Foundations - Nurses Revision

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.

Carry Out Gastric Lavage Read More »

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.

Prepare For Lumbar Puncture Read More »

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.

Prepare For Abdominis Paracentesis (Abdominal Tapping) Read More »

PERFORM SHORTENING AND REMOVAL OF DRAINS

SHORTENING OF DRAINS

Shortening and removal of drains refers to the process of adjusting or cutting to an appropriate length and then removing medical devices that are used to drain fluids or provide access to specific areas within the body

A drain: A surgical implant that allows removal of fluid and/or gas from a wound or body cavity.

Examples of Drains

Nasogastric Tube (NG Tube): This is used to drain stomach contents or provide nutrition. Shortening and removal may be necessary when the tube is no longer needed or needs adjustment.
Catheters: Catheters can refer to various types, such as urinary catheters and central venous catheters. Shortening and removal may be needed when the catheter is ready to be taken out.
Ventriculoperitoneal Shunts (VP Shunts): These are used to manage excess cerebrospinal fluid in the brain. While they are typically removed in a surgical procedure, adjustments or revisions may be needed during a patient’s treatment.
Vascular Access Ports: These are used for long-term intravenous treatments. Ports are typically removed when they are no longer required, such as when a patient completes chemotherapy.
Jackson-Pratt Drain (JP Drain): Used to remove fluids that build up in surgical sites, such as after a mastectomy or abdominal surgery. They are typically removed when the drainage decreases to an acceptable level.
Hemovac Drain: Similar to the JP drain, the Hemovac drain is used to remove blood and fluids from surgical sites. It is also removed when drainage decreases.
Penrose Drain: A soft, flat rubber tube used to allow drainage from a wound. It may be removed when the wound has healed sufficiently.
Chest Tube: Inserted into the chest to remove air or fluids, often in cases of pneumothorax or pleural effusion. They can be removed when they are no longer needed.
Biliary Drainage Tube: Used to drain bile from the liver or gallbladder when there is a blockage. Removal depends on the patient’s condition and the resolution of the blockage.
Ureteral Stent: Placed in the ureter to promote urine flow, often after urological surgeries. They may need to be shortened or removed when they are no longer needed.
Gastrostomy Tube (G-tube): Used for long-term enteral feeding, often in patients who cannot eat normally. Removal may be considered when the patient can resume oral feeding.

Indications of Drains

Nasogastric Tube (NG Tube):

Gastric decompression: To remove stomach contents and gas to relieve abdominal distention.
Enteral feeding: To provide nutrition and medications when oral intake is not possible.
Gastric lavage
Medication administration

Foley Catheter (Indwelling Urinary Catheter):

Urinary retention: To relieve the inability to urinate.
Monitoring urinary output: In critically ill or surgical patients.
Post-operative use: For surgeries involving the urinary tract.
Bladder irrigation
Urologic procedures

Ventriculoperitoneal Shunt (VP Shunt):

Hydrocephalus: To divert excess cerebrospinal fluid (CSF) from the brain to the abdominal cavity.
Normal pressure hydrocephalus (NPH): To manage the accumulation of CSF in older adults.
Traumatic brain injury
Meningitis

Central Venous Catheter (CVC):

Intravenous medications and fluids: To administer chemotherapy, total parenteral nutrition (TPN), or other treatments.
Hemodialysis access: For patients with renal failure.
Frequent blood draws: In critically ill patients or those with challenging peripheral access.
Long-term parenteral nutrition (TPN)
Transfusion of blood products
Cardiac monitoring and pacing
Administration of chemotherapy
Emergency resuscitation

Thoracostomy Tube (Chest Tube):

Pneumothorax: To remove air from the pleural space.
Pleural effusion: To drain fluid or blood from the pleural cavity.
Post-surgical use: After thoracic surgery to prevent pneumothorax or pleural effusion.
Hemothorax
Empyema
Lung abscess
Trauma
Pulmonary embolism

Classifications of Drains

Drains are categorized based on various factors, including their functionality and design. Here, we discuss the classifications of drains:

Open vs. Closed Drains

Open Drains:

These drains include corrugated rubber or plastic sheets.
Drain fluid collects in a gauze pad or stoma bag.
Simpler design and less expensive: They are typically cheaper and easier to assemble compared to closed drains.
Can drain large volumes of fluid: They have a larger drainage capacity and can handle significant fluid buildup.
Easier to monitor: They allow visual inspection of the drainage, making it easier to assess the volume and type of fluid.
They increase the risk of infection.
Example: Penrose drain.

Closed Drains:

Consist of tubes draining into a bag or bottle.
Reduced risk of infection: They create a sealed system, minimizing the risk of contamination and infection.
More precise fluid measurement: They provide a more accurate measure of the volume of drainage.
Less risk of leakage: The closed system reduces the chance of drainage leaking out.
Can be connected to suction devices: They can be easily connected to suction devices for continuous drainage.
These drains include chest and abdominal drains.
The risk of infection is reduced.
Example: Jackson-Pratt drain.

Active vs. Passive Drains

Active Drains:

Active drains are maintained under suction, which can be low or high pressure.
Both open (e.g., Sump drain) and closed (e.g., Jackson-Pratt, Hemovac drain) drains can be active.

Advantages of Active Drains:

More efficient drainage: They provide continuous suction or pressure, leading to faster and more complete drainage.
Can handle larger volumes of fluid: They are designed to handle significant fluid buildup and can be more effective in removing blood clots.
Reduced risk of infection: The continuous drainage can help prevent bacterial growth and reduce the risk of infection.
Keep the wound dry.
Efficient fluid removal.
Can be placed in various locations.
Prevent bacterial ascension.
Allow evaluation of the volume and nature of fluid.

Disadvantages of Active Drains:

More complex and expensive: They require a power source or other components, which can increase the cost and complexity.
Higher risk of malfunction: They have a greater chance of malfunction or failure compared to passive drains.
More difficult to manage: They require more specialized knowledge and may necessitate frequent adjustments and monitoring.
High negative pressure may injure tissue.
Drains can be clogged by tissue.

Passive Drains:

Passive drains operate without suction and rely on pressure differentials, overflow, and gravity between body cavities and the exterior.
Passive drains include closed (e.g., NGT, Foley’s catheter, T-Tube) and open (e.g., Penrose drain, corrugated drain) drains.

