All from Canadian clinical nursing skills and techniques Lab Two - Orthopaedic Care: Fractures, broken bones Treatment for fractures: Immobilization - Cast, splint Open/closed reduction Traction External Fixation - used for complex fractures, limb lengthening Cast - immobilize, correct deformed, stable weakened joints Can use splint over cast when someone is at risk for a lot of swelling and someone who requires a lot of skin care, since splints can be removed easier. Cast - Nursing care: Assessments: Neurovascular, pain, compartment syndrome, skin integrity, DVT, respiratory, GI, Compare to opposite extremity to see baseline Turning and repositioning to prevent pressure ulcers. Pt typically turned every 2 hours Log rolling - always turn to unaffected side Hip Spica - place prone twice a day to relieve pressure Teaching - don’t stick anything down cast to scratch instead use air dryer on cold setting, educate on signs and symptoms, let them know about ROM on opposite limb to keep up function, educate on help repositioning they shouldn’t be doing it themselves, educate on skin protection (tape on ruff edges of cast), slings to help relieve weight of a heavy cast Traction - pulling force using weight, realigning bones, helps minimize muscle spasms 2 types - skin and skeletal Assessing traction - note skin integrity (even whole body), don’t make big position changes, can remove skin traction 3 times a day to assess skin but can’t remove skeletal traction, neurovascular assessment every hour when they first get it but then every 4 hours, respiratory and GI. Skeletal traction/external fixation - cleaning pin sites, each pin is considered its own wound. Asses pin sites every 8 hours Cleaning pin site: Same sterile technique as always Wet gauze around then dry, then get a wet 2 by 2 and wrap it around and leave it there and then get a dry 2 by 2 and leave it on top of it to hold it in place. Lab Three - Ostomy Care Why people have Ostomy - Bowel diseases, trauma Ostomy - Artificial opening made in the body for the bowels to empty Colonostomy - stoma in large intestine or colon Ileostomy - stoma placed in transverse or ascending colon Before surgery, health care providers see the patient to mark the stoma site. It’s recommended that the site be marked on the abdomen away from abdominal scars, creases, skin folds, or belt line Effluent - Output, influenced by medications, hydration status, food eaten Peristoma skin - Skin around the stoma, skin should be normal, a little red due to adhesive. Stoma should be red, pink and moist Healthy stoma and surrounding skin signs: Color/moisture: Stoma should be red or pink and moist (Grey, purple, black or very dry report immediately) Size: in the 4-6 weeks after surgery, the stoma will likely decrease in size. Measure stoma with each pouch change Peristomal skin: Normally intact with some reddening after adhesive is removed (blisters, rash or excoriated skin is not normal) Wear PPE as required to reduce exposures and transmission of microorganisms Budded Stoma: Retracted Stoma: Every 3-7 days are when pouches are changed If the pouch is leaking it needs to be changed asap because it can lead to chemical or enzymatic injury to the skin. Empty bags when its ⅓ to half full. One piece pouch with Velcro closure: Two piece pouching system with separate skin barrier and attachable pouch: Changing the Stoma: Asses - Swelling, irritation, how full it is, how much effluent, location, color, Changing the stoma - pt in supine, may have to use adhesive remover, clean stoma with regular warm tap water, do not scrub the skin. If you touch the stoma minor bleeding is normal. measure stoma to see how big you need to cut opening, trace with pencil and then cut and stick on. Hold there with your hands because the heat will help the adhesive stick but don’t need to push hard. Close end of pouch with clip. Don’t forget to clip bag Lab 4 and 5 - Wound Care I & II Wound Care I 10 principles of wound care: Cleanse the wound Deprive the wound (sharp, mechanical, autolytic, chemical, biological) Treat Infection Eliminate dead space (Packing wounds) Absorb excessive drainage Maintaining a therapeutic environment (limit dressing changes, using warm fluids) Protect from injury Support therapy ( pain management, odor control) Autolytic - removal of necrotic tissue Mechanical - Remove both devitalized and debris and viable tissue Sharp - removal of de-vascularizied tissue, callous, or hyperkeratotic tissue with the aid of scissors, scalpel Chemical - Uses ointment or gel with enzyme that softens unhealthy tissue Biological - Uses living organisms