INP Final Exam
Reasons for Ostomy Procedures
Indications for Ostomy
Trauma to the gastrointestinal (GI) tract can necessitate an ostomy.
Disease processes such as Crohn's disease may require surgical intervention.
Congenital abnormalities may lead to the need for an ostomy.
Types of Ostomies
Gastrointestinal Ostomies
Sigmoid: Located at the end of the colon.
Descending: Located in the left side of the abdomen.
Transverse double-barreled: Divides the colon into two stomas.
Ascending: Located on the right side of the abdomen.
Loop: A loop of bowel is brought to the surface.
Ileostomy: An opening from the ileum to the abdominal wall.
Urostomies
Ileal loop: A segment of the ileum is used to divert urine.
Transureteroureterostomy: Connects ureters to a stoma.
Double urostomy: Involves an internal pouch or external stoma.
Ostomy Characteristics and Management
Permanent vs Temporary Ostomies
Permanent ostomy: The intestinal tract is not reattached; rectum and anus may be removed.
Temporary ostomy: Created for a limited time, allowing the bowel to rest before reattachment.
Components of an Ostomy
A permanent ostomy consists of a pouch and a stoma.
The stoma should be monitored for size, color, and protrusion.
Nursing Care for Ostomy Patients
Preoperative Nursing Care
Clear liquid diet 24-72 hours prior to surgery.
Fecal matter removal via laxatives and enemas if necessary.
Prophylactic antibiotics may be administered.
Postoperative Nursing Care
Monitor vital signs, surgical site, and stoma output.
Assess for signs of infection and complications.
Maintain NPO status until bowel function resumes.
Complications and Management
Postoperative Complications
Post-op ileus: Temporary impairment of bowel motility; occurs in ~5% of patients.
Peristomal skin complications: Includes denudation, dermatitis, and fungal infections.
Stoma Complications
Necrotic stoma: Indicates poor blood supply.
Mucocutaneous separation: Separation of the stoma from the skin.
Prolapse: Stoma protrudes excessively.
Care of the Ostomy Pouching System
Changing the Bag
Remove the old bag carefully to avoid skin irritation.
Wash the stoma with warm water and mild soap to maintain hygiene.
Apply the new bag ensuring a good seal to prevent leaks.
Secure the bag properly to ensure it stays in place.
Addressing Air in the Bag
Burp the bag to release excess air and reduce ballooning.
Open the end of the bag to allow air to escape, if necessary.
Emptying the Bag
Empty the bag into a toilet or at the bedside as needed.
Clean the cuff and wipe it out to maintain cleanliness.
Empty the bag when it is 1/3 to 1/2 full to prevent overflow.
Changing the Faceplate
Change the faceplate every 3-5 days or as needed (PRN).
Remove the old faceplate carefully to avoid skin damage.
Measure the stoma and cut the opening to fit, allowing 1/8 - 1/6 inch (2-3mm) around the stoma.
Apply stoma paste around the opening to ensure a good seal.
Use skin prep before applying the new faceplate.
Measuring the Stoma
Fresh stomas can change in size for the first 4-6 weeks; measure with every appliance change.
Weight changes can affect the size and shape of the stoma.
Prolapsed stomas and hernias may also change the size.
Use stoma paste to fill any gaps for a better fit.
Patient Education - Ostomy
General Care Instructions
Understand the physiology of the ostomy for better management.
Learn how to care for the stoma, peri skin, and how to empty & change the device.
Maintain a proper diet to support health post-surgery.
Diet Specific Teachings
For ileostomy patients, increase hydration by 1-2 cups per day.
Diet can affect odor, frequency, gas, and hydration levels.
Postoperative Documentation for an Ostomy
Documentation Requirements
Use an ostomy flow sheet for tracking patient progress.
Document abdominal distention, tenderness, bowel sounds, and presence of gas.
Record effluent/output and condition of sutures, including perianal sutures.
Surgical Procedures and Definitions
Types of Ostomy Procedures
Colectomy: Removal of the entire colon creating an ileostomy, located in the lower abdomen (LLQ).
Ileostomy: Liquid discharge containing digestive enzymes, drained by a collection pouch.
Double-barreled colostomy: Distal stoma leads to the rectum, discharging small amounts of mucous.
Definitions of Key Terms
Anastomosis: Surgical joining of two ducts or bowel segments.
Hartmann's Procedure: Involves a proximal colostomy and a distal stapled-off colon.
Ileoanal Pouch: Creation of a pouch from the small intestine attached to the anus for continence.
Psychological Support for Patients
Nursing Interventions
Encourage social interaction to reduce feelings of isolation.
Provide information about available support groups.
Guide patients to express their concerns regarding their condition.
Explore lifestyle changes and realistic alternatives with the patient.