Advantages of Passive Drains:

Simpler design and less expensive: They are typically less complex and cost-effective compared to active drains.
Less risk of complications: They generally have a lower risk of malfunction or infection compared to active drains.
Easier to manage: They require less maintenance and can be managed by nurses and other healthcare professionals.
Allow evaluation of volume and nature of fluid.
Prevent bacterial ascension.
Eliminate dead space.

Disadvantages of Passive Drains:

Less efficient drainage: They rely on gravity and may not drain fluids effectively, especially in large volumes.
Increased risk of infection: The open design increases the risk of contamination and infection.
Difficult to monitor drainage: The drainage volume may be difficult to measure accurately, leading to potential complications.
Gravity differences may affect the location of the drain.
Drains can easily become clogged.

Types of Drains:

Pigtail Drain:

Inserted under radiological guidance: This ensures precise placement and minimizes complications.
Used to remove unwanted body fluids from organs, ducts, or abscesses: This includes fluids like pus, bile, blood, or urine.
The tip forms a pigtail shape, facilitating drainage: This shape helps prevent the drain from getting clogged and ensures efficient removal of fluids.
Advantages:

Can be placed in difficult-to-reach areas.
Low risk of tissue damage due to its flexibility.
Effective in draining thick, viscous fluids.

Disadvantages:

May be prone to blockage.
Requires radiological expertise for insertion and maintenance.

Hemovac Drain:

A fine tube with multiple holes at the end: Allows for efficient collection of fluids from a larger area.
Attached to an evacuated glass bottle for suction: Provides continuous suction, promoting rapid drainage.
Drains blood under the skin: Often used for post-operative drainage following surgery or trauma.
Advantages:

Efficient in removing blood and other fluids.
Provides constant drainage, reducing the risk of blood clots forming.

Disadvantages:

Risk of suction malfunction or breakage.
May cause discomfort or pain if placed incorrectly.
Requires regular emptying and monitoring.

Penrose Drain (Open Drain):

A soft, flexible drain: Easy to insert and adapt to various anatomical structures.
Empties into absorptive dressing material passively: Relies on gravity and capillary action for drainage.
Prevents fluid from moving from areas of greater pressure to areas of lesser pressure: Helps control fluid accumulation and reduce swelling.
Advantages:

Simple design and low cost.
Can be used for short-term drainage.
Minimal risk of mechanical complications.

Disadvantages:

Less efficient drainage than closed systems.
Increased risk of infection due to the open design.
Not suitable for large volume drainage or high-risk areas.

T-Tube:

Placed into the common bile duct: Allows for drainage of bile after biliary surgery.
Connected to a small pouch (bile bag): Collects and allows for easy monitoring of bile drainage.
Used for temporary post-operative drainage of the common bile duct removed once the bile duct is healed.
Advantages:

Helps prevent bile duct obstruction.
Facilitates healing by allowing bile to drain.
Allows for monitoring of bile drainage.

Disadvantages:

Can cause discomfort or pain.
Requires regular emptying and monitoring.
May be prone to blockage or leakage.

Chest Tube (Closed Drain):

Used to drain hemothorax, pneumothorax, pleural effusion, chylothorax, and empyema: Effective for removing fluid and air from the chest cavity.
Inserted into the pleural space in the 4th intercostal space above the upper border of the rib below (4th to 6th): Requires careful placement to ensure effectiveness and minimize complications.
Advantages:

Efficient in removing fluids and air from the chest cavity.
Reduces pressure on the lungs, allowing for better breathing.
Minimizes the risk of infection due to the closed system.

Disadvantages:

Requires specialized training and equipment for insertion and management.
Can cause pain or discomfort.
May be prone to kinking or blockage.
Complications to assess for include arterial thrombosis, air embolism, hematoma, bleeding, and infection.

Nasogastric Tube (NG Tube):

Passed through the nostrils to the stomach: Allows for access to the stomach for various procedures.
Indications include gastric juice aspiration, lavage in cases of poisoning, overdose medication, and feeding: Versatile tool for managing stomach contents and providing nutritional support.
Advantages:

Provides access to the stomach for various procedures.
Relatively safe and easy to insert.
Can be used for short-term or long-term management.

Disadvantages:

Can cause discomfort or irritation.
May cause nausea or vomiting.
Complications include epistaxis, aspiration, and erosions in the nasal cavity and nasopharynx.

Urinary Catheters:

Hollow, flexible tubes used to collect urine from the bladder: Provides a way to drain urine from the bladder.
Indications include relieving urinary obstructions, managing bladder weakness or nerve damage, draining the bladder during and after surgery, and treating urinary incontinence: Essential for managing urinary issues and ensuring bladder health.
Catheter materials can include rubber, silicone, or latex
Advantages:

Allows for effective urine drainage.
Reduces urinary tract infections.
Provides a way to monitor urine output.

Disadvantages:
Can cause discomfort or pain.
Risk of infection if not properly maintained.
May be associated with bladder stones or urinary retention.

PROCEDURE FOR SHORTENING AND REMOVAL OF DRAINS

Requirements

Top Shelf	Bottom Shelf
Stitch removing pack containing	Bottle of antiseptic solution
– Stitch Scissors
– Non-toothed dissecting forceps
– 2 dressing forceps
– Cotton wool swabs
– Gauze
– Sterile gloves
– Sterile safety pin
– Sterile dressing towel
– Receiver

Procedure

Removal of a Drain

Steps	Action	Rationale
1.	First clean the wound as for surgical dressing.	To reduce the risk of spreading infections.
2.	Cut and remove the stitch between the drain and the skin.	To loosen the drain.
3.	Take out the drain and place it in a receiver.	To prevent cross-infection.
4.	Gently compress the area, clean the wound, and apply a dressing.	Compression is done to drain the wound.
5.	Finish up as for simple dressing.	To protect against inversion of microorganisms.
6.	Document procedure.	For follow-up care.