to remove necrotic/dead tissue Types of dressings: Gauze Transparent Hydrocolloi ds Hydrogel Alginates/H ydrofibre Foam Use To protect surgical or minimally draining wounds or wound packing Securing IV tubing, keep a dressing in tact Autolytic debridement of noninfected wounds with slough or necrotic tissue; most commonly used for pressure injuries Most effective in promoting moisture in a dry wound bed, which supports wound healing For moderately to heavily draining wounds; shallow or deep wounds; pressure injury; venous ulcers Moderate to heavy exudate wounds Frequency of change Daily or when saturated Every 3-4 days or when drainage remains on periwound Every 5-7 days of when autolyzed material is within 1.5cm of border 2-4 days every 2 days,minim um 3-5 or 7 if no signs of infection or saturation Assessment of wound: Drainage (Serous, purulent, seurosanusant, another one) Assess periwound skin (boggy, dihesisence, granulated tissue) Measure length, width, depth Palpate edges to assess for tunneling Braden scale (pressure sores) Wound Irrigation: Offer pain meds first B/c it can be painful Wear PPE - Gown, Gloves Goggles Use sterile gloves if needed (Clinical judgement, policy) Remove dressing, put dsg in garbage, wash hands, new gloves Use 35mL syringe - due to pressure and 19 gauge angiocath Fill with normal saline or tap water (whatever is ordered) and push on wound until it ruins clear If a wound is really deep and small wound - might need to use soft cath to go in further Once runs clear - dry wound edges and apply another dressing Packing Wounds: Asses for pain and offer meds Remove old dressing (if tape used pull in direction of hair growth and parallel with skin) With gloved hand or forceps remove dressing one layer at a time, observing drainage and appearance. Keep soiled dressings from patients eye sight. If dressing is stuck to wound can moisten to help remove Inspect wound and periwound (appearance, color, size, length, width, depth) Fold dressing with drainage contained inside and remove gloves inside out. Irrigate wound, clean from least to most contaminated Apply new dressing and or pack wound Secure dressing, label date, time, initials Need to count number of gauze that gets put in wound and what comes out. Can pack with 4x4, 2x2 or ribbon for narrow deep wounds If using ribbon need to measure the lengths and if you use more than one you need to tie them together If you have to cut or tie ribbon you will need sterile gloves May need to irrigate wound Ensure packing material is damp Don’t pack higher than wound surface Principles for wound packing: - Use wound characteristics to decide what type of packing is appropriate - Make sure packing material os safe to use - Clean periwound skin, apply barrier to skin - Moisten packing material with non toxic solutions (saline) don’t use iodine - Use non woven gauze, loosen or fluff before packing - Loosely pack wound, not tight - Don’t let packing material touch surrounding skin - Lightly fill all wound dead space with packing - Don’t pack higher than wound surface - Document and measure the amount of packing being added/removed Culture and sensitivity: If this is ordered do after wound is cleaned Aerobic - Oxygen, close to surface, 1 by 1 cm for 5 secs Anaerobic - No O2, go deep in wound, rotate gently. Label swab with pt name, map, your initials, date, time, put in biohazard bag and send to lab Wound Care II: Open or closed drains system: Open - Penrose drain, gotta check/change drain sponges to ensure health of peri skin around the wound Closed drain systems - primates drainage of air and fluid from pleural space, lung re-expansion occurs as the fluid or air is removed Closed - Jacksonprat, hemovac More common, drains into a device to measure and empty Empty when half full Hemovac - Up to 500mls in 24h Jacksonprat - 100-200mls in 24h To drain: Empty when half full of drainage or air Wear clean gloves Open drain and tip sideways Once empty squeeze drain Clean with alcohol swab and compress Standard sterility With drain when cleaning - going around in a circle while moving out, also clean UP the drain but every time you lose contact get a new swab. (Clean and dry) Apply new drain sponge Removing a drain: Closed drains are usually sutured in (use suture removal kit) Once suture is cut, ask pt to take deep breath and pull out but if any resistance let a physician know and don’t pull out. Shortening Penrose drain: Means pulling out the drain a certain amount Use a ruler and measure then safety pin, then cut excess off Negative pressure wound therapy: Vac, picco dressing - uses suction