Therapeutic Procedures

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Information about Therapeutic Procedures

Published on September 18, 2007

Author: jben501

Source: slideshare.net

Description

THERAPEUTIC PROCEDURES - SELECTED TOPICS ON COMMON NURSING PROCEDURES

THERAPEUTIC PROCEDURES SELECTED TOPICS ON COMMON NURSING PROCEDURES

UNIVERSAL PRECAUTIONS HANDWASHING BARRIER METHOD STERILIZATION AND DISINFECTION IMMUNIZATION ENVIRONMENTAL CONTROL AND SANITATION ISOLATION

HANDWASHING

BARRIER METHOD

STERILIZATION AND DISINFECTION

IMMUNIZATION

ENVIRONMENTAL CONTROL AND SANITATION

ISOLATION

SURGICAL ASEPSIS MAINTENANCE OF STERILE FIELD MEDICAL AND SURGICAL ASEPTIC TECHNIQUES

MAINTENANCE OF STERILE FIELD

MEDICAL AND SURGICAL ASEPTIC TECHNIQUES

THERAPEUTIC EXERCISES ISOMETRIC ISOTONIC ROM

ISOMETRIC

ISOTONIC

ROM

CHEST PHYSIOTHERAPY BREATHING COUGHINGPOSTURAL DRAINANGE PERCUSSION AND VIBRATION INCENTIVE SPIROMETER SUCTIONING TRACHEOSTOMY CARE OXYGEN THERAPY

BREATHING

COUGHINGPOSTURAL DRAINANGE

PERCUSSION AND VIBRATION

INCENTIVE SPIROMETER

SUCTIONING

TRACHEOSTOMY CARE

OXYGEN THERAPY

Chest Physiotherapy It is the combination of percussion, vibration, and postural drainage Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes Vibration is done during 5 exhalations Postural drainage is done for 15-20 minutes usually performed 3-4 times a day. Instruct the client to increase fluid intake to liquefy secretions This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery. This procedure is done before meal or 90 minutes after a meal

Chest Physiotherapy

It is the combination of percussion, vibration, and postural drainage

Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes

Vibration is done during 5 exhalations

Postural drainage is done for 15-20 minutes usually performed 3-4 times a day.

Instruct the client to increase fluid intake to liquefy secretions

This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery.

This procedure is done before meal or 90 minutes after a meal

Oxygen Therapy Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen. Humidify the oxygen first before you administer. Check for bubbles in the humidifier to promote adequate flow of oxygen Check for kinks in the tubing Position: semi-fowlers/ high fowlers position Place cautionary readings: “NO smoking: Oxygen is in used” Instruct the client not to use woolen blankets as this may create static electricity

Oxygen Therapy

Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen.

Humidify the oxygen first before you administer.

Check for bubbles in the humidifier to promote adequate flow of oxygen

Check for kinks in the tubing

Position: semi-fowlers/ high fowlers position

Place cautionary readings: “NO smoking: Oxygen is in used”

Instruct the client not to use woolen blankets as this may create static electricity

pulmonary function tests tidal volume- 500 residual volume- 1200 expiratory reserve volume –1200 inspiratory reserve volume – 3100 Vital Capacity- tidal volume + IRV + ERV = 4800 Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000 Forced Residual Capacity – ERV + RV

tidal volume- 500

residual volume- 1200

expiratory reserve volume –1200

inspiratory reserve volume – 3100

Vital Capacity- tidal volume + IRV + ERV = 4800

Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000

Forced Residual Capacity – ERV + RV

incentive spirometry – hold 2-6 sec; 4-5 times/H endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly visualization – X ray Lung Scxan – 20-40mins isotopes in body for 8 H laryngoscopy Bronchoscopy Thoracentesis- consent, VS and baseline X-ray + post Procedural

incentive spirometry – hold 2-6 sec; 4-5 times/H

endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly

visualization –

X ray

Lung Scxan – 20-40mins isotopes in body for 8 H

laryngoscopy

Bronchoscopy

Thoracentesis- consent, VS and baseline X-ray + post Procedural

Tracheostomy Care tie new trache tie before removing the old tie to prevent accidental dislodgement use precut gauze and perform care OD at least. soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well suction prn, oral care prn

tie new trache tie before removing the old tie to prevent accidental dislodgement

use precut gauze and perform care OD at least.

soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well

suction prn, oral care prn

Oxygen Delivery Equipment cannula – 2-6 LPM – 24-45% Mask – 5-8 LPM – 40-60% parial rebreather – 6-10 LPM – 60-90% non rebreather – 10-15 LPM – 95-100% tent – 4-8 LPM – 30-50 % Venturi mask – 2-3 LPM – 24-28% 4 LPM – 30% 6 LPM – 35% 8 LPM – 45% 14LPM – 55%

cannula – 2-6 LPM – 24-45%

Mask – 5-8 LPM – 40-60%

parial rebreather – 6-10 LPM – 60-90%

non rebreather – 10-15 LPM – 95-100%

tent – 4-8 LPM – 30-50 %

Venturi mask –

2-3 LPM – 24-28%

4 LPM – 30%

6 LPM – 35%

8 LPM – 45%

14LPM – 55%

Suctioning PURPOSE: To obtain sputum sample. NURSING ALERT: Hyperoxygenate the patient before and after the procedure. Apply intermittent suction on withdrawal of the catheter. Do not suction the patient for more than 15 seconds. Thoracentesis PURPOSE: Aspiration of fluid and /or air from the pleural space . NURSING ALERT: Check the consent. Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder. Instruct the patient not to cough, breath deeply or move during the procedure. After the procedure: Position the patient on the unaffected side/puncture site up. Check for bleeding at the puncture site and monitor the respiratory function. Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.

Suctioning

PURPOSE: To obtain sputum sample.

NURSING ALERT:

Hyperoxygenate the patient before and after the procedure.

Apply intermittent suction on withdrawal of the catheter.

Do not suction the patient for more than 15 seconds.

Thoracentesis

PURPOSE: Aspiration of fluid and /or air from the pleural space .

NURSING ALERT:

Check the consent.

Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder.

Instruct the patient not to cough, breath deeply or move during the procedure.

After the procedure: Position the patient on the unaffected side/puncture site up.

Check for bleeding at the puncture site and monitor the respiratory function.

Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.

ENEMA They act by distending the intestines that increases peristalsis and expulsion of feces and flatus. Enemas serve the following purpose: Relief of constipation Relief of flatulence Lowers down body temperature Evacuates feces in preparation for diagnostic procedures Administration of medications

They act by distending the intestines that increases peristalsis and expulsion of feces and flatus.

Enemas serve the following purpose:

Relief of constipation

Relief of flatulence

Lowers down body temperature

Evacuates feces in preparation for diagnostic procedures

Administration of medications

ENEMA Take note of the general principles of Enema: Tube: lubricate and insert 3-4 inches Position: adult- left lateral; infants and children- dorsal recumbent Administration- administer the enema in a minimum of 15 minutes duration. Conatainer’s Height- 12 inches above the rectum Temperature- 42°C or less

Take note of the general principles of Enema:

Tube: lubricate and insert 3-4 inches

Position: adult- left lateral; infants and children- dorsal recumbent

Administration- administer the enema in a minimum of 15 minutes duration.

Conatainer’s Height- 12 inches above the rectum

Temperature- 42°C or less

types: carminative – expel flatus – 60 –180 ml. retention oil – 1 –3 hours(LUBRICANTS) BULK FORMERS-METAMUCIL-12 HOURS-INC.OFI wetting/stool softeners- Colace(days) Chemical hypertonic irritant-increases peristalsis-castor oil, Bisacodyl, Cascara)-SUPPOSITORIES-30 MIN Saline- Epson salts, milk of mg(rapid)/mg citrate return flow – haris flushing , colon irrigation fleet – commercial oil 1-3 H retention others – 5 to 10 mins. cleansing- irritating( hypertonic osmotic)) high 1000 ml low 500 ml

types:

carminative – expel flatus – 60 –180 ml.

retention oil – 1 –3 hours(LUBRICANTS)

BULK FORMERS-METAMUCIL-12 HOURS-INC.OFI

wetting/stool softeners- Colace(days)

Chemical hypertonic irritant-increases peristalsis-castor oil, Bisacodyl, Cascara)-SUPPOSITORIES-30 MIN

Saline- Epson salts, milk of mg(rapid)/mg citrate

return flow – haris flushing , colon irrigation

fleet – commercial

oil 1-3 H retention

others – 5 to 10 mins.

cleansing- irritating( hypertonic osmotic))

high 1000 ml

low 500 ml

T = 40-43 ‘ C ( 105 – 110 ‘ F CHILDREN 37.7 ( 100 ‘ F) APPROXIMATELY 30 CM ( 12 INCHES) BUT HIGH IN CLEANSING ( 30 – 45 CM. ) 12 TO 18 CM. INSERT 7 – 10 CM ( 3-4 INCH)-ADULT 5 – 7.5 CM. –CHILD 2.5 – 3.5 – INFANT IF FEELING OF FULLNESS – CLAMP – 30 SECS

T = 40-43 ‘ C ( 105 – 110 ‘ F

CHILDREN 37.7 ( 100 ‘ F)

APPROXIMATELY 30 CM ( 12 INCHES) BUT HIGH IN CLEANSING ( 30 – 45 CM. ) 12 TO 18 CM.