Shortening of a Drain

Steps	Action	Rationale
1.	Clean wound as for surgical dressing.	To prevent cross-infection.
2.	Pull the drainage tube with the dissecting forceps. If it is the first dressing post-operatively, there will be a need to cut the stitch between the drain and the skin before adjusting to the prescribed length.	To loosen the drainage.
3.	Use sterile forceps or gloves to insert the safety pin across the drain and to close the pin.	To secure the drain in position and to prevent infection.
4.	Dress the wound and finish as for a simple dressing.	To prevent inversion of microorganisms.
5.	Document the procedure.	For easy continuity of care.

Hospital Standards Procedures.

Emptying a Drain

Steps	Action	Rationale
1.	Perform hand hygiene.	Hand hygiene reduces the risk of infection.
2.	Collect necessary equipment.	Having the required supplies readily available, such as a drainage measurement container, non-sterile gloves, waterproof pad, and alcohol swab, ensures a smooth and efficient procedure.
3.	Apply non-sterile gloves and goggles or a face shield where necessary.	Personal protective equipment (PPE) reduces the transmission of microorganisms and protects against accidental exposure to body fluids.
4.	Maintaining principles of asepsis, remove the plug from the pouring spout as indicated on the drain.	Aseptic technique is crucial to prevent contamination. Opening the plug away from your face reduces the risk of accidental splashing of body fluid.
5.	Gently tilt the opening of the reservoir toward the measuring container and pour out the contents. Note the character of drainage: color, consistency, odor, and amount.	Pouring away from yourself prevents exposure to body fluids. Monitoring and documenting the characteristics of drainage are essential for patient care and record-keeping.
6.	Swab the surface of the pouring spout and plug with an alcohol swab. Place the drainage container on the bed or a hard surface, tilt it away from your face, and compress the drain to flatten it with one hand.	Swabbing with alcohol maintains cleanliness. Flattening the drain before closing helps expel air, ensuring efficient functioning of the drainage system.
7.	Place the plug back into the pour spout of the drainage system, maintaining asepsis.	Reinserting the plug while maintaining aseptic principles reestablishes the vacuum suction in the drainage system.
8.	Secure the device onto the patient’s gown using a safety pin; ensure the drain is functioning; make sure that enough slack is present on the tubing.	Securing the drain minimizes the risk of inadvertent removal. Providing adequate slack accommodates patient movement and prevents tension at the drain insertion site.
9.	Discard drainage according to agency policy.	Proper disposal procedures protect healthcare workers against exposure to blood and body fluids.
10.	Remove gloves and perform hand hygiene.	Hand hygiene should be performed after removing gloves, as gloves are not puncture-proof or leak-proof. Hands may become contaminated during glove removal.
11.	Document the procedure and findings accordingly. Report any unusual findings or concerns to the appropriate healthcare professional.	Documentation ensures accurate recording of drainage and any changes. If multiple drains are present, numbering and noting their locations in the chart is essential. Any significant changes or concerns must be reported to the healthcare provider per agency policy.

Removal of Drains

Steps	Action	Rationale
1.	Confirm that the prescriber’s order correlates with the amount of drainage in the past 24 hours.	Ensuring the prescriber’s order aligns with recent drainage amounts is crucial for safe removal. It helps avoid early removal if the drainage is not yet at an acceptable level.
2.	Explain the procedure to the patient; offer analgesia and a bathroom visit as required.	Patient education and offering analgesia reduce anxiety about the procedure. Preparing the patient for the sensation they might experience during removal promotes cooperation. Analgesia ensures comfort during the procedure.
3.	Assemble supplies at the patient’s bedside: dressing tray, sterile suture scissors or sterile blade, cleansing solution, tape, garbage bag, outer dressing.	Organizing supplies in advance ensures efficiency and readiness for the procedure, enhancing patient safety and comfort.
4.	Apply a waterproof drape or mackintosh for setting the drain onto once it has been removed.	This provides a designated place for the removed drain, preventing contamination and maintaining cleanliness.
5.	Perform hand hygiene.	Hand hygiene before the procedure reduces the risk of introducing microorganisms from other sources to the patient.
6.	Apply non-sterile gloves and PPE accordingly.	Wearing non-sterile gloves and appropriate PPE as assessed at the point of care reduces the risk of transmission of microorganisms and provides added protection against contamination.
7.	Release suction on the reservoir and empty; measure and record volumes greater than 10 ml. Remove the dressing.	Releasing suction ensures safe removal. Measuring and documenting the drainage volume is crucial for patient care and record-keeping.
8.	Clean and dry the incision and drain site following principles of asepsis.	Preparing the wound and surrounding area through aseptic cleaning minimizes the risk of infection.
9.	Carefully cut and remove the securing suture following principles of asepsis.	Removing the suture safely is essential to avoid complications and ensure smooth removal of the drain.
10.	While holding two to three 4 × 4 sterile gauze in the non-dominant hand, stabilize the skin.	Sterile gauze helps absorb any additional drainage during the removal process, reducing the risk of introducing microorganisms. Stabilizing the skin minimizes discomfort to the patient during the procedure.
11.	Ask the patient to take a deep breath and exhale slowly; remove the drain as the patient exhales. Firmly grasp the drainage tube close to the skin with the dominant hand, and with a swift and steady motion, withdraw the drain.	Patient cooperation, distraction, and timed removal reduce discomfort. The gentle resistance felt during removal is expected, but if resistance is strong, taking a pause and encouraging relaxation is essential.
12.	Place the drain and tubing onto a waterproof pad or into a garbage bag. Remove gloves.	Proper disposal prevents contamination of the environment and maintains hygiene.
13.	At this point, some nurses may clean and dry the wound.	The decision to clean the wound can vary based on the specific situation and healthcare provider’s preferences.
14.	Dress the wound with a sterile dressing.	Dressing the wound post-removal is essential as drain sites may continue to drain for a few days.
15.	Discard the drain and garbage.	Proper disposal follows agency policy and decreases the risk of exposure to blood and body fluids for others.
16.	Perform hand hygiene.	Hand hygiene after the procedure minimizes the risk of contamination.
17.	Assess the dressing 30 minutes after drain removal. Likewise, ask the patient to call if they notice any increased drainage from the site.	Monitoring for changes in drainage after removal is essential for patient safety and early detection of complications.
18.	Document the procedure (including drain removal, drain output and characteristics, how the patient tolerated the procedure, dressings applied) accordingly. Report any unusual findings or concerns to the appropriate healthcare professional.	Accurate and timely documentation and reporting are crucial for patient care and safety, ensuring that any concerns are addressed promptly.