to help drain wound, keep it moist, prevent Edema Used when: Large pressure ulcers, diabetic ulcer, a wound that’s dehissed, a wound with tunneling, some post opsurgical wounds (C-section), partial thickness burns, DON'T USE WHEN: Necrotic tissue, malignancy in wound, expose organs/nerves, untreated osteomyelitis, Vac: Used for drainage wounds Have to cut sponge to fit exactly in wound, not touching peri skin, transparent film goes over wound and you get very tiny hole, then you put on suction lining up with hole then attach to vacuum and set to the pressure ordered. Make sure no air leaks, and pumps are open. Picco: Not for drainage wounds Lab 6 - Nasogastric Tube (Can be a skill) Why people require NG tubes: - NPO - People in Coma’s - When people just can’t tolerate eating food due to nausea, etc. Can be used for: - Feed - Suction/decompressing (common after surgery). When people are on suction some patients are ordered to replace the losses (Patient loses 100mL gastric contents = run 100mL of saline, etc, through IV) - Medications Contraindications of NG tube: - Basal skull fracture, trauma/surgery to face/skull - Altered level of LOC - Altered level of clotting (due to risk for bleeding) - Impaired gag/cough reflex Types/gastric: - Nasogastric - in stomach - Tubes that are weighted are inserted by radiology - Salem sump - used for suction Assessments before insertion: - LOC - Gag reflex - Coagulation studies - Hydration status - Abdominal/GI assessment - Check nasal Patency (they can breath through both nostrils) - Check vitals, keep O2 sat on to keep an eye on O2 Insertion: - High Fowler's position (head of bed at 30-45 degrees) - Blue pad on chest due to throw up - Measure tip of nose, earlobe then to xiphoid process but for children go to abdomen - Need tape, gloves, tongue depressor, penlight - Instruct patient to take deep breath, advance tube each time patient swallows. One tube passes nasopharynx, get pt to tilt chin to chest - - Once its in and the black line is level w nares, temporarily anchor to cheek then insert 30mL of air and drawback to 5-10mLs on a pH strip. It should be lower or equal to 5 to be in the stomach. If its in the right spot then securily tape the tube. To verify NG tube placement in adults they need an X-ray but not in children Irrigation: - Flushing it out - Irrigate before between and after meds - Before starting feeds - After you check placement - Flush water/NS 30mLs. - Slowly push fluids into tube, don’t use a lot of force - Each medications needs to be dissolved in their own 30mLs of water (3 medications means 3 cups of meds) Administering feed: - Given at room temp - Have to check placement every time you use NG tube - Never put more than 4h worth of feed in the bag at a time due to bacterial growth - Administer medications using gravity feed Gastric residual volume (GRV) - How much gastric contents are left in stomach - Check if they have intermittent feeding - Check before feeding - Check before giving meds - If someone is getting a continuous feed check every 4-6h - Normal GRV - More than 250 don’t put it back, but if its less than 250 you can put it back PEG Tube: - More permanent tube - Surgically placed in stomach - Still check placement before using - All rules are still the same as NG tube How to check GRV: - Use a 60mL syringe and keep taking out until you get no more. If less than 250 put it back in. After meds: - Keep head of bed elevated for 1 hour Removing NG tube: - Need blue pad, gloves Flush 10-20mL of air to clear contents in tube Remove tape Ask pt to take deep breath and haul out in one continuous motion Types of feed: - Gravity feed: can use syringe and can slow up or slow down by lifting or lowering - Gravity feed: with bag, similar to IV bags with drip chamber and clamps, use judgment to set rate, typically how long it takes someone to eat a meal (20-30 mins) - Kangaroo pump: Same as IV med administration, prime pump, set rate - Lab 7 - CVADS Why people need CVADS: - history of poor peripheral access - Drugs are harsher on veins (chemo) - Need repeated access - Increased access for blood transfusions/sampling Type: - depends on duration and what pt needs Depends on age, co-morbities Number of lumens depend on how many infusions they have Types of cvad: - non tunneling: Good for days-weeks. - Tunneled (Hickman): sits just under the skin, can be good for long term - PICC: longer term but not permanent. ( a year) Usually in the upper arm but held in Place by sutures. - Implanted port: needs to be accessed to be used with non coring needle Complications: - infection: DO blood cultures to