Objectives of Blood Transfusions
Primary Objectives
Increase circulating blood volume to replace blood loss (e.g., trauma, surgery).
Increase RBC count and maintain hemoglobin levels (e.g., anemia).
Provide cellular components as replacement therapy (e.g., clotting factors for hemophilia).
Blood Classification and Compatibility
Blood Type Systems
ABO System: Classifies blood based on A and B antigens.
Rh System: Classifies blood based on the presence of the Rh factor (D antigen).
Blood Types and Antigens
There are 4 blood types: A, B, AB, O.
Type A: Antigen A, Antibody B.
Type B: Antigen B, Antibody A.
Type AB: Antigen A & B, no antibodies (universal recipient).
Type O: No antigens, Antibodies A & B (universal donor).
Rh Factor and Compatibility
Rh positive: Presence of Rh factor; Rh negative: Absence of Rh factor.
Rh- cannot receive Rh+ blood; Rh+ can receive Rh- blood.
Blood Product Types and Uses
Types of Blood Products
Plasma (FFP): Used for clotting disorders; ABO compatible but not necessarily Rh compatible.
WBCs: Used for neutropenia; rare.
Platelets: Used for low platelets and active bleeding; crossmatch preferred.
PRBC (Packed RBCs): Used for anemia and severe blood loss; ABO and Rh must be compatible.
Albumin: Synthetic product for volume replacement; no crossmatch required.
Alternatives to Blood Transfusions
Iron transfusions/supplements to boost hemoglobin production.
Erythropoietin to stimulate RBC development; not ideal for active bleeding.
Procedures and Considerations for Blood Transfusions
Administration Procedures
Review doctor's order to transfuse.
Confirm consent for transfusion.
Provide information to the patient regarding the planned transfusion.
Confirm pre-transfusion testing or collect pre-transfusion sample (if applicable).
Assemble required equipment.
Pre-Transfusion Testing
Type & Screen: Tests patient's blood type, often for pregnant women.
Crossmatch: Combines blood product and patient sample for compatibility.
Informed Consent and Patient Teaching
Informed consent must include description of blood component, risks, benefits, and alternatives.
Patient teaching should cover the need for transfusion, components involved, and signs of adverse reactions.
Monitoring and Adverse Reactions
Monitoring During Transfusion
Monitor for adverse reactions such as chills, fever, rash, and pain at the infusion site.
Report any unusual symptoms immediately.
Adverse Reactions
Common reactions include chills, fever, rash, shortness of breath, and lower back pain.
Document any adverse reactions in the patient's medical record.
IV Setup and Patient Assessment
IV Setup for Blood Administration
Use straight type IV tubing with a special filter and no y-port.
Prime a second line with Normal Saline (NS) solution to hang on the same pole.
Patient Assessments Prior to Administration
Conduct a chest assessment to identify preexisting concerns.
Obtain baseline vital signs within 30 minutes before starting the transfusion.
Medication and Blood Product Retrieval
Pre-Medication Administration
Pre-medications require a physician's order.
Consider Diphenhydramine and/or Acetaminophen for patients with a history of transfusion reactions.
Blood Product Retrieval Protocol
Only RNs or LPNs can obtain blood products from the lab.
Verify patient identification, TMS number, blood component, ABO group, Rh status, and lot number with blood bank personnel.
Pre-Transfusion Safety Check
Steps for Safety Check
Confirm the prescriber's order.
Confirm patient identification by matching full name and DOB with ID bracelet and TMS form.
Compare TMS form with TMS ID number.
Compare blood product name and lot number, transcribing onto the BPV record.
Ensure compatibility of blood groups for recipient and donor.
Conduct a visual inspection for clots or debris.
Sign the BPV record and check the expiry date.
Transfusion Administration and Monitoring
Initiating the Transfusion
Prime the administration line and filter with the blood component or compatible solution.
Initiate transfusion slowly for the first 15 minutes as a 'test dose.'
Conduct 1:1 direct observation of the patient by the RN for the first 5 minutes.
Monitoring During Transfusion
Vital signs and chest assessment should be completed after the first 15 minutes.
LPN can take over care after the initial 15 minutes, monitoring vital signs and assessments every hour (Q1H) and as needed.
Post-Transfusion Care and Complications
Post-Administration Protocol
Flush the administration set with NS after transfusion.
Safely discard empty blood component containers and supplies as per facility policy.
Complete all documentation related to the transfusion event.
Common Transfusion Reactions
Allergic reactions can range from mild (urticaria) to life-threatening (anaphylactic).
Febrile, nonhemolytic reactions are the most common, caused by antibodies against donor white blood cells or plasma proteins.
Overview of Blood Transfusion Reactions
Types of Transfusion Reactions
Febrile, Nonhemolytic Reactions: Commonly caused by antibodies against donor white blood cells, platelets, or plasma proteins.
