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Tuesday, September 18, 2007

Therapeutic Procedures

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Therapeutic Procedures Slideshow Transcript

Slide 1: THERAPEUTIC PROCEDURES SELECTED TOPICS ON COMMON NURSING PROCEDURES

Slide 2: UNIVERSAL PRECAUTIONS  HANDWASHING  BARRIER METHOD  STERILIZATION AND DISINFECTION  IMMUNIZATION  ENVIRONMENTAL CONTROL AND SANITATION  ISOLATION

Slide 3: SURGICAL ASEPSIS  MAINTENANCE OF STERILE FIELD  MEDICAL AND SURGICAL ASEPTIC TECHNIQUES

Slide 4: THERAPEUTIC EXERCISES  ISOMETRIC  ISOTONIC  ROM

Slide 5: CHEST PHYSIOTHERAPY  BREATHING  COUGHING\\POSTURAL DRAINANGE  PERCUSSION AND VIBRATION  INCENTIVE SPIROMETER  SUCTIONING  TRACHEOSTOMY CARE  OXYGEN THERAPY

Slide 6: Chest Physiotherapy  It is the combination of percussion, vibration, and postural drainage  Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes  Vibration is done during 5 exhalations  Postural drainage is done for 15-20 minutes usually performed 3-4 times a day.  Instruct the client to increase fluid intake to liquefy secretions  This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery.  This procedure is done before meal or 90 minutes after a meal

Slide 7: Oxygen Therapy   Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen.  Humidify the oxygen first before you administer.  Check for bubbles in the humidifier to promote adequate flow of oxygen  Check for kinks in the tubing  Position: semi-fowlers/ high fowlers position  Place cautionary readings: “NO smoking: Oxygen is in used”  Instruct the client not to use woolen blankets as this may create static electricity

Slide 8: pulmonary function tests tidal volume- 500   residual volume- 1200  expiratory reserve volume –1200  inspiratory reserve volume – 3100 Vital Capacity- tidal volume + IRV + ERV =  4800  Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000  Forced Residual Capacity – ERV + RV

Slide 9: incentive spirometry – hold 2-6 sec; 4-5  times/H  endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly  visualization – X ray  Lung Scxan – 20-40mins isotopes in body for 8 H  laryngoscopy  Bronchoscopy  Thoracentesis- consent, VS and baseline X-ray +  post Procedural

Slide 10: Tracheostomy Care  tie new trache tie before removing the old tie to prevent accidental dislodgement  use precut gauze and perform care OD at least.  soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well  suction prn, oral care prn

Slide 11: Oxygen Delivery Equipment cannula – 2-6 LPM – 24-45%   Mask – 5-8 LPM – 40-60%  parial rebreather – 6-10 LPM – 60-90%  non rebreather – 10-15 LPM – 95-100%  tent – 4-8 LPM – 30-50 %  Venturi mask – 2-3 LPM – 24-28%  4 LPM – 30%  6 LPM – 35%  8 LPM – 45%  14LPM – 55% 

Slide 12: Suctioning  PURPOSE: To obtain sputum sample.  NURSING ALERT:  Hyperoxygenate the patient before and after the procedure.  Apply intermittent suction on withdrawal of the catheter.  Do not suction the patient for more than 15 seconds.  Thoracentesis  PURPOSE: Aspiration of fluid and /or air from the pleural space.  NURSING ALERT:  Check the consent.  Position: Sitting on the side of the bed with feet on a chair, leaning  over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder. Instruct the patient not to cough, breath deeply or move during  the procedure. After the procedure: Position the patient on the unaffected  side/puncture site up. Check for bleeding at the puncture site and monitor the  respiratory function. Notify the physician if signs of pneumothorax, air embolism and  pulmonary edema occur.

