Professional Documents
Culture Documents
PLASMA VALUES
A. Albumin: 3.6-5.0 g/dl (see also Proteins, below)
B. Alcohol: negative
C. Alkaline phosphatase
adults 30-85 ImU/ml
children greater than two years 85-235 ImU/ml
o two to eight years 65-210 ImU/ml
o nine to 15 years 60-300 ImU/ml
D. Ammonia
adults 9-33 mol/liter
children 40-80 g/dl
newborns 90-150 g/dl
E. Alpha fetoprotein (AFP) <25 ng/ml
F. Bilirubin, direct - up to 0.3 mg/dl
G. Bilirubin, indirect - 0.1-1.0 mg/dl
H. Bilirubin total
adults and children 0.3-1.1 mg/dl
newborns 1-21 mg/dl
I. Bleeding time one to nine minutes
J. Calcium 8.6-10.3 mg/dl
K. Chloride 97-110 mmol/liter
L. Creatinine 0.5-1.7 mg/dl
M. Creatinine clearance 107-139 ml/min - can vary by age
norms: 20 years .84 to 100 years .132
N. Fibrinogen 150-360 mg/dl
O. Gamma globulin 0.8-1.6 g/dl
P. Glucose fasting
adults 65-110 mg/dl
children 51-85 mg/dl
newborns 30-80 mg/dl; >24 hrs. 42-68 mg/dl
Q. Glucose (two hour postprandial) < 140 mg/dl
R. Glucose Tolerance Test
fasting 70-105 mg/dl; 30 minute < 200 mg/dl
one hour < 200 mg/dl
two hours < 140 mg/dl
three hours 70-105 mg/dl
four hours 70-105 mg/dl
S. Iron
male: 45-160 g/dl
female: 30-160 g/dl
T. Lead 120 (g/dl or less) <25 g/dl
U. Lipids (total) 400- 800 mg/dl
V. Cholesterol <200 mg/dl
W. HD
females: 30-85 mg/dl
males: 30-65 mg/dl
X. ldl< 190 mg/dl
Y. Triglycerides <250
Z. Phospholipids 180-320 mg/dl
AA. Free fatty Acids 9.0-15.0 mM/L
BB. Partial thromboplastin time, activated (APTT) 21-32 seconds tow
to three times when anticogulated)
CC. Phosphorus
adults 2.5-4.5 mg/dl
children 3.5-5.8 mg/dl
DD. Potassium 3.8-5.0 mEq/L
EE.Protein (total) 6.2-8.2 g/dl
albumin 3.6-5.0 g/dl
globulin 2.3-3.4 g/dl
FF.Prothrombin Time (PT) 11.3-18.5 seconds (tow to three times when
anticogulated)
GG. Rheumatoid factor negative
HH. Sodium 135-145 mEq/L
II. Thyroid tests
JJ. Thyroxine T4 4.5-12.0 g/dl
KK. TSH 0.35-6.20 U/ml
LL. Urea Nitrogen 8-25 mg/L
MM. Uric acid 3-8 mg/dl
a. pH 7.35-7.45
b. PCO2 35-45 mm Hg
c. HCO3- 22-26 mEq/L
d. PO2 arterial 80-100 mm Hg
e. Oxygen saturation 95-100%
f. Urine specimens
1. Types
1. random
1. obtained from client voiding naturally, from
urinary catheter or diversion bag
2. used for routine urinalysis
2. clean-voided or midstream
1. after appropriate cleansing of urethral
meatus, client collects urine after initial
stream has cleansed urethra
2. used for culture and sensitivity
3. men should retract foreskin and cleanse glans
3. sterile
1. obtained directly from indwelling urinary
catheter
2. needle and syringe used to obtain specimen
from special port within urinary catheter
3. sterile technique maintained
4. timed
1. used for tests of renal function and urine
composition (creatinine clearance, steroids,
hormones)
2. first urine specimen is discarded and for next
period of time, all urine is collected
3. client may be required to void at specific
times
4. missed specimens or those contaminated with
feces or other elements render the test
invalid
5. client voids last specimen at end of timed
period
2. Specimen should be refrigerated if it is to be kept for more
than one hour
3. Immediate information on pH, glucose, protein, ketones
and blood can be obtained by using commercial reagent
stick
4. Pediatric considerations
1. offer small child fluid about 30 minutes before
needed specimen
2. use terms that child can understand to explain
procedure
3. use special collection bags for newborns and infants
5. Common tests
1. routine urinalysis tests and normal values
2. pH: 4.6-8.0
3. protein: up to 10mg/ml
4. glucose: negative
5. ketone: negative
6. blood: up to two RBCs
7. specific gravity: < 1.025
8. microscopic examination
1. wbc's: zero to eight per high powered field
2. bacteria: negative
3. casts: negative
6. Culture and sensitivity
1. used to determine bacterial growth and specific
antibiotics that are effective against those specific
bacteria
2. requires sterile or clean-voided specimen
7. Urine values
g. Urine specimens
1. Types
1. random
1. obtained from client voiding naturally, from
urinary catheter or diversion bag
2. used for routine urinalysis
2. clean-voided or midstream
1. after appropriate cleansing of urethral
meatus, client collects urine after initial
stream has cleansed urethra
2. used for culture and sensitivity
3. men should retract foreskin and cleanse glans
3. sterile
1. obtained directly from indwelling urinary
catheter
2. needle and syringe used to obtain specimen
from special port within urinary catheter
3. sterile technique maintained
4. timed
1. used for tests of renal function and urine
composition (creatinine clearance, steroids,
hormones)