Acute Hemolytic Reactions: Result from ABO-incompatible blood products or antibodies in the recipient's plasma.
Circulatory Overload: Occurs when blood products are administered faster than the circulation can accommodate.
Sepsis: Caused by bacterial contamination of transfused blood products.
Initial Manifestations of Reactions
Febrile, Nonhemolytic: Sudden chills, tachycardia, hypertension, dyspnea, fever, headache, flushing, anxiety, muscle pain.
Acute Hemolytic: Low back pain, chills, fever, shortness of breath, tachycardia, flushing.
Circulatory Overload: Dyspnea, cough, hypertension, headache, distended neck veins, pulmonary congestion, increased heart rate.
Sepsis: Rapid onset of chills, high fever, marked hypotension, or shock.
Nursing Management of Transfusion Reactions
General Management Steps
Stop the Transfusion: This is the first step in managing any suspected transfusion reaction.
Maintain IV Access: Keep the IV site open with saline to ensure continued access for medications.
Monitor Vital Signs: Check vital signs frequently, especially during the first 15 minutes of transfusion.
Specific Management for Each Reaction
Febrile, Nonhemolytic: Administer antipyretics as ordered and do not restart the transfusion.
Acute Hemolytic: Stop the transfusion, save the blood bag for follow-up, and treat symptoms as they arise.
Circulatory Overload: Turn down or stop the transfusion, position the patient upright with feet dependent, and administer diuretics as needed.
Sepsis: Stop the transfusion, obtain blood cultures, and administer antibiotics, IV fluids, and vasopressors as ordered.
Patient Education and Monitoring
Signs and Symptoms to Monitor
Patients should be educated to monitor for symptoms such as shortness of breath, fever, chills, hives, rash, itching, and pain at the infusion site.
Report any unusual symptoms immediately to nursing staff.
Emergency Protocols
Always review the agency's algorithm for managing transfusion reactions before administering blood products.
Ensure emergency equipment and medications are available during transfusions.
Blood Product Selection and Compatibility
Types of Blood Products and Indications
Compatibility and Administration Guidelines
Blood must be transfused within 4 hours of obtaining it from the lab.
No other solutions or drugs should be administered through the same line while blood is infusing to prevent cell destruction.
The infusion must begin within 30 minutes of obtaining blood from the lab.
Overview of Chest Tubes
Definition and Purpose
A chest tube, or thoracostomy tube, is inserted through the thorax to remove fluid and/or air from the pleural space.
It promotes re-expansion of the lungs and prevents re-entry of air or fluid into the pleural space.
Common Indications for Use
Chest surgery: Used post-operatively to drain fluids.
Chest trauma: To manage air or fluid accumulation due to injury.
Pneumothorax: Both spontaneous and tension types require drainage.
Hemothorax: Collection of blood in the pleural cavity.
Empyema: Accumulation of pus in the pleural cavity.
Purpose of Chest Tubes
Chest tubes are inserted to remove air or fluid from the pleural space.
They prevent air or fluid from re-entering the pleural space.
They help restore normal intrapleural and intrapulmonic pressures.
Types of Chest Tube Systems
Single Chamber System: Allows air from a pneumothorax to escape, preventing re-entry into the pleural space.
Two-Chamber System: Drains fluid into a collection chamber while allowing air to flow into the water seal chamber.
Three-Chamber System: Includes a suction control compartment that may or may not be used.
Types of Pneumothorax
Spontaneous Pneumothorax
Occurs without major injury, often in tall, thin males.
Caused by rupture of a weak area on the lung, allowing air to leak into the pleural space.
Tension Pneumothorax
A life-threatening condition where air enters the chest cavity but cannot escape.
Leads to increased pressure in the pleural space, collapsing the lung.
Chest Tube Drainage System Components
Chamber Functions
Collection Chamber: Receives fluid from the chest cavity.
Water-Seal Chamber: Acts as a one-way valve to prevent air from re-entering the pleural space.
Suction Control Chamber
Applies controlled suction to the drainage system.
The level of fluid in this chamber determines the amount of suction applied.
Safety and Monitoring
Bedside Safety Checks
Ensure two hemostats or approved clamps are available at the bedside.
Have waterproof tape and sterile dressing ready for emergencies.
Keep a container of sterile water available for alternative water seal in case of tube detachment.
Patient Assessment
Monitor level of consciousness and orientation.
Check vital signs including SpO2 and pain levels.
Assess respiratory rate, character, and breath sounds.
Inspect the insertion site for subcutaneous emphysema.
Complications and Management
Subcutaneous Emphysema
Characterized by a crackling sensation on palpation, indicating air in soft tissues.
