2. tubes and lines pt 2

gastric tubes, chest tubes, pacemakers, respiratory tubes

when are NG/OG tubes used

when the pt is unable to swallow safely

NG/OG tubes are used when a pt cannot swallow safely. when might this be (5)

declining consciousness, stroke, aphasia, cognitive decline resulting in poor nutrition, oral/esophageal tumor resulting in obstruction

how do we use NG tubes during an overdose

NG tube is inserted to suction gastric contents, or provide a neutralizing agent (activated charcoal)

T or F: prior to initial NG tube use, a CXR is done to confirm placement

true

how do we see NG and OG tubes on a radiograph

they have a radiopaque strip

during xrays, if a pt has an NG/OG tube that is being used for a feeding pump, what must we not do + why

don’t place them supine; increases risk of aspiration

describe NG/OG tube insertion and handling

the approx length is externally marked prior to insertion, then tube is lightly secured, then CXR is done to confirm placements. once confirmed, the tube is firmly secured with tape or neck ties

ideal NG tube position

tip should be at least 10cm past the gastro-esophageal junction

on an xray, where will the end of the NG tube be

10cm below the diaphragm, aka over the gastric bubble

complications of NG tubes (6)

tissue trauma, esophageal/mediastinal perforation, pneumothorax, aspiration, hemorrhage, rarely death

list 2 common mispositions for NG tube placement

tip entering the right bronchus, or looping back towards the larynx

describe the optimal appearance of an NG tube on an xray (not just where it ends)

should be // to the spine and slightly left of the SPs, enters the stomach at the diaphragm level, curves with the shape of the stomach and passes the gastric bubble, the weighted tip should point downwards and be slightly angled L/R

describe the incorrect NG tube placement

ends in the right bronchial tree

describe the incorrect NG tube placement

loops back within the esophagus

describe the incorrect NG tube placement

insufficient insertion; needs to be longer

where do chest tubes go

into the pleural space

role of chest tubes

remove fluid or air

what types of pts need chest tubes

those from ICU, CCU, or trauma, or non-acute pt with chronic lung pathologies where fluid builds up in the chest

where are chest tubes inserted

5th intercostal space + slightly anterior to the midaxillary line

what are chest tubes connected to outside of the body

drainage receptables or mechanical suction units

list the two types of chest tubes

large bore, small bore

what are large bore chest tubes used for

pneumothorax (air removal)

what are small bore chest tubes used for

fluid drainage

how are we able to see chest tubes on radiographs

they have a radiopaque strip

where in the body will large bore chest tubes terminate + why

superior/anterior portions of the pleural cavity; air rises

where in the body will small bore chest tubes terminate + why

inferiorly/posteriorly; fluid sinks

before positioning a pt with a chest tube, how are chest tubes secured and how do we move with them

they’re secured to the mattress via kelly clamps, so we remove the clamps before positioning

complications of chest tube insertion (4)

pneumothorax, surgical emphysema, tension pneumothorax, hemorrhage

role of pacemakers

maintain adequate heart rate; used when the natural pacemaker isn’t fast enough or if there is a block in the electrical conduction system

how do we program modern pacemakers

externally programmable, the cardiologist can set optimum pace mode for each pt

what are temporary PMs used for + give examples

treat short term heart problems; slow heartbeat from a heart attack, surgery, or overdose

what are permanent PMs used for

long term heart rhythm problems

how does the pacemaker work

provides low levels of electrical stimulation to the heart muscle; it can sense the pts heart rate and provide stimulation when needed

describe internal pacemakers

surgically implanted inside the pt chest

how big is the generator component of an internal pacemaker

size of a matchbox, weighs 20g

describe external pacemakers

bulk remains in a pocket created under the skin, the leads are placed transvenously

rules for 24h post insertion for pacemakers

pt cannot abduct or lift their left arm

complications of pacemaker insertion

lead dislodgement, pneumothorax, lead migration, lead failure, generator failure

how long is the lifespan for the pacemaker’s generator

10 years

purpose of respiratory tubes

assist with airflow to the lungs by bypassing obstructions, preventing aspiration, or controlling breathing

list the 2 types of respiratory tubes

tracheostomy tubes, endotracheal tubes

where are ETTs inserted

mouth or nasal passage into the trachea

role of ETTs

help with respiratory collapse resulting from paralysis, pulmonary edema, or adult respiratory distress syndrome, or they’re used for airway management during procedures that use general anesthesia

describe the optimal location of ETTs

fixed at the mouth, the distal tip is in the trachea at 5-7cm superior to the carina

complications of ETT insertion

tip inserted too far = single lung ventilation or collapse on the contralateral side, esophageal insertion = abdomen ventilation, pneumomediastinum and surgical emphysema = air introduced to the surrounding area (ST/heart)

what is a trachesotomy

surgical opening in the anterior neck and into the trachea

ETT ventilation via tracheostomy is not recommended past which time frame

14-21 days

how are tracheostomy tubes secured

fixed to the skin by a fabric strip tied around the pts neck

optimal tip location for tracheostomy tubes

at the midpoint between the upper end of the tube and the carina (6cm above the carina)

complications of tracheostomy tube insertions

bleeding, pneumothorax, permanent damage to vocal cord nerve, accidental removal, infection of insertion site, malpositioning