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Care of The Patients ears

EAR IRRIGATION

Ear irrigation is the process of flushing the external ear canal with sterile water or sterile saline.

Ear irrigation is a procedure where a warm, gentle stream of water is used to flush out debris, wax, or other foreign objects from the ear canal. It is the washing of the external auditory canal with a stream of fluid.

Ear syringing, also known as ear lavage, is a similar procedure but uses a larger volume of water and a more forceful stream, delivered through a syringe.

Aims /Purposes of Ear Irrigation

Remove earwax: This is the most common reason for ear irrigation. Accumulated earwax can block the ear canal, leading to hearing loss, discomfort, or even infection.
Remove foreign objects: Small objects, such as insects or seeds, can become lodged in the ear canal and need to be removed.
Cleanse the ear canal: Irrigation can help to remove dirt, debris, or other substances that may be present in the ear canal.

Indications for Ear Irrigation:

Earwax impaction: To soften and remove impacted cerumen.
Foreign body in the ear: Dislodge a foreign body (except hygroscopic substances like ethanol, sodium chloride).
Otitis externa (swimmer’s ear): To cleanse the ear canal and remove debris that may be contributing to this infection.
Chronic otitis media with effusion (glue ear): To cleanse the ear in case of purulent discharge caused by middle ear infection.
Preparation for ear surgery: To cleanse the ear canal before certain ear surgeries.
Prior to hearing tests: To improve the accuracy of hearing tests by removing debris that may interfere with sound transmission.
Removal of ear mold impressions: To remove a mold impression from the ear canal after an ear impression is taken for hearing aids or other devices.
Relief of ear pressure: To relieve ear pressure caused by changes in altitude or air pressure.
To relieve localized inflammation and discomfort: Can be used to reduce inflammation and discomfort in the ear canal.
For antiseptic effect: Can be used to deliver antiseptic solutions to the ear canal.
To apply heat or cold: Can be used to apply warm or cold water to the ear canal for therapeutic purposes.
To evaluate vestibular functions (e.g. bi-thermal caloric test): Used to assess the function of the balance system in the inner ear.

Contraindications of Ear Irrigation

Perforated Eardrum: A perforated eardrum (a hole in the eardrum) allows water to enter the middle ear, which can lead to infection. Irrigation could further damage the eardrum and worsen the situation.
Active Ear Infection: An ear infection, especially if it’s acute or severe, can make the ear canal more sensitive and prone to irritation. Irrigation could worsen pain, inflammation, and potentially spread the infection.
Recent Ear Surgery: The ear canal needs time to heal after surgery. Irrigation could disturb the healing process and potentially lead to complications.
History of Ear Surgery: Depending on the type of surgery, irrigation may not be safe. For example, if a ventilation tube has been inserted, irrigation could push the tube out of place.
Excessive Pain or Discomfort: If ear irrigation causes significant pain or discomfort, it should be stopped immediately. This could indicate a problem with the ear canal or a more serious condition.
Certain Medical Conditions: Conditions like diabetes, immune system disorders, or certain skin conditions could make the ear canal more susceptible to infection after irrigation.

Prescribed Solution/Solution that can be used:

Boric acid 2-4% solution
Sodium bicarbonate solution 1%
Normal saline
Hydrogen peroxide 2%
Sterile water

Equipment:

Tray:

Ear Syringe in a Receiver
Auroscope
Basin and Vomitus Bowl
Receiver

Clean Gloves
Mackintosh Cape
Patient’s Towel
Cotton Swabs
Prescribed Solution:

Boric acid 2-4% solution
Sodium bicarbonate solution 1%
Normal saline
Hydrogen peroxide 2%
Sterile water
Bowl of warm water for solution temperature regulation

Bedside:

Adjustable Light and Screen
Plastic Apron
Handwashing Equipment

Procedure for ear irrigation

Explain the procedure to the patient to obtain consent and cooperation
Provide privacy by screening or closing nearby windows.
Wash hands,
Prepare the equipment and bring at bedside.
Position the patient in sitting up.

Steps	Action	Rationale
1.	Follow general rules of nursing procedures.
2.	Inspect the auditory canal using the otoscope under good light.
3.	Ask the patient to sit and tilt the head slightly toward the affected ear. Place the mackintosh and towel over the shoulder and upper arm, under the affected ear. Place the curved part of the receiver below the tilted ear.
4.	Request the patient to support the receiver under the ear.
5.	Clean the auricle and meatus of the auditory canal with cotton wool swabs moistened with the solution.
6.	Fill the bulb syringe with irrigating solution. If an irrigating container is used, allow air to escape from tubing.	Air forced into the ear canal is noisy and therefore unpleasant for the patient.
7.	Straighten the auditory canal by pulling the auricle down and back for the child and up and back for an adult.	To straighten the auditory canal so that the solution can flow the entire length of the canal.
8.	Insert the tip of the syringe gently; direct a steady slow stream of solution against the roof of the auditory canal, using sufficient force to remove the secretions.	Gentleness aids in preventing injury to the tympanic membrane. Continuous in and out flow of the irrigating solution prevents pressure in the canal.
9.	Observe the patient throughout syringing.	To detect complications and be ready to act.
10.	When the irrigation is completed, place a cotton ball loosely in the auditory meatus and request the patient to lie on the affected ear on a towel or absorbent pad.	Cotton ball absorbs fluid while gravity allows remaining fluid in the canal to escape from the ear.
11.	Dry the patient’s auricle and remove the patient’s towel and mackintosh cape.
12.	Wash hands.
13.	Document the procedure, appearance of discharge and patient’s response.
14.	Clear away.
15.	Decontaminate items used in the procedure.
16.	Return in 10 to 15 minutes and remove the cotton ball and review the patient.	To detect pain that may indicate injury to the tympanic.

Care of The Patients ears Read More »

Opthalmology

Ophthalmology

Ophthalmology is a branch of medicine that deals with the diagnosis and treatment of diseases and disorders related to the eyes.

Definition of Terms

Ophthalmologist: A medical or osteopathic doctor specializing in eye and vision care. Ophthalmologists diagnose and treat all eye diseases, perform eye surgery, and prescribe and fit eyeglasses and contact lenses to correct vision problems. Many ophthalmologists are also involved in scientific research on the causes and cures for eye diseases and vision disorders.
Optometrist: A healthcare professional providing primary vision care ranging from sight testing and correction to the diagnosis, treatment, and management of vision changes. An optometrist is not a medical doctor.
Optician: A technician trained to design, verify, and fit eyeglass lenses and frames, contact lenses, and other devices to correct eyesight.
Ophthalmic Nurse: A nursing professional focused on assessing and treating patients with various eye diseases and injuries.

Role of Ophthalmic Nurses

Provide first aid treatment in cases of eye injuries and emergencies.
Perform preliminary physical examinations, such as blood tests, to detect possible underlying illnesses that could contribute to eye problems (e.g., hypertension).
Conduct initial screenings on patients.
Collect medical histories.
Assist in eye examinations.
Offer tips and advice to help patients manage eye pain and other symptoms.
Demonstrate how to administer medication.
Educate patients on the treatment of ocular conditions.
Prepare patients for surgery and assist during operations.
Provide after-surgery care for patients.
Conduct various eye tests and procedures.

Ophthalmic Emergencies and Urgent Cases

Emergencies requiring immediate medical attention include:

Sudden vision loss:

Central retinal artery occlusion: Blockage of the artery supplying the central retina.
Central retinal vein occlusion: Blockage of the vein draining blood from the retina.
Giant cell arteritis: Inflammation of the arteries in the head, including those supplying the eye.
Retinal detachment: Separation of the retina from the back of the eye, especially if the macula (central part of the retina) is still attached.

Primary acute glaucoma: Rapid increase in pressure within the eye, causing pain, blurred vision, and halos around lights.

Trauma:

Penetrating or perforating injuries: Objects entering the eye.
Chemical burns: Exposure of the eye to chemicals.

Orbital cellulitis: Infection of the tissues surrounding the eye.

Urgent cases requiring prompt medical attention, but not considered true emergencies:

Corneal ulcer: Open sore on the cornea, causing pain, redness, and blurred vision.
Vitreous hemorrhage: Bleeding into the vitreous humor (jelly-like substance filling the back of the eye), causing blurred vision or floaters.
Acute dacryocystitis: Inflammation of the lacrimal sac (tear sac), causing pain, swelling, and redness.
Optic nerve disorders: Conditions affecting the optic nerve, causing vision loss or other visual disturbances.
Ocular tumors: Growths within the eye, which may affect vision or require treatment.
Acute uveitis: Inflammation of the middle layer of the eye, causing pain, redness, and blurred vision.

EYE CARE

Eye care is characterized as the special attention given to the eyes to prevent complications.

Natural Cleansing: The production of tears and the blinking mechanism provide a natural cleansing process for the eyes (Harrison, 2006). When this process is interrupted, the eyes may need to be artificially cleansed to remove debris, prevent dryness, and ensure eyelid closure (Dawson, 2005).

Eye Cleansing: Eye cleansing can be performed alone or with eye swabbing, instilling eye medication, and applying eye padding/dressing/shield.

Indications for Eye Care:

Children Undergoing Eye Surgery: Pre-operative and post-operative eye care is important to ensure the eye is clean, free from infection, and well-prepared for surgery. This care includes instilling prescribed eye drops, maintaining proper hygiene, and following specific instructions from the ophthalmologist.
Children Whose Eyes Cannot Close Properly: Hydrocephalus, cerebral palsy, facial nerve palsy, and other conditions affecting eyelid closure,, where eyelid function may be compromised, maintaining eye moisture and cleanliness is essential to prevent corneal damage and infection.
Unconscious, Sedated, or Muscle-Relaxed Children: These children cannot blink or close their eyes effectively, making them prone to dryness and exposure to keratitis. Regular eye care, including lubrication and protective measures, is necessary to prevent complications.
Presence of Infection (e.g., Conjunctivitis/Neonatal Conjunctivitis): Eye infections require careful cleansing and medication administration to control and eradicate the infection. This prevents the spread of infection and promotes faster healing.
Infants with Non-Infected Sticky Eye Due to Underlying Causes (e.g., Blocked Tear Ducts): Conditions like blocked tear ducts can cause sticky discharge. Regular eye cleaning helps keep the eye clear and reduces the risk of secondary infections.
Immunosuppressed Children: These children are more susceptible to infections due to their weakened immune systems. Regular and prompt eye care helps prevent opportunistic infections and maintain eye health.
Trauma: Eye injuries require prompt and careful cleaning to remove debris, prevent infection, and manage pain. Eye care post-trauma is crucial for recovery and to avoid further damage.
Chronic Eye Conditions (e.g.,Dry Eye Syndrome): Conditions causing chronic dryness need regular lubrication to maintain comfort and prevent damage to the cornea and conjunctiva.
Post-Chemotherapy/Radiation Therapy: Children undergoing cancer treatments may experience eye issues due to the side effects of therapy. Regular eye care can mitigate symptoms like dryness and irritation.
Congenital Eye Disorders (e.g., Ptosis, Congenital Glaucoma): Children with congenital eye disorders may need regular eye care to manage symptoms, prevent complications, and support overall eye health.
Post-Cataract Surgery: After cataract surgery, careful eye care is necessary to ensure proper healing, prevent infection, and manage any postoperative complications.
Severe Allergies: Children with severe allergies may experience frequent eye irritation and discharge, necessitating regular cleaning and medication application.
Exposure to Environmental Irritants: Children exposed to smoke, dust, or chemicals need regular eye cleaning to remove irritants and prevent damage.

Purpose of Performing Eye Care:

Maintain Eye Cleanliness: Regular eye care helps keep the eyes clean, promoting comfort for the patient and reducing the risk of cross-infection, particularly in clinical settings.
Prevent Eye Dryness: Various methods are employed to keep the eyes moist and comfortable. These include:
Methylcellulose Drops: Used for general lubrication.
Ointments: Provide longer-lasting moisture.
General Lubricants: Help maintain moisture balance.
Polyacrylamide Hydrogel Dressings: Effective for unconscious, sedated, or paralyzed children as they moisten and lubricate the eye area while maintaining eyelid closure.
Hypromellose Drops (Artificial Tears): Used to supplement natural tears and prevent dryness.
Ensure Eyelid Closure: Using polyacrylamide hydrogel dressings like Geliperm® helps keep the eyelids closed, which is crucial for preventing exposure to keratitis in patients who cannot close their eyes naturally.
Treat Existing Eye Infections: Proper eye care is essential for treating infections, involving cleaning the eye and administering appropriate medications to eradicate the infection and prevent its spread.
Prepare for Medication Administration: Ensuring the eye is clean and free from debris before administering medications enhances the effectiveness of the treatment and reduces the risk of complications.
Protect the Eye During Phototherapy: When using phototherapy light lamps, especially in newborns with jaundice, eye care measures are taken to protect the retina from potential damage caused by the light exposure.
Support Healing Post-Surgery: After eye surgeries such as cataract removal, meticulous eye care supports the healing process, reduces the risk of infection, and helps manage post-operative discomfort.
Manage Allergic Reactions: In cases of severe allergies, eye care involves cleaning and administering anti-allergy medications to reduce irritation and prevent secondary infections.
Facilitate Proper Drainage: For conditions like blocked tear ducts, regular eye care helps in facilitating drainage and reducing discomfort and infection risk.
Prevent Damage in Systemic Conditions: In children with systemic conditions like diabetes, regular eye care is vital to monitor and manage potential complications, thus preserving eye health.
Educate Caregivers: Eye care is a tool for educating caregivers on proper eye care techniques, signs of complications, and the importance of maintaining eye hygiene ensures consistent and effective care for the child.

Purpose of Eye Medications:

Topical medication is the preferred route for treating eye diseases. Eye medications are delivered to:

Treat infections.
Provide intraocular treatment for diseases such as glaucoma.
Prepare for and recover from surgical procedures.
Dilate pupils for eye examinations and/or refraction.
Provide lubrication.

Care of the Child Undergoing Eye Surgery:

The care involves pre-operative, intra-operative, and post-operative care.

Pre-operative Care:

Common conditions requiring surgical intervention include trauma, Cataracts, Foreign body eye, Congenital malformations, Glaucoma, Eye injuries, Astigmatism or strabismus, Sagging of the upper eyelid (ptosis) and detached retina. The ophthalmologist will determine the treatment and procedure, ranging from a simple incision to total removal of the eyeball (enucleation).

Admission: The child will be admitted to a warm and clean bed in the pediatric surgical ward. The bed will have enough light to ensure a comfortable environment for the child and will be free from environmental dust to minimize the risk of infection.
History taking: Take a detailed history of the child’s medical background, including any previous surgeries, allergies, or medical conditions, also inquire about any medications the child is currently taking.
Physical examination. A thorough physical examination will be conducted and will assess the child’s overall health and identify any potential risks or concerns. The physical examination will include checking vital signs such as heart rate, blood pressure, and temperature and the child’s eyes will be examined to evaluate the specific condition requiring surgery and to ensure there are no additional eye health issues.
Observation: Vital signs (temperature, respiration, pulse, blood pressure). Observation of the affected eye.
Investigations: History taking from the child and parent, Physical examination of the eye, tests like Visual acuity test, Visual field test and Tonometry test for fluid pressure inside the eye (evaluates for glaucoma) are ordered and done.
Physical Orientation: Thorough orientation to the hospital environment to help the patient post-operatively, especially if vision is impaired. Assist older children to learn details of their room (location of furniture, doors, windows, etc.). Familiarize the patient with voices and daily sounds.
Education: Thorough education about post-operative care and restrictions. Keep the head still, avoid reading, showers, shampooing, tub baths, bending over, lifting heavy objects, and sleeping on the operative side.
Explaining the Diagnosis and the Need for Surgery: Communicate with the patient, explaining the diagnosis and the reasons for the recommended surgery. This helps the patient understand the importance of the procedure and alleviates any concerns or fears they may have.
Reassurance and Counseling: It is important to provide emotional support and reassurance to the patient, addressing any anxieties or fears they may have about the upcoming surgery. Counseling may also be provided to help the patient cope with the stress associated with the procedure.
Booking and Scheduling the Operation: The date and time for the surgery are scheduled, taking into account the patient’s availability and the surgical team’s availability. In some cases, surgeries may be booked several months in advance, and the patient should be informed about what to do in case of any problems or changes before the scheduled date.
One Week Before Surgery: Preoperative tests and assessments may be conducted, such as blood tests, imaging studies, and specific examinations related to the surgical procedure. The patient may also be instructed to take certain medications or eye drops as prescribed.
A Day Before Surgery: In some cases, the patient may be required to be temporarily admitted to the hospital the day before the surgery. During this time, the patient’s feeding and hygiene needs are addressed, and a detailed history and physical examination, including ophthalmological tests, are performed. The patient is also informed about the personal requirements and procedure-related instructions.
Day of Operation: The patient is required to sign a consent form, indicating their agreement for the operation. Depending on the anesthesiologist’s instructions, the patient may need to be nil per os (NPO), refraining from eating or drinking for at least 8 hours prior to surgery. Reassurance, hygiene measures, removal of jewelry, and administration of pre-medication, if necessary, are also carried out. Hydration may be provided as instructed.
Rest and Sleep: Ensure rest and minimize noise and bright light.
Physical Preparation:
- Bowel Prep: Bowel preparation is sometimes required before surgery to empty the bowels and prevent straining post-operation. This may involve taking a laxative or using an enema the evening before surgery.
- Hair Removal: Hair removal, such as shaving of eyebrows, cutting of eyelashes, and shaving of the face, should only be done on the surgeon’s order. In some cases, hair removal may be necessary to ensure a sterile surgical field.
- Postoperative Bed Preparation: Depending on the type of surgery, it may be necessary to prepare a postoperative bed with side rails and sandbags for head immobilization. This is done to ensure the patient’s safety and prevent any accidental movement or injury during the recovery period.
Transportation to the Operating Room: When it is time for the patient to be taken to the operating room, two nurses accompany the patient. This is done to ensure the patient’s safety and provide any necessary support during the transportation process.