2. first urine specimen is discarded and for next
period of time, all urine is collected
3. client may be required to void at specific
times
4. missed specimens or those contaminated with
feces or other elements render the test
invalid
5. client voids last specimen at end of timed
period
2. Specimen should be refrigerated if it is to be kept for more
than one hour
3. Immediate information on pH, glucose, protein, ketones
and blood can be obtained by using commercial reagent
stick
4. Pediatric considerations
1. offer small child fluid about 30 minutes before
needed specimen
2. use terms that child can understand to explain
procedure
3. use special collection bags for newborns and infants
5. Common tests
1. routine urinalysis tests and normal values
2. pH: 4.6-8.0
3. protein: up to 10mg/ml
4. glucose: negative
5. ketone: negative
6. blood: up to two RBCs
7. specific gravity: < 1.025
8. microscopic examination
1. wbc's: zero to eight per high powered field
2. bacteria: negative
3. casts: negative
6. Culture and sensitivity
1. used to determine bacterial growth and specific
antibiotics that are effective against those specific
bacteria
2. requires sterile or clean-voided specimen
7. Urine values
Instructions
Sit up straight. This exercise may be done in a half lotus sitting position or in a
chair.
Bring your arms up to shoulder level. Clasp your hands together and press them
onto your chest. Lift your head up and stare at the ceiling, hold this position a
second or two, let the muscles in the neck area stretch. Drape a towel around
your neck if this movement is difficult for you .
INHALE then EXHALE and lower your head, press your chin onto your chest.
Simultaneously stretch your arms straight out in front of your chest at shoulder
level. Inhale and return the hands to the chest and lift the head up and back.
This is 1 set, do 3 sets.
Pleural fluid analysis
obtained via thoracentesis (see Respiratory
Diagnostic tests on page 6 of this lesson)
indications: inflammation, infection or malignancy
Peritoneal fluid analysis
obtained via paracentesis (see Gastrointestinal
Diagnostic tests on page 6 of this lesson)
indications: gross ascites
Cerebrospinal fluid analysis (a listing of normal
cerebrospinal fluid values can be found in the Taber's
Glossary)
obtained via lumbar, cisternal or ventricular
puncture (See Neurologic Diagnostic tests on page 6
of this lesson) (illustration )
indications: inflammation, infection
Dia
gnostic Tests--Common Laboratory Tests
o Gastrointestinal disorders
o Cardiovascular disorders
o Respiratory disorders
o Neurological disorders: cerebrospinal fluid
o Musculoskeletal disorders: blood tests
o Integumentary disorders
o Endocrine and hormonal disorders
o Renal system
o Genitourinary system
o Hematologic disorders
Diagnostic Tests--Other
o Visualization tests: endoscopy, laparoscopy
Direct inspection of a body part using an instrument with a
light (endoscope, laparoscope)
Performed by inserting the instrument directly into a body
opening or into a body cavity via a surgical incision
Fiberoptic instruments may be used to enhance client
comfort, to improve instrument flexibility, and to facilitate
visualization
May be performed under local or general anesthesia
(illustration )
1. Blood or serum
a. Serum electrolytes
8 AM <60 pg/ml
4 PM 10-50 pg/ml
e. Plasma Cortisol
f. Catecholamines
j. Growth hormone
l. ESR
m. CRP
2. Urine
a. 17-hydroxysteroids
b. Free catecholamines
c. Osmolality
3. Karyotyping
(illustration 1 , illustration 2 )
Instructions
2. Paracentesis (illustration )
a. drains abdominal fluid of client with ascites
b. small incision is made just below umbilicus
and trocar is inserted
c. nursing interventions
i. client should void before procedure
ii. sit client with feet firmly on floor
iii. remove fluid slowly over a period of 30-
90 minutes to prevent sudden changes
in blood pressure
iv. monitor client for hypovolemia or
electrolyte imbalance
v. observe incision site for leaking or
bleeding
vi. obtain and label specimens for
laboratory analysis
L. Respiratory
2. Pulmonary function tests
a. use a spirometer and record how efficiently
lungs exchange oxygen and carbon dioxide
b. client sits upright, wears noseclip and
breathes into mouthpiece.
c. uses
i. to diagnose lung disease
ii. to evaluate the extent of functional
disability
iii. to evaluate lung function pre-
operatively
iv. to evaluate how lungs respond to
bronchodilators
d. measurements:
*Abnormal Values: values less than 80% of predicted norm.
Definition: A watery cushion that protects the brain and spinal cord from
physical impact and bathes the brain in electrolytes and proteins.
