Points & Concepts to Ponder!

#1
Essential Procedures
ENEMA Purpose Types Remove flatulence Remove feces For dx purposes To feed the client OR prep

ENDOSCOPY Visualization of the esophagus,stomach and duodenum To remove tissue specimen Remove abnormal tissue growth Inform cindent NPO remove denture Position client left sims position After Clients avoid eating drinking Until the gag reflex return Observe for bleeding fever abdominal pain OXYGENATION Purpose Promote lung expansion Mobility of secretion Patent airway Promote oxygenation Breathing pattern Nurse Position SF Increase fluid intake Deep breathing exercise Coughing reflex Chest physiotheraphy Cotton clothes NO SMOKING sign on door 6ft distance of the client to tank Assess O2 drowning O2 delivery Nasal cannula Face mask Face tent Venture mask Partial rebreather and non rebreather PARACENTESIS Position Sitting leaning forward Unconscious: supine with head elevated at 45 Instruct to stay still during position Do no cough Administer antitussive to suppress coughing reflex Do x-ray to determine area or site of injection Instruct client to inhale deeply then hold breath upon insertion Instruct pt to do valsalva maneuver upon removal Apply occlusive dressing to prevent Pneumothorax Observe aseptic technique Monitor VS apply pressure dressing Assess puncture site for bleeding and Crepitus Monitor for complications o Pneumothorax o Atelectasis o Embolism o Pulmo edema o Hemothorax Removal of fluids Removal of air

Cleansing enema- remove feces Carminative enema- expel Retention enema- oil, medication Return flow/ harrish flash Contraindication Prolapsed of anus Pelvic trauma Medication Kayexalate Neomycin Positioning Left sims lateral Volume of fluids 150-250mL infant 250-350mL toddler 300-500mL school age child 500-750mL adolescent 750-1000mL adult TYPES OF Retention Types ENEMA Infused solution is not immediately expelled Low pressure enema (12inches)

Oil retention o Lubricates the colon for evacuation o About 120-200mL of solution Nutrients enema o Administration of medication Sedative enema Emollient enema Barium enema o Provides contrast media for colon x ray Non retention Infused soln is expelled immediately High pressure enema (18inch) Types Carminative o Helps expel flatus from the rectum and provides relief from gaseous distention Cleansing enemas Cleansing enema Non retention Prepares the intestine for certain dx procedures Relives constipation prevent involuntary escape of fecal material during Sx procedure Help regulates bowel Types Hypotonic (tap) 500-100mL Distend intestine, increase peristalsis, soften stool 15mins Isotonic 500-1000mL Distends intestine onc peristlasis, soften stool 15 mins Soap suds 500-1000mL Distends intestine onc peristlasis, soften stool 15 mins Oil 120-200mL Distends intestine onc peristlasis, soften stool 30 mins

3rd ICS increase for air ICS 4th decrease fluid

ECG Needle aspiration For pleural effusion For pneumothorax For hemathorax For empyema For PTB

Measure electrical conductivity of the heart Monitor cardiac distress Determine cardiac activity Avoid caffeine tea, choco cola and coffee Avoid bronchodilator Fasting for 4hrs Position: supine

Waves P wave- atrial depolarization QRS- ventricular depolarization T wave- ventricular repolarization U wave- purkinje fiber P wave- contraction ST segment elevation- ischemia T wave inversion- ischemia Pathologic Q wave- MI Inverted U wave- hypokalemia T wave flat- ischemia

PARACENTESIS Removal of accumulated fluid in the peritoneum Needle aspiration of fluid in the abdominal cavity Ascites fluid examination Treatment of massive ascites- as therapeutic purpose Trocar and cannula may be used Positioning: siting up with resting in stool Semi fowlers position Bedrest after 24hrs Turn every 2hrs Assess weight NGT Lavage- bringing-out Gavage- feeding Compression Decompression Nursing Consideration Check patency Assess the ffg: o Infection o Gag reflex o Mental status o Ability of the client to follow instruction Position: HFowlers Place towel across the chest Tube Salem sump o For continuous suctioning o Lavage Miller abbot o Intestinal suction o Decompression Sengstaken Blakemore tube o Treatment of esophageal varices o Compression Nursing Consideration Inspect the solution before hanging Control flow rate of the solution Position of the patient (fowlers) Temp (warm to room temp to prevent diarrhea and cramps) Check the ff prior to the feeding o Placement o Patency o Residual content Check bowel sound Height of feeding (12/18inch) TRACHEOSTOMY maintain patency Purpose performing tracheostomy care reduces the risk of infection it maintains patency of the pts airway it facilitates the healing of the stoma site it prevent infection it promotes clients comfort Before VS ease of breathing, rate, rhythm, lung sounds secretions present drainage from the tracheostomy dressing or ties incision site status

Nursing Consideration hyperoxygenate the patient before and after suctioning humidify the O2 clean first the inner cannula, soak to hydrogen peroxide then sterile water (5-10min) forcep or obturator must always be available at bedside of the chest of the patient make sure to have an extra tracheostomy set at bedside minimize cough Note temporary or permanent RN is the one to inflate the balloon French (Fr) TPN Contents Indication Risk Site -

Fluids Fats Chon Electrolytes Vitamins Trace elements Acute pancreatitis Malnutrition Severe burns Ulcerative colitis Enteric fistula ARF hepatic failure infection electrolyte imbalance fluid overload glucose imbalance Pneumothorax Air embolism Clotted line Subclavian Brachial

COLOSTOMY Irrigation Do it in a commode/ comfort room if possible (sitting position) Hang the solution at IV stand, never in door knob The solution be on the level of the shoulder of the client Height is important to regulate the pressure Lubricant to be use is water based Nursing consideration Never used betadine Avoid gas forming foods or foul smelling foods Explore clients feelings Do not use cotton, use gauze Indication Permanent colostomy Abdominoperineal resection for lower rectal cancer Temporary colostomy May be created from transverse colon from cecum Nursing Maintenance of proper diet to maximize living Promote regular exercise Promote comfort Maintenance of skin integrity Care Keep patient free from foul odor Clean colostomy site regularly Keep sealed the bag Proper diet must be followed Prevent diarrhea and constipation Inspect the patient stoma regularly Keep the stoma site clean and dry