Post-operative Care:

When the nurses arrive at the theater to pick up the child after surgery, the first step is to check the child’s vital signs and obtain a detailed report from the theater staff who performed the surgery. This ensures continuity of care and that all necessary information is communicated effectively.
The patient is taken to the pediatric surgical ward in a post-operative bed, positioning the child face down as ordered by the surgeon. This specific positioning is important for optimal recovery and to prevent complications.

Upon arrival at the pediatric surgical ward, the following post-operative care procedures are implemented:

Initial Care and Positioning.

Vital Observations: Regular monitoring of vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
Positioning: The child is positioned in bed as prescribed, usually face down to ensure recovery and prevent complications.
Immobilization: If ordered, sandbags may be used to immobilize the head to prevent any unnecessary movement that could affect healing.
Safety Measures: If both eyes are bandaged, the side rails of the bed are kept raised to prevent falls. The call bell is placed within easy reach of the patient’s head for safety and communication.
Rest and sleep: The child is allowed to rest in the ward temporarily to recover from the effects of anesthesia. The bed positioning continues to be monitored to ensure it aligns with the surgeon’s instructions.

Ongoing Observations:

Bleeding: Continuous monitoring for any signs of bleeding from the surgical site.
Dressings: Regular checks to ensure dressings are secure and dry. Any signs of infection or complications are promptly addressed.

Welcoming the Child:

The child is gently welcomed back to the ward and from the effects of anesthesia. Comforting words and reassurance are provided to help ease any anxiety or discomfort they may feel upon waking.
Apply non-sterile gloves (to remove old eye dressing or patches/shields and discard them appropriately. If eye dressings are difficult to remove from the eyelid / lashes, apply gauze moistened with 0.9%w/v NaCl solution to the eye dressing.
Assess the general condition of each eye and surrounding tissue before proceeding for:-

Redness
Swelling
Abrasions
Irritation (itching, stinging, burning)
Discharge (colour, odour, volume)
Eyelid position (partial/full closure, blink)
If cooperative, ask the child to look upwards, or if uncooperative gently hold the child with parental assistance and then gently pull the lower lid downwards to part the eyelid.
If there is evidence of any encrustation on the eyelids and lashes, dampen sterile gauze with 0.9%w/v NaCl solution and apply to the eye.
If there is any discharge, perform an eye swab before proceeding with eye cleansing

Performing Eye Swabbing:

Use a sterile cotton wool swab to roll over the conjunctival sac inside the lower eyelid.
Place the swab in the transport medium and transport immediately to the laboratory.
For suspected Chlamydia Infection, perform the eye swab after eye cleansing.

Performing Eye Cleansing:

Use 0.9% NaCl or sterile water in a sterile gallipot.
Moisten sterile gauze with the solution.
Wipe the eye from the inside aspect to the outside aspect, using a new gauze square for each stroke.
Clean the non-infected eye first.
Decontaminate hands again.

Instilling Eye Medication:

Cleanse the eye(s) before instilling medication.
Check the child’s identification band against the medication prescription chart.
Adolescents over 16 may consent to the procedure, but supervision is required if the medication affects vision.
Use new medication containers post-surgery.
Position a hand gently on the forehead while holding the medication container.
Place a tissue/non-sterile gauze swab under the lower eyelid and gently pull down the lower eyelid.

Applying Eye Padding/Dressing(s)/Shields:

Eye Padding: Apply gauze over the closed eyelid and secure it with tape.
Eye Dressings: Use polyacrylamide hydrogel dressings (Geliperm®) to cover the closed eyelid.
Eye Shield: Apply a clear shield over the affected eye and secure it with clear tape.

Precautions:

Secure eye dressings with an eye shield or reinforce loose tape.
Restrain the arms of children and disoriented patients as appropriate.
Constantly watch sleeping patients to maintain proper positioning.
Avoid jarring the bed to prevent startling the patient.
Monitor for depression or suicidal tendencies in newly blinded patients.
Check the physician’s orders before giving anything by mouth to avoid nausea and vomiting.

Approaching the Patient:

Always speak to the patient upon entering their area and before touching them.
Explain each procedure or activity fully.
Reinforce orientation to surroundings.
Inform the patient when leaving their area.

Diversional Activity:

Provide non-fatiguing activities if eyes are not bandaged.
Encourage visitors to chat or read to the patient.
Use a radio for entertainment and to keep the patient informed.

Nursing Care of the Patient with Vision Loss:

Physical Orientation: Describe the room and its contents in detail and lead the patient around the room.
Precautions: Inform the patient about any changes in the room, keep doors fully open or closed, maintain the placement of toilet articles, and remove hazardous items.
Assisting the Patient: Address the patient by name, inform them when leaving, and allow them to place their hand on your arm or shoulder when walking.
Encourage Independence: Encourage the patient to be self-sufficient.

Complications of eye surgery;

Infections such as Endophthalmitis: A serious infection inside the eye. This can lead to vision loss if not treated promptly.
Fluid and Swelling like Cystoid Macular Edema: Swelling and fluid build-up in the macula, the central part of the retina responsible for sharp, central vision. This can cause blurred vision.
Corneal Edema: Swelling of the cornea, the clear outer layer of the eye. This can cause blurry vision and discomfort.
Bleeding (Hyphema): Bleeding in the front chamber of the eye, the space between the cornea and the iris. This can cause pain, redness, and blurry vision.
Tissue Damage such as Capsule Rupture: The capsule surrounding the lens may rupture during surgery, leading to loss of vitreous gel, the clear jelly-like substance that fills the eye. This can cause blurry vision and other complications.
Retinal Detachment: The retina, the light-sensitive tissue at the back of the eye, can become detached from the underlying choroid. This can lead to permanent vision loss.
Cataract Formation: While rare, eye surgery can sometimes trigger the development of a new cataract.
Glaucoma: Eye surgery can, in some cases, increase the pressure inside the eye, potentially leading to glaucoma.
Dry Eye Disease: Dry eye can become worse or develop after eye surgery due to changes in the eye’s surface.

Care at Home After Eye Surgery

Bathing

Clean your eyelid edges: At least twice a day with a moist, clean face cloth, avoiding pressure on the upper eyelid.
Showering/Bathing: You may shower or take a tub bath and wash your hair the day after surgery.
Avoiding Soap/Water in Eye: Ensure no soap or water enters the eye for at least one week.
Eye Make-up: Do not wear eye make-up for at least one week.
Avoid Fibrous Materials: Do not use cotton balls or make-up remover pads near your eye or under the eye shield.

Care of Your Eye

Protective Eye Shield: Wear your protective eye shield when sleeping or lying down for at least one week to protect from accidental bumps or scratches.
Cleaning the Eye Shield: Clean it once a day with 70% isopropyl alcohol and allow it to air dry before reusing.
Glasses: You may wear your old glasses if needed. Vision may be better without them in the operated eye.
Attaching the Shield: Attach the tape to your forehead over the shield and tape it to your cheek.

Activity

Permissible Activities: You may watch TV, read, or go for walks if you feel up to it.
Saunas and Hot Tubs: Avoid these for at least one week.
Sleeping Position: Avoid sleeping on the operated side for at least two weeks.
Straining and Lifting: Avoid straining or lifting anything over 10 lbs. (4.5 kg) for at least two weeks or until your surgeon advises otherwise.
Swimming/Submersion: Avoid swimming or submerging your head in water for at least three weeks.
Strenuous Activities: Do not engage in very strenuous activities or rough contact sports for at least four weeks or until cleared by your surgeon.
Eye Protection: Avoid rubbing or bumping your eye for at least six weeks.
Sexual Activity: Resume when you feel comfortable.
Driving: Do not drive until your surgeon gives you the okay.

Healthy Eating

Diet: Resume your regular diet after surgery.
Avoid Constipation: Prevent constipation and forceful straining during bowel movements by increasing fluids, activity, and fiber in your diet.

Medications

Regular Medications: Restart all regular medications you took before surgery unless instructed otherwise by your doctor.
Postoperative Eye Drops: Obtain all prescriptions for postoperative eye drops and take them as directed by your surgeon.
Artificial Tears: You may use artificial tears like Refresh™ or Genteal™ to reduce scratchiness. Wait 30 minutes after using prescription eye drops before using artificial tears.

When to Seek Help

Worsening Eyesight: If your eyesight worsens.
Increasing Pain: If you experience increasing pain or ache in the eye.
Redness: If there is increasing redness.
Swelling: If there is swelling around the eye.
Discharge: If there is any discharge from the eye.
New Symptoms: If you notice new floaters, flashes of light, or changes in your field of vision.

How to Instill Eye Drops

Wash Your Hands: Ensure your hands are clean before touching your eye drops.
Tilt Your Head: Look at the ceiling from a sitting or lying position.
Form a Pocket: Use one or two fingers to gently pull down your lower eyelid to form a pocket.
Instill the Drop: Keeping both eyes open, gently squeeze one drop into the eye pocket. Avoid letting the bottle top touch your eye, eyelashes, fingers, or any surface.
Close the Eye: Close the eye for 30 to 60 seconds to let the drops absorb.
Avoid Rubbing: Do not rub your eyes after applying the drops. Gently blot the eye area with a tissue if needed.
Multiple Drops: When using multiple eye drops, wait about three minutes after instilling the first medication before applying the next.

Responsibility of nurse during ophthalmology

The Nurse’s Role in Ophthalmic Visual Acuity Testing

Visual acuity, the measurement of central vision sharpness, is a cornerstone of any ophthalmic examination. An accurate assessment is important for diagnosis and treatment planning. It tests the entire visual system, from the occipital cortex (brain) to the cornea (front of the eye).

Nurses responsibilities include;

1. Preparing the Patient:

Explaining the Test: Clearly explain the purpose of the test and how it’s conducted, ensuring the patient understands the process.
Addressing Concerns: Answer any questions the patient may have regarding the test.
Ensuring Comfort: Make the patient feel comfortable and relaxed. Offer assistance with positioning and support.
Assessing Language Barriers: Identify and address any language barriers to ensure comprehension.

2. Performing the Test:

Using the Appropriate Chart: Select the appropriate visual acuity chart based on the patient’s age, literacy, and any specific needs (e.g., Snellen chart for adults, LEA chart for children).
Maintaining Proper Distance: Ensure the patient is positioned at the correct distance from the chart (typically 20 feet or 6 meters).
Occluding the Non-Tested Eye: Properly cover the non-tested eye to avoid cross-viewing.
Recording Results: Accurately document the visual acuity reading for each eye, including the distance from the chart and the line identified.

3. Identifying Factors that May Affect Acuity:

Refractive Error: Assess for signs of refractive errors (nearsightedness, farsightedness, astigmatism) that could impact visual acuity.
Media Opacity: Observe any cloudiness in the ocular media (cornea, lens, vitreous) that may interfere with light transmission and affect acuity.
Patient Cooperation: Recognize and document any lack of patient cooperation or comprehension that could affect the accuracy of the test.

4. Reporting Observations:

Communicating with the Ophthalmologist: Communicate any relevant observations, including patient cooperation, suspected refractive errors, or signs of media opacity to the ophthalmologist for further assessment and diagnosis.

Factors Influencing Accurate Visual Acuity Testing:

Patient Cooperation: The patient must understand and follow instructions, including focusing on the chart and maintaining a fixed gaze.
Recognition of Forms: The patient needs to be able to identify the forms displayed on the chart.
Ocular Media Clarity: The cornea, lens, and vitreous must be clear for light to pass through and reach the retina.
Focusing Ability: The eye must be able to focus properly on the chart.
Eye Convergence: Both eyes need to work together to converge on the target.
Retinal Function: The retina must be able to receive and process the visual information.
Intact Visual Pathways: The optic nerve and brain pathways must be intact for visual information to travel to the brain.

Common charts used in the measurement of distance visual acuity

The most common chart for measuring distance visual acuity in a literate adult is the Snellen chart. Distance vision is tested at 6 meters, as rays of light from this distance are nearly parallel. If the patient wears glasses constantly, vision may be recorded with and without glasses, but this must be noted on the record. Each eye is tested and recorded separately, the other being covered with a card held by the examiner.

Snellen’s Chart

Heavy block letters, numbers, or symbols printed in black on a white background are arranged on a chart in nine rows of graded size, diminishing from the top downwards. The top letter can be read by the normal eye at a distance of 60 meters, and the following rows should be read at 36, 24, 18, 12, 9, 6, 5, and 4 meters, respectively.

Procedure:

One eye is tested at a time, with the other eye covered.
The patient reads lines of letters, starting from the top and working down.
The smallest line the patient can read correctly indicates their visual acuity.

Recording: Visual acuity is recorded as a fraction (e.g., 20/20, 6/6), where the numerator represents the distance at which the patient can read the line and the denominator represents the distance at which a person with normal vision can read that same line.

Using the pinhole in the measurement of visual acuity

Occasionally, a patient’s visual acuity may be below average, which could be a result of a refractive error not corrected by glasses, or due to the patient wearing an old pair of prescription glasses. One effective, but very simple, way to see if distance visual acuity can be improved through spectacles or a change of prescription is a pinhole. A pinhole disc only allows central rays of light to fall onto the macula and does not need to be refracted by the cornea or lens. A ‘pinhole disc’ is used if the VA is less than 6/6 or 6/9, which may improve VA. If a considerable increase in vision is obtained, it may usually be assumed that there is no gross abnormality, but rather a refractive error.

Purpose: Used when visual acuity is below average, to determine if the problem is refractive error (uncorrected by glasses) or another condition.
Method: A pinhole disc restricts light to pass through a small opening, improving focus and reducing blur caused by refractive errors.
Interpretation:

If visual acuity significantly improves with the pinhole, it suggests a refractive error.
If visual acuity does not improve, it may indicate another underlying eye condition.

Sheridan Gardner Test Chart

The Sheridan Gardner test chart can be used for children and patients who are illiterate. This test type has a single reversible letter on each line. For example, A, V, N. The child holds the card with these letters printed on and is asked to point to the letter on his card which corresponds to the letter on the test type. This test can also be used for very young children as they do not have to name a letter.

Procedure:

The patient holds a card with the same letters printed on it.
The examiner points to a letter on the chart.
The patient points to the corresponding letter on their card.

Kay Picture Chart

The Kay picture chart is again used with patients who are illiterate or with children. Instead of letters, the book contains pictures, which are also of varying sizes. The patient is asked what the picture represents. In order to avoid any misunderstanding amongst patients with language difficulties, it is good practice to ask the hospital’s official interpreter to translate for patients.

Tumbling E chart

The tumbling E chart is mainly used for patients who are illiterate. In the chart, the Es face in different directions. The patient is asked to hold a wooden E in his hand and to turn it the same way as the one the examiner is pointing to on the test chart.

Procedure:

The patient holds a wooden “E”.
The examiner points to an “E” on the chart.
The patient rotates their wooden “E” to match the orientation of the “E” on the chart.

CARE OF THE PATIENT’S EYES.

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Opthalmology Read More »

Prepare For Neural Assessment

NEUROLOGICAL EXAMINATION

This is a type of patient assessment which aims at detecting the functions of the cranial nerves in
relation to the five senses.