Formation: The fluid is formed by the choroid plexuses of the lateral and third
ventricles. That of the lateral ventricles passes through the foramen of Monro
to the third ventricle, and through the aqueduct of Sylvius to the fourth
ventricle. There it may escape through the central foramen of Magendie or the
lateral foramina of Luschke into the cisterna magna and to the cranial and
spinal subarachnoid spaces. It is reabsorbed through the arachnoid villi into the
blood in the cranial venous sinuses, and through the perineural lymph spaces of
both the brain and the cord. (illustration 1 , illustration 2 ).
CSF may appear red following a recent subarachnoid hemorrhage or when the
lumbar puncture that obtained the CSF caused traumatic injury to the dura
that surround the fluid. Centrifugation of the fluid can distinguish between
these two sources of blood in the spinal fluid: the supernatant is usually
stained yellow (xanthochromic) only when there has been a recent
subarachnoid hemorrhage.
Many conditions may cause increases in total protein: infections, such as acute
or chronic meningitis; multiple sclerosis (when oligoclonal protein bands are
present); Guillain-Barr syndrome; and chronic medical conditions like cirrhosis
and hypothyroidism (when diffuse hypergammaglobulinemia is present). The
concentration of glucose in the CSF rises in uncontrolled diabetes mellitus and
drops precipitously in meningitis, sarcoidosis, and some other illnesses.
Malignant cells in the CSF, demonstrated after centrifugation or filtering, are
hallmarks of carcinomatous meningitis.
N. Cardiovascular system
1. Hemodynamic monitoring: invasive cardiac catheter
a. reflects left ventricular end diastolic pressure
b. use of a balloon-tipped, flow-directed catheter to
provide continuous monitoring (illustration )
c. catheter introduced via subclavian vein or by
cutdown and passed through right side of heart to
pulmonary artery
d. may be inserted at the bedside or under fluoroscopy
e. normal parameters
f. complications of hemodynamic monitoring
i. pneumothorax
ii. dysrhythmias
iii. infection, sepsis, thrombophlebitis
g. nursing interventions: monitor values, assess and
change dressings, maintain patency with fluids,
calibrate equipment, remove lines, obtain specimens
h. Intra-arterial pressure
i. catheter in a major artery and attached to
transducer
ii. most common site: radial artery
iii. usually inserted at bedside
iv. also used to obtain arterial blood gas samples and
other diagnostic studies
v. normal parameters
1. peak systolic: 100 mm Hg
2. end diastolic: 60-80 mm Hg
3. mean 70-90 mm Hg
vi. complications: clot formation, decreased or absent
pulse, hematoma, infection, hemorrhage
i. Cardiac output (CO)
i. volume of blood heart beats per minute
ii. thermodilution technique using blood temperature
changes
iii. known volume of solution is injected at a specific
rate into the right atrium
iv. temperature-sensitive probe measures temperature
of blood as it passes through catheter
v. contraindications: bleeding disorders,
immunosuppression
vi. cardiac output (CO) (heart rate x stroke volume) 4-
8L/min
vii. nursing care of client with cardiac catheter
1. explain procedure to client
2. obtain baseline vital signs and rhythm strip
3. place client in supine position
4. calibrate pressure monitor
5. obtain chest x-ray to guide catheter
placement
6. obtain arterial blood gases as ordered
7. change dressings and tubing as ordered
8. maintain patency of catheter
9. monitor and record vital signs and pressures
as ordered
10.observe for complications
Instructions
Bring the arms up to shoulder level and move them forward in front of the
chest. Press the palms together. INHALE.
Now EXHALE and lower your head pressing the chin into the nap of the neck.
Now INHALE, move your arms apart. Lift the head up, continue to move your
arms apart and backward as far as is comfortable and lift your head up, looking
up, press the arms back so that you can feel the contraction in the shoulder
blades. Hold for a short time and continue this arm movement forward then
backward in rhythm with the breath.
Do this only twice.
Procedures
o General nursing interventions for all procedures
Explain procedure to client and significant others. Use a
translator if indicated.