CARE OF WOUNDS WITH DRAINAGE

Important Points in the Care of Closed Drainage

Step	Action	Rationale
1	Maintain the end of the tube from the wound below the water in the drainage bottle.	This prevents air from passing back up the tube into the wound.
2	Seal the tubing first with either clips or artery forceps before emptying the bottle.	To prevent air entry into the lungs.
3	Measure the amount of water or antiseptic in the drainage bottle and subtract this amount from the total when measuring the drainage.	To get the correct amount of fluid drained from the wound.
4	Observe for any abnormal deposits, colour, and odour.	To aid diagnosis and follow up/progress.
5	Keep a clip or artery forceps at the bedside incase of an accident to the tubing.	To be able to clip the tube immediately to prevent air going to the lungs in case of accident to the tubing.
6	Maintain sterility of the bottle and should never be lifted up to the bed level or above.	To maintain asepsis and also to prevent back flow of fluid from the drainage chamber to the pleural cavity.

PERFORM SHORTENING AND REMOVAL OF DRAINS Read More »

Administer drugs appropriately

Administer Prescribed Medicines Appropriately

A medicine is any chemical substance in a regulated dose intended for use in the medical diagnosis, cure, treatment, or prevention of disease or any substance that is prescribed and administered to patients to produce therapeutic effects in the body.

Rights Related to Medicine Administration

The rights that should be observed:

Right patient.
Right medicine.
Right dosage.
Right route.
Right time.
Right storage.
Right formulation.
Right disposal.
Right site.
Right equipment.

Routes Used in Administering Medicines

SYSTEMIC ROUTE

ENTERAL ROUTE

Oral: Drugs taken by mouth, including tablets, capsules, liquids, and suspensions, that are absorbed through the stomach or intestinal lining.
Sublingual: Drugs placed under the tongue that dissolve and are absorbed into the bloodstream via the tissues under the tongue, providing rapid onset of action.
Buccal: Drugs placed between the gums and cheek, where they dissolve and are absorbed into the bloodstream through the buccal mucosa.
Rectal: Suppositories or enemas administered into the rectum, where they are absorbed through the rectal mucosa.

PARENTERAL ROUTE

Injections:

Intravenous (IV): Direct injection into a vein for immediate systemic effect.
Intramuscular (IM): Injection into a muscle, where the drug is absorbed into the bloodstream.
Subcutaneous (SC): Injection into the fatty tissue under the skin.
Intra-arterial: Injection directly into an artery, typically used in specialized medical procedures.
Intra-articular: Injection into a joint space for local effect.
Intrathecal: Injection into the cerebrospinal fluid in the spinal canal.
Intradermal: Injection into the dermis layer just beneath the epidermis, often used for allergy testing and tuberculosis screening.
Epidural: Injection into the epidural space surrounding the spinal cord, commonly used for pain relief during labor and surgery.
Intraperitoneal: Injection into the peritoneal cavity in the abdomen, used in some chemotherapy treatments.
Intracardiac: Injection directly into the heart muscle, often used in emergencies.

LOCAL ROUTE

Skin topical: Application of creams, ointments, gels, or lotions to the skin for local treatment of skin conditions.
Intranasal: Sprays or drops administered through the nasal passages for local or systemic effect.
Ocular drops: Solutions or suspensions administered into the eyes to treat local conditions like infections or glaucoma.
Otic drops: Solutions administered into the ear canal to treat local ear conditions such as infections.
Intraosseous: Injection directly into the bone marrow, used in emergency situations when IV access is not available.
Intralymphatic: Injection into the lymphatic system, used in certain cancer treatments and vaccinations.
Intrapleural: Injection into the pleural space surrounding the lungs, used for treating pleural effusions and certain cancers.
Inhalation: Drugs administered through the respiratory tract, typically using inhalers or nebulizers, for rapid absorption into the bloodstream via the lungs.
Transdermal: Patches or gels applied to the skin that release the drug slowly for absorption over time.
Mucosal:

Throat: Lozenges, sprays, or gargles for local treatment of throat conditions.
Vaginal: Creams, tablets, or rings inserted into the vagina for local treatment of infections or hormonal therapy.
Rectal: Suppositories or enemas for local treatment of rectal or lower gastrointestinal conditions.

INHALATION

Inhalation is the breathing of air vapor or volatile medicine into the lungs.

Types

Dry inhalation: Oxygen Administration: this is given when the respiratory capacity is diminished as in chest injuries, pneumonia and cardiac failure.
Moist/steam inhalation: It is used in case of inflammation of air passages and the nasal sinuses. These are given to:

Warm and moisten the air breathed in and relieve irritation e.g. in bronchitis, after tracheotomy and other chest conditions.
To relieve inflammation and coughing e.g. in colds.
To relieve congestion and oedema e.g. in sinusitis and acute laryngitis.
Nebuliser: this produces vapors which is inhaled by the patient for example in asthma to relieve spasms of the bronchial tubes or for the relief of chest pain in angina pectoris. Other indications include Respiratory diseases eg asthma, pneumonia, Airway obstruction, Nasal congestion, Nasal bleeding, Chest injuries and Cardiac failure.

Forms of Medicines

Liquids:

Solutions: Medicine dissolved in water.
Syrups: Medicine dissolved in sugar and water.
Mixtures: Medicine mixed with liquid but not dissolved in it.
Milks: White medicine substances mixed with water.
Emulsions: Medicine mixed with oil and water.
Elixirs: Medicine dissolved in a sweetened flavored solution containing alcohol.
Tinctures: Medicine dissolved in alcohol or alcohol and water.
Fluidextracts: Medicine that has been boiled and evaporated to concentrate their strength and dissolve them in alcohol.
Liniments: Medicine mixed in oil, soap, or alcohol (for external use only).
Lotion: Mixed with water for external application.