Slide 13: ENEMA They act by distending the intestines that  increases peristalsis and expulsion of feces and flatus.  Enemas serve the following purpose: Relief of constipation  Relief of flatulence  Lowers down body temperature  Evacuates feces in preparation for diagnostic  procedures Administration of medications 

Slide 14: ENEMA Take note of the general principles of Enema:   Tube: lubricate and insert 3-4 inches  Position: adult- left lateral; infants and children- dorsal recumbent  Administration- administer the enema in a minimum of 15 minutes duration.  Conatainer’s Height- 12 inches above the rectum  Temperature- 42°C or less

Slide 15: types: carminative – expel flatus – 60 –180 ml.  retention oil – 1 –3 hours(LUBRICANTS)  BULK FORMERS-METAMUCIL-12 HOURS-INC.OFI  wetting/stool softeners- Colace(days)  Chemical hypertonic irritant-increases peristalsis-  castor oil, Bisacodyl, Cascara)-SUPPOSITORIES-30 MIN Saline- Epson salts, milk of mg(rapid)/mg citrate  return flow – haris flushing , colon irrigation  fleet – commercial   oil 1-3 H retention  others – 5 to 10 mins. cleansing- irritating( hypertonic osmotic))   high 1000 ml  low 500 ml

Slide 16: T = 40-43 ‘ C ( 105 – 110 ‘ F   CHILDREN 37.7 ( 100 ‘ F)  APPROXIMATELY 30 CM ( 12 INCHES) BUT HIGH IN CLEANSING ( 30 – 45 CM. ) 12 TO 18 CM.  INSERT 7 – 10 CM ( 3-4 INCH)-ADULT  5 – 7.5 CM. –CHILD  2.5 – 3.5 – INFANT IF FEELING OF FULLNESS – CLAMP – 30  SECS

Slide 17: amount   18 mos – 50-200 ml  18 mos – 5 y – 200-300 ml  5 – 12 years – 300 – 500 ml  12 – above – 500 – 1000 ml. rectal tubes  infants-10-12F  toddler – 14 –16F  school age – 16-18F  adult – 22 – 30F 

Slide 18: ENEMAS- PRESCRIBED AMOUNT AND TIME  HYPERTONIC – 5-10MINS – VARIES  HYPOTONIC(TAP)-15-20MIN – 500- 1000ML  ISOTONIC(SALINE)-15-20MIN- 50ML  SOAP SUDS- 10-15MIN- + 3-5 ML. SOAP  oil( MINERAL/COTTONSEED) – 30-60 MIN- 90-120ML.

Slide 19: COLOSTOMY CARE  ostomy – divert and drain fecal material  temporary ( trauma / inflammatory condition)  permanent ( Cancer / congenital or Birth defects  stoma– red , initial slight bleeding - normal, no redness or irritation 2 to 5 inches sorrounding the areano burning sensation

Slide 20:  parts:  periostomal seal  adhesive square – solid wafer disk skin barrier liquid skin sealant  drainable end  pouch ( Can be washable)  pouch belt  face plate

Slide 21:  ileostomy – no irrigation , wet fecal material , appliance all the time , meticulous skin care,prevent skin breakdown, constant flow not regulated, bag emptied half full  colostomy – solid , can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation  avoid gas forming foods and nuts , but can have any food at tolerated after 6 weeks… yogurt recommended

Slide 22:  dry skin before applying appliance  karaya – barrier to prevent contamination with excreta  appliance can be up to 2 weeks  broadwell 48 – 72 hours to check for periostomal skin  24-48 hours if eroded / ulcerated  refer to enterostomal therapy nurse  with deodorant ( Charcoal filter Disk)

Slide 23: Catheterization, urinary PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter.  NURSING ALERT:   Know the necessary facts:

Slide 24: Principles Male Female  Position Supine Dorsal recumbent  Length of tube 40 cm./ 15.75 in. 22cm./ 8.66  in. French number or  Circumference #14- 16 #18  Length of tube to  be inserted 2-3 in. 6-9 in.  Balloon size 5-10 ml. (30 ml 5-10 ml  Can be used to  achieve hemostasis  of the prostatic area  following prostatectomy   Place to secure lower abdomen Inner thigh 

Slide 25: procedure is sterile   The   Maintain a close system   The draining bag must always be below the bladder   The catheter bag should not be allowed to lie on the floor   Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it