Obtain written consent for all invasive procedures that
carry risk (e.g., lumbar puncture not venipuncture)
Allow client to ask questions, express concerns, fears
Help client relieve his or her anxiety
Involve significant others in procedure as appropriate
Carry out procedure according to institutional policy and
procedure
Provide emotional support during procedure
Tell client what is going to happen during procedure
Post-procedure, observe for complications
Record all procedures and client's response to them
Obtain and label all specimens and send to lab for analysis
Document character of all specimens obtained
Maintain medical asepsis
Initiate standard precautions as indicated by CDC guidelines
o Gastrointestinal intubation
Routes
nasopharynx: nasogastric, nasointestinal
oropharynx
through abdominal wall by incision: gastrostomy,
jejunostomy
via endoscopy: percutaneous endoscopic gastrostomy
(PEG) or jejunostomy, (PEJ)
Requires a provider's order
Uses
diagnostic
gastric decompression
gastric irrigation
feeding
Nasogastric and nasointestinal
types of tube
nasogastric
single lumen: Levine
Salem
nasointestinal
single lumen: Cantor, Harris
double lumen: Miller-Abbott
complications of prolonged nasal intubation
nasal erosion, sinusitis
pharyngitis, esophagitis, esophageal sphincter
incompetence
gastric ulceration, pulmonary aspiration
aspiration risk is higher with nasal tubes
nursing interventions in gastric or intestinal
intubation:
5. Gastrostomy/jejunostomy
a. tube placement is in upper left quadrant of abdomen
b. for clients who cannot tolerate nasal route, or for
long term enteral feeding
c. provides more secure and reliable access
d. nursing care
i. cleanse skin around insertion site daily with
warm water and mild soap
ii. apply dressing if indicated
iii. observe for complications
e. complications
i. skin breakdown at insertion site
ii. infection
iii. seepage of enteral formula or gastric drainage
Consider your individual peak time when scheduling your examination. For
example
if you are a morning person
schedule a morning exam.
C. Ostomy
1. Surgical procedure which creates an opening into the
abdominal wall for fecal or urinary elimination
(enterostomy)
2. Portion of intestinal mucosa or ureter brought through
abdominal wall creating a stoma through which feces or
urine drains
3. Types
a. bowel: ileostomy or colostomy (illustration )
b. urinary diversions
i. ileal conduit (ileal loop)
ii. ureterostomies
4. Ileostomy
a. stool is liquid, frequent, highly alkaline, contains
digestive enzymes
b. requires constant pouching and frequent emptying
5. Colostomy: thicker, formed stool
a. transverse colon: must be pouched at all times
b. sigmoid colon: can be managed by daily irrigation, so
no need for pouch
6. Urinary diversions
a. ileal loop or conduit
i. a segment of the ileum is removed and used
as a passage for urine
ii. one end forms a stoma on the abdominal wall,
the other is sutured closed
iii. the ureters are implanted into the segment
iv. a pouch is worn to collect urine
v. remainder of bowel is reanastamosed. Client
has normal bowel movements through anus
vi. urine should be yellowish; may contain mucus
shreds
b. continent urinary diversion
i. reservoir for urine made from parts of small
or large bowel
ii. client needs no pouch
iii. reservoir is catheterized at specific times to
drain urine
c. ureterostomy
i. one or both ureters are brought through the
abdominal wall to form a stoma(s)
ii. stomas are pouched to collect urine
iii. usually a temporary measure performed on
infants until ileal loop can be done
iv. complications include skin breakdown,
infection, necrosis
7. Nursing interventions for a client with ostomy; additional
guidelines for nursing care:
a. empty pouches when they are about 1/3 to 1/2 full
b. if needed, protect skin around ileostomy stoma
c. ostomies threaten body image.
d. fears of mutilation, shame, rejection are common
e. clients may feel powerless because they cannot fully
control bodily functions
f. assist client to establish normal elimination routine.
Report immediately if:
i. stoma oozes blood when touched
ii. you see blood in pouch
iii. you see bleeding from stoma
iv. urinary diversion output is less than 30cc/hour
v. urine smells foul
vi. there is blood in urine, or it is very cloudy
vii. client reports burning sensation around base
of urinary diversion stoma
viii. client reports back pain, chills, or fever
g. teach client
i. the types of equipment and their use
ii. how to irrigate colostomy
iii. prevention of complications
iv. how to avoid constipation, diarrhea, excessive
gas
v. that it is vital to drink plenty of fluids
D. Casts
1. Externally applied structure that holds bone in one position
2. Uses
a. immobilization
b. prevent bone or muscle deformity
c. support of a weakened limb
d. promote healing
e. permit early weight bearing on affected limb
3. Types of casting materials
a. plaster of paris
i. natural material
ii. indicated in cases of
severely displaced fractures
unstable fracture fragments
iii. when multiple castings are indicated: serial
casting
iv. application: takes at least 24 hours to dry
v. advantages
low allergic response
offers rigid protection
easy to apply
inexpensive
vi. disadvantages
long drying time (24 to 48 hours)
weight - plaster casts are heavy
materials may crumble and disintegrate
at edges
not waterproof
b. fiberglass
i. synthetic material
ii. indicated in cases of
non-displaced fractures
long term casting
iii. advantages
light weight
