trach care/suctioning/postmortem/dx tx Exam 3

what is the purpose of suctioning 

• remove secretions 

• prevents aspirations 

• improves respiration/ventilation 

contraindication of suctioning

• arrhythmias

• hypoxemia

• truama

unless if the pt is going to die

what is the form of suctioning that techs can perform

oropharyngeal

what forms of suctioning are sterile procedures

• nasopharyngeal (not common)

• endotracheal tubes

• tracheostomy tubes

what should the suction regulator be set to

at least 120

endotracheal tube 

• used for emergencies and procedures

• placed through vocal cords 

• has cuff to prevent air leak/mvmt/aspiration 

what is the correct cuff technique for an endotracheal tube

• must check to ensure inflated

• must be released at least every 8 hours CHART

• if pediatric can be cuffed or not

what state must the patient be in, inorder to place an endotracheal tube

the pateint must be sedated

tracheostomy 

• long term airway managment 

• directly into the treacha through insertion below the larynx 

• a while after tube is taken out patinet may recive passy muir valve to talk 

important things to note regarding tracheostemy tubes

• must have oburator at bed side at all times

• never untie both sides of the ties at the same time without help

ventilator required pneumonia (VAP) bundle

• suction only as needed

• HOB at least 30-45 degrees at all times

• provide oral care daily at least

• caution DVT prophylaxis (provide heprin or anoxaparin for blood clot prevention)

• PUD prophylaxis

nursing care for tracheostemy 

• sterile dressing change at least DAILY

• can become blocked and cause resp distress

• must be sterile technique

what complications can arise due to lack of sterile tracheostey care

• HAI or VAP

• cardiac dysrhythmia

• hypoxemia

• truama

how do you know a patinet needs to be suctioned

• by checking breath and lung sounds

• must do ^ before and after suctioning and during every nursing assessment

• pt must be on vitals at all times

what are signs of respirotry distress in a patient with a tracheostemy 

• dyspnea

• poor skin color (arround the mouth) 

• bubbling or rattling breath sounds 

• decreased o2 saturation 

in order to avoid complications during tracheostemy suctioning it is importantnt to

• avoid hyperinflation and hyperventilation 

• gently rotating catheter, withdrawing while suctioning 

• suction for 5-10 seconds max

• wait 2-3 minutes inbetween passes

a nurse is caring for a client who has a wound infection. which of the following actions should the nurse take when obtaining a wound drainage specimen for culture

clense the would with 0.9 sodium chloride saline irrigation before obtaining the specimen

a nurse is caring for a client who is scheduled for a bone marrow aspriation. the client asks the nurse about the sites the provider might use for the procedure. Which of the following locations should the nurse identify as one of the sites used ofr this procedure

sternum

a nurse is caring for a client who has an indwelling cath and a prescription for a urine specimen for culture and sensitivity. which of the follwoing actions should the nurse take 

withdraw 3-5 ml of urie from the port 

nurse is caring for terminally ill pt exibiting signs of impending death. the pts medical record states that the pt is a practicing roman catholic. which of the following actions is appropriate

offer to make arrangements for the sacrament of the sick

a nurse is providing post mortem care for an adult pt, which of the following actions should the nurse take

• give the patient personal belongings to the family

• determine whether the pt will have an autopsy

a nurse on a medical surgical unit is providing care for a group of clients. the nurse should delegate collection of which of the following specifmens to the AP 

random stool specimen 

nurse instructs female pt about collecting midstream. what indicates an understanding of the procedure

ill urinate a little then stop

nurse is caring for patient whos informed consent form has been signed in preparation for a procedure the pt says “i have decided not to do the procedure” what actions should the nurse take

inform the provider that the pt is withdrawing consent

pt reports throbbing headache after lumbar puncture. which action facilitates resolution of the headache 

increase fluid intake 

nurse is preparing a blood speciment form a pt by venipuncture. pt is recieving fluids though IV cath inserted in the basilic vein of the right forearm. what site should the blood be obtained from

left forearm

pt needs a stool collected, what action should the nurse take while obtaining the specimen

send the specimen container immediately to the lab

nurse is teaching pt how to do fecal occult blood testing. which statement indicates a need for further teaching 