Often described as sounding like 'snap, crackle, pop'.
Tubing Inspection and Management
Regularly check for leaks, kinks, and fluid-filled loops in the drainage tubing.
Manage excess tubing to prevent occlusion or compression.
Patient Assessment and Monitoring
Key Assessment Areas
Respiratory status and quality.
Insertion site and tubing condition.
Drainage characteristics (amount, color, consistency).
Signs and Symptoms to Monitor
Chest pain or tightness.
Increased heart rate and respiratory rate.
Decreased blood pressure and diminished breath sounds.
Nursing Interventions
Positioning and Mobility
Position patient in semi to high Fowler’s for optimal lung expansion.
Encourage deep breathing, coughing, and incentive spirometry hourly while awake.
Patient Education and Comfort
Educate patient and family on management and signs to watch for.
Manage pain effectively and encourage early ambulation.
Chest Tube Maintenance
Drainage System Management
Ensure the drainage system is upright and below the level of tube insertion.
Regularly inspect for leaks, kinks, and fluid-filled loops.
Handling Complications
If drainage suddenly increases or is bright red, notify the physician and assess the patient.
Persistent bubbling in the water-seal chamber indicates an air leak.
Documentation and Reporting
Key Documentation Elements
Document respiratory status, patency of the chest tube, and characteristics of drainage.
Record vital signs and status of the chest dressing.
Reporting Changes
Report any changes in drainage quantity or characteristics immediately.
Mark the time of measurement and fluid level in the collection chamber.
Chain of Infection
Key Concepts
The Chain of Infection consists of six components: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.
Each component must be present for an infection to occur, highlighting the importance of breaking the chain to prevent disease transmission.
Key Descriptions
Infectious Agent: Pathogen that causes disease (e.g., bacteria, viruses).
Reservoir: Natural habitat of the infectious agent (e.g., humans, animals, environment).
Portal of Exit: Pathway for the infectious agent to leave the reservoir (e.g., respiratory tract, blood).
Mode of Transmission: How the infectious agent is spread (e.g., direct contact, airborne).
Portal of Entry: Route through which the infectious agent enters a new host (e.g., mucous membranes, broken skin).
Susceptible Host: Individual who is at risk of infection due to weakened immune system or other factors.
Infection Prevention in Acute Care
Key Concepts
Infection prevention is critical in acute care settings to protect patients and healthcare workers.
A systematic approach is necessary to minimize the risk of healthcare-associated infections (HAIs).
Steps for Infection Prevention
Point of Care Risk Assessment: Evaluate the risk of infection at the point of care.
Routine Practices: Implement standard precautions for all patients.
Specialized Accommodation and Signage: Use isolation precautions as needed.
Barrier Equipment: Utilize personal protective equipment (PPE) to protect against exposure.
Dedicated Equipment: Ensure equipment is designated for specific patients to prevent cross-contamination.
Limited Transport: Minimize patient movement to reduce infection risk.
The 4 Cs for Leaving a Patient's Room
Key Concepts
The 4 Cs are essential steps to ensure safety when leaving a patient's room under precautions.
The 4 Cs Steps
Clean Hands: Patient must perform hand hygiene before leaving the room.
Clean Clothes: Patient should wear a clean gown or clothes.
Contained Wounds/Body Fluids: Ensure all wounds are covered and body fluids are contained.
Cooperative: Patient must be able to follow instructions regarding the 4 Cs.
Common Healthcare Associated Infections
Key Concepts
HAIs are infections that patients acquire while receiving treatment for other conditions within a healthcare setting.
Common Types of HAIs
Urinary Tract Infection: Most common (40%), often associated with catheters.
Bloodstream Infection: Most preventable, commonly linked to central lines; S. aureus is a common cause.
Surgical Site Infection: Most costly (up to 22%), resulting from surgical procedures.
Pneumonia: Highest mortality rate, particularly in ventilated patients.
Consequences and Prevention of HAIs
Consequences of HAIs
Increased morbidity and mortality rates among patients.
Prolonged hospitalization due to complications.
Increased healthcare costs associated with treatment.
Rising resistance to antimicrobials due to overuse.
Preventing HAIs
Prevent Infection: Conduct point of risk assessment regularly.
Diagnose & Treat: Ensure appropriate diagnosis and treatment of infections.
Use Antimicrobials Wisely: Avoid unnecessary use to prevent resistance.
Prevent Transmission: Implement strict infection control measures.
Identify & Minimize: Recognize potential risks and minimize exposure.
Precautions for Specific Illnesses
Key Concepts
Different illnesses require specific precautions to prevent transmission.
Precautions by Illness
Influenza: Droplet & contact precautions required.
Tuberculosis: Airborne precautions necessary.
C-difficile: Contact plus precautions needed.