easy to apply
moisture-proof
fast: dries in 15 minutes, cures in one
hour
colors and patterns help client adjust
to immobilization
iv. disadvantages
short drying time requires speed and
accuracy
more rigid than plaster; may bind if
tissues swell
extra rigidity may cause tissue
breakdown under the cast
more expensive than plaster castings
4. Types of casts
a. short arm/leg
i. cylindrical cast
ii. allows for flexion or extension of elbow and
knee
b. long arm/leg
i. cylindrical cast
ii. does not allow elbow or knee to move
c. spica arm/hip
i. support bar is applied between extremities
ii. permits greater stabilization
iii. cut window over epigastrium for patient
comfort after eating
5. Cast application
a. cast must extend to the joint above and below the
point of fracture
b. assessment prior to cast application
i. skin: inspect for irritation, laceration, skin
breakdown
ii. neurovascular status check
iii. edema/swelling
c. windowing:
i. square or diamond hole cut in cast over
certain area
ii. indications
observation of surgical incision
observation of skin
relieve pressure over bony prominence
iii. nursing interventions
cast may crack at window site -
weakest part of the cast
appropriate padding/petaling of open
window
d. bivalving
i. indications
swelling
infection or high potential for infection
pain
ii. techniques
lengthwise splitting of the cast with
cast saw
apply ace wrap or tape to hold cast
together
still immobilizes
e. petaling
i. edging the cast with soft padding or moleskin
ii. indications
prevent irritation or skin breakdown at
rough edges of cast
protect cast from perspiration, feces,
urine
protect perineal area
PRINCIPLES OF TRACTION
A. Maintain the prescribed line of pull
1. Especially important in patients with fractures
2. Maintain proper body alignment
B. Always maintain continuous pull unless intermittent traction is
prescribed
C. Prevent friction
1. Friction will alter the line of pull
2. Friction will impair the traction's efficiency
3. But never lubricate pulleys
D. Identify and maintain counteraction
1. Countertraction is the force opposing the pull of traction
2. Generally provided by the patient's body
3. If countertraction is not maintained the patient is not in traction
4. Sign of loss of countertraction is that the patient slides down in
bed
5. Especially problematic with Buck's Traction
6. Keep bed flat
7. Elevate the foot of the bed with shock blocks
E. Counter traction for pelvic traction is generally achieved by putting the
bed in the William position (both knees and hips are flexed at 30
degrees)
A. types of skin traction
iv. complications
skin breakdown
detachment of traction device
v. limitation: can apply only five to seven lbs.
loading force
d. skeletal traction
iv. burr holes drilled into skull and tongs inserted and attached to weights
or halo bolts inserted then attached to body cast
v. tongs used for cervical fractures preoperatively
d. static traction
e. continuous traction pull
f. dynamic traction
g. intermittent application of traction
h. straight traction
i. running
7. Complications
Information about crutch walking can be found in Lesson 5: Basic Care and
Comfort
or client to navigate stairs with crutches, remember "up with the good, down
with the bad."
To go up stairs, lead with the unaffected "good" leg, and follow with the
affected "bad" leg.
To go down stairs, lead with the affected "bad" leg, and follow with the
unaffected "good" leg.
Instructions
Sit with the spine straight. Reach the hands behind the back. First touch the
fingers together, then try to press the palms together.
Lift the hands up as high on the back as is comfortable for you. Hold for as long
as is you can. Breathe normally.
Follow with shoulder lifts.
Nursing interventions
explain procedure to client
monitor hemodynamic status continuously
monitor acid-base balance
monitor electrolytes
ensure sterility of system
maintain a closed system
discuss diet and restrictions on:
protein intake
sodium intake
potassium intake
fluid intake
reinforce adjustment to prescribed medications that
may be affected by the process of hemodialysis
monitor for complications of dialysis related to:
arteriosclerotic cardiovascular disease
congestive heart failure
stroke
infection
gastric ulcers
hypertension
calcium deficiencies (bone problems such as
aseptic necrosis of the hip joint)
anemia and fatigue
depression, sexual dysfunction, suicide risk
o Continuous ambulatory peritoneal dialysis (CAPD)
A form of intracorporeal dialysis that uses the peritoneum
for the semipermeable membrane.
Advantages of CAPD versus hemodialysis
more freedom
less physical and psychosocial interference
fewer dietary and fluid restrictions
simple and easy to use
provides satisfactory biochemical control of uremia
Procedure for CAPD
an indwelling catheter is permanently implanted in
the peritoneum
for each dialysis exchange: to this catheter, attach a
connector and insert it into a sterile plastic bag of
dialysate solution.
infuse the solution via gravity for ten minutes
(average two liter volume)
the solution now dwells in the peritoneal cavity for a
length of time specified by the health care provider,
usually four to six hours.
at the end of the dwell time, the solution is released
and drained into a bag, via gravity.
drainage time is approximately ten to 20 minutes,
during which time ultrafiltration occurs.
clients average four exchanges per day, including
one overnight which allows for uninterrupted sleep
during the night.