Sight
Hearing
Smell
Taste
Touch or feeling

It is also an evaluation of a person’s nervous system. The nervous system consists of the brain, the spinal cord, and the nerves from these areas. There are many aspects of this exam, including an assessment of motor and sensory skills, balance and
coordination, mental status (the patient’s level of awareness and interaction with the environment),
reflexes, and functioning of the nerves.

Indications of a neurological exam

A complete neurological exam may be done:
1. During a routine physical
2. Following any type of trauma
3. To follow the progression of a disease
4. If the person has any of the following complaints:

Headaches
Blurry vision
Change in behavior
Fatigue
Change in balance or coordination
Numbness or tingling in the arms or legs
Decrease in movement of the arms or legs
Injury to the head, neck, or back
Fever
Seizures
Slurred speech
Weakness
Tremor

5. Assess the level of consciousness.
6. Determine the extent of paresthesia (loss of senses in a body part).
7. Assess the function of the cranial nerves.

IMPORTANTS POINTS TO NOTE
When carrying out this assessment, the substances used for example for sense of taste, smell,
touch or feeling should not be visualized by the patient so that they do not mention or describe
something because they had already seen, this is because it interferes with real findings.

EQUIPEMENT FOR THE PROCEDURE

Tray with

Ophthalmoscope or torch to assess for pupil dilatation and constriction(eye reaction)
Senelles chart to assess for visual acuity.
Autoscope for viewing into the ear.
Tuning fork to evaluate for the hearing sense.
Pins or needles for sense of touch e.g pain or loss of sensensation in an area.
Cotton wool in a gallipot for tactile sensation
A bottle of hot or cold water to assess for the sense of touch or even taste.
A bottle of salt and sugar for taste.
A bottle of coffee or lemon for sense of smell
Nasal speculum to inspect the nose.
Tape measure to measure areas that have lost senses of touch.
Skin pencil to demarcate areas of no sense of touch or feeling.
A patellar hammer to assess for tendon and motor reflexes.
NB: If patients gait is to be assessed, then it requires one to walk so that the movements are
well observed.
On the Bed-side
Hand washing equipment
>Screen
>Safety box
>A good source of light at
the bedside

Components of a neurological exam

The following is an overview of some of the areas that may be tested and evaluated during a neurological
exam:
Mental status:
These include the following
1. Level of awareness: may be assessed by conversing with the patient and establishing his or her
awareness of person, place, and time
2. Attentiveness: Is the patient paying attention to you and your questions or is he distractible and
requiring re-focusing?
3. Orientation: to self, place, time. Disorientation to time typically occurs before disorientation to
place or person. Disorientation to self is typically a sign of psychiatric disease.
4. Speech & language: includes fluency, repetition, comprehension, reading, writing, naming.
5. Memory: includes registration and retention.
6. Higher intellectual function: includes general knowledge, abstraction, judgment, insight and
reasoning.
7. Mood and affect: The primary purpose of assessing mood and affect in the neurological exam is
to determine if psychiatric disease may be interfering with the neurological assessment.

Evaluation of the cranial nerves:

There are 12 cranial nerves. During a complete neurological exam, most of these nerves are evaluated
to help determine the functioning of the brain:

Cranial nerve I (olfactory nerve): This is the nerve of smell. The patient may be asked to identify
different smells with his or her eyes closed.
Cranial nerve II (optic nerve): This nerve carries vision to the brain. A visual test may be given and
the patient’s eye may be examined with a special light.
Cranial nerve III (oculomotor): This nerve is responsible for pupil size and certain movements of
the eye. The patient’s healthcare provider may examine the pupil (the black part of the eye) with
a light and have the patient follow the light in various directions.
Cranial nerve IV (trochlear nerve): This nerve also helps with the movement of the eyes.
Cranial nerve V (trigeminal nerve): This nerve allows for many functions, including the ability to
feel the face, inside the mouth, and move the muscles involved with chewing. The patient’s
healthcare provider may touch the face at different areas and watch the patient as he or she
bites down.
Cranial nerve VI (abducens nerve): This nerve helps with the movement of the eyes. The patient
may be asked to follow a light or finger to move the eyes.
Cranial nerve VII (facial nerve): This nerve is responsible for various functions, including the
movement of the face muscle and taste. The patient may be asked to identify different tastes
(sweet, sour, bitter), asked to smile, move the cheeks, or show the teeth.
Cranial nerve VIII (acoustic nerve): This nerve is the nerve of hearing. A hearing test may be
performed on the patient.
Cranial nerve IX (glossopharyngeal nerve): This nerve is involved with taste and swallowing. Once
again, the patient may be asked to identify different tastes on the back of the tongue. The gag
reflex may be tested.
Cranial nerve X (vagus nerve): This nerve is mainly responsible for the ability to swallow, the gag
reflex, some taste, and part of speech. The patient may be asked to swallow and a tongue blade
may be used to elicit the gag response.
Cranial nerve XI (accessory nerve): This nerve is involved in the movement of the shoulders and
neck. The patient may be asked to turn his or her head from side to side against mild resistance,
or to shrug the shoulders.
Cranial nerve XII (hypoglossal nerve): The final cranial nerve is mainly responsible for movement
of the tongue. The patient may be instructed to stick out his or her tongue and speak.

Cranial Nerves Mneumonic to help you easily remember the cranial nerves

Nurses role in neurological examination

Provide a clam, suitable environment
Collect the personal data with patient &family members
Set the equipment needed for neurological examination
Assess the current level of consciousness, monitor vital parameters – temperature, pulse,
respiration, blood pressure, pupillary reaction, whether decelerating or decorticating.
Thorough mental status examination should be done & recorded
Assessment of cranial nerves should be done correctly & recorded.
Assessment of motor, sensory & cerebellar functions should be done & be recorded accurately.
During the examination, she should maintain a good support with patient &family members.
She should instruct the procedure correctly& then they should be asked to do it.
Should be informed to the concerned un it doctors if there is any.

GLASSGOW COMA SCALE MONITORING

EYE OPENING	VERBAL RESPONSE	MOTOR RESPONSE	SCORE
None	None	None	1
Eyes open to pain	Incomprehensible speech or sounds	Abnormal Extension	2
Eyes open to verbal Command	Inappropriate responses	Abnormal Flexion	3
Eyes open spontaneously	Confused conversation	Withdrawals from pain	4
	Oriented	Localizes pain	5
		Obeys Commands	6

GRADING

A score of 13 above mild Level of Consciousness

A score between 9-12 moderate Level of Consciousness

A score below 8 severe Level of Consciousness

Prepare For Neural Assessment Read More »

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Perform Colostomy Care

Colostomy Care

Colostomy is the surgical procedure of creating of an opening (ie. Stoma) into the colon intestine through the abdominal wall.

A colostomy is an operation that redirects the colon from its normal route, down toward the anus, to a new opening in the abdominal wall. The opening is called a stoma.

An ileostomy is a surgical procedure that brings a portion of the small intestine (the ileum) to the surface of the abdomen, creating an opening called a stoma. This opening allows stool to exit the body directly, bypassing the colon entirely.

Feature	Ileostomy	Colostomy
Intestinal Segment	Ileum (small intestine)	Colon (large intestine)
Stool Consistency	Liquid or semi-liquid	Can range from liquid to formed
Frequency	Frequent (multiple times a day)	Less frequent than ileostomy
Odor	Stronger odor	Generally less strong than ileostomy
Control	Limited control over bowel movements	More potential for control over bowel movements
Reasons	Ulcerative colitis, Crohn’s disease, colon cancer, etc.	Similar reasons to ileostomy, but also for conditions specific to the colon

Purpose of colostomy care

It allows for drainage or evacuation of colon contents to the outside of the body.

Needs for the colostomy care:

Maintain Stoma and Peristomal Skin Integrity: This includes protecting the stoma from trauma, irritation, and infection, as well as maintaining the health of the skin surrounding the stoma.
Prevent Skin Breakdown: This includes minimizing the risk of lesions, ulcerations, excoriation, and other skin issues caused by fecal contaminants.
Prevent Infection: Colostomy care should prioritize preventing bacterial and fungal infections that can occur due to exposure to fecal matter.
Promote General Comfort: This includes minimizing discomfort, irritation, and odor associated with the colostomy.
Enhance Self-Image and Self-Concept: Colostomy care should consider the psychological impact of living with a colostomy and aim to promote a positive self-image and body image.
Ensure Effective Fecal Evacuation: This includes using appropriate pouching systems that effectively collect and contain fecal matter.
Reduce Odor: Colostomy care should involve strategies to minimize unpleasant odors, such as regular pouch changes, odor neutralizers, and proper hygiene practices.

Indications of Colostomy

Tumors of the Colon: This includes both benign and malignant tumors that require surgical intervention.
Trauma and Perforation of the Colon: Severe injuries to the colon can necessitate a colostomy to allow for healing and prevent infection.
Inflammatory Diseases of the Colon: Conditions like ulcerative colitis, Crohn’s disease, and diverticulitis may require a colostomy to manage inflammation, reduce symptoms, and allow for healing.
Congenital Anomalies of the Gastrointestinal Tract (GIT):

Hirschsprung’s Disease: This congenital condition causes a lack of nerve cells in the colon, leading to constipation and fecal retention.
Necrotizing Enterocolitis: This serious condition, primarily seen in premature infants, involves inflammation and death of the bowel.
Imperforate Anus: This condition occurs when the anus is absent or blocked, requiring surgical intervention.
Other Anomalies: Other congenital malformations of the colon, such as anorectal malformations, may require a colostomy.

Type of colostomy:

By Location

Ascending Colostomy: Located in the ascending colon, on the right side of the abdomen. It produces more frequent, liquid stools.
Transverse Colostomy: Located in the transverse colon, across the abdomen. Stools are usually semi-solid and less frequent.
Descending Colostomy: Located in the descending colon, on the left side of the abdomen. Stools are usually formed and more consistent.
Sigmoid Colostomy: Located in the sigmoid colon, in the lower left abdomen. Stools are generally formed and can sometimes be controlled by regulating bowel movements.

By Duration:

Permanent Colostomy: This type of colostomy is intended to be long-term or lifelong. It’s usually performed when the original colon has been removed or severely damaged.
Temporary Colostomy: This type of colostomy is intended to be temporary, used to allow a portion of the colon to heal or to divert stool flow while other surgeries are performed.

By colostomy operation.

Loop Colostomy: This type involves creating a loop of the colon that is brought to the surface of the abdomen. The loop is divided by a bridge of tissue, with one opening for stool and the other for mucous discharge. A loop colostomy is often the method of choice when a colostomy is meant to be temporary because it’s easier to reverse.
End Colostomy: This type involves bringing the end of the colon to the surface of the abdomen, creating a single opening for stool. An end colostomy is often done when the colostomy is expected to be permanent. In this procedure, after your bowel is cut, the end of the remaining active bowel is stitched to the opening in your abdominal wall, and the end of the remaining inactive bowel is sealed.
Double-Barrel Colostomy: This type involves bringing both ends of the colon to the surface of the abdomen, creating two separate openings.

Characteristics of faces according to the site of colostomy:

Type	Consistency	Frequency	Odor	Skin Irritation	Pouching	Control
Ileostomy	Liquid	Frequent (multiple times per day)	Strong	High	Continuous	Low
Ascending Colostomy	Liquid or semi-liquid	Frequent	Strong	Moderate	Continuous	Low
Transverse Colostomy	Mushy or semi-solid	Less frequent	Strong	Moderate	Continuous	Moderate
Descending Colostomy	Solid	Less frequent	Moderate	Low	Needed	Moderate
Sigmoid Colostomy	Similar to normal bowel movements	Closer to normal bowel frequency (1-2 times/day)	Similar to normal	Low	Often needed, longer wear times possible	High

Note:

Control: Refers to the ability to control bowel movements.
Pouching: Continuous pouching means the pouch needs to be worn all the time.

Procedure of Colostomy Care

Requirements

Top shelf	Bottom shelf
– Bowl of warm water	– Disposable gloves
– Gauze swabs	– Soap in a dish
– Cotton balls	– New colostomy bag
– Graduated container	– Colostomy adhesive and measuring guide
– Large receiver	– Barrier cream
	– Towel

Procedure

Steps	Action	Rationale
1.	Follow the general rules.
2.	Turn down the bed clothes.	To expose the stoma and to avoid soiling bed clothes
3.	Remove the soiled bag gently, taking care not to pull the skin.	To protect underlying skin from damage.
4.	Wash the area around the stoma with soapy water and dry well. Apply a little barrier cream if necessary.	To remove excretions and old adhesive.
5.	Re-measure the stoma and make the correct measurement.	To make sure that the bag fits correctly.
6.	Cut the correct size of circle in the stoma adhesive, using the measuring guide and apply it on the stoma.	An opening that is too small can cause trauma to the stoma, exposed skin will be irritated by urine if opening is too large
7.	Apply a clean bag on the stoma	To prevent infection.
8.	Remove the soiled articles, assess patient’s response to the procedure and leave the patient comfortable.	Promotes more patient’s understanding about the colostomy and the need for more instructions.
9.	Wash and dry hands.

Procedure of the Colostomy care in children

Assemble the needed equipment.
Explain procedure to child, encourage child interaction to alley anxiety.
Wash hand with soap and water, rinse and dry, to prevent contamination of hand, reduce risk infection transmission
Put on gloves to avoid transmission of infections.
Place a towel or disposable waterproof (mackintosh) under the child, to prevent seepage of feces onto skin.
Auscultate for bowel sound.
Place linen saver on abdomen around and below stoma opening.
Carefully remove pouch and wafer appliance and place in plastic waste bag (save tail closure for reuse) :remove wafer by gently lifting corner with finger of dominant hand while pressing skin downward with fingers of non-dominant hand remove small sections at a time until entire wafer is removed. place 4×4- in , gauze over stoma opening
Assess stoma and peristomal skin, observe existing skin barrier, and stoma for color , swelling , trauma , healing : stoma should be moist and reddish pink .
Empty pouch ; measure waste in graduated container before discarding and record amount of fecal content .
Remove and discard gloves , perform hand washing , and wear new gloves.
Remove used pouch and skin barrier gently by pushing skin away from the barrier to reduce skin trauma.
Cleans peristomal skin gently with warm tap water using gauze pads .
Measure stoma for correct size of pouching system needed , using the manufacturer’s measuring guide.
Select appropriate pouch for client based on client assessment. With a custom cut –to- fit Pouch , use an ostomy guide to cut opening on the pouch. prepare the pouch by removing backing from barrier and adhesive.
Leaving intact adhesive covering of skin-barrier wafer .
Remove gauze and apply stoma paste around stoma or to edges of opening in wafer .
Remove adhesive covering of wafer, and place wafer on skin with hole centered over stoma: hold in place for about 30 sec .
Center pouch over stoma and place on wafer.
Praise the child for helping
Restore or discard all equipment appropriately
Remove and discard gloves and perform hand hygiene
Spray room deodorizer , if needed to get rid of unpleasant odor.
Record type of pouch ,skin barrier, amount, appearance of faeces, condition of stoma and skin around it

Nursing Diagnosis:

1. Comfort Alteration related to abdominal incision evidenced by:

Reports of pain at the incision site.
Grimacing or guarding behavior.
Elevated pain scores on a pain scale.
Difficulty with movement or ambulation.
Restlessness or anxiety related to pain.

2. Impaired Skin Integrity related to the presence of stoma evidenced by:

Presence of redness, swelling, or irritation around the stoma.
Skin breakdown, such as abrasions, fissures, or ulcers.
Reports of discomfort or itching around the stoma.
Leakage or drainage from the stoma.

3. Body Image Disturbance related to the presence of stoma evidenced by:

Expressing negative feelings or self-consciousness about the stoma.
Avoiding social situations or activities.
Difficulty looking at or touching the stoma.
Statements about feeling unattractive or different.

4. Knowledge Deficit related to stoma care and lack of experience evidenced by:

Asking numerous questions about stoma care.
Demonstrating incorrect stoma care techniques.
Expressing anxiety or fear about managing the stoma.
Lack of confidence in performing self-care activities.

Nurses Consideration

Assessment of the Stoma

The stoma should be pink. A dusky blue stoma indicates ischemia, and a brown-black stoma indicates necrosis.
Assessment of stoma color should be done every 8 hours.
There is mild to moderate swelling of the stoma in the first 2-3 weeks after surgery. This could be due to trauma to the stoma or any medical condition that results in edema. Severe edema could be due to obstruction of the stoma, allergic reaction to food, or gastroenteritis.
Small oozing/bleeding from the stoma mucosa when touched is normal because of its high vascularity. Moderate to large amounts of bleeding from the stoma could indicate coagulation factor deficiency, lower gastrointestinal bleeding, etc.