Solids and Semisolids:

Capsules: Medicine enclosed in gelatine containers used for liquids, powders, and oils.
Powders: Medicine in powder form.
Pills: Medicines molded in a round shape coated with sugar.
Tablets: A solid dosage form of varying weight, size, and shape.
Enteric Coated Tablets: A tablet coated with a substance that blocks absorption of the medicine until it reaches the small intestines.
Lozenges: To be dissolved in the mouth for throat or oral treatment.
Ointment: Medicines mixed with oil or fat.
Pastes: Ointments with various powders added.
Suppositories: Medicines mixed with a firm base, which can be molded for insertion into a body cavity.
Ampoules: Sealed glass containers that contain a dose of powdered or liquid medicine.
Vials: Rubber-stoppered glass containers that may contain a single or several doses of medicines.

Time for Administering Medication

Four hourly: (eight times in 24 hours) 2 am., 6 a.m., 10 a.m., 2 p.m., 6pm, and 10 p.m.
Six hourly: (four times a day) 6 a.m., 12 p.m., 6pm, and 12 midnight.
Eight hourly: (three times a day) 6 a.m., 2 p.m., and 10 p.m.
Twelve hourly: (twice daily) 6 a.m. and 6 p.m.

Abbreviations Used in Prescriptions

Aa.: of each
Ad lib.: as much as desired
B.i.d. or b.d.: twice a day
t.d.s. or t.i.d.: three times a day
a.c.: before
P.c.: after
g.: gram
Gr.: grain
Gutt.: a drop
Mane: in the morning
Mist.: a mixture
Nocte: at night

q.h.: every hour
o.m.: every morning
o.n.: every night
p.r.n.: whenever necessary
q.4h: every 4 hours
s.o.s.: if necessary in an emergency
Stat: immediately
q.i.d.: 4 times a day/every 6 hours
o.d.: once a day

GENERAL RULES OF DRUG ADMINISTRATION

Read the instructions carefully and incase of any doubt ask the Doctor or ward in charge.
Never give a drug from a container or a bottle which is not clearly labeled.
Check the label against the instructions 3 times .The 1 st time before having the container, 2nd time before the drug is drawn, 3rd time before the drug is administered to the patient.
Give the drug following 10Rs i.e -right patient, right time, right dose, right route, right drug/medication, right formulation, right disposal, right storage, right equipment and right site.
Once a drug is drawn from its container it shouldn’t be returned.
Always identify the drug by reading its label on the container not by its color, smell, shape and size.
Do not transfer drugs to another container when the old label is still on.
Ask for clarification if any order regarding the dose is not readable.
Watch all patients for drug reactions, especially parental drugs.
If any drug changes its color, it should not be administered.
Liquid preparations should always be shaken before drawing from the bottles.
Never use a drug which has been left in an unlabeled container.
Always measure the dose of the drug in good light.
Observe strictly the time of administration of medication.

ORAL ADMINISTRATION

Requirements

Trolley

Top Shelf:

Bottles of mixtures
Bottle or boxes of tablets, capsules
Medicine cups
Teaspoons, mortar and pestle
Jug of drinking water, milk/fruit juice
Glasses
Medicine charts
Small medication tray
Scissors
Kidney dish

Bottom Shelf:

1 bowl of soapy water

Bedside:

Hand washing equipment

Procedure for Oral Administration

Steps	Action	Rationale
1.	Follow general rules of nursing procedures.	Ensures accuracy and prevents errors
2.	Observe the rules of medicine administration.	Ensures accuracy and prevents errors
3.	Arrange medication trolley in nurse’s station.	To save time and reduce error in medication administration
4.	Prepare medicine of one patient at a time, keeping medicine lists/charts together.	Ensures accuracy and prevents errors
5.	Verify the order for medication from the patient’s chart comparing with the medicine list and the label on the bottle.	Ensures accuracy
6.	Check the label on the medicine container three times (i.e. when taking it from the shelf, before pouring it into the medicine cup and before returning it to the shelf).	Ensures accuracy
7.	For tablets/capsules, pour required number from bottle into bottle cap and transfer to medication cup, for packaged tablet/capsule pour directly over the cup retain the strip.	Reduces errors in medication administration
8.	For liquid, hold medication cup to eye level and pour the prescribed amount.	Ensures accuracy
9.	For volume of less than 5ml, use a 5ml syringe without a needle to measure the amount prescribed.	Ensures accuracy
10.	Keep the label on the bottle uppermost against the palm of hand when pouring.	To avoid spilling liquid in place.
11.	Wipe the rim of the bottle before replacing the cork.	Prevents cap from sticking.
12.	Use only the dropper-supplied with liquids measured in drops.	Ensures accuracy
13.	Read the label again before replacing the container on the trolley.	Third check reduces errors.
14.	Place the measuring cup on the tray together with the drinking cup with water and then take it to the patient at the correct time.	Ensures timely administration
15.	Call the patient’s name, check the room or bed number against the medicine list before giving the medicine.	Confirms the patient’s identity
16.	Assess the patient’s condition including the level of consciousness and vital signs. For instance patients having digitalis the pulse rate should be checked before administering the medicine.	To rule out likely contraindications or side effects.
17.	Explain to the patient the medications to be given to the patient and clarify any questions or doubts.	Promotes the patient’s rights and compliance.
18.	Assist patient in sitting or side lying position.	Prevents aspiration
19.	Administer medicine properly, only one medicine at a time and offer a glass of water or milk.	Aids swallowing.
20.	If a patient has difficulty swallowing, grind the tablets in a mortar with pestle, crush it to fine powder and mix it with a small amount of water.	To ease swallowing.
21.	Prepare powdered medication at the bedside and give it to the patient.	Increases compliance.
22.	Give effervescent tablets immediately after dissolving.	It helps to improve the taste of medicine.
23.	If the patient is unable to hold medication in hand; assist to place the cup to the lip and slowly transfer medicine into the mouth using a spoon.	To support the patient.
24.	If medicines fall on the floor, discard and replace them.	To avoid contaminated medicine
25.	Stay with the patient until the medicine has been swallowed; if the patient is confused or disoriented his/her mouth should be checked to confirm that the patient has swallowed the medicine. If the medicine is vomited within 5 minutes report to the In-charge or Doctor. Medicines must never be left on the bedside table.	Ensures that patient receives prescribed medication at the correct time
26.	Assist the patient to a comfortable position.	Maintains patient’s comfort
27.	Dispose of soiled supplies, clean work area and wash hands.	Reduces transmission of infection
28.	Document the administration of the medication with date, time and signature immediately after administration.	To avoid errors and promote proper accountability.
29	Reassess the patient’s response to the medicine within one hour after giving it and any ill effects reported.	To detect therapeutic/ side effects or adverse effects.
30	The medicine cups are washed and returned to their proper place.	Promote hygiene.