Slide 26: CATHETER CHANGE  PLASTIC – 1 WEEK  LATEX – 2-3 WEEKS  SILICONE – 2-3 MOS.  PVC – 4-6 WEEKS

Slide 27: CLOSED INTERMITTENT IRRIGATION  ASPIRATE FROM PORT  CBI -3 WAY FOLEY CAHETER  CATHETER IRRIGATION ONLY – 200 ML.  BLADDER IRRIGATION – 1000ML  CLAMPS ON BOTH SIDES – ALTERNATELY RELEASED

Slide 28: URINARY DIVERSIONS- URINARY STOMA  ILEAL CONDUIT- EXTERNAL POUCH  KOCK POUCH – SMALL DRESSING OVER STOMA; BLADDER WALL SUTURED TO THE ABDOMEN  SUPRAPUBIC CATHETER – INTERMITTENT ATHETERIZATION q 3-4 HOURS

Slide 29: NORMAL AMOUNT/ DAY  1-3 / 500-600ML  3-5 / 600-700ML  5-8 / 700-100OML  8-14 / 800 – 1400ML  14 – ADULT / 1500 – 2500  CAN HOLD 500 – 750 ML

Slide 30: Bladder training Q2 hours and 30 mins void(Trigerring, Credes and valsalva) NEUROGENIC BLADDER Intermitent Catheterization – 2-3 hours if <150ml ----3-4 H weaning-intermittent clamping DTV 1-4 hours after removal for incontinence – kegels exercises

Slide 31: HEMODIALYSIS DONE 3-5 HOURS – 2-3 TIMES A WEEK   AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS  PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H  MONITOR FOR HEMORRHAGE  DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,M USCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONS

Slide 32: PERITONEAL DIALYSIS TENCKOFF,GORE-TEX CATHETER  WEIGH BEFORE AND AFTER, WARM DIALYSATE  CHON LOSS, INFECTION, -PERITONITIS(CLOUDY  OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V PREVENT CONSTIPATION BY INCREASING FIBER IN  DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION TYPES:  CAPD(4-6H INDWELLING),  AUTOMATED 30MINS EXCHANGES,  INTERMITTENT- 4X A WEEK – 10H/DAY,  CONTINOUS – 1 DAY INDWELLING 

Slide 33: DRESSINGS PROTECT FROM INJURY , BACTERIAL  CONTAMINATION  PROVIDE HUMIDITY  INSULATION  ABSORB DRAINAGE  DEBRIDE THE WOUND  PREVENT HEMORRHAGE  SPLINT / IMMOBILIZE  COMFORT GUAZE, SYNTHETIC , SECURING, TEGADERM 

Slide 34: TYPES OF DRESSINGS DRY TO DRY – TRAP NECROTIC DEBRIS  AND EXUDATE  WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE  WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING)  WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE

Slide 35: WOUND HEALING HEMOSTASIS---FIBRIN----  PHAGOCYTOSIS----( INFLAMMATION PHASE 3-4DAYS  FIBROBLAST—COLLAGEN--- CAPILLARIES----GRANULATION TISSUE--- ESCHAR---(PROLIFERATIVE 3 – 21 DAYS  MATURATION(PHASE 21 DAYS – 2 YEARS)

Slide 36: pressure ulcer dressings  drygauze stage II-IV  tegaderm film/ hydrocolloid – SI - SII  Absorptive Dressing III  Hydrogel – II - III

Slide 37: WOUND CARE PRIMARY   SECONDARY- INCREASED INFECTION INCREASED TIME INCREASED ESCHAR( PRESSURE SORES)  TERTIARY- ABD. DRAINAGE EXUDATES – SUPPURATION  PUS – ABCESS( PYOGENIC BACTERIA) 

Slide 38: SURGICAL DRAINS PENROSE – OPEN ENDS   CLOSED WOUND DRAINAGE ( SUCTION) – DECREASE ENTRY OF MICROBES- HEMOVAC / JACK PRATT TO RESERVOIR  D/C 3-7 DAYS POST – OP  PACKAGE – FACILITATE GRANULATION  IRRIGATION LAVAGE - STERILE