INSERT 7 – 10 CM ( 3-4 INCH)-ADULT

5 – 7.5 CM. –CHILD

2.5 – 3.5 – INFANT

IF FEELING OF FULLNESS – CLAMP – 30 SECS

amount 18 mos – 50-200 ml 18 mos – 5 y – 200-300 ml 5 – 12 years – 300 – 500 ml 12 – above – 500 – 1000 ml. rectal tubes infants-10-12F toddler – 14 –16F school age – 16-18F adult – 22 – 30F

amount

18 mos – 50-200 ml

18 mos – 5 y – 200-300 ml

5 – 12 years – 300 – 500 ml

12 – above – 500 – 1000 ml.

rectal tubes

infants-10-12F

toddler – 14 –16F

school age – 16-18F

adult – 22 – 30F

ENEMAS- PRESCRIBED AMOUNT AND TIME HYPERTONIC – 5-10MINS – VARIES HYPOTONIC(TAP)-15-20MIN – 500-1000ML ISOTONIC(SALINE)-15-20MIN- 50ML SOAP SUDS- 10-15MIN- + 3-5 ML. SOAP oil( MINERAL/COTTONSEED) – 30-60 MIN- 90-120ML.

HYPERTONIC – 5-10MINS – VARIES

HYPOTONIC(TAP)-15-20MIN – 500-1000ML

ISOTONIC(SALINE)-15-20MIN- 50ML

SOAP SUDS- 10-15MIN- + 3-5 ML. SOAP

oil( MINERAL/COTTONSEED) – 30-60 MIN- 90-120ML.

COLOSTOMY CARE ostomy – divert and drain fecal material temporary ( trauma / inflammatory condition) permanent ( Cancer / congenital or Birth defects stoma – red , initial slight bleeding - normal, no redness or irritation 2 to 5 inches sorrounding the areano burning sensation

ostomy – divert and drain fecal material

temporary ( trauma / inflammatory condition)

permanent ( Cancer / congenital or Birth defects

stoma – red , initial slight bleeding - normal, no redness or irritation 2 to 5 inches sorrounding the areano burning sensation

parts: periostomal seal adhesive square – solid wafer disk skin barrier liquid skin sealant drainable end pouch ( Can be washable) pouch belt face plate

parts:

periostomal seal

adhesive square –

solid wafer disk skin barrier

liquid skin sealant

drainable end

pouch ( Can be washable)

pouch belt

face plate

ileostomy – no irrigation , wet fecal material , appliance all the time , meticulous skin care,prevent skin breakdown, constant flow not regulated, bag emptied half full colostomy – solid , can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation avoid gas forming foods and nuts , but can have any food at tolerated after 6 weeks… yogurt recommended

ileostomy – no irrigation , wet fecal material , appliance all the time , meticulous skin care,prevent skin breakdown, constant flow not regulated, bag emptied half full

colostomy – solid , can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation

avoid gas forming foods and nuts , but can have any food at tolerated after 6 weeks… yogurt recommended

dry skin before applying appliance karaya – barrier to prevent contamination with excreta appliance can be up to 2 weeks broadwell 48 – 72 hours to check for periostomal skin 24-48 hours if eroded / ulcerated refer to enterostomal therapy nurse with deodorant ( Charcoal filter Disk)

dry skin before applying appliance

karaya – barrier to prevent contamination with excreta

appliance can be up to 2 weeks

broadwell 48 – 72 hours to check for periostomal skin

24-48 hours if eroded / ulcerated

refer to enterostomal therapy nurse

with deodorant ( Charcoal filter Disk)

Catheterization, urinary PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter. NURSING ALERT:        Know the necessary facts:

PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter.