INHALATION

Inhalation is the breathing of air vapor or volatile medicine into the lungs.

Types

Dry inhalation: Oxygen Administration: this is given when the respiratory capacity is diminished as in chest injuries, pneumonia and cardiac failure.
Moist/steam inhalation: It is used in case of inflammation of air passages and the nasal sinuses. These are given to:

Warm and moisten the air breathed in and relieve irritation e.g. in bronchitis, after tracheotomy and other chest conditions.
To relieve inflammation and coughing e.g. in colds.
To relieve congestion and oedema e.g. in sinusitis and acute laryngitis.
Nebuliser: this produces vapors which is inhaled by the patient for example in asthma to relieve spasms of the bronchial tubes or for the relief of chest pain in angina pectoris. Other indications include Respiratory diseases eg asthma, pneumonia, Airway obstruction, Nasal congestion, Nasal bleeding, Chest injuries and Cardiac failure.

DRY INHALATION (Oxygen administration)

It is given when the respiratory tract is diminished as in chest injuries, cardiac failure and pneumonia.

REQUIREMENTS FOR OXYGEN ADMINISTRATION

Clean tray

Rubber tubing.
BLB oxygen mask.
Flowmeter.
Nasal catheter.
Gallipot with gauze pads.
Humidifier with distilled water

Bedside

Oxygen source.
Screen

PROCEDURE

Steps	Action	Rationale
1	Refer to the general rules	Keeps standard
2	Turn and test the oxygen cylinder before bringing everything to the bedside	Conserves time and energy
3	Determine need for oxygen therapy in patient and check physician’s order for rate, device used, concentration	Reduces risk of error in administration
4	Position patient in sitting up or one side	Promotes comfort
5	For nasal cannula use; connect nasal cannulae to oxygen set up with humidification, check if oxygen is flowing out of prongs	Humidification prevents dehydration of mucous membranes
6	Place prongs in the patient’s nostrils 2 inches, place tubing over and behind each ear with adjuster comfortably under the chin or place tubing around the patient’s head with the adjuster at the back or base of the head and place gauze pads at ear beneath the tubing as necessary	Facilitates oxygen administration and patient comfort. Pads reduce irritation and pressure
7	Encourage patient to breathe through the nose, with the mouth closed	Nose breathing provides for optimal delivery of oxygen to the patient
8	For B.L.B mask use; attach face mask to oxygen source start the flow of oxygen at the specified rate, for a mask with a reservoir allow oxygen to fill the bag before proceeding to the next step	The bag is the oxygen supplier to the patient
9	Position the face mask over the patient’s nose and mouth, adjust the elastic strap around patient’s head, adjust the flow rate	A loose or poorly fitting mask will result in oxygen loss
10	Apply padding behind ears as well as scalp where elastic band passes	Padding prevents skin irritation
11	Reassess patient’s respiratory status, including respiratory rate, effort, and lung sounds	Assesses effectiveness of oxygen therapy
12	Document relevant information in the patient’s record	Ensures accurate medical records

Parts of an Oxygen Flowmeter

PARENTERAL ROUTE (INJECTION)

Requirements

Trolley

Top shelf	Bottom shelf
Small Tray. Sterile syringes and needles of all capacities and appropriate size. Prescribed sterile medications in ampoules or vials. Patient’s charts and medicine lists. Gallipot with swabs. Antiseptic solution in a gallipot. Ampoule file Sterile water for injection Injection dishes Tourniquet. Cannula of appropriate gauge. Strapping Pair of scissors. Clean gloves	Sharps Safety Box. Receiver for used swabs. Receiver for used gloves. Small pillow for supporting the arm. Macintosh and towel
	Bedside
	Screen. Handwashing equipment.

Procedure

A. Intradermal or Intracutaneous Injection

Steps	Action	Rationale
1.	Refer to general and medicine administration rules for injections.
2.	A tuberculin syringe or 1 ml syringe is used and needles.
3.	Identify the patient, put in a comfortable position.
4.	Clean the skin with an antiseptic swab and allow the site to dry.	Exposes the selected site.
5.	If it is a BCG vaccination, clean the site with water.
6.	Stretch the patient’s skin, draw it tight and introduce the needle at an angle parallel to the skin.
7.	Gently and slowly inject the medicine while observing for a small wheal to appear.
8.	Carefully withdraw the needle.
9.	Do not massage the site after removing the needle.	This may alter the test results.
10.	Circle the area with a pen and record time, and request the patient not to wash the area until it is assessed for the intended outcome.	If it was for diagnostic purposes e.g., Mantoux test.
11.	Inspect for signs of reaction when the stated duration of time has reached.
12.	Report and record results.
13.	Clean away the used equipment.

B. Subcutaneous Injection or Hypodermic

Steps	Action	Rationale
14.	Help patient assume position depending on site selected.	Ensures free access to site.
15.	Choose a suitable needle gauge; take a 1 ml or 2 ml syringe depending on the dosage.
16.	Draw the medicine into the syringe.
17.	Expel the air by holding the syringe with the needle pointing up.
18.	Place the syringe in the injection dish.
19.	Explain the procedure to the patient, asking him/her not to move while the injection is being given.	Encourages cooperation and allays anxiety.
20.	Select the site and clean it with an antiseptic swab and let the area dry first.
21.	Grasp and pinch or squeeze the patient’s skin gently between the finger and thumb of your left hand and insert the needle at an angle of 45°.	Provides for easy and less painful entry into subcutaneous tissue.
22.	Pull back the (piston) plunger and inject the medicine slowly.	Determines if the needle is in a blood vessel.
23.	When the medicine has been injected completely, place a swab over the needle and withdraw the needle quickly and smoothly.	Reduces discomfort.
24.	If there is any bleeding at the site, apply firm gentle pressure with a swab until it stops.
25.	Make the patient comfortable and record the medicine given on the patient’s treatment sheet.
26.	Discard syringe, gloves, and swabs appropriately and clear away the equipment.	Promotes infection control measures.

