Comprehensive Nursing Lab and Clinical Skills Study Guide
Tracheostomy Care and Airway Suctioning Guidelines
Prior to performing suctioning on a patient with a tracheostomy, the nurse must ensure the suction pressure is set within the correct therapeutic range, which is defined as . Effective suctioning technique requires the nurse to limit the duration of each suctioning pass to between to prevent hypoxia. In terms of frequency and recovery, the nurse must wait for a duration of between suction passes to allow the patient to re-oxygenate, and the procedure should be limited to a maximum of in total.
During the insertion of a suction catheter, if a patient such as Mrs. Taurine begins to cough upon insertion, the most appropriate clinical action is to pull back the suction catheter by and then begin the suctioning process. It is incorrect to continue inserting the catheter until resistance is met if coughing occurs early, nor should the procedure be immediately discontinued unless the patient's oxygen saturation or stability is compromised. For a patient with a tracheostomy tube, a common and appropriate nursing diagnosis is the risk of altered skin integrity, particularly around the stoma site.
Routine tracheostomy care involves specific steps to maintain hygiene and safety. Inappropriate actions include securing tracheostomy ties too tightly; the correct technique is to ensure that can fit snugly under the tie to prevent skin breakdown or airway constriction. When changing ties, they should be knotted in the eyelets of the faceplate, avoiding slipknots or asking the patient to hold their breath unnecessarily. The cleaning process involves using hydrogen peroxide to clean around the faceplate and stoma, followed by a rinse with normal saline. The inner cannula should also be removed and placed in a sterile basin with hydrogen peroxide to soak.
Artificial airways may utilize special equipment such as a fenestrated tube. The specific purpose of a fenestrated tracheostomy tube is to allow the patient to talk by permitting air to pass through the vocal cords. For a newly established tracheostomy, essential equipment must be available at the bedside, such as an obturator and an emergency replacement tube of the same size and one size smaller.
Urinary Catheterization and Bladder Management
Patients returning from urological surgery with closed continuous bladder irrigation (CBI) may exhibit "bloody red" drainage. If the patient's vital signs are within normal limits, the nurse should reassure the family that this is a normal finding at this time and that the drainage will gradually become lighter and appear more blood-tinged as recovery progresses. When an indwelling urinary catheter is removed, such as at , the patient is typically expected to void within a to window, making them due to void by approximately .
Following the removal of a catheter, certain sensations are expected during the first voiding, including mild burning, discomfort, or producing only a small amount of urine. However, symptoms such as fever and back pain are not expected outcomes and may indicate a complication like a urinary tract infection. The most common complication that nurses should educate patients about prior to discharge after catheter removal is the risk of developing a urinary tract infection, as urinary catheters are the most common cause of nosocomial (health care-associated) infections.
To minimize the risk of injury during the removal of an indwelling catheter, the nurse must check the documentation to determine the volume of fluid used to inflate the balloon (typically or ) and then use a syringe to deflate it completely. Tugging on the catheter or using scissors to cut the valve are inappropriate and dangerous techniques. Furthermore, the nurse should question an order for a urinary catheter if it is for a non-medical reason, such as obtaining a drug screening for employment for a stable patient, as this can be done through non-invasive means.
Aseptic Technique and Sterile Field Maintenance
The maintenance of a sterile field is critical to preventing infection. A sterile field is considered contaminated if moisture is noted on the packages of sterile gauze, as moisture allows for the migration of microorganisms through capillary action. Other contamination triggers include reaching over the sterile field, leaving the field unattended (e.g., leaving the room to get more supplies), or allowing a non-sterile item to touch the field. The outer () perimeter of the sterile field is always considered non-sterile; therefore, any sterile item that lands in this border must be discarded.
When setting up a sterile field, the nurse should assess the patient's immediate needs, such as pain levels or the need to use the bathroom, to ensure the patient can remain still during the procedure. However, assessing if the patient has ambulated earlier in the day is unnecessary for the specific task of setting up a sterile field for a dressing change. To maintain sterility while wearing sterile gloves and waiting for assistance, the nurse should interlock their fingers and keep their hands above waist level. Hands should never fall below the waist or go behind the back.
When adding supplies to a sterile field, the nurse should not allow the wrapper of the pre-packaged supply to touch the sterile field. When adding sterile liquids, the nurse should hold the bottle with the label facing the palm to prevent the liquid from damaging the label and should avoid extending their arm over the sterile field while pouring. Sterile liquids are typically considered contaminated if they have been open for more than .
Wound Assessment, Irrigation, and Drainage Systems
Wounds are categorized by depth; a partial-thickness wound extends through the epidermis and the dermis. A wound that heals by secondary intention is characterized by the formation of significant granulation tissue, and the resulting scarring can be severe, with a potential for permanent dark redness at the site. This is distinct from primary intention, which involves minimal tissue loss and minimal scarring.
In wound management, the nurse may use clean gloves for changing the dressing on chronic pressure injuries, whereas surgical wounds typically require sterile technique. Before performing a painful dressing change or wound irrigation, the nurse's first action should be to provide analgesic medications as ordered to ensure patient comfort. Documentation of a wound should occur after the wound has been cleansed, as the removal of exudate allows for a more accurate assessment of the wound bed color and tissue health.
Wound irrigation requires controlled pressure to be effective without causing tissue trauma. The general rule is to keep the irrigation pressure between . Irrigation can help in the removal of yellow slough tissue, but black eschar (necrotic tissue) generally requires surgical or chemical debridement rather than just irrigation. When preparing irrigation solution, the nurse should review the provider's orders for the specific solution type but must never warm the irrigant in a microwave; it should be warmed to body temperature using safe methods like a warm water bath. Findings such as new drainage or increased redness should be reported to the health care provider.
Surgical drainage systems include the Hemovac and Jackson-Pratt (JP) drains. The purpose of these systems is to provide constant suction to remove and collect drainage from a wound to facilitate healing. For a Hemovac system, suction is created by manually compressing the device. For a Jackson-Pratt drain, suction is maximized by compressing the bulb while replacing the port cap. The nurse should empty these containers regularly and should report any sudden increase in drainage volume to the primary care provider.