Mumps: Droplet precautions are essential.
VRE (Vancomycin-resistant Enterococcus): Contact precautions are required.
HIV: Routine precautions should be followed.
Purpose and Overview of Neurological Assessment
Purpose of Neurological Assessment
To evaluate sensory neurons and motor responses.
Determines if the nervous system is impaired.
Components of Neurological Assessment
Typically includes a physical exam and review of medical history.
Varies in levels: screening, complete assessment, and neuro check.
Components of a Complete Neurological Assessment
Mental Status Assessment
Level of Consciousness (LOC) is evaluated.
Orientation to person, place, and time is assessed.
Memory is tested: immediate recall, short-term, and long-term.
Cranial Nerve Function
Smell test (Cranial Nerve I: Olfactory).
Visual acuity and field tests (Cranial Nerve II: Optic).
Eye movement in six directions (Cranial Nerves III, IV, VI).
Facial movements (Cranial Nerve VII: Facial).
Shoulder shrug and head turn (Cranial Nerve XI: Accessory).
Motor Function
Coordination tests: finger-to-nose, heel-to-toe walking.
Assessment of muscle strength and tone.
Observation for involuntary movements.
Sensory Function
Random application of stimuli to assess sensation.
Comparison of sensory responses symmetrically.
Reflexes
Check integrity of sensory and motor pathways.
Includes deep tendon reflexes (e.g., bicep, patellar) and cutaneous reflexes (e.g., plantar).
Involuntary Movements and Reflex Grading
Types of Involuntary Movements
Fasciculation: Continuous twitching of a muscle.
Tic: Repetitive twitching at inappropriate times.
Myoclonus: Sudden jerks at regular intervals.
Rest tremor: Slow tremor that disappears with movement.
Intention tremor: Worsens with voluntary movement.
Grading Reflexes
Reflexes graded on a 4-point scale:
0: No response.
1+: Sluggish response.
2+: Active response (normal).
3+: Brisk response (slightly hyperactive).
4+: Very brisk, hyperactive with clonus.
Neuro Check and Monitoring
Purpose of Neuro Check
Monitors neurologic status in patients with known disorders.
Helps determine increased intracranial pressure (ICP).
Components of Neuro Check Assessment
Vital Signs monitoring.
Glasgow Coma Scale (GCS) assessment.
Pupil examination.
Limb movement evaluation.
Frequency of Vital Signs Checks
First hour: Q15min x 1 hour.
Second hour: Q30min x 1 hour.
Next four hours: Q1hour x 4 hours.
After six hours: Q4hours x 24 hours.
Glasgow Coma Scale (GCS)
Overview of GCS
Measures level of consciousness (LOC) using a standardized scale.
Consists of three categories: Eye Opening, Verbal Response, and Motor Response.
Scores range from 3 (deep coma) to 15 (fully alert).
Provides consistent assessment data for neurological status.
Sternum stimulation is discouraged for assessment.
GCS Scoring Breakdown
15: Alert and fully oriented.
13-14: Mild head injury or sedated state.
9-12: Moderate head injury.
<8: Severe head injury or coma.
3: Totally comatose, unresponsive.
Clinical Application of GCS
Used in emergency settings to assess brain function.
Helps in determining the severity of head injuries.
Aids in monitoring changes in a patient's neurological status.
Neurological Checks
Pupil Assessment
Determines intracranial pressure (ICP).
Assess size and reaction to light in both bright and dark conditions.
Document pupil reaction as brisk, sluggish, or absent.
Limb Movement Assessment
Evaluates motor function and spinal cord integrity.
Assess both limbs simultaneously for response to commands.
Use painful stimuli if no response is observed.
Posturing Types
Decorticate (Flexor Posturing): Indicates damage to the cerebral cortex; arms flexed, legs extended.
Decerebrate (Extensor Posturing): Indicates damage to the brain stem; arms and legs extended.
Seizure Management
Nursing Interventions During Seizures
Protect the patient from injury during a seizure.
Position for adequate ventilation and drainage of secretions.
Document assessments accurately before, during, and after the seizure.
Seizure Precautions
Assess seizure history.
Inspect environment for safety hazards.
Prepare bed with padded side rails and position low.
Ensure medical equipment is available.
Never leave a seizing patient alone.
Post-Seizure Care
Turn the patient to the side to prevent aspiration.
Provide reassurance and answer any questions.
Place the patient in a non-stimulating environment.
Cranial Nerves and Functions
Overview of Cranial Nerves
Responsible for various functions including movement, sensation, and autonomic control.
Each cranial nerve has specific roles related to sensory and motor functions.
Matching Cranial Nerves to Functions
Glossopharyngeal: Taste, gagging, swallowing.
Oculomotor: Eyelid and eyeball movement.
Hypoglossal: Controls tongue movement.
