Week 12 Discussion ~ Medical Surgical Nursing 2015
What 3 items need to be at the bedside of a patient with a recent tracheostomy? For safety, ensure that a tracheostomy tube of the same type (including an obturator) and size (or one size smaller) is at the bedside at all times, along w/a tracheostomy insertion tray.
Differentiate emergency care for the client who decannulates their tracheostomy tube within 72 hours of insertion and after 72 hours of insertion. 
Within 72 Hours Tube dislodgement in the first 72 hours after surgery is rare but life-threatening. If it happens within 72 hours after surgery, it is a medical emergency because the tracheostomy tract has not matured, the stoma has not healed, and replacement is difficult. The tube may end up in the subcutaneous tissue instead of in the trachea. The stoma should be covered to prevent air leakage and the patient should be ventilated with
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Week 12 Discussion ~ Medical Surgical Nursing 2015
an Ambu bag and mask until a physician replaces the tube or inserts an ET tube. After 72 Hours If decannulation occurs after 72 hours, extend the patient’s neck and open the tissues of the stoma w/a curved Kelly clamp to secure the airway. With the obturator inserted into the tracheostomy tube, quickly and gently replace the tube and remove the obturator. Check for airflow through the tube and for bilateral breath sounds. If you cannot secure the airway, notify a more experienced nurse, respiratory therapist, or physician for assistance. Ventilate w/a bag-valve mask. If the patient is in distress, call the Rapid Response Team for help.
What are the diagnostic tests and precautions for hospitalized TB patient?
Diagnostic Tests o NAAT (Nucleic Acid Amplification Test) – A new rapid test for tuberculosis that was developed and approved by the World Health Organization in 2010. Results are available in less than 2 hours. Widespread use of this test is endorsed and should soon replace other diagnostic methods. o Acid-Fast Bacillus Test – Not specific for TB, but it is used as a quick method to determine whether TB precautions should be started until more definitive testing can be completed w/either a two-step procedure or the QuantiFERON-TB Gold. o QuantiFERON-TB Gold o Blood Analysis – Uses QuantiFERON-TB Gold. Relatively rapid test w/results ready in 24 hours and is most useful in the acute care setting to determine whether a symptomatic patient has TB. o Sputum Culture – Confirms DX. Requires 1 to 4 weeks to determine a positive or negative result. o Tuberculin Test (Mantoux Test) – Most commonly used. Placed intradermally in the forearm. Does not indicate active disease, only exposure to disease. o CXR Precautions o Airborne Precautions in a well-ventilated room that has at least six exchanges of fresh air per minute. o All health care workers must wear an N95 or high-efficiency particulate air (HEPA) respirator when caring for the patient. o When hand and clothing contamination is a risk, use Standard Precautions w/appropriate contact protection (gowns and gloves). o Perform hand washing before and after patient care. o Precautions are discontinued when the patient is no longer infectious.
Why is it not recommended to administer high flow O2 to the client with COPD? Patient’s w/COPD who are breathing spontaneously should never receive high levels of oxygen therapy because it results in a decreased stimulus to breathe. Do not administer oxygen @ more Jennifer Cook
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Week 12 Discussion ~ Medical Surgical Nursing 2015 than 2 L/min unless a health care provider’s order is obtained. Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying O2, close monitoring is imperative to prevent unsafe increases in the patient's PaO2, which could result in apnea. In general, use a delivery system such as a Venturi mask or nasal cannula. Avoid routine use of a non-rebreather mask with 15 L/min of oxygen, unless the patient is not responding to lower flow rates. In some patients with chronic carbon dioxide retention, high flow oxygen may cause respiratory depression with the rapid rise in oxygen depressing the central ventilatory drive.
Which inhaler medications should be used as a rescue drug for the client with asthma?
Short-Acting Beta² Agonist (SABA) o Albuterol (Proventil, Ventolin) o Bitolterol (Tornalate) o Levalbuterol (Xopenex) o Pirbuterol (Masair) o Terbutaline (Brethaire) Cholinergic Antagonist – Ipratropium (Atrovent, Apo-Ipravent) – Can relieve and prevent asthma. Does not work as well as SABA’s but can be used in place of SABAs by patients who cannot tolerate side effects of beta² agonists.
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Week 12 Discussion ~ Medical Surgical Nursing 2015 Which medications should be taken on a regular schedule to prevent exacerbation's of asthma?