C. Intramuscular Injection

Steps	Action	Rationale
27.	Observe the general nursing rules.
28.	Read the prescription carefully and check the medicine with the other nurse, including the amount to be given.
29.	Assemble syringe and needle, put on gloves.
30.	Break open the top of the ampoule (by using a gauze swab or a file) or remove the top of the rubber cap.
31.	Reconstitute powdered medicines according to the instructions on the bottle.
32.	Put on gloves and draw up the prescribed dose of the medicine.
33.	Expel the air and remember that with antibiotics and multi-dose vials, the air is expelled into the container.
34.	Position the patient depending on the site chosen.	Proper positioning ensures muscle relaxation of the patient.
35.	Select, locate, clean the site and allow it to dry.
36.	Inject the medication; grasp and pinch the area surrounding the injection site or spread skin at site as appropriate.	Aids needle penetration in patients with thick muscles.
37.	Hold the syringe between thumb and forefinger and pierce skin at a 90° angle and insert the needle.
38.	Aspirate by holding the barrel steady with a non-dominant hand.	Helps to check if a needle is in a blood vessel.
39.	If the blood does not appear in the syringe, inject the medication slowly and steadily.	Helps to disperse medication into muscle tissue, thus decreasing a patient’s discomfort.
40	Withdraw the needle slowly and steadily while supporting at the hub of the syringe and needle. With non-dominant hand support the skin surface using cotton swab for applying counter traction at the site	Helps to reduce discomfort and prevent pulling of tissues when needle is withdrawn
41	Apply gentle pressure at the site with a dry cotton swab but do not massage.	Massaging irritates tissues at the injection site.
42	Discard the un capped needle and syringe appropriately.	Promotes infection prevention and control.
43	Clear away, remove gloves and wash hands.
44	Record procedure including the name of medication, dose, site and response of the patient.	Reduces chances of medication errors

D. Intravenous Injection

Steps	Action	Rationale
45.	Prepare the injection tray and take it to the patient’s bedside.	Ensures all necessary items are available for the procedure.
46.	Identify the patient and explain the procedure to the patient.	Alleys anxiety.
47.	Screen the bed and put on gloves.	Provides privacy.
48.	Place a small pillow and a protective sheet under the patient’s arm.	Promotes comfort and protects the beddings.
49.	Expose the patient’s forearm and anterior surface of the elbow.	Ensures easy access to the injection site.
50.	Inspect the selected vein, if it is visible and clear; apply a tourniquet or a sphygmomanometer cuff around the patient’s upper arm and inflate sufficiently about 8 to 10 cm above the site.	Helps to distend and enlarge the vein.
51.	Request the patient to close and open the fist for a minute.	Promotes venous filling and visibility.
52.	Clean the area with an antiseptic and dry with a sterile swab.	Reduces microorganisms.
53.	Expel air from the syringe.	Ensures accurate dosing and prevents air embolism.
54.	Hold the patient’s arm and with your left thumb exert pressure about 3 cm below the chosen site and make the skin tight.	Stabilizes the vein and reduces movement.
55.	Insert the needle at an angle of 15-45 degrees with its bevel up then quickly and steadily insert into the vein. Pull back the piston slightly if blood is aspirated.	Ensures that the needle is in the vein.
56.	Remove the tourniquet or deflate the cuff and inject the medicine slowly.	Prevents excessive pressure in the vein and ensures proper delivery of medication.
57.	When the medicine is injected, put a swab over the site and withdraw the needle.	Minimizes bleeding and ensures cleanliness.
58.	Apply pressure at the site with a swab for some seconds to make sure there is no bleeding. If oozing continues, apply a swab and a piece of strapping.	Prevents bleeding.
59.	Record the medicine in the patient’s chart and clear away.	Ensures accurate medical records and maintains order.

SOME OF THE RECOMMENDED VEINS FOR INTRAVENOUS INFUSION

BACK OF THE HAND

FOREARM

LOWER EXTREMITY

Dorsal metacarpal veins

Basilic vein
Cephalic vein

Basilica vein and Cephalic

Femoral and saphenous vein in the thigh

Dorsal venous plexus, medial and lateral marginal veins in the foot

Femoral and saphenous vein in the thigh

COMPLICATIONS OF INTRAVENOUS INJECTIONS

Incorrect IV Site Placement: Inserting the IV into the wrong vessel (e.g., artery instead of vein) can lead to severe consequences.
Medication Errors: Misidentification of medications, incorrect dosages, or incompatible mixing can result in serious adverse reactions.
Rapid Administration and Undesired Effects: Delivering medications too quickly can lead to undesirable effects like hypotension, cardiac arrhythmias, allergic reactions, and fluid overload.
Thrombophlebitis: Inflammation of a vein, often with a blood clot, can occur due to frequent IV injections, improper technique, or certain medications.
Circulatory Overload: Infusing too much fluid too quickly can overwhelm the circulatory system, leading to fluid buildup and strain on the heart and lungs.
Embolism: A blood clot, air bubble, or foreign matter blocking a blood vessel can occur due to thrombophlebitis, improper IV line placement, or air entering the line.
Shock: Severe allergic reactions, blood loss, or sepsis can lead to a life-threatening decrease in blood flow to vital organs.
Infiltration/Extravasation: When IV fluids leak out of the vein into the surrounding tissues, it can cause pain, swelling, and tissue damage.
Phlebitis: Inflammation of a vein without a clot, often caused by irritation from the IV catheter or medication.
Air Embolism: Air entering the bloodstream through the IV line can travel to the heart or lungs, causing blockage and potentially leading to respiratory distress or cardiac arrest.
Catheter-Related Bloodstream Infection (CRBSI): A serious complication where bacteria enter the bloodstream through the IV catheter, leading to fever, chills, and potentially sepsis.
Nerve Damage: Incorrect placement of the IV catheter can damage nerves in the area, resulting in pain, numbness, or weakness.
Hematoma: Bleeding into the surrounding tissues from the IV puncture site, appearing as a bruise.
Phlebosclerosis: Hardening of the vein due to repeated IV punctures or irritation from the catheter.