Complications related to CAPD
infection
infectious peritonitis
catheter malfunction
communication between the peritoneum and the
pleural cavity
leakage of dialysate
hyper- or hypovolemia
bleeding
obstruction
Nursing interventions
explain procedure to client
assist health care provider according to institutional
procedure
monitor intake and output
observe for signs of complications
record characteristics of output dialysate
teach client
dietary restrictions
how to weigh self daily
that if infections occur, CAPD will not be
feasible long-term
findings of infection
strict aseptic technique
to wash hands before and after dialysis
exchanges
that skipping exchanges raises risk of renal
failure
to inspect bag before use for leaks, alteration
in color
discuss early warning signs of peritonitis:
abdominal pain
cloudy peritoneal fluid
abdominal tenderness
malaise
o Cardiovascular
Intraaortic balloon pump (IABP)
device that helps blood circulate after myocardial
failure
sausage-shaped balloon is threaded via
femoral artery into aorta
balloon inflates with diastole and deflates
with systole
used to treat cardiogenic shock
contraindications:
aortic regurgitation
dissection
abdominal aortic aneurysm
complications
insertion site:
infection
bleeding
hematoma
diminished or absent pulse
thrombus
generalized
aortic dissection or perforation
thrombocytopenia
dysrhythmias
myocardial failure
nursing interventions
explain procedure to client
obtain informed consent
take baseline vital signs, hemodynamic
parameters and ECG
monitor vital signs, hemodynamic status and
ECG as ordered
monitor client's level of consciousness (LOC)
obtain arterial blood gases as ordered
provide emotional support to client and family
monitor intake and output
client must not bend leg in which balloon was
inserted
monitor for complications
fever
Pacemakers
a battery-powered pulse generator that stimulates
the heart via electrodes that touch myocardium
use:
hemodynamic and life support
to correct dysrhythmias
types
atrial pacing
ventricular pacing
atrioventricular sequential and physiologic
pacing
three kinds of pacemakers
asynchronous (fixed rate): pace at a preset
rate, regardless of persons rhythm
demand (standby): pace only if intrinsic rate
declines below rate set on pacemaker
synchronous: sensing circuit detects atrial and
ventricular activity
indications for pacing
symptomatic bradyarrhythmia
symptomatic tachyarrhythmia
asystole
prophylaxis in persons with high risk
bradycardia
diagnosis of dysrhythmias during
electrophysiologic testing
Pacemakers
a battery-powered pulse generator that stimulates
the heart via electrodes that touch myocardium
use:
hemodynamic and life support
to correct dysrhythmias
types
atrial pacing
ventricular pacing
atrioventricular sequential and physiologic
pacing
three kinds of pacemakers
asynchronous (fixed rate): pace at a preset
rate, regardless of persons rhythm
demand (standby): pace only if intrinsic rate
declines below rate set on pacemaker
synchronous: sensing circuit detects atrial and
ventricular activity
indications for pacing
symptomatic bradyarrhythmia
symptomatic tachyarrhythmia
asystole
prophylaxis in persons with high risk
bradycardia
diagnosis of dysrhythmias during
electrophysiologic testi
g. complications of pacemakers
i. infection
ii. perforation of myocardium
iii. pneumothorax
iv. hemothorax
v. dysrhythmias
vi. thrombosis
vii. failure
viii. syncope
ix. hypotension
x. pallor
xi. hiccups
xii. shortness of breath
h. nursing interventions
i. explain procedure to client
ii. initiate preoperative care
iii. post-procedure
initiate post-anesthesia care
monitor vital signs and ECG as ordered
maintain bed rest as ordered
observe for signs of complications
iv. teach client
pacemaker's set rate
how to take pulse (rate and rhythm)
findings of pacemaker failure, wound
infection
activity limitations
hazards: high output electrical
generators: welding equipment, radar,
microwaves, MRI
importance of carrying medical alert
jewelry and information
need for periodic battery replacement
avoidance of contact sports and those
that involve swinging arms (golf,
hunting)
importance of medical follow-up
i. nursing interventions
i. explain procedure to client
ii. initiate preoperative care
iii. post-procedure
initiate post-anesthesia care
monitor vital signs and ECG as ordered
maintain bed rest as ordered
observe for signs of complications
iv. teach client
pacemaker's set rate
how to take pulse (rate and rhythm)
findings of pacemaker failure, wound
infection
activity limitations
hazards: high output electrical
generators: welding equipment, radar,
microwaves, MRI
importance of carrying medical alert
jewelry and information
need for periodic battery replacement
avoidance of contact sports and those
that involve swinging arms (golf,
hunting)
importance of medical follow-up
2. Automatic implantable cardioverter-defibrillator (AICD)
g. pulse generator implanted in subcutaneous pocket.