Long-Acting Beta² Agonist (LABA) o Formoterol (Foradil) o Salmeterol (Serevent)
Describe the assessment findings of right and left sided heart failure. Why are they different?
Right-Sided HF – Associated w/↑ systemic venous pressures and congestion. o Systemic venous congestion o Peripheral edema o Jugular distention o Enlarged liver and spleen o Anorexia and nausea o Dependent edema (legs and sacrum) o Distended abdomen o Swollen hands and fingers o Polyuria at night o Weight gain o Increased blood pressure (from excess volume) or decreased blood pressure (from failure) o Other Info:
The heart's pumping action moves "used" blood that returns to the heart through the veins through the right atrium into the right ventricle. The right ventricle then pumps the blood back out of the heart into the lungs to be replenished with oxygen.
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Week 12 Discussion ~ Medical Surgical Nursing 2015 Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure. When the left ventricle fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart's right side. When the right side loses pumping power, blood backs up in the body's veins. This usually causes swelling in the legs and ankles.
Left-Sided HF (Previously known as CHF, but still widely used) – Associated w/↓ cardiac output and ↑ pulmonary venous pressure. o Impaired tissue perfusion o Pulmonary congestion o Edema o Weakness o Fatigue o Dizziness o Angina o Acute confusion o Restlessness o Palpitations o Pallor o Weak peripheral pulses o Cool extremities o Hacking cough, worse at night o Dyspnea/Breathlessness o Crackles or wheezes in lungs o Frothy, pink-tinged sputum o Oliguria (scant urine output) o Tachypnea o S3/S4 summation gallop o Decreased blood flow to the major body organs can cause dysfunction, especially renal failure. Can occur when the patient is at rest. o The pulse may be tachycardic, or it may alternate in strength (pulsus alternans). o Other Info:
The heart's pumping action moves oxygen-rich blood as it travels from the lungs to the left atrium, then on to the left ventricle, which pumps it to the rest of the body. The left ventricle supplies most of the heart's pumping power, so it's larger than the other chambers and essential for normal function. In left-sided or left ventricular (LV) heart failure, the left side of the heart must work harder to pump the same amount of blood. There are two types of left-sided heart failure. Drug treatments are different for the two types.
Systolic failure: The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation. Diastolic failure (also called diastolic dysfunction): The left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can't properly fill with
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Week 12 Discussion ~ Medical Surgical Nursing 2015 blood during the resting period between each beat.
Differentiate the clinical manifestation of arterial versus venous insufficiency.
Arterial Insufficiency – Patients w/an acute arterial occlusion describe severe pain below the level of the occlusion that occurs even at rest. The affected extremity is cool or cold, pulseless, and mottled. Small areas on the toes may be blackened or gangrenous. o Patient reports claudication after walking about 1 – 2 blocks o Rest pain usually present o Pain at ulcer site o End of Toes o Between the toes o Deep o Ulcer bed pale, w/even edges o Little granulation tissue o Cool or cold foot
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Week 12 Discussion ~ Medical Surgical Nursing 2015 o o o o o o o
Decreased or absent pulses Atrophy of skin Hair loss Pallor w/elevation Dependent rubor When acute, neurologic deficits noted Often presents with the “six P’s” of ischemia: Pain Pallor Pulselessness Paresthesia Paralysis Poikilothermy (coolness)
Venous Insufficiency o Chronic nonhealing ulcer o No claudication or rest pain o Moderate ulcer discomfort o Patient reports of ankle or leg swelling o Ulcer bed pink o Brown pigmentation o Ankle area o Usually superficial, w/uneven edges o Granulation tissue present o Ankle discoloration and edema o Full veins when leg slightly dependent o No neurologic deficit o Pulses present o May have scarring from previous ulcers
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Week 12 Discussion ~ Medical Surgical Nursing 2015 References
"Bedside Tracheostomy: A Step-by-step Guide." Medical Economics. Web. <http://www.modernmedicine.com/modern-medicine/content/bedside-tracheostomy-stepstep-guide?page=full>. Ignatavicius, Donna D. Medical-surgical Nursing: Patient-centered Collaborative Care. 7th ed. St. Louis: Elsevier Saunders, 2013. Print. "Types of Heart Failure." Types of Heart Failure. Web. <http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Typesof-Heart-Failure_UCM_306323_Article.jsp>.
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