Protecting the Skin

The skin should be washed with mild soap, rinsed with warm water, and dried thoroughly before the skin barrier is applied.
Skin barriers include petroleum jelly gauze or protective ointment smeared around the stoma to keep the skin from becoming irritated. Hollister skin or stoma adhesive barriers are applied. However, the ointment must be removed at frequent intervals to ascertain that the skin under the protective coating remains in good condition.
The patient is provided with dressing items for changing the dressings and colostomy. A dressing tray is needed for this.

Clothing

Immediately after surgery, many patients choose to wear loosely fitting clothes.
Clients should not wear a leather belt over the stoma to avoid irritation.
All pouching systems are waterproof, so clients can bathe, shower, and swim while wearing them.
Clients can remove soiled pouches and shower without them but not with an ileostomy because bowel function with an ileostomy is fairly frequent and unpredictable.

Activity

Heavy lifting is prohibited for 6-8 weeks after abdominal surgery to prevent hernia, which can occur in the incision and around the stoma.

Diet

Clients should follow a low-fiber diet for approximately 1 month. After one month, a person with a colostomy can follow a regular diet.
Ileostomy diet should be closely monitored. Foods that cause blockage, such as popcorn, many vegetables, nuts, and meat, should be avoided.

Client and Family Teaching

The medical team assists the client and family with various aspects of ostomy care.

Health Education

The patient should be able to do the following before being discharged:

Change the colostomy bag: apply and change the pouch to collect intestinal drainage and empty it when it is 1/3 full to prevent leakage.
Care for the skin, control odor, maintain general hygiene, care for the stoma, and identify signs of complications. They should be able to cleanse the skin and use skin barriers and deodorants to prevent skin breakdown and bad odor.
Understand the importance of fluids and food in the diet: identify a well-balanced diet and dietary supplements to prevent nutritional deficiencies, identify foods that reduce diarrhea, gas, or obstruction, drink at least 3 liters per day to prevent dehydration unless contraindicated, and increase fluid intake during hot weather, excessive sweating, and diarrhea to replace losses.
Know how to get additional supplies—addresses of supply departments.
Understand the importance of follow-up care: report signs and symptoms of fluid and electrolyte deficits, fever, diarrhea, skin irritation, other stoma problems such as changes in appearance or function, changes in the peristomal area, tenderness, redness, and pain.

Selecting the Pouch

The colostomy bag should be transparent, plastic, odor-proof, cut large enough to envelop the stoma, and fit snugly to prevent fecal contents from getting onto the skin and staining the patient’s gown or bed linen. It should have a valve for drainage of the content or be changed whenever it is full if it does not have this provision.
The pouch should not be placed directly on the skin without the skin barrier.
The volume, color, and consistency of the drainage are recorded each time the bag is changed, and the condition of the skin is observed for irritation. The content of the ascending and transverse colon is liquid in nature, while that from the descending and sigmoid colon is semi-formed or formed.
The patient should be observed for fluid and electrolyte imbalance if large volumes of drainage are present. In the case of an ileostomy, in the first 24-48 hours post-operatively, there will be a high volume output of 1000-1800 ml/day, but it should reduce to 800ml daily.
Encourage the patient to take 2-3 liters of fluids daily and more if diarrhea is present.

Colostomy Irrigation

This is intended to regulate bowel function and treat constipation. It is a small enema done through the stoma using lukewarm water (500-1000ml), but a soft large bore catheter is used to avoid bowel perforation. Do not force the tube if there is resistance to Tubal entry.

Feeding after Colostomy and Control of Smell

The diet should be of low-roughage initially and then reintroduced later gradually. Seeds should be chewed properly, and hard ones avoided to prevent small bowel obstruction.
Foods that cause smell should be avoided, e.g., eggs, onions, fish, cabbage, alcohol, etc.
Gas-forming foods should be avoided or eaten in moderation, e.g., beans, onions, cabbage, potatoes, beer, carbonated beverages, etc.
Diarrhea-causing foods such as alcohol, spinach, green beans, coffee, spicy foods, and raw fruits should be avoided.
A regular diet is encouraged later on, and a normal one is very important as long as the above is put into consideration.

Assisting the Patient to Adapt Psychologically to a Changed Body and Sexual Activity

Stress the need for the patient to care for the colostomy but do not force them until they show readiness to do so.
Every effort should be made to keep the patient as clean and dry as possible, as they may become depressed at the sight of fecal drainage, particularly if it is so liquid and soils the bed linen and gown.
Soiled linen should be disposed of neatly and quickly.
Reassure the patient that fear of continuous drainage should not keep them from moving about freely.
The social impact of the stoma is interrelated with the psychological, physical, and sexual aspects.
Concerns of people with stomas include the ability to resume sexual activity, altering clothing styles, the effect on daily activities, sleeping while wearing a pouch, passing gas, presence of odor, cleanliness, and deciding when or if to tell others about the stoma. The fear of rejection from a partner or the fear that others will not find them desirable as a sexual partner can be a concern. The nurse should encourage open communication about feelings and realize that the patient needs time to adjust to the pouch and body changes before feeling secure in their sexual functioning.
Pregnancy is possible with a colostomy, but the number of pregnancies needs to be limited.

Nursing Care Guidelines

General Care

Be gentle yet professional: Approach all aspects of ostomy care with empathy and professionalism to ensure patient comfort and trust.
Observe stoma condition: Regularly inspect the stoma for any changes in color, size, or appearance.
Maintain cleanliness: Change any appliances, dressings, or linens that become soiled to prevent infection.
Check for undissolved medications: When changing an ileostomy appliance, inspect for any undissolved tablets or capsules that may indicate absorption issues.
Provide special skin care: Protect the skin around the stoma with appropriate barriers and treatments to prevent irritation and infection.
Clean with care: Once the stoma is healed, clean it with mild soap and water. Avoid using alcohol, and discontinue soap if it causes irritation. If redness or yeast-like growth appears, consult a healthcare provider.
Encourage independence: Teach the patient how to remove and apply new appliances, and what to monitor and report regarding bowel changes.
Support emotional health: Allow the patient to express their feelings, encourage questions, and address any misconceptions they may have.

Abnormal and Danger Signs in a Stoma

Abnormal sounds: Unusual noises from the stoma may indicate issues.
Excessive bleeding: Any significant bleeding should be reported immediately.
Color changes: Darkening of the stoma can indicate stenosis and compromised blood supply. Bleaching or extreme lightening suggests a lack of circulation.
Drying of the stoma: The stoma should remain moist; drying may indicate problems.
Signs of infection: Look for redness, swelling, or discharge.
Edema of the stoma: Swelling could indicate an obstruction or other complications.

Routine Observations

Appliance size: Ensure the appliance fits correctly—not too tight to cut off circulation, but snug enough to prevent leakage.
Daily weight: Monitor the patient’s weight daily to assess for any significant changes that could indicate fluid or nutritional imbalances.
Electrolyte balance: Regularly check blood work results to monitor for any imbalances.
Stool assessment: Record the amount and character of stool to identify any changes or issues.
Vital signs: Regularly monitor vital signs to detect any early signs of complications.

Complications of Colostomy

1. Surgical Complications:

Wound Infection: Bacteria can enter the surgical wound, causing inflammation, pain, and potential delay in healing.
Hemorrhage: Bleeding from the surgical site can occur, requiring prompt medical attention.
Parastomal Hernia: A bulge of abdominal contents through the weakened abdominal wall around the stoma.

2. Stoma-Related Complications:

Stenosis: Narrowing of the stoma, leading to difficulty passing stool and potential blockage.
Prolapse: The stoma protrudes outwards from the abdomen, potentially causing discomfort and interfering with pouch adherence.
Retraction: The stoma can retract or shrink, making it challenging to attach the colostomy bag securely.
Necrosis: Death of stoma tissue, usually due to insufficient blood supply, requiring emergency surgery.

3. Skin Issues:

Skin Irritation and Breakdown: Prolonged exposure to fecal matter can lead to skin irritation, inflammation, and ulceration around the stoma.
Infection: Infection can occur in and around the stoma, leading to discomfort and complications.

4. Bleeding and Obstruction:

Bleeding: Some bleeding from the stoma is normal, but excessive bleeding can indicate issues such as infection or trauma.
Obstruction: Blockages can occur in the colostomy, preventing the passage of stool and leading to discomfort and potential complications.

5. Fluid and Electrolyte Imbalance:

Dehydration: Patients with a colostomy are at risk for dehydration because they lose fluids and electrolytes through the stoma.
Electrolyte Imbalance: Patients with a colostomy may also experience an electrolyte imbalance, which can occur when they lose too many electrolytes through the stoma.

6. Psychosocial and Nutritional Issues:

Psychosocial Issues: Patients may experience body image disturbances, depression, or anxiety related to the presence of a colostomy.
Nutritional Deficiencies: Patients with a colostomy may also experience nutritional deficiencies because they may not be able to absorb nutrients properly.

Perform Colostomy Care Read More »

Carry Out Gastric Lavage

Gastric lavage is the process of cleaning out stomach contents.

Gastric lavage is a gastrointestinal decontamination technique that aims to empty the stomach of toxic substances by the sequential administration and aspiration of small volumes of fluid via a nasogastric tube or stomach tube.

Gastric lavage is the process of washing out of the stomach via a nasogastric tube or stomach tube.
Lavage is ordered to wash out the stomach (after ingestion of poison or an overdose of medication, for example) or to control gastrointestinal bleeding. If the patient does not have a nasogastric tube in place already, the physician will order the insertion of the appropriate tube.

Indications for Gastric Lavage:

Ingestion of toxic substances: Gastric lavage is indicated when a patient has swallowed anything unwanted or poisonous. It is a method to remove toxic substances from the stomach before they are absorbed into the systemic circulation.
Pre-endoscopic procedure: Gastric lavage can be performed to clear the contents of the stomach before an upper endoscopic procedure. This helps to improve visualization during the procedure.
Collection of stomach acids for testing: Gastric lavage can be used to collect stomach acids for diagnostic testing.
Relief of gastric pressure: Gastric lavage can be used to relieve pressure in the stomach in cases where there is a blockage in the stomach or nearby areas like the intestine. This can help alleviate symptoms and prevent complications.
Collection of sputum in children: Gastric lavage is useful in collecting sputum samples from children who cannot produce it. It is a preferred procedure for children suspected of having pulmonary tuberculosis.
Cooling technique in hyperthermic patients: Gastric lavage can be used as a cooling technique in hyperthermic patients. By irrigating the stomach with cool fluids, it helps to lower the body temperature.
Diagnostic tool for gastric hemorrhage: Gastric lavage can be used to diagnose inflammatory conditions like gastric hemorrhage. Through examining the lavage fluid about the presence and severity of bleeding.
Poisoning cases: Gastric lavage is commonly performed in cases of poisoning, especially when it is life-threatening or when the patient’s history is not available. It can help remove toxic substances from the stomach and reduce the absorption of the poison.
Ingestion of substances: Also used incases of;

Ingestion of potentially life threatening substances e.g. chloroquine, cyclic antidepressants e.g. amitriptyline, imipramine.
Ingestion of large amounts of a substance not absorbed to charcoal e.g. iron, lithium.
Ingestion of substance which have propensity to form bezoars (a mass found trapped in the GIT) e.g. iron salicylates such as aspirin, acetylsalicylic acid

Contraindications of Gastric Lavage:

Comatose and convulsing patients: Gastric lavage should not be performed on patients who are comatose or experiencing seizures.
Ingestion of a corrosive substance: Gastric lavage is contraindicated in cases where the ingested substance is a strong acid or strong alkaline, as it can cause further damage to the esophagus and stomach.
Pills too large for lavage tube: If the pills or tablets ingested are too large to pass through the lavage tube, gastric lavage should not be performed.
Patients at risk of hemorrhage or gastrointestinal perforation: Individuals who have a pre-existing condition that puts them at risk of bleeding or gastrointestinal perforation should not undergo gastric lavage.
Ingestion of hydrocarbons and detergent: Gastric lavage is contraindicated in cases of ingestion of substances such as ethanol (a hydrocarbon) and detergent.
The poison ingestion is not toxic at any dose: If the ingested poison is not toxic at any dose, gastric lavage is not necessary.
The poison ingestion is adsorbed by charcoal and adsorption is not exceeded by the quantity ingested: If activated charcoal can effectively adsorb the poison and the quantity ingested does not exceed the adsorption capacity, gastric lavage may not be required.
Presentation many hours after poisoning: If the patient presents several hours after the poisoning incident, gastric lavage may not be beneficial.
A highly efficient antidote is available: If there is a highly efficient antidote available for the ingested poison, gastric lavage may not be necessary.

Complications of Gastric Lavage:

Increase gastric delivery of tablets into the small bowel: Gastric lavage can potentially push tablets or pills further into the small bowel, increasing their absorption .
Aspiration of gastric contents: There is a risk of aspiration, where the gastric contents can enter the lungs, leading to respiratory complications. This occurs in approximately 3% of patients undergoing gastric lavage .
Esophageal rupture: Although rare, there is a risk of esophageal rupture during the lavage procedure .
Cardiac complications: In certain poisonings, such as those involving propranolol or calcium channel blockers, gastric lavage can precipitate extreme bradycardia, cardiac arrest, and asystole due to the effects on cardiac conduction .
Nasal trauma: Insertion of the lavage tube can cause nasal trauma.
Tracheal intubation: In cases where the airway is unprotected, tracheal intubation may be required before performing gastric lavage.
Electrolyte imbalance and hypothermia: The administration of large volumes of fluid during gastric lavage can potentially lead to electrolyte imbalances and hypothermia.

Procedure for Gastric Lavage

Gastric lavage is a clean procedure.

Requirements

Trolley

Top Shelf	Bottom Shelf	At the Bed Side
– Rubber tubing, stomach tube, funnel	– Mackintosh cape and towel	– Suction machine if the patient is unconscious
– Connection and clip	– Receiver	– Hand washing facilities
– 2 Gallipots	– Jar for stomach contents	– Screens
– Bowl of swabs	– Lubricant
– Vomitus bowl	– Adhesive strapping
– 20 ml syringe	– Bucket for collecting stomach contents
– Litmus paper	– 3 receivers
– Jar of water

Procedure for Gastric Lavage

Steps	Action	Rationale
1.	Follow the general rules. Collect the equipment needed and prepare the trolley Explain the procedure to the patient. Screen the bed and close the adjacent windows Bring the trolley to the bedside	To enable cooperativeness. To ensure privacy. To prevent unnecessary movement.
2.	Place a bucket on the floor at the bedside.	To collect wastes.
3.	Request the patient to sit up if conscious. If unconscious, put the patient in a prone position and place a mackintosh cape and towel around the patient’s neck and bed clothes.	To protect the bed and patient.
4.	Connect up the funnel to the tubing using a connector but keep the stomach tube separate until it has been passed.	To prevent aspiration of the fluid by the patient.
5.	Lubricate the tube and pass it over the tongue into the pharynx and esophagus.	To ease passage of the tube.
6.	Keep on asking and encouraging the patient to swallow.	To gain patient’s cooperation.
7.	Connect the syringe on the tube and withdraw some stomach content.	To ensure that the tube is in the stomach.
8.	Test the stomach content with a litmus paper to confirm that you are in the stomach.	Acidic stomach content will turn blue litmus paper red.
9.	Clip the stomach tube with an artery forceps and place it in the receiver.	To prevent backflow of stomach contents.
10.	Apply a clip to the funnel and tubing then attach it to the stomach tube.	To prevent the flow of fluids before starting the procedure.
11.	Open the clip and allow approximately 300 mls of fluid to run into the lower funnel until level begins to rise; invert the funnel into the bucket to siphon out the stomach contents. Repeat the procedure until the fluid which is returning is clear. Note the nature of the stomach contents.	To empty the stomach of unwanted or harmful contents.
12.	Clip the stomach tube, withdraw it from the stomach evenly and quickly, disconnect the tube from the funnel and tubing and place it in the receiver.	To prevent trauma to the patient.
13.	Give the patient a mouthwash, thank him and clear away the requirements.	To encourage patient’s comfort.
14.	Wash your hands and document the findings. (a). Type and amount of lavage solution used. (b). Appearance, odor, color, and amount of gastric return. (c). Patient’s tolerance to procedure. (d). Disposition of specimens. Clear away all the requirements.

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Prepare For Lumbar Puncture

LUMBAR PUNCTURE(Spinal Tap)

Lumbar puncture is a sterile procedure in which a spinal needle is inserted, between the third and fourth lumbar vertebrae in the lower spine at the subarachnoid space i.e. the space between the spinal cord and its covering, the meninges to obtain samples of cerebrospinal fluid (CSF) for qualitative analysis.