NURSING ALERT:

       Know the necessary facts:

Principles Male Female Position Supine Dorsal recumbent Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in. French number or Circumference #14- 16 #18 Length of tube to be inserted 2-3 in. 6-9 in. Balloon size 5-10 ml. (30 ml 5-10 ml Can be used to achieve hemostasis of the prostatic area following prostatectomy Place to secure lower abdomen Inner thigh

Principles Male Female

Position Supine Dorsal recumbent

Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in.

French number or

Circumference #14- 16 #18

Length of tube to

be inserted 2-3 in. 6-9 in.

Balloon size 5-10 ml. (30 ml 5-10 ml

Can be used to

achieve hemostasis

of the prostatic area

following prostatectomy



Place to secure lower abdomen Inner thigh

       The procedure is sterile        Maintain a close system        The draining bag must always be below the bladder        The catheter bag should not be allowed to lie on the floor        Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it

       The procedure is sterile

       Maintain a close system

       The draining bag must always be below the bladder

       The catheter bag should not be allowed to lie on the floor

       Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it

CATHETER CHANGE PLASTIC – 1 WEEK LATEX – 2-3 WEEKS SILICONE – 2-3 MOS. PVC – 4-6 WEEKS

PLASTIC – 1 WEEK

LATEX – 2-3 WEEKS

SILICONE – 2-3 MOS.

PVC – 4-6 WEEKS

CLOSED INTERMITTENT IRRIGATION ASPIRATE FROM PORT CBI -3 WAY FOLEY CAHETER CATHETER IRRIGATION ONLY – 200 ML. BLADDER IRRIGATION – 1000ML CLAMPS ON BOTH SIDES – ALTERNATELY RELEASED

ASPIRATE FROM PORT

CBI -3 WAY FOLEY CAHETER

CATHETER IRRIGATION ONLY – 200 ML.

BLADDER IRRIGATION – 1000ML

CLAMPS ON BOTH SIDES – ALTERNATELY RELEASED

URINARY DIVERSIONS-URINARY STOMA ILEAL CONDUIT- EXTERNAL POUCH KOCK POUCH – SMALL DRESSING OVER STOMA; BLADDER WALL SUTURED TO THE ABDOMEN SUPRAPUBIC CATHETER – INTERMITTENT ATHETERIZATION q 3-4 HOURS

ILEAL CONDUIT- EXTERNAL POUCH

KOCK POUCH – SMALL DRESSING OVER STOMA; BLADDER WALL SUTURED TO THE ABDOMEN

SUPRAPUBIC CATHETER – INTERMITTENT ATHETERIZATION q 3-4 HOURS

NORMAL AMOUNT/ DAY 1-3 / 500-600ML 3-5 / 600-700ML 5-8 / 700-100OML 8-14 / 800 – 1400ML 14 – ADULT / 1500 – 2500 CAN HOLD 500 – 750 ML

1-3 / 500-600ML

3-5 / 600-700ML

5-8 / 700-100OML

8-14 / 800 – 1400ML

14 – ADULT / 1500 – 2500

CAN HOLD 500 – 750 ML

Bladder training Q2 hours and 30 mins void(Trigerring, Credes and valsalva) NEUROGENIC BLADDER Intermitent Catheterization – 2-3 hours if <150ml ----3-4 H weaning-intermittent clamping DTV 1-4 hours after removal for incontinence – kegels exercises

Q2 hours and 30 mins void(Trigerring, Credes and valsalva)

NEUROGENIC BLADDER

Intermitent Catheterization – 2-3 hours if <150ml ----3-4 H

weaning-intermittent clamping

DTV 1-4 hours after removal

for incontinence – kegels exercises

HEMODIALYSIS DONE 3-5 HOURS – 2-3 TIMES A WEEK AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H MONITOR FOR HEMORRHAGE DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONS

DONE 3-5 HOURS – 2-3 TIMES A WEEK

AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS

PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H

MONITOR FOR HEMORRHAGE

DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONS

PERITONEAL DIALYSIS TENCKOFF,GORE-TEX CATHETER WEIGH BEFORE AND AFTER, WARM DIALYSATE CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION TYPES: CAPD(4-6H INDWELLING), AUTOMATED 30MINS EXCHANGES, INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLING

TENCKOFF,GORE-TEX CATHETER

WEIGH BEFORE AND AFTER, WARM DIALYSATE

CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V

PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION

TYPES:

