PCC Oxygenation and elimination

airway clearance

-positioning and postural drainage

-incentive spirometer

-mobilizing secretions: chest physiotherapy, turn cough and deep breathing (TCDB), hydration, humidification of O2, medications such as expectorants, decongestants and steroids

coughing and breathing techniques

mobilizing secretions- know what each one does

artificial airways

-oropharygneal

-nasopharygneal

-endotracheal tube: orotracheal, nasotracheal, tracheostomy; cuffed vs noncuffed

-monitor for complications, requires suctioning to clear secretions

chest tubes

-inserted into the PLEURAL SPACE

-purpose: to evacuate air of fluid

-3 major types: water-seal, dry-seal or portable

nursing assessment for vitals, spo2, pulmonary assessment, color, consistency, amount of drainage, pain

oxygenation

how well the cells, tissues, organs of the body are supplied with O2

-diaphragm helps with breathing so if anything affects it then its an issue

mechanical ventilation

inhalation vs exhalation

respiration (chemical)

internal vs external

-exchange of O2 and co2 in the alveoli and capillary membrane

-chemoreceptors and level of O2 stimulate us to breathe and monitors Co2

assessment of O2 status

-physical exam

-medical history

-breathing pattern

-respiratory effort

-pulse oximetry

-diagnostic testing : ABG’s (arterial blood gas), peak flow monitoring, imaging

COCA

color, odor, characteristics, amount

diagnostic testing

-lab studies: occult blood, O and P (ova-egg and parasite), stool culture

-vitamin c can cause false negative for occult test

-direct visualization: colonoscopy (tube looks in colon), sigmoidoscopy (tube looks in sigmoid)

-radiographic views: flat plate of abdomen, GI series, CT

-know nursing responsibilities/ patient prep for all tests

fecal occult blood test (Guiac)

-follow hospital policy for collection technique

-collect stool smear on card

-apply reagent

-blue=positive

-high rate of false negatives and false positives

stool specimen

-verify order

-use standard precautions,

colonoscopy

-informed consent: may be done inpatient or outpatient

-bowel prep: clear liquid diet, then NPO

-conscious sedation

-post-procedure: recover from anesthesia, assess for bleeding or perforation

management of diarrhea

-stool for C+S, O+P, C diff toxin, WBC

bowel diversion- ostomy

stoma+ part of intestine exposed

-illeostomy_ part of illeus exposed

-colostomy: (placed in colon)

-purpose: colitis, cancer, diverticulus,, tramau

-temporary or permanent

-placement planned with WOCN (wound, ostomy, and continence nurse)

-healthy stoma= pink

-lower profusion= purple stoma

ostomy care

-fit to stoma (1/8 inch larger than stoma)

-change the bag every 3-5 days

-skin barrier

-empty when 1/3 full

-patient education: involve the patient in care, consult with the wound nurse, and diet education

-pyschosocial concerns: body image, sexuality, support groups

-NOTHING GOES INTO THE OSTOMY

NG tube

-purposes: decompress the Gi tract, administer feeding/meds, lavage of GI bleed or posioning

types: salem sump, small bore, dobhoof tubes

nursing interventions: follow proper insertion assessment and technique, confirm placement (x-ray, check suction, evaluate, and record output

purpose of kidneys

-waste elimination, maintain fluid balance, maintain electrolytes, and acid/base balance, and regulate BP

bladder

-can hold 500-1000ml of urine; once 250-400ml collect, stretch receptors send a signal to the brain and indicate the need to urinate

output: adults produce 1500-2000 ml per day (and will urinate roughly 5-6 times). minimum output is 30ml/hr

urine characteristics

-color : pale straw )expected

-red urine: blleding or diet related

-bright orange: or rust colored may be with certain meds

-dark amber: high level of bilirubin resulting fom liver dysfunctin, muscle breakdown

odor: stronger odor when concentrated, ammonia smell=stagnant, sweet and fruity odor- ketones (diabetes mellitus)

clarity: should be clear-becomes cloudy after standing several minutes

-initially cloudy: protein or bacteria

amount: adults nromally boid 1500-2000 ml a day

min output is at least 30ml/hr

factors imacting urination

-age, pregnancy, diet, immobility, pain, psychosocial factors, surgical procedures, and meds (acetaminophen)

urinary retention

-retention is inability to empty bladder completely

-etiologies include:

-obstruction, inflammation and swelling, neurological conditions, meds, anxiety

urinary catherization

• straight I and O: obtain specimen, relieve urinary retention

• indwelling (folley)- accurate I and O, post-operatively, not for incontinence

• 3 way= CBI (murphy drip)