Lumbar puncture refers to the introduction of a special needle into the subarachnoid space to withdraw cerebral spinal fluid.

The site of the puncture can be between the 3rd and 4th or 4th and 5th Lumbar vertebrae where there is no danger of damaging the spinal cord.

Indications of Lumbar puncture

1. Measure cerebrospinal fluid (CSF) pressure: Increased pressure within the skull, known as intracranial pressure, can be a sign of various conditions. A lumbar puncture can measure CSF pressure and assess for potential complications.

2. Assist in the diagnosis of suspected CNS infections: This includes:

Bacterial or viral meningitis: Inflammation of the meninges, the membranes surrounding the brain and spinal cord.
Meningoencephalitis: Inflammation of both the meninges and the brain.
Intracranial or subarachnoid hemorrhage: Bleeding within the skull or the space between the brain and the meninges.
Some malignant disorders: Cancerous conditions affecting the central nervous system (CNS).

3. Evaluate and diagnose demyelinating or inflammatory CNS processes: This includes:

Diagnosis of Multiple Sclerosis (MS): MS is an autoimmune disease that affects the central nervous system. CSF analysis can detect oligoclonal bands, which are characteristic of MS.
Guillain-Barré Syndrome (GBS): An autoimmune disorder affecting the peripheral nervous system, leading to muscle weakness and paralysis. A lumbar puncture can reveal elevated protein levels in the CSF.
Acute Disseminated Encephalomyelitis (ADEM): A rare inflammatory disease of the brain and spinal cord.

4. Infuse medications: This includes:

Spinal anesthesia before surgery: Numbing the nerves in the spinal canal to provide pain relief during surgery.
Contrast material for diagnostic imaging: This includes:

Inject dye (myelography): Visualize the spinal canal and nerves.
Radioactive substances (cisternography): Evaluate the flow of CSF.

Chemotherapy drugs directly into the spinal canal: Treat certain types of cancer affecting the CNS.

5. Treat normal pressure hydrocephalus: A condition where excess CSF accumulates in the brain, leading to symptoms like walking difficulties and cognitive decline.

6. Treat cerebrospinal fistulas: Abnormal connections between the CSF space and other parts of the body.

7. Treat idiopathic intracranial hypertension (IIH): A condition of increased pressure within the skull with no clear cause.

8. Placement of a lumbar CSF drainage catheter: A thin tube inserted into the spinal canal to drain excess CSF.

Contraindications

Space occupying lesion: A computerized tomography (CT) scan or MRI prior to a lumbar puncture can be obtained to determine if there is evidence of a space-occupying lesion that results in increased intracranial pressure.
Severe coagulopathy or bleeding disorders: Due to the significant risk of epidural hematoma formation.
Severe degenerative vertebral joint disease: There will be difficulty in passing the needle through the degenerative arthritic inter-spinal space like in Spinal stenosis.
Severe spinal deformities: Patients with severe spinal deformities, such as scoliosis, may have an increased risk of complications.
Skin infection near the puncture site: The presence of skin infection near the site of the lumbar puncture increases the risk of contamination of infected material into the CSF.
Increased intracranial pressure due to a brain tumor: Cerebral or cerebellar herniation with severe neurological deterioration may occur after the withdrawal of CSF fluid.
Patient refusal: Ultimately, the decision to undergo a lumbar puncture is the patient’s choice. If a patient refuses the procedure, their wishes must be respected.

Equipment for Lumbar Puncture

Top shelf

Bottom shelf

Bed side

Sterile lumbar puncture pack containing:

– 3 Gallipots

– 2 Sterile drapes

– Sterile towel

– Cotton and gauze swabs

– Receivers

– Receiver containing sponge holding forceps, dissecting and artery forceps.

– 2 spinal needles.

– A pair of sponge holding forceps

– A pair of sterile gloves.

– Masks

Gallipots are for;

> Gallipot for antiseptic lotion

> Gallipot for sterile cotton swabs

> Gallipot for sterile gauze swabs.

A tray containing:

– Two 10 ml sterile syringes with needles

– Two 2 ml sterile syringes with needles

– Two pairs of sterile gloves

– Two lumbar puncture needles

– Lignocaine 2%

– Antiseptic solution like Iodine, methylated spirit or alcohol.

– At least 3 specimen bottles

– Dressing mackintosh and towel

– Adhesive tape/colloid

– 2 drums of gauze dressings and swabs

– Emergency tray

– Spinal manometer

– Laboratory request forms

– Emergency tray

– Cheatle forceps

– Hand washing equipment

– Screen

– Safety box

– Bedpan and urinal

– A good source of light at the bedside

Procedure for Lumber Puncture

Steps	Action	Rationale
1.	Follow the general rules.
2.	Offer a bedpan to the patient.	To promote comfort.
3.	Position the patient in any of the following positions: i. The patient may sit up on the stool and bend forward with the head between the knees ii. The patient may lie in a lateral position with the buttocks close to the edge of the bed; the knees and hip fully flexed drawn towards the chin, one pillow is placed under the head. A fracture board is provided.	A flexed position increases the space between the vertebrae. A hard surface prevents sagging in the bed and interference with the procedure.


4.	Encourage the patient to remain in a flexed position until the procedure is completed.	Prevent risk of trauma.
5.	Leave the patient covered and expose only the lumbar region.	To provide privacy.
6.	Provide good light at the lumbar region.	To see the right site clearly.
7.	Assemble the requirements for the top shelf of the trolley.	Promote easy access.
8.	Pour antiseptic lotion into one of the gallipots and the doctor cleanses the puncture site then drapes the area.	For infection prevention and control
9.	Wash hands, dry and put on gloves.	To maintain sterility
10.	Assist the doctor in cleaning the lumbar region, giving local anaesthesia and in performing the lumbar puncture in between the 3rd and 4th or 4th and 5th lumbar vertebrae.	Promote success of the procedure and prevent injury to the spinal cord.
11.	Unscrew the specimen bottles and place them about 1 cm below the needle to receive the cerebral spinal fluid.	To avoid contamination.
12.	Reassure the patient and observe the condition, colour, pulse and respiration rate, and report any changes or complaints.	To detect complications on time.
13.	Label the specimen, and take them to the laboratory with a laboratory request form.	For diagnosis of causative organisms.
14.	Assist the doctor to seal the puncture site with tincture benzoin or collodion and apply the dressing.	To prevent leakage of CCF
15.	Instruct the patient to stay confined to bed in a flat position and to be moved only if necessary for at least 12 hours.	To avoid complications like severe headache and backache.
16	The used equipment is cleared away.	To promote ward maintenance,
17	Monitor patient’s condition for ¼ , ½ 1, 2 and 4 hourly for 24 hrs depending on the patient’s condition.	To detect complications and manage appropriately.
18	Clear away the trolley and wash hands.	To prevent the spread of infections.
19	Document the procedure.	To promote follow up.

Points To remember:

A manometer is given to the Doctor to measure CCF when required.
Extreme care is taken to ensure aseptic technique throughout the procedure.
Encourage the patient to remain in a flat position in bed for 24 hours.

Nurses Roles in Lumbar Puncture

Before the Procedure

Explain the procedure to the patient: Inform the patient about the purpose of the lumbar puncture, the procedure details, where it will be done, and who will perform it.
Obtain informed consent: Ensure the patient signs a consent form if required by the institution.
Reinforce diet: Advise the patient that fasting is not required.
Promote comfort: Instruct the patient to empty the bladder and bowel before the procedure.
Establish baseline assessment data: Perform vital signs monitoring and a neurologic assessment of the legs, including movement, strength, and sensation.
Position the client: Assist the client to assume a lateral decubitus (fetal) position near the side of the bed with the neck, hips, and knees drawn up to the chest. Alternatively, have the patient sit on the edge of the bed while leaning over a bedside table.
Instruct to remain still: Emphasize that the patient must lie very still throughout the procedure to prevent traumatic injury.

During the Procedure

Arrange the equipment for use as per the doctor’s convenience.
Protect the bed: Use a mackintosh and draw sheet.
Position the patient for easy access.
Provide a stool for the doctor to sit on during the procedure.
Expose the site to be punctured.
Help monitor the patient’s condition.
Maintain the patient’s position.
Reassure the patient to stay calm during the procedure.

After the Procedure

Apply brief pressure to the puncture site: To avoid bleeding, apply pressure and cover the site with a small occlusive dressing or band-aid.
Place the patient flat on the bed: The patient should remain flat for 4 to 6 hours, as instructed by the physician, and may turn from side to side without elevating the head.
Monitor vital signs, neurologic status, and intake and output: Assess these every 4 hours for 24 hours to evaluate the patient’s condition.
Monitor the puncture site: Watch for signs of CSF leakage and drainage of blood, including positional headaches, nausea, vomiting, neck stiffness, photophobia, imbalance, tinnitus, and phonophobia.
Encourage increased fluid intake: Advise the patient to drink up to 3,000 ml of fluids in 24 hours to replace the CSF removed during the lumbar puncture.
Label and number the specimen tube correctly: Ensure all samples are properly labeled and sent to the laboratory immediately for evaluation.
Administer analgesia as ordered: Provide pain relief for headaches that may occur after the procedure.

Normal Results of Lumbar Puncture

Pressure: 70 to 180 mm H2O.
Appearance: CSF is normally clear and colorless.
CSF total protein: 15-45 mg/dL.
Gamma globulin: 3 to 12% of the total protein.
CSF glucose: 50 to 80 mg/dL.
CSF cell count: No red blood cells (RBCs); 0-5 white blood cells (WBCs) per microliter, all mononuclear.
CSF chloride: 118 to 130 mEq/L.

Complications of Lumbar Puncture

The lumbar puncture procedure must be performed with extreme care and aseptic technique to avoid complications such as:

Headache: Commonly due to leakage of cerebrospinal fluid (CSF) into nearby tissues, affecting around 25% of patients.
Meningitis: Infection of the protective membranes covering the brain and spinal cord.
Bleeding into the Spinal Canal: Hemorrhage that may cause nerve damage or other complications.
Sudden Death: Rare but severe complication, often due to increased intracranial pressure.
Medullary Compression: Pressure on the spinal cord, which can lead to neurological issues.
Edema or Hematoma at the Puncture Site: Swelling or blood collection at the puncture site.
CSF Leakage: Leakage through the dural defect after needle withdrawal.
Reaction to Anesthesia: Adverse effects due to the anesthesia used during the procedure.
Epidural or Subdural Abscess: Infection in the space around the spinal cord.
Transient Difficulty in Voiding: Temporary difficulty in urination post-procedure.
Transillar Herniation: Displacement of brain tissue due to pressure changes.
Local Pain: Caused by nerve root irritation during the procedure.
Post-Lumbar Puncture Headache: Occurs in about 25% of patients due to CSF leakage.
Back Discomfort or Pain: Pain at the site of the puncture.
Brainstem Herniation: Caused by increased intracranial pressure due to conditions like brain tumors.

Prevention of Post-Lumbar Puncture Headache

To prevent post-lumbar puncture headache, consider the following measures:

Avoid Strong Light: Keep the room darkened to reduce discomfort.
Hydration: Encourage the patient to drink plenty of fluids to stabilize CSF levels.
Analgesics: Provide pain relief medication as prescribed.
Foot of the Bed Raised (Trendelenburg Position): Elevate the foot of the bed to reduce CSF leakage and pressure on the puncture site.

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Perform Tracheostomy Care

Tracheostomy Care

A tracheostomy is a surgical procedure usually either temporary or permanent that involves creating an opening in the neck in order to place a tube into a person’s windpipe.

The tube is inserted through a cut in the neck below the vocal cords( larynx) to allow air to enter the lungs.
Breathing is then done through the tube, bypassing the mouth, nose, and throat. A tracheostomy is commonly referred to as a stoma. This is the name for the hole in the neck that the tube passes through.

Definition of Terms

Decannulation: The process whereby a tracheostomy tube is removed once the patient no longer needs it.
Humidification: The mechanical process of increasing the water vapor content of an inspired gas.
Stoma: An opening, either natural or surgically created, which connects a portion of the body cavity to the outside environment (in this case, between the trachea and the anterior surface of the neck).
Tracheostomy: A surgical procedure to create an opening between 2-3 (3-4) tracheal rings into the trachea below the larynx.
Tracheal Suctioning: A means of clearing thick mucus and secretions from the trachea and lower airway through the application of negative pressure via a suction catheter.
Tracheostomy tube: A curved hollow tube of rubber or plastic inserted into the tracheostomy stoma (the hole made in the neck and windpipe (Trachea) to relieve airway obstruction, facilitate mechanical ventilation or the removal of tracheal secretions.
Intubation: The insertion of a tube into a hollow organ, especially the trachea, to establish or maintain an airway.
Mechanical Ventilation: The use of a machine to assist or control breathing.
Artificial Airways: A variety of devices, such as endotracheal tubes, tracheostomy tubes, and laryngeal masks, that are used to maintain an open airway.
Respiratory Therapy: A branch of medicine that focuses on the diagnosis, treatment, and prevention of respiratory diseases.
Oxygen Therapy: The administration of supplemental oxygen to patients who are not able to obtain adequate oxygen from the air.
Pulmonary Hygiene: Measures taken to maintain the health of the lungs and airways, such as deep breathing exercises, coughing, and airway clearance techniques.

Indications for Tracheostomy:

Airway Obstruction:

Foreign bodies in the airway: Tracheostomy can be used to remove foreign objects from the airway that cannot be removed by other methods.
Upper Airway Obstruction: Tracheostomy may be necessary in cases of acute upper airway obstruction caused by a foreign object, soft tissue edema, or more lasting damage to the upper airway.
Burns of the neck and face: Tracheostomy may be necessary to secure the airway in patients with severe burns to the neck and face.
Tumors of air passage: Tracheostomy may be performed to relieve airway obstruction caused by tumors in the larynx, trachea, or bronchi.
Bulbar paralysis-Neurological conditions e.g. recurrent laryngeal nerve: Tracheostomy can be performed in patients with bulbar paralysis (weakness of the muscles of the tongue, palate, and pharynx) to maintain an airway.
Severe asthmatic attacks: Tracheostomy may be needed in cases of severe asthma attacks where other treatments fail.
Diphtheria: Tracheostomy can be performed to relieve airway obstruction caused by diphtheria.
Congenital Anomalies: Tracheostomy may be indicated in cases of congenital anomalies such as laryngeal hypoplasia or vascular web that cause airway obstruction.
Trauma: Severe neck trauma resulting in injury to the thyroid or cricoid cartilages, hyoid bone, or great vessels may necessitate a tracheostomy to secure the airway. Tracheostomy can be life-saving in cases of trauma to the neck and airway, such as gunshot wounds.
Subcutaneous Emphysema: Tracheostomy may be performed in cases of subcutaneous emphysema, where air accumulates in the subcutaneous tissues of the neck, leading to compromised airway patency.
Facial Fractures: Extensive facial fractures, particularly those involving the mid-face and mandible, can cause upper airway obstruction. Tracheostomy may be necessary to ensure adequate breathing.
Upper Airway Edema: Trauma, burns, infection, or anaphylaxis can cause upper airway edema, leading to airway compromise. Tracheostomy may be performed to secure the airway in such cases.
Severe Sleep Apnea: In cases of severe sleep apnea that are not amenable to other treatment modalities, tracheostomy may be considered as a last resort to provide a patent airway during sleep.

Ventilation & Airway Management:

To reduce the dead air space: Tracheostomy can reduce the amount of dead space in the airway, making it easier to breathe.
To by-pass an upper airway obstruction: Tracheostomy can bypass an obstruction in the upper airway (nose, mouth, pharynx, larynx) by providing an alternate route for air to pass.
Prolonged Artificial Ventilation: Patients who require prolonged mechanical ventilation are at risk of tissue damage and increased work of breathing due to prolonged endotracheal intubation. Tracheostomy reduces the risk of tissue damage, facilitates communication, and decreases the work of breathing, making it easier to wean the patient off the ventilator.
Inability to Maintain an Airway Independently: Patients with reduced function in cranial nerves V, VII, IX, X, or XII, damage to the brain stem, or poor consciousness levels may be unable to maintain a patent airway. Tracheostomy provides a secure airway and ensures adequate oxygenation and ventilation.

Secretion Management & Aspiration Prevention:

To facilitate removal of secretions and to prevent aspiration of secretions, food into the lungs when normal swallowing is impossible because of a reduced state of unconsciousness or muscular paralysis: Tracheostomy can help to remove secretions from the airway and prevent aspiration in patients who are unable to swallow properly.