Slide 39: CHEST TUBES AND DRAINAGE SYSTEMS 1-DRAINAGE   2-WATERSEAL  3-COLLECTION/SUCTION SEALED PATENCY-AFTER 3 DAYS  REEXPANDED  FLUCTUATIONS IN WATER SEAL CHAMBER  RUBBER TIPPED CLAMPS/ FORCEPS; VASELINIZED GAUZE;EXTRA BOTTLE

Slide 40: NUTRITIONAL SUPPORT NGT-GAVAGE AND LAVAGE TPN

Slide 41: Nasogastric Tube Insertion   Purposes: Gastric Gavage- gastric feeding  Gastric Lavage- stomach irrigation  For decompression  Medication and supplemental fluid administration  Principles:   Position: High-Fowler’s position  Length of tube to be inserted: measured from the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm.  Lubricate the tip of the tube by a water soluble lubricant before insertion  Secure the NGT by taping to the bridge of the nose

Slide 42: Gastroenteral Feedings  This is the administration of formula through a tube  placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall. Remember these principles:  Position: fowler’s or sitting position  Prior to feeding, assess the bowel sounds and residual  content Assess for tube placement and patency:  Introduce 5-20 ml of air into the NGT and auscultate. Gurgling  sounds must be auscultated. X-ray most accurate  Aspirate gastric content  Immerse the tip of the tube in water, no bubbles must be  produced. Height of feeding: 12 inches above the patient’s point  of insertion Instill 60 ml of water into the NGT after feeding to  cleanse the lumen of the tube

Slide 43: TOTAL PARENTERAL NUTRITION  peripheral< 2 weeks – phlebitis  PIC – Basilic / cephalic  PCC – subclavian  Triple Lumen- infuse and draw blood;TPN;Medications  Atrial- Hickman/Biovac and Groshong; Huber needle port

Slide 44: TOTAL PARENTERAL NUTRITION TPN-IV with bacterial filter(2-3L)   TNA – 1 liter/D-no filter  If no available solution D10W –ok –initial at 50ml/hr hyperglycemia- hyperosmolar(HA, N and  Vomiting,fever, chills, malaise)  Infection ( IV tubing and filter Q24 changed,solutions refrigerated and warmed just prior to administration  Pneumothorax

Slide 45: Heat and Cold Therapy  An intervention the reduces inflammation  Principles:  Cold application is generally safer than heat application.  Heat application usually requires a doctor’s order  Cold application is done within 72 hours after an injury, while heat application is done after 72 hours.  The application of heat and cold is done at a maximun of 30 minutes (an average of 15-20 minutes)  Check the area applications are done every 15 minutes.

Slide 46: Anti-embolism Stocking  Helps prevents thrombophlebitis by promoting venous return from the legs  It usually requires a doctor’s order  The client’s extremeties must be properly measured to assure therapeutic effect  Apply stockings before getting out of bed. If the client forgot to wear the stockings, instruct himn or her to assume modified trendelenburg’s position for 15-20 minutes  The stockings must be removed every 8 hours for 20-30 minutes  Assess the skin integrity

Slide 47: DOSAGES AND CALCULATION CONVERSIONS   MEDICATION DOSAGES D/A X V = Q  INFUSIONS  TOTAL VOLUME X DROP FACTOR  TIME IN HOUR ( 60 MIN.) THERAPEUTIC DOSE   CLARKS RULE  BSA COMPUTATION  IV INFUSION FOR BURNS

Slide 48:  MEDICATION ADMINISTRATION RIGHT DRUG RIGHT DOSAGE RIGHT ROUTE RIGHT TIME RIGHT PATIENT RIGHT ATTITUDE RIGHT DOCUMENTATION