CAPD(4-6H INDWELLING),

AUTOMATED 30MINS EXCHANGES,

INTERMITTENT- 4X A WEEK – 10H/DAY,

CONTINOUS – 1 DAY INDWELLING

DRESSINGS PROTECT FROM INJURY , BACTERIAL CONTAMINATION PROVIDE HUMIDITY INSULATION ABSORB DRAINAGE DEBRIDE THE WOUND PREVENT HEMORRHAGE SPLINT / IMMOBILIZE COMFORT GUAZE, SYNTHETIC , SECURING, TEGADERM

PROTECT FROM INJURY , BACTERIAL CONTAMINATION

PROVIDE HUMIDITY

INSULATION

ABSORB DRAINAGE

DEBRIDE THE WOUND

PREVENT HEMORRHAGE

SPLINT / IMMOBILIZE

COMFORT

GUAZE, SYNTHETIC , SECURING, TEGADERM

TYPES OF DRESSINGS DRY TO DRY – TRAP NECROTIC DEBRIS AND EXUDATE WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING) WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE

DRY TO DRY – TRAP NECROTIC DEBRIS AND EXUDATE

WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE

WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING)

WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE

WOUND HEALING HEMOSTASIS---FIBRIN----PHAGOCYTOSIS----( INFLAMMATION PHASE 3-4DAYS FIBROBLAST—COLLAGEN---CAPILLARIES----GRANULATION TISSUE---ESCHAR---(PROLIFERATIVE 3 – 21 DAYS MATURATION(PHASE 21 DAYS – 2 YEARS)

HEMOSTASIS---FIBRIN----PHAGOCYTOSIS----( INFLAMMATION PHASE 3-4DAYS

FIBROBLAST—COLLAGEN---CAPILLARIES----GRANULATION TISSUE---ESCHAR---(PROLIFERATIVE 3 – 21 DAYS

MATURATION(PHASE 21 DAYS – 2 YEARS)

pressure ulcer dressings dry gauze stage II-IV tegaderm film/ hydrocolloid – SI - SII Absorptive Dressing III Hydrogel – II - III

dry gauze stage II-IV

tegaderm film/ hydrocolloid – SI - SII

Absorptive Dressing III

Hydrogel – II - III

WOUND CARE PRIMARY SECONDARY- INCREASED INFECTION INCREASED TIME INCREASED ESCHAR( PRESSURE SORES) TERTIARY- ABD. DRAINAGE EXUDATES – SUPPURATION PUS – ABCESS( PYOGENIC BACTERIA)

PRIMARY

SECONDARY- INCREASED INFECTION INCREASED TIME INCREASED ESCHAR( PRESSURE SORES)

TERTIARY- ABD. DRAINAGE

EXUDATES – SUPPURATION

PUS – ABCESS( PYOGENIC BACTERIA)

SURGICAL DRAINS PENROSE – OPEN ENDS CLOSED WOUND DRAINAGE ( SUCTION) – DECREASE ENTRY OF MICROBES- HEMOVAC / JACK PRATT TO RESERVOIR D/C 3-7 DAYS POST – OP PACKAGE – FACILITATE GRANULATION IRRIGATION LAVAGE - STERILE

PENROSE – OPEN ENDS

CLOSED WOUND DRAINAGE ( SUCTION) – DECREASE ENTRY OF MICROBES- HEMOVAC / JACK PRATT TO RESERVOIR

D/C 3-7 DAYS POST – OP

PACKAGE – FACILITATE GRANULATION

IRRIGATION LAVAGE - STERILE

CHEST TUBES AND DRAINAGE SYSTEMS 1-DRAINAGE 2-WATERSEAL 3-COLLECTION/SUCTION SEALED PATENCY-AFTER 3 DAYS REEXPANDED FLUCTUATIONS IN WATER SEAL CHAMBER RUBBER TIPPED CLAMPS/ FORCEPS; VASELINIZED GAUZE;EXTRA BOTTLE

1-DRAINAGE

2-WATERSEAL

3-COLLECTION/SUCTION

SEALED PATENCY-AFTER 3 DAYS REEXPANDED

FLUCTUATIONS IN WATER SEAL CHAMBER

RUBBER TIPPED CLAMPS/ FORCEPS; VASELINIZED GAUZE;EXTRA BOTTLE

NUTRITIONAL SUPPORT NGT-GAVAGE AND LAVAGE TPN

NUTRITIONAL SUPPORT

NGT-GAVAGE AND LAVAGE

TPN

Nasogastric Tube Insertion Purposes: Gastric Gavage- gastric feeding Gastric Lavage- stomach irrigation For decompression Medication and supplemental fluid administration Principles: Position: High-Fowler’s position Length of tube to be inserted: measured from the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm. Lubricate the tip of the tube by a water soluble lubricant before insertion Secure the NGT by taping to the bridge of the nose

Nasogastric Tube Insertion

Purposes:

Gastric Gavage- gastric feeding

Gastric Lavage- stomach irrigation

For decompression

Medication and supplemental fluid administration

Principles:

Position: High-Fowler’s position

Length of tube to be inserted: measured from the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm.