“i will continue to take my blood thinner as prescribed” 

what information indicates the patient is activley dying

• cheyne stokes breating, noisy respirations

• blood pressure 62/40

• hr 42/min

• pt does not arouse to verbal tactical or painful stimulation

• no urine output in the last 4 hours

nurse is assessing an older adult who is recieving end of life care, which assessment findings identify as Cheyne Stokes respirations

breathing ranging from very deep to very shallow with periods of apnea

when obtaining urine from a foley 

• clamp 30 minutes before to block the lind to the bag so that the urine builds up

• clense port and collect 

• label on the cup never the lid 

for a 24 hour urine specimen the pt should

• discard the first specimen and start the time immediatley after

• save ALL urine after

when swabbing for flu or covid what should you do

circles for at least 15 seconds ½ or ¾ inch into nostril

when obtaining a meoccult/guiac test the patient should

• avoid iron, red meet and blood thinners

• blue color indicates postive results

• if pt is on blood thinners they need to get clearence to stop

when recieving wound cultures 

test fresh exudate from the center of the wound 

when helping with a lumbar puncture the nurse should

• place pt in left lateral position with knees flexed or sit leaning forward

• pt must be flat 30 to 60 minutes after

• instruct pt to report HA, drainage, redness, swelling, temp, pain

while assissting with invasive procedures these things must happen

• written consent

• ensure proper positioning

• be aware of contraindication

• patient teaching

when assisitng with a liver biopsy 

• assess for bleeding, and have the pt remain on the right side for 2 hours

• if bleeding go to hospital 

an ankle brachial pressure index is used to detect

perihperal vascular disease

hospice

• quality of life care (good pain control and ample family support)

• comfort care

palliative care

• comfort with or without curative intent

• one or more treatment

what are the four levels of hospice care 

• routine home care

• inpatient respite care

• continuous care

• general inpatinet care

nurse is always on call 

what factors influce the loss and greif response

• spiritual beliefs

• gender

• socioeconomic status

• support system

• cause of death

signs of impending death

• loss of muscle tone

• slowing of the circualtion

• changes in respirtations (chyene stokes)

• sensory impairment

for family veiwing after death

• clean, pleasent enviroment

• make body appear natural and comfortable

• remove unnecessary equipment, soiled linens and supplies

• follow agency policy when caring for tubes ( autopsy)

after death the patients should be lying

• supine with pillow under head and shoulders 

• arms at sides or across abdomen 

• close eyelids 

• insert dentures an close mouth 

rigor mortis

stiffening from body 2-4 hours

algor mortis

decrease of body tempurature

livor mortis

discoloration in dependent areas due to blood pools

what care should you give the patients post mortem 

• wash soiled areas 

• place pad underneath

• clean gown 

• brush hair

• remove jewlery except for wedding band

• adjust linen to cover the pt to shoulders

• soft light and chairs 

ARORA

arkansas regional organ recovery agency

when supporting the family post mortem

• theraputic communication

• be empatheic

• explain what is to be expected and what is happening

• encourage loved ones to participate in care

• supoort those who feel unable to care or be with the pt

closed awareness

not aware of impending death

mutual pretense 

client, family, team members know prognosis but dont discuss 

open awareness

patinet and others know about impeding death and feel comfortable discussing it

nursing interventions for giving hope

• __ of care not __ of life

• listen attentively

• encourage sharing of feelings

• provide accurate infomation

• support choices when possible

• assists patients to find meaning/reminise

• encourage realistic goals

• no false assurances

• facilitate communciation with families

• make referals for psychosocial, spirtiual counseling

proxy directive

apoints someone to make medical decisions, suplement to a living will or medical directive

advanced directive

written documnets outlinng preferences regarding medical treatment, prefered setting, insights to their values and beliefs