Abducens: Turns eye laterally.
Vagus: Innervates heart, lungs, and GI tract.
Key Cranial Nerve Functions
Facial: Controls facial expressions, saliva, and taste.
Trigeminal: Facial sensation and chewing.
Acoustic: Sense of balance and hearing.
Reflexes and Neurological Functions
Babinski Reflex
Elicited by running a blunt object along the sole of the foot.
A positive Babinski reflex indicates abnormal motor control pathways from the cerebral cortex.
Functions of the Neurological System
Movement initiation and coordination.
Reception and perception of sensory stimuli.
Cognitive functions including thinking and memory storage.
Overview of LPN IV Therapy Responsibilities
Initiation of IV Therapy
LPNs can start IVs after completing additional education.
Use of short peripheral devices is permitted for IV initiation.
Administration Guidelines
LPNs administer parenteral solutions to clients with stable health.
IV bag changes are allowed via peripheral access only.
Indications and Physician's Orders
Indications for Peripheral IV Therapy
Treat or prevent fluid loss and electrolyte disturbances.
Administer blood products and IV medications.
Provide parenteral nutrition for short-term needs.
Physician's Order Requirements
Must include patient identification information.
Specify the solution to be administered and the rate of administration.
Patient Preparation and Venous Access
Patient Preparation for IV Therapy
Assess for allergies and explain the intended purpose of therapy.
Discuss anticipated length of therapy and associated risks and benefits.
Selecting the Correct Venous Access Device
Consider length of therapy and type of procedure.
Assess patient’s age, activity level, and condition of veins.
IV Therapy Sizing and Device Types
IV Therapy Sizing
Common sizes for IV devices:
14: largest size, used in emergencies.
16 & 18: often used for trauma cases.
20-22: most common for adults.
24: used for pediatric and frail adults.
Types of Venous Access Devices
Over-the-needle catheters are commonly used.
Winged-set types are also available for specific situations.
Complications and Management
Common Problems with IV Insertion
Phlebitis, infiltration, and extravasation are common issues.
Mechanical, bacterial, and chemical phlebitis can occur due to various irritants.
Signs for Changing IV Sites
Change sites when pain, erythema, or edema is present.
IV sites initiated under suboptimal conditions should be changed within 24-48 hours.
Discontinuation of IV Lines
Process for Discontinuing an IV Line
Confirm reason for removal.
Explain procedure to the patient.
Perform hand hygiene and apply gloves.
Clamp IV tubing and remove tape.
Withdraw catheter while applying pressure to the site.
Doctor's Orders and Clinical Indications
A doctor's order is not required for removal if clinically indicated.
Document the procedure and inspect the catheter tip for integrity.
Overview of Intravenous Medication Administration
Definition and Advantages
Intravenous (IV) medication administration involves delivering concentrated medications directly into a vein.
Main advantage: Immediate elevation of serum levels and high concentration in vital organs, bypassing absorption and breakdown processes.
Comparison with Oral Doses
IV doses are generally smaller than oral doses due to direct entry into the bloodstream.
Factors influencing IV medication prescriptions include medication properties, desired effects, patient condition, and preferences.
Advantages and Disadvantages of IV Medication Administration
Advantages
Provides immediate, fast-acting therapeutic effects.
More consistent absorption compared to other routes.
Minimal dilution required for some medications, accommodating patient fluid restrictions.
Accurate dosing as no medication is left in the tubing.
Disadvantages
Risk of significant harm or death if administered too quickly or incorrectly.
Once delivered, IV medications cannot be retrieved, posing risks during adverse reactions.
Potential for immediate toxic reactions and tissue damage from extravasation.
Modes of IV Medication Administration
Types of Administration
Large volume/continuous infusion: Typically 500 - 1000 mL, minimizes adverse effects but not suitable for all patients.
Piggyback/Concurrent: Uses 25 - 100 mL bags, reduces rapid dose infusion risks, and controls IV fluid intake.
IV Direct Administration
Not within LPN scope of practice, previously known as IV push.
Involves small volumes (max 20 mL) infused slowly (1-5 mins) via syringe.
Only specific medications can be administered this way.
Safe Administration Principles
Guidelines for Safe Administration
Follow the Seven Rights and perform 3 Checks before administration.
Review qualifications, route, IV site, preparation, and documentation procedures.
Drug Monographs
Provide essential drug information for healthcare staff, typically arranged in a standard format.
Include indications, contraindications, administration instructions, compatibility, adverse effects, and dosage.
Medication Reconstitution
Process and Components
Reconstitution involves adding a liquid (solvent/diluent) to powdered medication (solute).
The resulting liquid is called a solution.
Sterility and Diluents
Reconstitution is a sterile procedure, typically performed by pharmacy for large volumes and by nurses for smaller volumes.