Other Indications:

To permit long-term mechanical ventilation in permanent airway obstruction: Tracheostomy can be used to provide long-term mechanical ventilation in patients with permanent airway obstruction.
To permit oral intake and speech in a patient without aspiration: Tracheostomy allows for oral intake of food and liquids without the risk of aspiration in patients who are unable to swallow normally.
To provide easier access to the lower airways than possible through the nose or mouth: Tracheostomy provides direct access to the lower airways, allowing for easier suctioning and other airway management procedures.

Conditions that may require a tracheostomy include:

Anaphylaxis: Severe allergic reactions can cause swelling and constriction of the airway, making it difficult to breathe.
Birth Defects of the Airway: Certain congenital abnormalities can affect the structure or function of the airway, leading to breathing difficulties.
Burns of the Airway from Inhalation of Corrosive Material: Inhalation of corrosive substances can cause damage to the airway, leading to inflammation, swelling, and scarring.
Cancer in the Neck: Tumors in the neck region can compress or obstruct the airway, necessitating a tracheostomy to ensure adequate airflow.
Chronic Lung Disease: Conditions such as chronic obstructive pulmonary disease (COPD) or bronchopulmonary dysplasia (BPD) can result in long-term respiratory insufficiency, requiring prolonged respiratory support.
Coma: Individuals in a coma may require a tracheostomy to maintain a patent airway and facilitate mechanical ventilation.
Diaphragm Dysfunction: Weakness or paralysis of the diaphragm can impair breathing, and a tracheostomy may be necessary to assist with ventilation.
Facial Burns or Surgery: Severe facial burns or surgical procedures involving the face and neck can cause airway swelling or obstruction, necessitating a tracheostomy.
Infection: Severe infections of the airway, such as epiglottitis or deep neck infections, can compromise breathing and require a tracheostomy for airway management.
Injury to the Larynx or Laryngectomy: Trauma or surgical removal of the larynx can result in the loss of the natural airway, requiring a tracheostomy for breathing.
Injury to the Chest Wall: Severe chest wall injuries, such as fractures or trauma, can impair breathing and necessitate a tracheostomy for respiratory support.
Need for Prolonged Respiratory or Ventilator Support: Some individuals with chronic respiratory conditions or those requiring long-term mechanical ventilation may benefit from a tracheostomy to facilitate respiratory care.
Obstruction of the Airway by a Foreign Body: In cases where the airway is blocked by a foreign object that cannot be removed by other means, a tracheostomy may be performed to establish a secure airway.
Obstructive Sleep Apnea: Severe cases of obstructive sleep apnea, where breathing repeatedly stops during sleep, may require a tracheostomy as a treatment option.
Airway Obstruction: This can be caused by foreign objects lodged in the respiratory tract or congenital abnormalities such as Pierre Robin Sequence.
Bronchopulmonary Dysplasia (BPD): A chronic lung condition primarily affecting premature babies, where the underdeveloped lungs require additional respiratory support.
Chronic Obstructive Pulmonary Disease (COPD): A group of lung conditions characterized by shortness of breath and difficulties breathing, where tracheostomy may be considered for end-stage COPD patients.
Haemangioma: A condition where blood vessels collect and form a lump under the skin, leading to airway obstruction in some cases.
Infection: Certain infections, such as epiglottitis, can cause swelling and inflammation of the epiglottis, potentially obstructing the airways and requiring a tracheostomy.
Neck and Spine Injuries: Trauma to the neck or spine can result in respiratory trauma or airway obstruction, necessitating a tracheostomy for breathing support.
Neuromuscular Disorders: Conditions affecting the nervous system that result in progressive muscle weakness, which may require mechanical ventilation and a tracheostomy to protect the airways from aspiration.
Tracheal Stenosis: Abnormal narrowing of the trachea, which can hinder normal breathing and may require a tracheostomy to alleviate the symptoms.
Tracheomalacia: A rare condition primarily affecting children, characterized by soft cartilage in the trachea that collapses during respiration. In severe cases, a tracheostomy tube can help reinforce the vulnerable area.
Tumors: Tumors in the respiratory tract can obstruct the airways, leading to breathing difficulties. The severity and size of the tumor determine whether a tracheostomy is necessary.

Patients Who May Benefit from Tracheostomy:

1. Prophylactic Tracheostomy:

Pre-operative Requirement: Patients undergoing certain surgeries, particularly those involving the chest (thoracic surgery), may benefit from a prophylactic tracheostomy to ensure a secure airway during and after the procedure.

2. Patients with Compromised Respiration:

Apneic Patients: Patients who have stopped breathing after a cardiac arrest may require a tracheostomy to maintain airway patency and facilitate ventilation.
Unconscious Patients: Unconscious patients with inadequate ventilation may benefit from a tracheostomy to support their breathing.
Respiratory Failure: Patients in respiratory failure who require prolonged mechanical ventilation (greater than 1-2 days) may find tracheostomy to be a more comfortable and less invasive method of ventilation.

3. Trauma and Injury:

Head, Neck, and Chest Injuries: Patients with injuries to the head, neck, or chest, resulting in bleeding, edema, unconsciousness, muscular paralysis, fractured larynx or trachea, flail chest, etc., may require a tracheostomy to maintain a clear airway.

4. Infections and Inflammatory Conditions:

Fulminating Mouth and Throat Conditions: Patients with severe infections like diphtheria, Ludwig’s angina, or tonsillitis that obstruct the upper airway may benefit from a tracheostomy to ensure adequate breathing.
Upper Airway Obstruction: Patients with any condition that causes obstruction of the upper airway, regardless of the cause, may require a tracheostomy to establish a secure airway.

5. Secretions and Obstruction:

Accumulated Secretions: Patients with excessive secretions in the lower tracheobronchial tree, which can cause hypoxia and atelectasis (lung collapse), may benefit from a tracheostomy to facilitate removal of secretions and improve oxygenation.

6. Burns and Trauma:

Severe Burns: Patients with severe burns of the face, neck, and head, which can lead to airway obstruction due to swelling and scarring, may require a tracheostomy for airway management.
Thyroidectomy Complications: Patients who have undergone partial thyroidectomy may require a tracheostomy if bleeding occurs in the surrounding neck tissue, causing airway compression.

7. Neurological Disorders:

Impaired Swallowing: Patients with neurological disorders that impair swallowing, such as head injury, drug overdose, stroke (CVA), or bulbar paralysis, may need a tracheostomy to prevent aspiration (food or liquid entering the lungs).

8. Pulmonary Conditions:

Severe Pulmonary Edema: Patients with severe pulmonary edema, which reduces gas exchange in the lungs, may require a tracheostomy to facilitate mechanical ventilation and improve oxygenation.

Types of Tracheostomy.

Depending on the Timing:

Elective/Routine Tracheostomy: This is planned in advance, usually for a non-emergency situation. It might be chosen for long-term ventilation needs in patients with chronic conditions like ALS, spinal cord injuries, or certain types of cancer. This allows for preparation and better patient management.
Emergency Tracheostomy: This is performed urgently to secure the airway in life-threatening situations. Examples include severe airway obstruction due to trauma, infection, or allergic reactions. Speed is crucial in these cases to prevent respiratory failure.

Depending on the Cause:

Permanent Tracheostomy: This is intended for long-term airway management due to chronic conditions that prevent the patient from breathing independently. Examples include:
- Severe spinal cord injuries
- Muscular dystrophy
- Cerebral palsy
- Certain types of laryngeal cancer
- Severe airway obstruction from birth defects
Temporary Tracheostomy: This is used for a limited duration to manage temporary issues with breathing. Examples include:
- Severe airway obstruction due to infection or trauma
- Facilitating mechanical ventilation during recovery from surgery
- Allowing for airway clearance in patients with thick secretions
- Managing post-extubation airway issues

Depending on the Site:

High Tracheostomy: Performed at the level of the 2nd or 3rd tracheal ring. This is often used when the airway obstruction is higher up, like in the larynx or upper trachea. It might also be chosen for cases needing long-term ventilation.
Mid Tracheostomy: This is performed at a level between the high and low tracheostomies. While less common than the other two, it might be chosen based on the specific anatomy of the patient’s airway.
Low Tracheostomy: Performed at the level of the 4th or 5th tracheal ring. This is often used for lower airway obstruction, prolonged ventilation needs, and situations where surgery around the head and neck requires airway bypass.

Tracheostomy Tubes

Tracheostomy tubes are essential for patients requiring a long-term airway management. These tubes come in various types and sizes, designed to meet individual needs and anatomical variations.

Types of Tracheostomy Tubes:

Cuffed: These tubes have an inflatable cuff that seals the trachea, preventing air leaks and aspiration. They are used for mechanically ventilated patients or those at high risk of aspiration. Cuff pressure must be monitored closely to prevent tracheal damage.
Uncuffed: These tubes lack a cuff, allowing air to flow around the tube. They are suitable for patients who can breathe independently and have a low risk of aspiration. Uncuffed tubes also facilitate speaking and coughing.
Fenestrated: These tubes have openings on the outer cannula, allowing air to pass through the vocal cords when the inner cannula is removed. They are used for weaning from ventilation or speech therapy.
Non-fenestrated: These tubes lack these holes, meaning air cannot pass through the vocal cords when the inner cannula is removed. These tubes are typically used for patients who require mechanical ventilation or have a high risk of aspiration.
Double-Lumen: These tubes have two cannulas: a fixed outer cannula and a removable inner cannula. The inner cannula provides a clear passage for air and secretions, minimizing the risk of tube occlusion.
Single-Lumen: Single lumen tubes consist of the outer cannula only (there is not an inner cannula). Most pediatric tracheostomy tubes are single lumen tubes, because their diameters are too small to accommodate an inner cannula. However, the entire tracheostomy tube would require to be changed if an obstruction occurred inside the single lumen tube

Components of a Tracheostomy Tube:

Flange: This flat plate rests on the neck, holding the tube in place. It has holes for securing the tube with ties or straps.
Obturator: A cone-shaped device inserted into the tube during insertion to guide it and prevent tracheal wall injury. It is removed once the tube is in place.
Pilot Balloon: A small balloon connected to a valve, used to inflate or deflate the cuff and indicates its status.
Suction Port: An opening on the tube that allows connection to a suction catheter for removing secretions.

Tracheostomy tube Materials

1. Plastic: Polyvinyl chloride (PVC) and polyurethane are the most common plastics used.

Advantages:

Cost-effective: Plastic tubes are generally the most affordable option.
Disposable: Single-patient use, minimizing the risk of cross-contamination.
Widely available: Easily accessible in institutional settings.

Disadvantages:

Less flexible: Can be less comfortable for patients, especially those with smaller airways.
Potential for irritation: Some patients may experience irritation or allergic reactions to plastic.

2. Silicone:

Advantages:

Soft and flexible: Ideal for pediatric airways and patients with sensitive skin.
Secretion resistance: Silicone tubes are often manufactured without inner cannulas due to their ability to resist secretions.
Reusable: Can be sterilized and reused for the same patient.

Disadvantages:

More expensive: Silicone tubes are generally more costly than plastic tubes.
Less durable: May be more prone to damage or wear over time.

3. Metal (Jackson Tubes): Sterling silver or stainless steel.

Advantages:

Durable: Metal tubes are highly resistant to damage and wear.
Reusable: Can be sterilized and reused for multiple patients.

Disadvantages:

Rigid: Can be uncomfortable for patients and may cause irritation.
Heavy: May be more difficult to manage, especially for patients with smaller airways.
Limited availability: Less common in acute care settings due to their weight and rigidity.
Hub incompatibility: Many metal tubes lack the standard 15mm hub, making them incompatible with ventilator circuits and resuscitation equipment.

Providing Tracheostomy Care

Purposes/Aims of Providing Tracheostomy Care:

Maintain Airway Patency: Remove mucus and encrusted secretions to ensure a clear airway. Prevent airway obstruction due to accumulated secretions.
Prevent Infection: Maintain cleanliness and hygiene around the tracheostomy site. Use sterile techniques during all procedures. Monitor for signs of infection (redness, swelling, discharge).
Promote Healing: Facilitate wound healing and minimize skin excoriation (irritation) around the tracheostomy incision. Apply appropriate dressings to protect the site.
Ensure Comfort: Minimize discomfort associated with the tracheostomy tube. Provide proper positioning and support. Address any complaints of pain or irritation.
Prevent Displacement: Secure the tracheostomy tube to prevent accidental dislodgement. Monitor the tube’s position regularly.
Facilitate Communication: Provide alternative methods of communication for patients who are unable to speak. Use communication boards, writing tools, or sign language.
Improve Quality of Life: Enhance the patient’s overall well-being by improving their ability to breathe and communicate. Promote independence and participation in daily activities.

Pre-operative care for tracheostomy

Psychological preparation of the patient and relatives is very important. They must be reassured that the artificial opening will make the breathing much easier and a simple explanation given to them about the instruments that will be seen around the bed after operation. Simple breathing exercise should be encouraged, it’s important to explain to the patient that forcible breathing is not necessary when a tracheostomy tube is in position.

General Post-operative Care:

Postoperative Management – Immediate Care: Immediate post-operative care should be conducted in an intensive care unit equipped with adequate resuscitation tools.

Positioning: Receive the patient in a warm bed in a recumbent position. Once conscious, place them in a sitting-up position to prevent chest complications. Maintain this position for 48 hours.
Vital Signs: Monitor temperature, pulse, respiration, and blood pressure. Observe for cyanosis, noisy/moist/labored respirations, and increased pulse rate and respirations.
Environment: Ensure a warm room with increased oxygen content in the air, or administer humidified oxygen.
Communication: Provide a pen and paper, and a bell for calling the nurse. Teach the patient to place a finger over the hole of the negus tube if it is not in position.
Monitoring: The nurse should meticulously monitor the patient for vital signs, signs of hemorrhage, and other complications during the first 24-48 hours.
Suctioning: Perform continuous suctioning and cleaning of the inner cannula for the first 12-24 hours post-operatively.

Continuous Post-operative Care:

Humidification: Cover the tracheostomy tube with moist, clean gauze. Change this regularly if it becomes dry or soiled.
Airway Maintenance: Suction and clean the tube as needed. Prevent aspiration of water solutions through the tracheostomy and keep materials that could obstruct the tube away from the opening (e.g., bedsheets). Cover the opening with moistened gauze to prevent flies and insects from entering.
Resuscitation Equipment: Keep appropriate resuscitation equipment at the bedside for any accidents or obstructions.
Obstruction Signs: Assess for signs of obstruction, elevate the head of the bed, and auscultate the chest to determine the need for suctioning.
Respiratory Difficulty: Observe the patient for signs of respiratory difficulty. Note all signs of obstructed airway and take appropriate action. Check for signs of complications and report them immediately while addressing the problem.
Tracheostomy Site: Periodically observe the tracheostomy for signs of trauma or infection.
Asepsis: Practice strict asepsis, especially during suctioning and dressing changes to prevent the introduction of microorganisms into the airway.
Hydration: Provide adequate hydration (approximately 3 liters of fluid intake per day orally or intravenously) to liquefy secretions and maintain fluid balance. Keep accurate records of fluid intake and output.
Gentle Suctioning: Be gentle during suctioning as the tracheal mucosa is delicate. Movement of the tube during suctioning can irritate the site and predispose to infection, fistula, etc. Release the cuff frequently as ordered to relieve pressure on the tracheal wall.
Skin Care: Keep the skin around the tube clean and dry after suctioning. Apply zinc oxide to avoid irritation.
Dressing Changes: Change dressings as needed in an aseptic manner.
Alleviating Fear: Reassure the patient on how to manage with the tracheostomy in place and provide comprehensive health education on tracheostomy care.

Tracheostomy Tube Management:

Tube Changes: The rubber tube is changed by the doctor within 24-48 hours, followed by a silver tube after approximately 5 days.
Cleaning and Aspiration: Keep the tube clean and perform aspiration as needed. The inner tubing can be easily replaced with a spare if necessary, and the contaminated one should be washed under running water and sterilized.
Feeding: Feeding can be done via nasogastric tube or intravenously until the patient can resume normal feeding and swallowing reflex is confirmed by giving sterile water. Once the patient no longer chokes on water, feeding can begin. (Thickened fluids are sometimes easier to manage than thin fluids.) IV fluids are recommended for the first 24 hours, followed by oral fluids. Observe the patient for aspiration.
Hygiene: Frequent mouth washes and personal hygiene should be conducted regularly. Mouth care is essential to prevent the inhalation of septic material.