Lubricate the tip of the tube by a water soluble lubricant before insertion

Secure the NGT by taping to the bridge of the nose

Gastroenteral Feedings This is the administration of formula through a tube placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall. Remember these principles: Position: fowler’s or sitting position Prior to feeding, assess the bowel sounds and residual content Assess for tube placement and patency: Introduce 5-20 ml of air into the NGT and auscultate. Gurgling sounds must be auscultated. X-ray most accurate Aspirate gastric content Immerse the tip of the tube in water, no bubbles must be produced. Height of feeding: 12 inches above the patient’s point of insertion Instill 60 ml of water into the NGT after feeding to cleanse the lumen of the tube

Gastroenteral Feedings

This is the administration of formula through a tube placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall.

Remember these principles:

Position: fowler’s or sitting position

Prior to feeding, assess the bowel sounds and residual content

Assess for tube placement and patency:

Introduce 5-20 ml of air into the NGT and auscultate. Gurgling sounds must be auscultated.

X-ray most accurate

Aspirate gastric content

Immerse the tip of the tube in water, no bubbles must be produced.

Height of feeding: 12 inches above the patient’s point of insertion

Instill 60 ml of water into the NGT after feeding to cleanse the lumen of the tube

TOTAL PARENTERAL NUTRITION peripheral< 2 weeks – phlebitis PIC – Basilic / cephalic PCC – subclavian Triple Lumen- infuse and draw blood;TPN;Medications Atrial- Hickman/Biovac and Groshong; Huber needle port

peripheral< 2 weeks – phlebitis

PIC – Basilic / cephalic

PCC – subclavian

Triple Lumen- infuse and draw blood;TPN;Medications

Atrial- Hickman/Biovac and Groshong; Huber needle port

TOTAL PARENTERAL NUTRITION TPN-IV with bacterial filter(2-3L) TNA – 1 liter/D-no filter If no available solution D10W –ok –initial at 50ml/hr hyperglycemia- hyperosmolar(HA, N and Vomiting,fever, chills, malaise) Infection ( IV tubing and filter Q24 changed,solutions refrigerated and warmed just prior to administration Pneumothorax

TPN-IV with bacterial filter(2-3L)

TNA – 1 liter/D-no filter

If no available solution D10W –ok –initial at 50ml/hr

hyperglycemia- hyperosmolar(HA, N and Vomiting,fever, chills, malaise)

Infection ( IV tubing and filter Q24 changed,solutions refrigerated and warmed just prior to administration

Pneumothorax

Heat and Cold Therapy An intervention the reduces inflammation Principles: Cold application is generally safer than heat application. Heat application usually requires a doctor’s order Cold application is done within 72 hours after an injury, while heat application is done after 72 hours. The application of heat and cold is done at a maximun of 30 minutes (an average of 15-20 minutes) Check the area applications are done every 15 minutes.

Heat and Cold Therapy

An intervention the reduces inflammation

Principles:

Cold application is generally safer than heat application.

Heat application usually requires a doctor’s order

Cold application is done within 72 hours after an injury, while heat application is done after 72 hours.

The application of heat and cold is done at a maximun of 30 minutes (an average of 15-20 minutes)

Check the area applications are done every 15 minutes.