Common diluents include sterile water and sterile normal saline solution.
Common Diluents
Sterile water and sterile normal saline solution are the most commonly used diluents for medication reconstitution.
These diluents ensure the medication is safe and effective for patient use.
Identifying Diluents
The type of diluent to use can be found in the manufacturer's directions and drug monographs.
Proper identification of diluents is crucial for the effectiveness of the medication.
Key Information for Reconstitution
Important information includes the type and amount of diluent, storage directions, and strength/concentration after reconstitution.
Understanding these factors helps ensure the medication's efficacy and safety.
Storage and Shelf Life
Directions for storing reconstituted medication must be followed to maintain stability.
The shelf life indicates how long the medication remains effective after reconstitution.
IV Medication Administration
Labeling Requirements
IV medication bags must be labeled with patient name, medication name, dose, nurse's initials, base solution, preparation date/time, and expiration date.
Proper labeling prevents medication errors and ensures patient safety.
Volume and Additives
The maximum volume of additive allowed in a bag is 10% of the bag volume.
If the additive exceeds 10%, an equivalent volume must be withdrawn from the bag.
Infusion Rates and Calculations
Infusion rates must be calculated based on the desired dose and concentration of the medication.
Example: For Aminophylline 250 mg in 500 mL, the rate for 65 mg/hr is 130 ml/hr.
Monitoring and Interventions
Monitor for signs of adverse reactions, phlebitis, or extravasation during IV administration.
Interventions include stopping the infusion, notifying the physician, and documenting the incident.
Compatibility and Incompatibility
General Compatibility
Most IV drugs are compatible with commonly used IV solutions.
Compatibility is essential to prevent adverse reactions during administration.
Types of Incompatibility
Physical incompatibility: visible reactions causing haziness or precipitate.
Chemical incompatibility: degradation of the drug without visible signs.
Therapeutic incompatibility: undesirable combined effects of drugs.
Mixing IV Drugs
Mixing should only be done when essential for patient needs, not for convenience.
Understanding the risks of incompatibility is crucial for safe medication administration.
Emergency Protocols
Adverse Reactions
If an adverse reaction occurs, stop the infusion and notify the physician immediately.
Document the reaction and notify pharmacy as required.
Phlebitis and Extravasation
Signs of phlebitis include swelling and pain at the IV site; interventions include stopping the IV and treating the site.
For extravasation, stop the infusion, do not remove the IV, and notify the physician.
Flow Rate Calculations
Flow rates for medications must be calculated based on physician orders and drug concentrations.
Example: Heparin 1000 units/h from a 40,000 units in 1000 mL bag results in a flow rate of 25 mL/hr.
Overview of Parenteral Nutrition
Definition and Purpose
Parenteral nutrition (PN) is a specialized nutrition support provided intravenously.
Aims to prevent and restore nutritional deficits, allow bowel rest, and supply adequate caloric intake.
The primary goal is to transition back to using the GI tract as soon as safely possible.
Types of Parenteral Nutrition
Total Parenteral Nutrition (TPN) is for patients who cannot ingest or digest food normally.
Peripheral Parenteral Nutrition (PPN) is for short-term nutritional needs and is less calorically dense.
TPN is administered via central veins, while PPN is through large peripheral veins.
Components of Parenteral Nutrition
Main components include dextrose, amino acids, lipid emulsions, water, electrolytes, trace elements, and vitamins.
Amino acid/dextrose solutions typically range from 1000-2000 ml and may appear yellow due to multivitamins.
Lipid emulsion solutions are milky and typically range from 100-250 ml.
Nutritional Concepts
Metabolism Basics
Anabolism refers to building up molecules from smaller units, while catabolism is the breakdown of molecules.
Basal metabolic rate is the energy expenditure at rest, measured in calories.
Nitrogen Balance
Positive nitrogen balance occurs when nitrogen intake exceeds nitrogen loss, essential for growth and recovery.
Negative nitrogen balance indicates that nitrogen loss exceeds intake, often seen in malnutrition or illness.
Nutritional Deficiencies
Cachexia is a syndrome characterized by severe weight loss and muscle wasting, often due to chronic illness.
Wasting syndrome involves significant weight loss (10% or greater) due to chronic conditions.
Administration and Monitoring of Parenteral Nutrition
Administration Protocols
A dedicated IV line with specific tubing is required for PN administration.
A 2 healthcare provider check is necessary for initiation, bag changes, and rate changes; LPN can be the second check.
Patient Monitoring
Daily monitoring includes body weight, lab reviews, blood glucose levels, and vital signs.
Initial bloodwork components include CBC, electrolytes, and liver function tests.
Complications Related to Parenteral Nutrition
Complications can be categorized into metabolic, catheter-related problems, and sepsis.