see what type of infection - Dislodgement: will need new one, if it’s fully out make sure Site is covered to prevent from infection - Clot - Throbmen: can get pt to lift arm above head, cough, make sure line is not kinked, turn head to the side - Catheter broke/damaged: measure to see how much is broke. If it’s just a nick in the line clamp above and call doctor Catheter migration: needs scan to see where it moved Infiltration: similar to migration Air Embolism: know signs and symptoms and how to treat Nursing care: Assessments (depends on what they have it for): hydration status, I/O, lab values, signs of infection getting better/worse, skin assessments, is everything in tact, does pt have allergies. Flushing: Need to use 10mL in 10mL syringe. Always flush before doing anything w a CVAD Will always use 10mL w CVAD Can flush with normal saline Can lock with heparin if prescribed Before flush - Clean with swab, attach syringe, aspirate*, push pause flush, then disconnect Important reminder: some lines have clamps. Keep clamp closed until syringe is attached, once attached you can release clamp then clamp off before removing syringe dressing change: Gauze Transparent Pt in comfortable position, head of bed slightly elevated, arm out Nurse wear a mask and pt should wear a mask and turn head away With Clean gloves take off old dsg, then remove catheter stabilization device. Might need to swab Go Clean under wings to make it easier to come off. Put sterile gloves on You Clean w a chlorhexidine stick To clean up the line pick up line with gauze and use swab to clean Need to add swabs to tray maintaining sterility Cap change: Steps on bright space Discontinuing non tunneled cvad - position pt in supine - Harm arm elevated In pillow w blue pad under - Apply all PPE - remove dsg and stabilization device - Cleanse site w cholor - Ask pt to bear down - Remove line in one continuous motion - Once out put gauze down Inspect line ti make sure it’s intact Dispose In biohazard Pt lie down for 30 mins Accessing a port: Sterile Stabilize port with thumb and forefinger Insert at 90° Once in aspirate and check for placement After flush and apply clear dsg Lab 8 - Tracheostomy care: Tracheostomies are used in patients for: - Long term airway management because of obstruction - Airway clearance needs - Long term need for mechanical ventilator A TT is cuffed or uncuffed. A cuff on a TT serves the same purpose as the cuff on an ET. Cuffs are made of a balloonlike inflatable plastic typically inflated with air, although there are brands that are inflated with liquid such as water or saline. Uncuffed tubes allow patients the ability to clear the airway, but they provide no protection from aspiration. It is also more difficult to use positive-pressure ventilation in patients with these types of TTs. Some TT’s allow patients to speak. Bedside equipment for a trach patient: - O2 admin equipment with appropriate delivery devices - Suction machine and equipment - Suction tubing - Suction Caths - Sterile saline - Additional trach tubes, one the same size and one smaller - Obturator - Manual self inflating resuscitation bag - 10mL syringe Trach emergencies: 1. Tube Dislodgement/decannulation: Signs: - Inability to pass suction catheter past the length of the tube - Presence of subcutaneous emphysema near incision or stoma - Signs of respiratory distress - High-pressure alarm on ventilator - Flange of TT not flush with neck - Decreased SpO2 - Patient able to speak around the TT Interventions: - Call for help - If stoma is less than 1 week old: - Notify surgeon - Bag-mask ventilation - Prepare for intubation or surgical reinsertion of new TT - If stoma is well established: (typically greater than 1 week old) - Replace with a new TT, inserting at a 90-degree angle into the trachea, then angling downward another 90 degrees 2. Tube Obstruction: Signs: - Respiratory distress - Inability to pass suction catheter - Resistance felt when using the self-inflating resuscitation bag Interventions: - Call for help - Remove and inspect the inner cannula (if one present); clean or replace with a new one - Mature site (>1 week) Replace the TT (if changing inner cannula did not relieve the obstruction) Patient may need more invasive intervention, such as bronchoscopy Immature site (<1 week) Ensure TT is in correct position Prepare for more invasive intervention, such as oral endotracheal intubation, tracheostomy revision, or placement of a longer TT 3. Hemorrhage: Signs: - More than minimal bleeding at stoma site Interventions: - Notify health care provider - Provide O2 if not already in place
