advanced skills exam 3

pneumothorax r/t chest tube

air in pleural space

d/t trauma, surgery complication, smoking, COPD

hemothorax

blood in pleural space

d/t GSW, MVA, falling, puncture

hemopneumothorax

blood and air in pleural space

tension pneumothorax 

sx: o2 sats very low, trachea deviated to opposite side 

dry suction

check valve that controls level of suction, needs tiny bit of h2o in chamber B

A: suction control

B:

C:

D:

E: bellows, confirms that suction is working. Not working=does not come out. Not working? Start turning suction until you get it where it needs to be

wet suction

uses water and height of water to control suction

A: suction control. Bubbling=air leak, could see evaporation. Should be at 2 mark at all times

B: tidal, should see gentle bubbling, fluctuation breathing normal in/out, fluctuation could mean there is chest reexpansion, air leak (make sure tubing is connected, assess pt)

C:

D:

E:

what can UAP do with chest tube?

Repo, VS, ambulate (cannot disconnect/reconnect to wall)

proper care for chest tubes

• check water levels, drainage

• keep below chest level

• keep upright

• no dependent loops/kinks

• check dressing 

• check if they have pain before/after

what do you do if tube gets pulled out of pleural space?

• cover site (do not want air to get in)

• prepare for it to be replaced

what do you do if tube gets pulled out of drainage system?

• put in NS

• get new unit

what do you do if tube site is bloody?

• assess pt

• hold pressure with gloved hand

• consider why it is ripped out

when can the tube be DC’d?

• lungs have expanded on xray

• drainage changes (less or none)

• no fluctuation

• less dyspnea on exertion

• respiratory status improves (higher o2, on room air, color changed)

tactile fremitus

• what is it? vibration

• how do you assess it? have pt say “9” repeatedly and feel/listen for vocal resonance

• normal = equal vibes

• abnormal = increase in sound/vibes=pneumonia, decrease in vibes= COPD

AP vs transverse diameter

AP < transverse

1:1 vs 1:2

1:1 = NOT normal, barrel chest/COPD, hyperinflated

1:2 = normal

rhonchi

bubbling, very wet sounding

crackles

rice krispy, velcro

wheeze

high pitched, musical, asthma

stridor

upper airway obstruction

friction rub

creaky leather d/t inflammation/infection, very painful

what is the top respiratory assessment to determine adequate ventilation?

spo2

assessments prior to surgery that might identify an at risk pt

at risk: COPD, emphysema, lung cx, asthma, obese (at risk for aspiration d/t diaphragm pushing up on sphincter), smokers

interventions for at risk pts

HOB up, IS, PPI, C&DB

proper IS use

deep breath before putting on lips, put on lips, slow deep breath in, hold, breathe out, HOB 90 degrees (at least 65), should be coughing

decompression

use? : trauma, overdose

what types of tubes?: salem (NO petroleum lube)

contraindication: facial trauma, esophageal varices

proper insertion techniques (NG tube)

measure nose-ear-xyphoid

GI/resp/nostril assessment

coughing? pull out, pull back, look in mouth for coiling

no drainage: not far down enough

assessments to determine if NG tube is placed correctly

gastric pH (1-4)

xray

push air into tubing and listen with stethoscope

why intermittent vs continuous?

it can get stuck on lining

NG tube documentation:

assessments

length of tube

type/french of tube

how pt tolerated

drainage

abd girth

if pt feels better

potential problems with the tube & troubleshooting

tube clogged: food particles, stool, drainage can be thick/sticky

irrigate with warm water until something comes back

make sure you account for i/o

what happens to pt when tube is clogged?

sx will start coming back (nausea, abd distended, no new drainage)

why do pts get feeding tubes?

oncology, anorexia, stroke

methods for feeding tubes

continuous with pump, bolus, gravity (hang at least 1 ft higher than where tube is inserted)

advantages of gastrostomy vs NG

more comfortable, less irritation in throat/nares, protected self image, long term use, less complications

verifying placement of feeding tube

could accidentally put in lung, with continuous you need to verify placement before each feed, before giving meds, before it is interrupted

using a brand new j/g tube?

• can be used right away, but has to be slow (3-5 ml) d/t refeeding syndrome (bloating, n/v/d)

• not digesting it (vomiting, aspiration, bowels still aren’t working well after surgery/tube is placed)

aspiration

sx: LOC changes, coughing, low spo2, color changes

suspected aspiration?: stop feeding, sit up, o2 if needed, c&db, call MD. Also.. put HOB up, consider rate

how to prevent contamination of feeding tubes

make sure nothing is expired (everything good for 24 hrs)

how to take care of feeding tube site

Clean with soap/water daily, pat dry, put drain sponge around, normal for skin around tube to be a little red/crusted.

Infected when foul odor, purulent drainage, warm/raised/pain

what to do if pt is constipated?

Consult dietary/pharm about adding more fiber into feed, stimulant laxatives, ambulation, making sure there is enough fluids (tap water is OK, avoid tap water is pt is severely immunosuppressed)

what to do if pt has diarrhea?

• slow down rate

• collab with dietary/pharm

feeding tube contraindications

• EOL

• bowel obstruction

• paralytic/prolonged ileus

• gut ischemia

• if gut is not working