Metabolic complications include hypoglycemia, hyperglycemia, and refeeding syndrome.
Sepsis is the most serious complication associated with PN.
Role of LPN in Parenteral Nutrition
Scope of Practice
LPNs do not start or monitor parenteral nutrition but provide care in a team nursing approach.
They can perform daily assessments and monitor patients receiving PN.
Responsibilities
LPNs assist in the administration of PN by ensuring proper identification and documentation.
They are involved in monitoring for complications and reporting any concerns to the healthcare team.
Overview of Tracheostomy and Related Procedures
Definitions and Procedures
Tracheostomy: A surgical incision into the trachea to create an airway.
Endotracheal Intubation: Insertion of a tube into the trachea via the mouth or nose for airway protection and ventilation.
Tracheostomy Tube: An artificial airway inserted into the trachea.
Purpose of Tracheostomy
Bypass obstructed upper airway.
Facilitate removal of secretions.
Assist with long-term mechanical ventilation.
Prevent aspiration of oral and gastric secretions.
Types of Tracheostomy Tubes
Cuffed vs. Uncuffed: Cuffed tubes provide an airtight seal; uncuffed allow airflow around the tube.
Fenestrated vs. Non-fenestrated: Fenestrated tubes allow speech and airflow; non-fenestrated do not.
Disposable vs. Non-disposable: Inner cannulas can be either.
Tracheostomy Care and Nursing Considerations
Nursing Assessment and Care
Assess vital signs, SpO2, and respiratory status regularly.
Monitor secretions: amount, color, and consistency.
Ensure emergency supplies are available at bedside.
Suctioning and Humidification
Suctioning is necessary to maintain a patent airway and remove excess secretions.
Humidification is crucial as tracheostomy bypasses natural humidification mechanisms.
Infection Control and Hygiene
Regular cleaning of the inner cannula is essential to prevent obstruction.
Hand hygiene and cough etiquette are critical to prevent infections.
Complications and Management
Common Complications
Mucus Plugs: Can obstruct the airway; managed by hydration and humidity.
Tracheal Stenosis: Narrowing due to scar tissue from prolonged intubation.
Tracheoesophageal Fistula: Abnormal connection between trachea and esophagus.
Prevention Strategies
Ensure adequate fluid intake and humidity.
Regularly assess and manage cuff pressure to prevent tracheal damage.
Patient Education and Lifestyle Adjustments
Lifestyle Considerations
Avoid swimming and be cautious in showers to prevent aspiration.
Use high-necked clothing in cold weather to protect the tracheostomy site.
Communication and Nutrition
Patients may need alternative communication methods, such as lip reading or communication boards.
Dietary adjustments may be necessary, including pureed foods or thickened fluids.
LPN Scope of Practice with NG Tubes
Responsibilities of LPNs
LPNs are not permitted to insert NG tubes.
LPNs can assist with intubation procedures.
LPNs are responsible for the care and maintenance of NG tubes.
LPNs can discontinue NG tubes when necessary.
Understanding NG Tubes
NG stands for nasogastric, referring to tubes inserted through the nose into the stomach.
Used for various purposes including decompression, feeding, and irrigation.
Purpose and Contraindications of Nasogastric Tubes
Purposes of NG Tubes
Decompression: Removes gas and fluids from the stomach.
Gavage: Provides feeding for patients unable to swallow.
Compression: Applies pressure to stop bleeding in the GI tract.
Lavage: Irrigates the stomach for various medical reasons.
Contraindications for NG Tube Insertion
Absolute contraindications: Severe midface trauma, recent nasal surgery.
Relative contraindications: Coagulation abnormalities, esophageal varices, nasal problems, oral or facial surgery, history of aspiration.
Insertion and Care of Nasogastric Tubes
Steps for Inserting an NG Tube
Assess patient and educate about the procedure.
Verify physician's order and gather necessary supplies.
Position the patient in high Fowler's position.
Measure the tube length from the tip of the nose to the earlobe to the xiphoid process.
Lubricate and insert the tube, securing it properly.
Securing and Confirming NG Tube Placement
Secure the tube using a skin barrier and tape.
Confirm placement before use by checking tube length, measuring pH of aspirate, and observing aspirate color.
X-ray confirmation is used during insertion or if placement is questioned.
Monitoring and Medication Administration via NG Tubes
Monitoring and Care
Regular oral/nasal care and monitoring of intake/output.
Assess gastric residual for feeding tubes and check for patency.
Monitor weight and relevant lab values (e.g., electrolytes, ABGs).
Medication Administration Principles
Prefer liquid medications when possible and ensure proper tube size and placement.
Flush the tube with 30 mL of water before and after medication administration.
Turn off suction during medication administration and document all fluids used.