the abdominal surface • Performed for patients with cancer of the colon, intestinal obstructions, intestinal trauma, or inflammatory diseases of the colon • May be permanent or temporary until intestinal healing occurs Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 95 Skills for Gastrointestinal Disorders • Ostomies (continued) Ileostomy • A surgical formation of an opening of the ileum onto the surface of the abdomen through which fecal matter is emptied • Performed for patients with inflammatory bowel conditions and cancer of the large intestine • Stoma looks like a colostomy but it is smaller and located lower on the abdomen • Patient wears a pouch to collect the semiliquid fecal matter Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 96 Figure 20-21 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Ostomy pouches and skin barriers. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 97 Skills for Gastrointestinal Disorders • Nasal Irrigation It soothes inflamed mucous membranes and washes away dried mucus, secretions, and possible foreign matter. It may be accomplished with the use of a specially designed electronic device or a bulb syringe. Patients with acute or chronic nasal conditions and patients who inhale allergens and toxins may derive benefits from nasal irrigations. It is contraindicated with advanced destruction of the sinuses, foreign bodies, and frequent nosebleeds. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 98