Slide 49: PARENTERAL ADMINISTRATION IM – G 18-21 ; 1 1/2 INCH, Z-TRACK • ( RETRACT)  SC/SQ – G 24-26;1/2 – 1 INCH ; 45’ ; DO NOT RETRACT OR MASSAGE ( INSULIN AND HEPARIN) • INTRADERMAL- 10-15’; G26-27;1\\2 INCH BEVEL UP • INTRAVENOUS – TOURNIQUET, STERILE PROCEDURE ; 10-25 ; RELEASE TOURNIQUET IF WITH BACKFLOW

Slide 50: IV THERAPY  backflow means patent line  solutions for specific diseases and contraindications of certain solutions  management and troubleshooting  check for phlebitis and infiltration  change line everyday  keep site sterile

Slide 51: BLOOD TRANSFUSION line – PNSS   vital signs – baseline then Q15 x 4; Q30 x 2; then q h  4 –6 hours  blood typing and crossmatching  watch out for blood transfusion reactions hemolytic  anaphylactic  febrile  hypervolemic  septic 

Slide 52: Hygiene and comfort measures

Slide 53:  BEDMAKING- OD  PERINEAL CARE – FRONT TO BACK  OUTERTO INNER, ONE COTTONBALL PER STROKE BEDBATHING AND ND SHAMPOO   FOOT, HAIR , SKIN AND NAIL CARE  ORAL CARE  EYE AND EAR CARE

Slide 54: THERAPEUTIC BATH SALINE – 4 ML- 500 ML   OATMEAL/AVENO – SOOTHES SKIN IRRITATION, LUBRICATES  CORNSTARCH- IN COLD WATER – SOOTHES IRRITATION  Na CHO3 – 4 ml. – 500 ml H2O cooling / relieves irritation  KMnO4 – tablets dissolved in H2O – clears and  disinfects

Slide 55: Rotating Tourniquet GET MEAN   APPLY PRESSURE TO 3 LIMBS ONE AT A TIME RELEASE / ROTATE EVERY 5 MINUTES. PRESSURE IN ONE EXTREMITY FOR ONLY 15 MINUTES  DO NOT RELEASE SIMULTANEOUSLY  PATIENT IN ORTHOPNEIC / FOWLERS POSITION

Slide 56: CPR and ACPLS Protocols 0-1 MINUTE ; CARDIAC IRRITABILITY   0-4 MINUTES; BRAIN DAMAGE NOT LIKELY  4-6 MINUTES; BRAIN DAMAGE POSSIBLE  6-10 MINUTES; BRAIN DAMAGE LIKELY  10 MINUTES-IRREVERSIBLE BRAIN DAMAGE

Slide 57: INFANTS HTCL MANEUVER, JAW THRUST IF  SPINAL INJURY IS SUSPECTED  INITIAL BREATHS – 2 – 1 1/2 SECS  SUBSEQUENT BREATHS 1 B/3 SECS; 20 BPM  USE 2 OR 3 FINGERS  DEPTH:1/2 TO 1 INCH  COMPRESSION AT LEAST 100/MIN  RATIO 5:1; CHECK AFTER 20 CYCLES  FOREIGN BODY OBSTRUCTIONS: BACKBLOWS AND CHEST THRUST

Slide 58: CHILDREN HTCL / JAW THRUST   2 BREATHS INITIAL DURATION OF 1- 1 ½ SECS  SUBSEQUENT 1 BREATH EVERY 3 SECONDS  20 BREATHS/ MIN  CAROTID ARTERY  HEEL OF HAND  1 TO 1 1\\2 INCH  100 BPM; CHECK AFTER 12 CYCLES  ABDOMINAL THRUST- FOR AIRWAY OBSTRUCTION

Slide 59: ADULTS  HTCL / JAW THRUST  INITIAL 2 BREATHS AT LEAST 2 SECS EACH  DEPRESS 1 ½ - 2 INCHES; RATE 60 TO 100  RATIO 5:1  AFTER 4 CYCLES ;RECHECK FOR 10 SECS

Slide 60: ERGONOMICS  TRANSFER TECHNIQUES  BODY POSITIONING  BODY MECHANICS





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