Post-operative Ambulation:

Mobility: After 48 hours, the patient may be allowed to sit in an armchair or move around the room.
Bath Safety: Never allow the patient to take a bath unattended, and ensure the water is shallow.
Drowning Prevention: If the patient slips, the nurse should immediately pull out the plug to minimize the risk of drowning.

Rules for Tracheostomy Management:

Hand Hygiene: Scrub hands, wear disposable gloves, and a mask.
Sterile Catheters: Use pre-packaged sterile disposable catheters.
Aseptic Technique: Do not allow the catheter to touch anything before aspirating the trachea.
Frequent Suctioning: Perform suctioning as frequently as possible to prevent the accumulation of secretions.
Catheter Disposal: Discard the catheter after each aspiration.
Inner Tube Replacement: Replace the inner tube as needed. Keep a supply of autoclaved tubes readily available.
Cleaning and Dressing: Clean the tracheostomy tubes and renew dressings regularly. Keyhole gauze is commonly used.
Lung Inflation: Always inflate the lungs after each suction session.

Equipment for Tracheostomy Care

Top Shelf	Bottom Shelf	Bedside
Tracheal dilators (various sizes)	Sterile gloves	Hand washing equipment
2 Artery forceps	Mouth care tray	Oxygen cylinder
3 Gallipots	Bell	Screen
2 Receivers	Pen and paper	Suction machine
Pair of scissors	Sodium bicarbonate	Safety box
Tray with 2 small tracheostomy tubes (one smaller than the other)	2 ml syringe
Appropriate suction catheter	A bottle of Normal saline
Three receivers	Protective gears
Sterile dressing pack	Drum of sterile gauze swabs

Tracheostomy Care Procedure

General rules

Introduce yourself and verify the client’s identity using agency protocol.
Explain the procedure to the client, outlining the steps, purpose, and how they can cooperate. Emphasize communication methods like eye blinking or raising a finger to indicate pain or distress.
Maintain infection control through hand hygiene and other appropriate measures.
Ensure client privacy.
Prepare the client and equipment:

Assist the client to a semi-Fowler’s or Fowler’s position to promote lung expansion.
Open the tracheostomy kit or sterile basins and pour the soaking solution and sterile normal saline into separate containers.
Establish a sterile field.
Open other sterile supplies as needed, including sterile applicators, suction kit, and tracheostomy dressing.

Tracheostomy Care Steps:

Suction the tracheostomy tube if necessary, using sterile technique.
Clean the inner cannula: Remove the inner cannula and clean it with the soaking solution using a sterile brush. Rinse thoroughly with sterile saline.
Replace the inner cannula: Securely reinsert the cleaned inner cannula.
Clean the incision site and tube flange: Use sterile saline and applicators to gently cleanse the skin surrounding the tracheostomy.
Apply a sterile dressing: Secure a clean and dry tracheostomy dressing around the tube and flange.
Change the tracheostomy ties: If necessary, change the ties to keep the skin clean and dry.
- Tape and pad the tie knot: Place a folded 4-in. x 4-in. gauze square under the tie knot and apply tape over it to prevent skin irritation and confusion with gown ties.
- Check the tightness of the ties: Frequently assess the tightness of the ties and position of the tracheostomy tube. Swelling of the neck can cause tightness, interfering with coughing and circulation. Loose ties can allow the tube to extrude.
Document all relevant information: Record suctioning, tracheostomy care, and dressing change, including your assessments.

Home Care Modifications:

Emphasize hand hygiene before performing tracheostomy care.
Explain the function of each part of the tracheostomy tube.
Demonstrate how to remove, change, and replace the inner cannula.
Instruct on cleaning the inner cannula two to three times a day.
Teach how to check and clean the tracheostomy stoma.
Explain suctioning technique if necessary.
Assess for infection symptoms (e.g., fever, increased secretions, change in color or odor of secretions).
Encourage parental involvement for children to promote comfort and teaching.
Provide contact information for emergencies.

Suctioning a Tracheostomy Tube:

Suctioning is done only as needed.
Maintain sterile technique.
Be aware of the increased frequency of suctioning during the immediate postoperative period.

Moistening and Filtering the Air

Steps	Action	Rationale
1	Soak a thin piece of gauze in sterile normal saline and place it across the opening of the tube.	To moisten the inhaled air and trap the dust.
2	Tape the gauze in position.	To secure it and prevent dislodging.
3	Document date and time.	To aid follow up of the patient.

Cleaning and Dressing of Tracheostomy Tube

Steps	Action	Rationale
1	Suction the existing tracheostomy tube immediately before removing it out.	To prevent mucus to block the airway as the tube is removed.
2	Remove the inner existing tube and immerse in half strength hydrogen peroxide.	To remove dry mucus secretion and decontaminate the tube.
3	Insert the new tube and tie it with tapes on the outer tube in the following way:	To secure it.
	– Assistant holds the existing tube while the second nurse cuts and removes the tapes from around the patient’s neck.
	– Assistant removes the existing tube while the second nurse immediately inserts the new tube into the stoma and removes the introducer (if applicable).
	– Check the tension of the ties to allow one finger to fit comfortably between the skin and the tapes, adjust if necessary. Finish the tapes by making a reef double knot and cut off any excess fabric leaving approximately 3 cm.
4	Apply a new tracheostomy dressing under the tapes.	To absorb the drainage.
5	Position and observe the patient’s breathing immediately after changing the tube.	To ensure normal breathing.
6	Do post tracheostomy suction.

Dressing Tracheostomy

Steps	Action	Rationale
1	Change the dressings carefully by loosening the soiled dressing from around the tube.	To promote infection prevention.
2	Clean the area with normal saline and dress with a sterile gauze swab.
3	After changing the dressings, check that the tapes of the tubes have not become loose.	To secure the tubes.
4	Document procedure and time.	To aid follow up of the patient.

Final Removal of the Tracheostomy Tubes

Steps	Action	Rationale
1	Cover the tube with a dressing for increasing periods of time (tracheotomy training) before removal of the tube to see how the patient breathes.	It is important to ensure that the patient is able to breathe normally before the tube is removed.
2	After removal, apply a dressing over the stoma until it closes.	To prevent infection.
3	Take the patient’s rate hourly for the first twelve hours.	To monitor breathing.

Points to remember

Change the gauze regularly as needed to prevent drying.
Ensure that the tubes are tied securely in position by tapes around the patients’ neck.
The knot is tied at the side of the patient’s neck.
Deflation of the cuff is only done if ordered by the doctor.
Ensure that the same amount of air is inserted each time.
A sterile inner tube must always be used when replacing.
Tracheotomy sutures are removed on the 7th day following operation, or as ordered by the Doctor.
Endure that there is a communication system at the bedside e.g. pen and paper, bell.
Give the patient a fluid diet or soft diet at first until the patient is accustorr-en to the tube then give a normal diet.
Make sure the patient is carefully observed for any signs of respiratory distress.

Suctioning

Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. The frequency of suctioning varies and is based on individual patient assessment.

Indications for suctioning.

Audible or visible signs of secretions in the tube.
Respiratory distress symptoms.
Suspected blockage or partial blockage of the tube.
Inability of the patient to clear secretions through coughing.
Vomiting.
Decreased oxygen saturation on pulse oximetry.
Changes in ventilation pressures (for ventilated patients).
Patient’s request for suctioning (older children).

Procedure Preparation

Ensure Tracheostomy Kit is present.
Appropriate size suction catheters (with graduations if available).
Tape measure with depth required for tracheostomy tube suctioning.
Setting the suction pressure to the correct range: 80-120mmHg is the recommended suction pressure for tracheostomy tube suctioning, with a maximum pressure of 120mmHg when the tube is occluded. Note that the Medigas suction gauges in use may measure pressure in kPa, with the equivalent of 80-120mmHg being 10-16kPa.

Procedure

Steps	Action	Rationale
1	Observe the general nursing rules.
2	Explain to the patient that the procedure may induce some cough.	To gain the patient’s cooperation.
3	Pinch the suction tube while entering the tracheostomy.	To prevent injury to surrounding tissues and pulling out the tracheostomy tube.
4	Insert the suction tube into tracheostomy tube down according to premeasured individual tracheostomy tube. Control the suction tube and gently suck out the mucus for 5-10 seconds.	To prevent trauma and induction of cough.
5	Then gently withdraw the catheter while maintaining suction until the mucus is completely removed from the tracheostomy tube.	To facilitate adequate air passage and ease breathing.
6	Clear away the used requirements, thank and leave the patient comfortable.	To ensure that the patient is breathing well and resting.
7	Document the procedure.	To promote continuity of care.

Detailed Procedure

Explain to the patient and their family that you are going to suction the tracheostomy tube.
Apply eye protection.
Perform hand hygiene, apply non-sterile gloves.
Remove the mask or breathing circuit.
Peel open suction catheter end and attach to suction tubing, check and adjust suction pressure gauge to between 80 – 120 mmHg.
Utilizing a non-touch technique gently introduce the suction catheter tip into the tracheostomy tube to the pre-measured depth.
Apply finger to suction catheter hole and; gently rotate the catheter while withdrawing. Each suction should not be any longer than 5-10 seconds.
Assess the patient’s respiratory rate, skin colour and/or oximetry reading to ensure the patient has not been compromised during the procedure.
Repeat the suction as indicated by the patient’s individual condition.
Look at the secretions in the suction tubing – they should normally be clear or white and move easily through the tubing. Document changes from normal color and consistency and notify the treating team if the secretions are abnormal color or consistency.
Rinse the suction catheter with sterile water decanted into a container (not directly from the bottle).
Replace suction catheter into the packaging.
Dispose of waste, remove gloves and perform hand hygiene

Note:

Suction catheters are to be routinely replaced every 24 hours or at any time if contaminated or blocked by secretions.
Suction water/and the container to be replaced every 24 hours.
Routine use of 0.9% sodium chloride is not recommended as there is little clinical evidence to support this. However, in situations where this may be of benefit e.g., thick secretions and/or to stimulate a cough 0.5ml of 0.9% sodium chloride can be instilled into the tracheostomy tube immediately prior to the suction procedure.

Special safety considerations:

Some patients may require assisted ventilation before and after suctioning. If required, this will be requested by the parent medical team. If the correct size suction catheter does not pass easily into the tracheostomy tube, suspect a blocked or partially blocked tube and prepare for immediate tracheostomy tube change.

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Perform Gastronomy Feeding

Gastronomy Feeding is feeding of a patient by means of an opening directly into the stomach through the abdominal wall.

They are commonly surgically inserted endoscopically through the abdominal wall, and held in place by an internal balloon or bumper and external fixator. Gastrostomy feeding is a successful method of enteral feeding providing daily nutritional requirements in specialist liquid form directly into a patient’s stomach via a flexible tube.

Indications of Gastrostomy feeding

Inability to Swallow Safely:

Dysphagia: Difficulty swallowing due to neurological disorders, muscular diseases, or structural abnormalities.
Aspiration risk: High risk of food or liquids entering the airway, leading to pneumonia.
Esophageal obstruction: Blockage of the esophagus due to tumors or strictures.
Carcinoma of the esophagus: Cancer of the esophagus.
Strictures of the esophagus: Narrowing of the esophagus, often due to inflammation or scar tissue.
Birth defects of the mouth: Congenital abnormalities affecting the mouth and swallowing ability.
Esophageal atresia: Congenital absence or closure of part of the esophagus.
Problems with sucking or swallowing: Difficulties in patients with debilitated diseases like stroke and dementia.

Prolonged Malnutrition:

Chronic illness: Conditions such as cancer, Crohn’s disease, or cystic fibrosis leading to long-term nutritional deficiencies.
Anorexia nervosa: Eating disorder characterized by extreme food restriction.
Severe weight loss: Inability to maintain adequate weight and nutritional intake.

Impaired Digestion & Absorption:

Short bowel syndrome: Significant reduction in the length of the small intestine, hindering nutrient absorption.
Malabsorption disorders: Conditions affecting the ability to absorb nutrients, such as celiac disease.

Delayed Gastric Emptying:

Gastroparesis: Delayed stomach emptying due to neurological or muscular dysfunction.
Delayed gastric emptying due to medication: Certain medications can slow down gastric emptying.

Coma or Altered Consciousness:

Severe brain injury: Loss of consciousness or inability to swallow safely.
Chronic vegetative state: Persistent unconsciousness without awareness or purposeful movement.

Chronic Vomiting or Reflux:

Severe gastroesophageal reflux disease (GERD): Persistent vomiting and acid reflux leading to malnutrition.
Intractable vomiting: Persistent vomiting despite medical treatment.

Premature Infants:

Premature birth: Infants born before 37 weeks of gestation may have underdeveloped digestive systems and require supplemental feeding.
Failure to thrive: Infants who fail to gain weight or grow adequately.

Operations of the upper gut: Procedures involving the alimentary canal, mouth, nose, and esophagus may necessitate gastrostomy feeding to allow for healing and recovery.

Methods of feeding via a gastrostomy

Bolus feeding: A volume of liquid feed given usually via a gravity set over a short duration, e.g. 15–20 minutes. The feed is usually delivered via a gravity set, relying on the force of gravity to push the feed into the stomach.
Continuous feed: This is a feed given via an electronic feeding pump, which allows clinicians and home caregivers to deliver set amounts of enteral formula in a consistent manner, over a desired duration of time. The pump regulates the rate of feed delivery, ensuring a consistent and continuous flow into the stomach.

Types of Feeding Tubes

Feeding tubes are classified based on their length and retention mechanism:

A. Long Tubes:

Percutaneous Endoscopic Gastrostomy (PEG): A long, flexible tube inserted through the abdominal wall and into the stomach. Placed endoscopically, meaning a thin, flexible tube with a camera is used to visualize the stomach and guide the tube placement. Offers a more minimally invasive approach compared to surgical placement.
Long Balloon-Retention Tube: A longer tube with a balloon at the end that is inflated within the stomach, securing the tube in place. Commonly used for individuals requiring longer-term feeding.
Malecot Tubes: A type of long tube that may be used for short-term feeding and is often used for drainage.

B. Skin-Level Tubes:

Firm Silicone Mushroom Retention: These tubes have a mushroom-shaped end that rests against the stomach lining, preventing accidental tube removal. Examples include Bard feeding tubes.
Balloon Retention: These tubes have a balloon near the end that is inflated inside the stomach, securing the tube in place. Examples include AMT MINI and MICKEY feeding tubes.

Procedure for administration of Gastrostomy feeding.

REQUIREMENTS

A tray containing;

A bowel containing funnel/feeding syringe, rubber tubbing, glass or plastic connection.
Feed at a suitable temperature [37°-38°] 240 to 300mls of strained nourishing fluid in a bowel of warm water.
Towel and mackintosh cape.
Warm water in a glass measure container.
Spigot in a sterile receiver.

At the bedside:

Hand washing facility.
Screen.

PROCEDURE

Steps	Action	Rationale
1.	Observe the general rules of nursing procedure.
2.	Expose the gastrostomy catheter.	To aid easy working.
3.	Protect the bed linen with a mackintosh and towel.	This prevents soiling of the bed.
4.	Wash hands and check temperature of the feed.	To prevent the spread of infection.
5.	Aspirate and measure the stomach content before giving the feed.	To ensure feeds are absorbed.
6.	Pinch proximal end of the gastronomy tube and connect funnel after removing the spigot.	To avoid air entry into the stomach.
7.	Pour 10mls of water into the funnel, let it run through the tube slowly and followed by a prescribed amount of feed. Rinse the tube with 10m Is of warm boiled water.	To ensure patent tube throughout the procedure.
8.	Pinch and disconnect the funnel when feeding is over and replace the spigot.	To prevent air entry into the stomach and backflow.
9.	When the wound has not yet healed carry out gastrostomy toilet i.e. clean skin around the tube with normal saline and apply a protective cream e.g. Zinc Oxide and cover with dry dressing.	To promote healing and prevent infection.
10	Record the type, food amount given, and time.	Monitor input and output.
11.	Provide oral hygiene, clean equipment and leave the patient comfortable.	To prevent infection to the patient.
12.	Clear the trolley and wash hands.	To prevent cross infection.

Complications of Gastrostomy Feeding

1. Tube-Related Complications:

Tube Obstruction: Blockage of the tube due to thickened feed, medications, or debris.
Primary Malposition: Incorrect initial placement of the tube.
Perforation of the Intestinal Tract: A hole in the intestinal wall caused by the tube.
Secondary Displacement of the Feeding Tube: The tube coming out of the stomach or moving out of position.
Knotting of the Tube: The tube becoming tangled within itself.
Accidental Tube Removal: The tube being pulled out of the stomach.
Breakage and Leakage of the Tube: The tube becoming damaged and leaking.
Leakage and Bleeding from Insertion Site: Fluid or blood leaking from the opening where the tube enters the skin.