When it detects ventricular tachycardia or
ventricular fibrillation, it delivers electrical shock to
heart
h. used to treat life-threatening ventricular
dysrhythmias
i. complications
i. infection
ii. malfunction
iii. battery failure
j. nursing interventions
i. explain procedure to client
ii. care of the surgical client
iii. administer medications as ordered
iv. monitor ECG as ordered
v. provide emotional support and reassurance
vi. teach client
findings of defibrillation discharge
importance of routine follow-up
findings of complications
limit activity as ordered
avoid strong magnetic fields
wear medical alert jewelry and
information
assure client that no household
appliance will affect AICD
Respiratory System
J. Artificial airways
1. Adult endotracheal tubes
a. polyvinyl tube with inflatable cuff
b. inserted through nose or mouth
c. distal end should be a few centimeters above the
carina
d. cuff around tube is filled with air
i. creates a seal in trachea
ii. air pressure in cuff < 25 cm H20 or client risks
pressure necrosis in the tracheal mucosa
e. size of tube varies with size of child or adult
f. pediatric tubes may not be cuffed
g. when tube is inserted, check for placement
i. listen for bilateral breath sounds
ii. look for bilateral chest movement
iii. chest x-ray
iv. measure exhaled carbon dioxide
v. measure pulse oximetry
h. nursing interventions
i. explain procedure to client
ii. regularly assess tube placement and security,
breath sounds, and bowel sounds
iii. mark tube length with teeth, or lips if
edentulous (toothless)
iv. suction to maintain airway patency; observe
secretions for color, consistency, and amount
v. assure inspired air is warmed and humidified
since upper airway is bypassed
vi. provide oral hygiene and care for area around
the tube as indicated
vii. observe for skin breakdown around tube site
viii. observe for possible complications of
aspiration; oral/nasal pressure sores;
accidental extubation; and oral, nasal and
pharyngeal damage
2. Tracheostomy
a. surgical opening through the neck into the trachea
b. indications
i. head and neck surgery
ii. long term airway access; for long-term
mechanical ventilation
iii. emergency airway
c. post-op complications
i. tube dislodgement
ii. subcutaneous emphysema
iii. bleeding
iv. infection
d. components of tracheostomy tubes
i. outer cannula
ii. inner cannula
iii. obturator
e. nursing interventions
i. explain procedure to client
ii. regularly assess tube placement and security
iii. care for tracheostomy as ordered
iv. suction to maintain airway patency (see
below)
v. provide adequate hydration
vi. periodically clean inner cannula and stoma
site
vii. provide regular oral hygiene
viii. change trach tube as ordered
ix. watch for skin irritation/infection at insertion
site
x. teach client
1. trach care
2. suctioning procedure
3. findings of complications
4. how to handle accidental
dislodgement/extubation with
obturator
3. Airway suctioning
a. removing secretions from the airway
b. sites for suction
i. nasopharynx, oropharynx, trachea, or bronchi
ii. through endotracheal tube or tracheostomy
c. equipment
i. use bulb syringe to suction nose/mouth of
neonates, infants
ii. catheter's outer diameter should be no larger
than one-half inner diameter of endotrachial
lumen
iii. determining length of catheter
1. measure from tip of nose to base of ear
to sternal notch
2. infant, young child: Insertion tolerance
range: eight to 14 cm
3. older child, adolescent: Insertion
tolerance range:14 to 20 cm
iv. sterile procedure in institution; clean
procedure at home.
v. suction when rhonchus is heard
vi. adjust vacuum pressure to between -80 and
-120 mm Hg
vii. insert suction catheter until resistance is met,
then withdraw catheter an inch or two
viii. apply suction intermittently when
withdrawing catheter
ix. rotate catheter during withdrawal
x. from time of insertion, spend no more than
five to ten seconds
xi. re-establish ventilation and oxygenation
xii. repeat procedure as indicated
xiii. pharyngeal suctioning: less depth, less risk of
complications than tracheal suctioning
d. nursing interventions
i. explain procedure to client
ii. explain that coughing, sneezing or gagging is
normal
iii. place client in semi-fowler's position if
condition allows
iv. maintain standard precautions
v. do not routinely instill saline into airway
vi. if secretions are thick, increase humidity of
inspired air and fluid intake
vii. provide patient with extra oxygen and extra
deep breaths before, during and after
procedure
1. if patient is receiving mechanical
ventilation, use ventilator
2. if patient is breathing spontaneously,
use manual resuscitation bag or
instruct to deep breathe
viii. compare client's respiratory status before and
after suctioning
ix. do not force catheter
K. Oxygen delivery devices
1. Nasal cannula
a. used at flow rates five to six liters per minute (LPM)
b. higher flow rates can be very uncomfortable and
cause nasal bleeding
c. delivered oxygen (FIO2) depends on liter flow,
client's tidal volume and respiratory rate. Each liter
is approximately 4% O2 added to 21% O2 found in
room air.
d. nursing interventions
i. explain procedure to client
ii. ensure prongs are in the nares
iii. pad tubing around the ears, as indicated
2. Simple face mask
a. used at flow rates between 5 - 12 LPM
b. must have at least 5 LPM to wash out carbon dioxide
from exhalation; recommended flow is 8 to 10 LPM
c. delivered oxygen (FIO2) depends on liter flow,
client's tidal volume and respiratory rate
d. not commonly used
3. Venti-mask (venturi mask)
a. uses air-entrainment principle to deliver precise FIO2
b. due to entrainment, provides high rate of total flow
c. available in a range of FIO2
d. depending on FIO2, flow rate four to ten LPM
e. nursing interventions
i. explain procedure to client
ii. keep nasal cannula on stand-by for meals
iii. assure venturi device does not become
blocked by bedding
iv. assess for dry mucous membranes
4. Non-rebreather mask
a. mask with added reservoir bag
b. used at flow rates six to 15 LPM
c. provides highest percentage of O2 available from any
mask, from 60-100%
d. used for sickest clients
e. nursing interventions
i. explain procedure to client
ii. client requires close monitoring
iii. intubation may be needed
iv. assure reservoir bag does not completely
collapse during peak inspiration
1. bag should deflate slightly when
patient inhales and expand when client
exhales.