Anti-embolism Stocking Helps prevents thrombophlebitis by promoting venous return from the legs It usually requires a doctor’s order The client’s extremeties must be properly measured to assure therapeutic effect Apply stockings before getting out of bed. If the client forgot to wear the stockings, instruct himn or her to assume modified trendelenburg’s position for 15-20 minutes The stockings must be removed every 8 hours for 20-30 minutes Assess the skin integrity

Anti-embolism Stocking

Helps prevents thrombophlebitis by promoting venous return from the legs

It usually requires a doctor’s order

The client’s extremeties must be properly measured to assure therapeutic effect

Apply stockings before getting out of bed. If the client forgot to wear the stockings, instruct himn or her to assume modified trendelenburg’s position for 15-20 minutes

The stockings must be removed every 8 hours for 20-30 minutes

Assess the skin integrity

DOSAGES AND CALCULATION CONVERSIONS MEDICATION DOSAGES D/A X V = Q INFUSIONS TOTAL VOLUME X DROP FACTOR TIME IN HOUR ( 60 MIN.) THERAPEUTIC DOSE CLARKS RULE BSA COMPUTATION IV INFUSION FOR BURNS

CONVERSIONS

MEDICATION DOSAGES

D/A X V = Q

INFUSIONS

TOTAL VOLUME X DROP FACTOR

TIME IN HOUR ( 60 MIN.)

THERAPEUTIC DOSE

CLARKS RULE

BSA COMPUTATION

IV INFUSION FOR BURNS

MEDICATION ADMINISTRATION RIGHT DRUG RIGHT DOSAGE RIGHT ROUTE RIGHT TIME RIGHT PATIENT RIGHT ATTITUDE RIGHT DOCUMENTATION

MEDICATION ADMINISTRATION

RIGHT DRUG

RIGHT DOSAGE

RIGHT ROUTE

RIGHT TIME

RIGHT PATIENT

RIGHT ATTITUDE

RIGHT DOCUMENTATION

PARENTERAL ADMINISTRATION IM – G 18-21 ; 1 1/2 INCH, Z-TRACK ( RETRACT) SC/SQ – G 24-26;1/2 – 1 INCH ; 45’ ; DO NOT RETRACT OR MASSAGE ( INSULIN AND HEPARIN) INTRADERMAL- 10-15’; G26-27;12 INCH BEVEL UP INTRAVENOUS – TOURNIQUET, STERILE PROCEDURE ; 10-25 ; RELEASE TOURNIQUET IF WITH BACKFLOW

IM – G 18-21 ; 1 1/2 INCH, Z-TRACK

( RETRACT)

SC/SQ – G 24-26;1/2 – 1 INCH ; 45’ ; DO NOT RETRACT OR MASSAGE ( INSULIN AND HEPARIN)

INTRADERMAL- 10-15’; G26-27;12 INCH BEVEL UP

INTRAVENOUS – TOURNIQUET, STERILE PROCEDURE ; 10-25 ; RELEASE TOURNIQUET IF WITH BACKFLOW

IV THERAPY backflow means patent line solutions for specific diseases and contraindications of certain solutions management and troubleshooting check for phlebitis and infiltration change line everyday keep site sterile

backflow means patent line

solutions for specific diseases and contraindications of certain solutions

management and troubleshooting

check for phlebitis and infiltration

change line everyday

keep site sterile

BLOOD TRANSFUSION line – PNSS vital signs – baseline then Q15 x 4; Q30 x 2; then q h 4 –6 hours blood typing and crossmatching watch out for blood transfusion reactions hemolytic anaphylactic febrile hypervolemic septic

line – PNSS

vital signs – baseline then Q15 x 4; Q30 x 2; then q h

4 –6 hours

blood typing and crossmatching

watch out for blood transfusion reactions

hemolytic

anaphylactic

febrile

hypervolemic

septic

Hygiene and comfort measures

Hygiene and comfort measures

BEDMAKING- OD PERINEAL CARE – FRONT TO BACK OUTER TO INNER, ONE COTTONBALL PER STROKE BEDBATHING AND ND SHAMPOO FOOT, HAIR , SKIN AND NAIL CARE ORAL CARE EYE AND EAR CARE

BEDMAKING- OD

PERINEAL CARE – FRONT TO BACK

OUTER TO INNER, ONE COTTONBALL PER STROKE

BEDBATHING AND ND SHAMPOO

FOOT, HAIR , SKIN AND NAIL CARE

ORAL CARE

EYE AND EAR CARE

THERAPEUTIC BATH SALINE – 4 ML- 500 ML OATMEAL/AVENO – SOOTHES SKIN IRRITATION, LUBRICATES CORNSTARCH- IN COLD WATER – SOOTHES IRRITATION Na CHO3 – 4 ml. – 500 ml H2O cooling / relieves irritation KMnO4 – tablets dissolved in H2O – clears and disinfects