2. Site-Related Complications:

Erosion, Ulceration and Necrosis of Skin and Mucosa: Damage to the skin and lining around the gastrostomy site.

3. Gastrointestinal Complications:

Intestinal Obstruction (Ileus): A blockage in the intestines.
Hemorrhage: Bleeding from the stomach or intestines.

4. Systemic Complications:

Inadvertent IV Infusion of Enteral Diet: Accidental injection of the feeding formula into a vein.
Infection at the Tube Insertion Site: An infection at the point where the tube enters the body.
Aspiration Pneumonia: Inhaling food or liquid into the lungs.
Nasopharyngeal and Ear Infection: Infection of the nose, throat, and ear.
Peritonitis: Inflammation of the lining of the abdominal cavity.
Infective Diarrhea: Diarrhea caused by infection.

5. Metabolic Complications:

Electrolyte Disturbances: Imbalances in the levels of electrolytes, such as sodium, potassium, and chloride.
Hyper- and Hypoglycemia: High or low blood sugar levels.
Vitamin and Trace Element Deficiency: Lack of essential vitamins and minerals.

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Prepare For Abdominis Paracentesis (Abdominal Tapping)

ABDOMINAL PARACENTESIS/PARACENTESIS ABDOMINIS

Abdominal paracentesis is a sterile surgical procedure in which a needle is inserted into the peritoneal cavity in order to drain out excess ascitic/peritoneal fluid.

This is the procedure done to aspirate fluid from the peritoneal space (ascites).

Paracentesis: it’s removal fluid from the belly. It is commonly called a ‟tap”.(Abdominal Tap)

Tapping of ascites is usually undertaken to take off small volumes of ascites for analysis. This is in comparison to paracentesis where a drain is inserted whereby larger volumes can be removed.

Indications of Abdominal Paracentesis

Specific Indications for Paracentesis:

New-Onset Ascites: Paracentesis is crucial for determining the underlying cause of ascites and differentiating between transudate and exudate.
Suspected Spontaneous or Secondary Bacterial Peritonitis: Paracentesis is performed to diagnose and treat these infections.

Diagnostic Purposes: Chemical, Bacteriological, and Cellular Analysis: Paracentesis allows for the study of the composition of the peritoneal fluid. This helps to diagnose;

Infections: Identifying bacteria or other microorganisms in the fluid can indicate peritonitis (infection of the peritoneum).
Cancer: The presence of cancerous cells can help diagnose certain types of cancer, like peritoneal carcinomatosis.
Other conditions: Analyzing the fluid can help determine the cause of ascites (fluid buildup in the abdomen), differentiate between transudate (fluid with low protein content) and exudate (fluid with high protein content).

Therapeutic Purposes:

Relieving Pressure Symptoms: Paracentesis can relieve discomfort and pressure associated with ascites, such as difficulty breathing, pain, and a feeling of fullness.
Draining Exudate in Peritonitis: In cases of peritonitis, paracentesis can help drain the infected fluid, as a treatment measure.
Creating an Artificial Pneumoperitoneum: This technique involves removing fluid and injecting air into the peritoneal cavity. It’s a less common practice but was once used to treat pulmonary tuberculosis affecting the base of the lungs.
Removing Blood or Pus: Paracentesis can be used to remove blood or pus from the peritoneal cavity in cases of trauma or other medical conditions.

Paracentesis can be performed in two ways:

Ascitic Tap: A small amount of fluid is removed for diagnostic purposes.
Paracentesis: A larger amount of fluid is removed for therapeutic purposes.

Contraindications to Paracentesis:

Bleeding & Severe Jaundice with Impending Hepatic Coma: Tapping in these cases may precipitate hepatic coma, making paracentesis contraindicated.
Uncooperative Patient: Paracentesis requires patient cooperation and a stable condition.
Skin Infection at the Proposed Puncture Site: An infected site increases the risk of complications, making paracentesis inadvisable(abdominal wall cellulitis).
Pregnancy: Paracentesis carries a potential risk to the fetus, making it contraindicated during pregnancy.
Severe Bowel Distension: This can make the procedure more difficult and risky, potentially leading to complications.
Coagulopathy: While opinions differ, some consider paracentesis contraindicated in patients with clinically evident fibrinolysis or disseminated intravascular coagulation (DIC).
Acute abdomen requiring surgery: This is an absolute contraindication for peritoneal fluid analysis.
Severe thrombocytopenia: A platelet count below 20 × 10^3/μL is a relative contraindication.
Distended urinary bladder: A distended urinary bladder is a relative contraindication for the procedure.

Investigations

Prior to Paracentesis

FBC and Clotting Screen: A complete blood count (FBC) and clotting screen assess platelet count and coagulation factors. Thrombocytopenia (low platelet count) can increase bleeding risk, and coagulopathy (impaired clotting) may necessitate platelet transfusion or fresh frozen plasma.
U&E, Creatinine, and LFTs: These tests assess kidney function, electrolyte balance, and liver function, providing insights into overall patient health and potential underlying causes of ascites.
Abdominal Ultrasound: While not always necessary, an ultrasound can be helpful to assess the extent of ascites, visualize the liver, pancreas, spleen, and lymph nodes, and potentially identify underlying pathologies like ovarian carcinoma or metastatic liver disease.

Routine Investigations of Ascitic Fluid

Specific Gravity: This measures the fluid’s density, providing information about the composition and potential cause of ascites.
Cell Count: A cell count assesses the number of white blood cells (WBCs), red blood cells (RBCs), and other cells present in the fluid, aiding in the diagnosis of infection, inflammation, or malignancy.
Bacterial Count: This helps identify the presence of bacterial infection.
Protein Concentrations: Assessing the protein levels helps differentiate between transudate and exudate.
Culture & Sensitivity: This helps identify the causative organism in suspected infections and guide antibiotic treatment.

Additional Investigations

Microscopy: Microscopic examination of the fluid can reveal specific characteristics like:
White Cell Count (WBC): A high neutrophil count (>250 cells/mm3) is diagnostic of Spontaneous Bacterial Peritonitis (SBP).
Red Blood Cell Count (RBC): Higher RBC levels (>1,000 cells/mm3) may raise suspicion of malignancy, such as hepatocellular carcinoma.
Gram Stain: This rapid stain can help identify bacteria, but it’s not always reliable. Samples should also be sent for culture and sensitivity.
Albumin or Protein Levels: Traditionally, ascites was classified as exudate (protein >25 g/L) or transudate (protein <25 g/L). However, the Serum Ascites-Albumin Gradient (SA-AG) is now considered a more reliable measure:
SA-AG = serum albumin concentration – ascitic albumin concentration
SA-AG ≥11 g/L: Suggests causes like cirrhosis, cardiac failure, or nephrotic syndrome.
SA-AG <11 g/L: Suggests causes like malignancy, pancreatitis, or tuberculosis.
Amylase: High levels in ascitic fluid may indicate pancreatitis-associated ascites.
Cytology: Cytology analysis can detect cancerous cells, though the yield is greater with larger-volume samples (>100 ml) and concentration techniques. It’s not as effective for diagnosing primary hepatocellular carcinoma.

Procedure to perform Abdominal Paracentesis

Trolley

Top shelf (with sterile trays)	Bottom Shelf (tray containing)	At the bedside
Bowl with two draper towels:1 fenestrated, 1 non fenestrated Bowl with sterile gauze swabs Bowl with sterile cotton swabs Galipot for antiseptic lotion Receiver with sponge holding forceps, cannula, sterile bottle for specimen if need be. Sterile towel for hand drying Sterile gloves Giving set/sterile drainage tube Drs sterile gown. Sterile calibrated Drainage bottle. Sterile tray containing ( sponge holding forceps, Window towel, 2 Small bowels, Swabs, cotton, 2 ml syringe, Subcutaneous needle, Scalpel blade, Trocar & cannula (Thompson’s ascites brocar & cannula), Suture materials (suture & skin needle, suture, scissors, tissue forceps & artery forceps)	Many tailed bandages Safety pins Adhesive tape/plaster Bottle with antiseptic lotion Lab request form Specimen bottles Tape measure Dressing towel and mackintosh Floor mackintosh Receiver for the used swabs Weighing scale Plastic mackintosh Vital observation tray Emergency tray Unsterile tray containing (Mackintosh & towel, Sterile gloves & masks, Tincture iodine, spirit & tincture benzoin, Novocain 1-2%/Xylocaine 2%, Adhesive tape & scissors, Kidney basins, pint pressure, bucket, IV bottles, backrest & abdominal binder, Spacemen bottles, Patients file, Pillow )	IV stand Screen for privacy Hand washing materials. Cardiac table (with, a bell, newspaper, small pillow)

Procedure

Steps	Action	Rationale
1.	Follow the general rules.
2.	Give a bedpan or urinal before the procedure.	To provide and avoid distractions.
3.	Put the patient in a sitting up position well supported.	Facilitates easy drainage of the fluid.
4.	Turn the bed clothes down to the top of the thighs.	To expose the area required for the procedure.
5.	Roll the gown or jacket up to expose the abdominal area, if it is cold cover the chest.	To prevent soiling it and maintain sterility.
6.	Assist doctor to give local anaesthesia and a small incision is made between the umbilicus and pubis in the left iliac fossa. The cannulae is inserted and secured in position with the strapping.
7.	Give specimen bottles to Doctor for collection of specimen if required.	To aid diagnosis.
8.	Assist the doctor to connect the drainage tubing to the bottle and place it below the bed.	To aid gravity for draining.
9.	Apply the many-tailed bandage firmly around the abdomen, and fasten it with a safety pin.	To secure the abdominal muscles that had been distended.
10.	When the procedure is finished, clear the trolley away and wash hands.	To maintain hygiene
11.	Inspect the many tailed bandages very frequently. Undo it and reapply it firmly as soon as it becomes loose.	To ensure continuous flow of fluids.
12.	When the drainage is finished remove the cannulae and seal the puncture with a sterile dressing.	To prevent infection from entering into the abdomen.
13.	Document the procedure, patient’s conditions and state, amount of drainage.	Monitor and evaluate progress
14.	Observe the patient’s condition and vital signs, half hourly and record while the fluid is draining and after the procedure.	To ensure that the patient’s condition is stable.
15.	The sterile tray for dressing is left at the bedside.	To save time when required

Procedure Care

Greet the patient and explain the procedure: Ensure the patient understands the procedure to gain consent and cooperation.
Provide privacy: Screen the patient and close nearby doors and windows.
Wash hands: Follow proper infection prevention and control protocols.
Prepare the equipment: Gather all necessary supplies and bring them to the bedside.
Weigh the patient: Record the patient’s weight.
Take baseline vital observations: Measure and record blood pressure (BP), pulse, temperature, and respiration.
Ask the patient to empty their bladder: Ensure the bladder is empty just before the procedure.
Position the patient: Usually, position the patient in a supine position with the head of the bed elevated to allow fluid to accumulate in the lower abdomen.
Remove the top linen: Expose the area to be worked on.
Take the abdominal circumference: Use a tape measure to record the abdominal circumference.
Undo the top clothing: Expose the necessary parts of the body.
Apply the dressing towel and mackintosh: Protect the bed with these materials. Place the floor mackintosh on the floor and the bottle on top.
Clean the site: Ensure the area is properly cleaned.
Apply sterile drapes: Maintain a sterile field.
Insert the cannula and connect to tubing: Secure the cannula at the site with plaster.
Pick sample, label, and prepare for lab delivery: Ensure the sample is correctly labeled.
Monitor vital observations and output flow throughout: Keep a close watch on the patient’s vitals and the fluid output.
When the required amount of output is reached, disconnect and secure the site: Ensure the site is properly secured after disconnection.
Repeat weight, abdominal circumference measurement, and post-procedure vital observations: Record these measurements.
Measure the content and record: Document the amount of fluid removed.
Thank the patient: Show appreciation and ensure the patient feels comfortable.
Leave the patient comfortable: Redress the patient with clothes and beddings and ensure a comfortable position.
Clear away and document the procedure: Properly clean up and document the procedure in the nurse’s record sheet.

Post-procedure Care

Apply an abdominal binder: Apply tightly from top to bottom to maintain intra-abdominal pressure.
Monitor the patient’s general condition: Report any changes in color, pulse, respiration, and BP immediately.
Examine the dressing at the puncture site: Check frequently for any leakage and reinforce the dressing if necessary.
Administer analgesics: Provide pain relief if the patient is in pain.
Send the specimen to the lab: Ensure the specimen is sent to the lab with a requisition form.
Replace and clean the articles: Make sure all used articles are cleaned and stored properly.
Wash hands thoroughly: Follow proper hand hygiene protocols.
Record the procedure: Document all details in the nurse’s record sheet.

Complications

Fainting: May occur if a large amount of fluid is removed. Prevent by applying an abdominal binder.
Peritonitis
Significant bleeding
Infection
Renal failure: Can occur due to reduced systemic circulation.
Hyponatremia: Resulting from repeated tapping.
Hepatic encephalopathy
Complicated bowel perforation
Paracentesis leak
Injuries to abdominal organs
Hypovolemia: Can lead to shock if fluids are drained rapidly.

Sites and Positioning of Patients for Abdominal Paracentesis

Sites

Midline Site: The common site is midway between the symphysis pubis and the umbilicus on the midline. This site is chosen to avoid injury to the urinary bladder and other abdominal organs.
Alternative Site: A point two-thirds along a line from the umbilicus to the anterior superior iliac spine can also be used.

Positioning

The client is positioned in Fowler’s position, supported by a backrest and pillows, near the edge of the bed.

Precautions

Aseptic Conditions: Paracentesis must be performed under strict aseptic conditions to avoid introducing infection into the peritoneal cavity. Limit catheter drainage time to less than 6-8 hours (some authorities suggest four hours) to reduce infection risk.
Setting: Can be performed in a hospice or ambulatory setting, provided sterile precautions are taken, preventing the need for hospital admission.

General Instructions

Explanation: Provide adequate explanations to gain the client’s confidence and cooperation, crucial for preventing injury to adjacent organs.
Aseptic Technique: Strict aseptic technique must be followed to prevent infection.
Bladder Management: Ask the client to void 5 minutes before the procedure to prevent bladder injury. Catheterize if any doubt exists.
Comfort: Keep the client warm and comfortable to prevent chills.
Shock Prevention: Be prepared to treat shock:
- Withdraw fluid slowly and apply clamps on the tubing.
- Withdraw small quantities of fluid at a time.
- Apply pressure on the abdomen with a many-tailed bandage, tightening it from above downwards as the fluid is drained.
- Keep the client warm.
- Continuously observe vital signs during the procedure.
Drainage Management:
- Raise the drainage receptacle on a stool. The greater the vertical distance between the tapping needle and the end of the tubing in the drainage receptacle, the faster the fluid is drained, increasing the risk of shock.
- Use a smaller gauge tapping needle/trocar to reduce puncture wound size and fluid leakage risk post-procedure.
- Control the fluid flow using clamps on the tubing.
- The nurse should remain with the client throughout the procedure to observe general condition and report any changes in color, pulse, respiration, or blood pressure to the doctor immediately, as these may indicate vascular shock and collapse.
Post-procedure Management:
- Repeated aspirations of ascitic fluid can result in hypoproteinemia; administer plasma protein if needed.
- Seal the wound immediately after the procedure to prevent infection and fluid leakage.
- Send collected specimens to the laboratory promptly.

Aftercare of the Client

Wound Care: Apply a sterile dressing and pressure bandage at the puncture site immediately after needle removal to prevent fluid leakage.
Abdominal Bandage: Tighten the abdominal bandage to maintain intra-abdominal pressure.
Monitoring: Check the client’s general condition after the procedure.
- Any changes in color, pulse, respiration, and blood pressure should be reported immediately.
- Vital signs should be checked half-hourly for two hours, then hourly for four hours, followed by four-hourly checks for 24 hours.
Specimen Handling: Send collected specimens to the laboratory with labels and a requisition form.
Dressing Examination: Frequently examine the dressing at the puncture site for any leakage. Reinforce the dressing if leakage is present.
Protein Levels: Estimate serum proteins to detect hypoproteinemia. Administer plasma proteins if hypoproteinemia is present.
Documentation: Record the procedure in the nurse’s record with date and time. Note the amount and character of the fluid drained, its color, and the effects of the treatment on the client.
Cleaning Equipment: Clean all used articles by washing with cold water, then warm soapy water, and rinse in clean water. Dry and send for autoclaving.

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