2. if bag collapses at inspiration, increase
liter flow to bag
v. assure pop-off valves on mask are not stuck
and work properly
5. Home oxygen therapy: three types
a. compressed oxygen comes in tank or cylinder
b. liquid oxygen in reservoir
c. oxygen concentrator extracts and concentrates
oxygen from the air
6. Positive pressure devices
a. CPAP (continuous positive airway pressure)
i. compressor provides air flow to client
ii. baseline of noninvasive positive pressure is
maintained throughout inspiration and
exhalation
iii. used primarily to treat sleep apnea at home
for maintenance of patient upper airway
b. BiPAP (bi-level positive airway pressure)
i. provides a baseline of noninvasive positive
pressure throughout inspiration and
exhalation
ii. provides positive pressure assist during client's
own spontaneous inspiratory effort
iii. used for clients in respiratory failure to rest
client and improve oxygenation to avoid
intubation
Frequent short review sessions (one to two hours) are most productive, as is
reviewing one to two hours before sleep at night. Long
term recall is enhanced to 70 to 80% when one reviews and then sleeps at least
two hours.
L. Ventilators
1. Machines' purpose
a. support and maintain client ventilation
b. improve ventilation
c. improve oxygenation
d. decrease work of breathing
2. Ventilator control modes: assist and synchronized
a. assist-control
i. preset rate at preset tidal volume
ii. if client initiates breath, machine delivers the
preset tidal volume
b. synchronized intermittent mandatory ventilation
(SIMV)
i. machine set to deliver a given rate at a preset
tidal volume
ii. clients can breathe on their own between
machine breaths but will determine own tidal
volume
iii. used to gradually decrease machine support of
breathing
3. Ventilator settings
a. tidal volume: amount of air delivered with each
machine breath
b. rate: number of breaths delivered by the machine in
a minute
c. FIO2: fraction of inspired oxygen
d. %O2: percent of oxygen (e.g., 60%)
4. Sighs: deep breaths (higher volume) delivered periodically
by ventilator
5. Positive end expiratory pressure (PEEP)
a. normal physiologic PEEP is equal or less than 5cm
H2O
b. provides a baseline of positive pressure throughout
exhalation
c. used to reduce airway collapse and intrapulmonary
shunting
6. Nursing interventions
a. explain equipment to client
b. monitor client's response to mechanical ventilation
c. assure ventilator is working properly
d. monitor artificial airway (as above)
e. assess and provide for adequate nutrition
f. monitor pulse oximetry and/or arterial blood gases
as ordered
M. Chest physiotherapy
1. Consists of coughing, chest wall percussion, vibration, and
postural drainage
2. Designed to improve airway clearance
3. Used for clients with retained tracheobronchial secretions
4. Cough: natural clearing mechanism
5. Chest wall percussion, vibration
a. percussion involves clapping chest with cupped
hands
b. vibration is downward vibrating pressure with flat
hand; done during exhalation
6. Postural drainage (illustration 1 illustration 2 )
a. gravitational clearance of airway mucous from
various bronchial segments
b. uses 10 different body positions
7. Percussion and vibration done in each position;
simultaneously client coughs or nurse suctions to remove
loosened secretions
8. Nursing interventions
a. explain procedure to client
b. place client in desired position according to lobe
being drained
c. percuss each area for at least three minutes
d. encourage client to cough after each area is
percussed and vibrated
Drainage Systems
N. Chest drainage
1. Chest tube
a. tube placed in the pleural space to remove air, fluid,
or both
b. tube placed anterior and superior to remove air
c. tube placed posterior and inferior to remove fluid
d. mediastinal tube
i. drains blood or fluid from around heart
ii. no tidaling in mediastinal drainage because
tube is not placed in lung cavity
2. Chest drainage devices
a. collection chamber
i. collects fluid
ii. monitor rate and nature of drainage
b. water seal chamber
i. provides a one-way valve: air leaves chest,
cannot reenter it
ii. check for bubbling in this chamber: indicates
air leak
iii. if no bubbling, check water level in this
chamber
iv. check for tidaling
c. suction control chamber
i. negative pressure transmitted to pleural
space is determined by this chamber, not by
the setting on the wall vacuum
ii. wet chamber - suction level determined by
water level
iii. dry chamber - suction level determined by
mechanical setting
d. nursing interventions
i. explain procedure to client
ii. do not allow dependent loops to form in the
tubing; position the tubing on the bed so that
there is straight gravity drainage to the
collection device
iii. do not routinely strip or milk the tubing; allow
for gravity drainage
iv. do not routinely clamp the chest tube
v. if the tube becomes dislodged and patient has
air leak,
I. apply non-occlusive dressing to allow
air to leave the chest and prevent
tension pneumothorax
II. reinsert tube immediately
vi. tube dislodged, but patient has no air leak
I. apply occlusive dressing
II. monitor carefully for respiratory
distress
III. depending on client's condition, tube
may or may not need to be replaced