SALINE – 4 ML- 500 ML

OATMEAL/AVENO – SOOTHES SKIN IRRITATION, LUBRICATES

CORNSTARCH- IN COLD WATER – SOOTHES IRRITATION

Na CHO3 – 4 ml. – 500 ml H2O

cooling / relieves irritation

KMnO4 – tablets dissolved in H2O – clears and disinfects

Rotating Tourniquet GET MEAN APPLY PRESSURE TO 3 LIMBS ONE AT A TIME RELEASE / ROTATE EVERY 5 MINUTES. PRESSURE IN ONE EXTREMITY FOR ONLY 15 MINUTES DO NOT RELEASE SIMULTANEOUSLY PATIENT IN ORTHOPNEIC / FOWLERS POSITION

GET MEAN

APPLY PRESSURE TO 3 LIMBS ONE AT A TIME RELEASE / ROTATE EVERY 5 MINUTES. PRESSURE IN ONE EXTREMITY FOR ONLY 15 MINUTES

DO NOT RELEASE SIMULTANEOUSLY

PATIENT IN ORTHOPNEIC / FOWLERS POSITION

CPR and ACPLS Protocols 0-1 MINUTE ; CARDIAC IRRITABILITY 0-4 MINUTES; BRAIN DAMAGE NOT LIKELY 4-6 MINUTES; BRAIN DAMAGE POSSIBLE 6-10 MINUTES; BRAIN DAMAGE LIKELY 10 MINUTES-IRREVERSIBLE BRAIN DAMAGE

0-1 MINUTE ; CARDIAC IRRITABILITY

0-4 MINUTES; BRAIN DAMAGE NOT LIKELY

4-6 MINUTES; BRAIN DAMAGE POSSIBLE

6-10 MINUTES; BRAIN DAMAGE LIKELY

10 MINUTES-IRREVERSIBLE BRAIN DAMAGE

INFANTS HTCL MANEUVER, JAW THRUST IF SPINAL INJURY IS SUSPECTED INITIAL BREATHS – 2 – 1 1/2 SECS SUBSEQUENT BREATHS 1 B/3 SECS; 20 BPM USE 2 OR 3 FINGERS DEPTH:1/2 TO 1 INCH COMPRESSION AT LEAST 100/MIN RATIO 5:1; CHECK AFTER 20 CYCLES FOREIGN BODY OBSTRUCTIONS: BACKBLOWS AND CHEST THRUST

HTCL MANEUVER, JAW THRUST IF SPINAL INJURY IS SUSPECTED

INITIAL BREATHS – 2 – 1 1/2 SECS

SUBSEQUENT BREATHS 1 B/3 SECS; 20 BPM

USE 2 OR 3 FINGERS

DEPTH:1/2 TO 1 INCH

COMPRESSION AT LEAST 100/MIN

RATIO 5:1; CHECK AFTER 20 CYCLES

FOREIGN BODY OBSTRUCTIONS: BACKBLOWS AND CHEST THRUST

CHILDREN HTCL / JAW THRUST 2 BREATHS INITIAL DURATION OF 1- 1 ½ SECS SUBSEQUENT 1 BREATH EVERY 3 SECONDS 20 BREATHS/ MIN CAROTID ARTERY HEEL OF HAND 1 TO 1 12 INCH 100 BPM; CHECK AFTER 12 CYCLES ABDOMINAL THRUST- FOR AIRWAY OBSTRUCTION

HTCL / JAW THRUST

2 BREATHS INITIAL DURATION OF 1- 1 ½ SECS

SUBSEQUENT 1 BREATH EVERY 3 SECONDS

20 BREATHS/ MIN

CAROTID ARTERY

HEEL OF HAND

1 TO 1 12 INCH

100 BPM; CHECK AFTER 12 CYCLES

ABDOMINAL THRUST- FOR AIRWAY OBSTRUCTION

ADULTS HTCL / JAW THRUST INITIAL 2 BREATHS AT LEAST 2 SECS EACH DEPRESS 1 ½ - 2 INCHES; RATE 60 TO 100 RATIO 5:1 AFTER 4 CYCLES ;RECHECK FOR 10 SECS

HTCL / JAW THRUST

INITIAL 2 BREATHS AT LEAST 2 SECS EACH

DEPRESS 1 ½ - 2 INCHES; RATE 60 TO 100

RATIO 5:1

AFTER 4 CYCLES ;RECHECK FOR 10 SECS

ERGONOMICS TRANSFER TECHNIQUES BODY POSITIONING BODY MECHANICS

TRANSFER TECHNIQUES

BODY POSITIONING

BODY MECHANICS

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