Common Sites for Intramuscular Injections

Gluteal Muscle: The outer upper quadrant of the buttock is the safest site, as it avoids the sciatic nerve.
Thigh Muscles: The upper outer third of the thigh muscles.
Deltoid Muscle: Used for small injections (up to 2 ml) if the patient has enough muscle mass, but this site should be avoided whenever possible.

COMPLICATIONS OF INTRAMUSCULAR INJECTIONS

1. Abscess Formation: This occurs when unsterile needles and syringes are used, or when oily substances are not injected deep enough. The injection site becomes inflamed and filled with pus.

Prevention: Strict adherence to aseptic technique, proper needle selection, and injecting oily substances deep into the muscle tissue are crucial.

2. Nerve Injury: Incorrectly positioning the needle can damage nearby nerves, causing pain, numbness, weakness, or paralysis.

Prevention: Thorough anatomical knowledge, correct landmark identification, and careful needle insertion are essential.

3. Tissue Damage/Necrosis: Injecting too much medication, using irritating substances, or repeated injections in the same site can lead to tissue damage and cell death.

Prevention: Administering the correct dosage, choosing less irritating medications, and rotating injection sites regularly can minimize this risk.

4. Hematoma: A hematoma forms when blood leaks into the surrounding tissue after the injection, causing a bruise or swelling.

Prevention: Applying pressure to the injection site after the injection can help prevent hematoma formation.

5. Pain and Discomfort: Intramuscular injections can be painful, especially if the medication is irritating or the injection technique is not correct.

Prevention: Using proper injection technique, choosing a suitable needle size, and warming the medication to room temperature can reduce pain.

6. Allergic Reactions: Some individuals may have an allergic reaction to the medication or the ingredients in the solution.

Prevention: Thorough patient history, allergy testing, and careful observation for signs of allergic reactions are crucial.

7. Injection into a Blood Vessel: The needle may unintentionally enter a blood vessel, leading to potential complications like drug overdose or embolism.

Prevention: Aspirating (drawing back on the plunger) before injecting helps to ensure the needle is not in a blood vessel.

8. Delayed-Onset Muscle Soreness: Some medications can cause muscle soreness or stiffness that may not appear until several hours or days after the injection.

Prevention: No specific prevention, but staying hydrated and avoiding strenuous activity after the injection may help.

9. Infection: Improper sterile technique can lead to infection at the injection site.

Prevention: Strict adherence to aseptic technique is essential.

10. Air Embolism: Although rare, air can be injected into the bloodstream, leading to complications like respiratory distress or cardiac arrest.

Prevention: Using proper technique to ensure no air is introduced into the syringe or needle.

Intravenous infusion equipment and the superficial veins of the forearm that may be cannulated

Formula for Calculating the Drop Rate

To calculate the drop rate, use the following formula:

Example:

The doctor has prescribed 1000 mls of 5% dextrose infusion to run in 10 hours. How many drops per minute will you regulate if the infusion set has a drop factor of 20?

Factors that May Affect the Flow Rate

Height of the Infusion Bottle: Raising the infusion bottle higher will increase the rate of flow, and lowering it will decrease the rate.
Patency of Infusion Set and Needle: A blood clot in the needle may stop the infusion. This may occur when there is a delay in changing the emptied infusion bottle.
Kinking of the Tubing or Faulty Position of the Needle: When the needle is against or away from the vein wall, it may affect the flow.
Tight Splint: A tight splint on or above the infusion needle will restrict the flow rate.
Blocked Air Vent: A blocked air vent will cause the infusion to stop running.

Care of the Patient While on Intravenous Infusion

Accurate Record Keeping: Keep an accurate record, including the time of starting the infusion, type of fluid, amount, and the prescribed rate of flow.
Frequent Assessment: Assess the patient at frequent intervals for signs of abnormal reactions such as pain, sweating, restlessness, or change of color.
Regular Site Inspection: Inspect the site at regular intervals for signs of infiltration.
Condition Monitoring: Take and record the patient’s condition regularly.
Daily Cleansing: If the infusion is running for some days, cleanse the area around the injection site with sterile gauze daily.

INSTILLING MEDICATION INTO EAR

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ADMINISTERING MEDICATION THROUGH NASO-GASTRIC TUBE

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ADMINISTERING RECTAL AND VAGINAL MEDICATION.

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Nursing Process

NURSING PROCESS

The Nursing process is an organized, systematic, dynamic method of giving individualized nursing care that focuses on identifying and treating unique responses of individuals or groups, to actual or potential alterations in health. (Nursing procedure Manual, 2015)

OR:

The nursing process is defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient–focused care.

Outline the CHARACTERISTICS of the nursing process

Cyclic and Dynamic: – it is an ongoing continuous process throughout the stages of illness and treatment and ends with the cease of the illness.
Goal directed and Client oriented: The nursing process is intended to treat the patient and is in the best interest of the patient.
Interpersonal and Collaborative: This goes to explain the amount of interaction that might be necessary between nurses, patients of similar illnesses and the medical team.
Universally applicable: This process is universally standard and no matter what the institution it may be, the process remains the same.
Scientific and Systematic: Every symptom or sign is a result of a scientific fact which leads to scientific methods of treatment and follow-ups. It is systematic and goes from step to step as in the phases mentioned below.
Requires critical thinking: The use of the nursing process requires critical thinking which is a vital skill required for nurses in identifying client problems and implementing interventions to promote effective care outcomes.

Explain the components of the nursing process
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

ASSESSMENT PHASE

The first phase of the nursing process is assessment.
It involves collecting, organizing, validating, and documenting the clients’ health status. Assessment involves data collection which is the process of gathering information regarding a client’s health status. The main methods used to collect data are health interviews and physical examination.

Types of data collected

Subjective data or symptoms: This is information obtained from the patient through an interview. It also includes symptoms felt by the patient only. It is only the patient who can tell you information e.g. present complaints, past medical history, past surgical history etc
Objective data or signs: This is the information that is measurable, tangible data collected via the senses, such as sight, touch, smell, or hearing e.g. vomiting, distended abdomen, presence of edema, lung sounds, crying, skin color, and presence of diaphoresis.

NURSING DIAGNOSIS PHASE.

A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an
individual, family, group, or community.
NB: Medical diagnosis is different from a nursing diagnosis because nursing diagnosis refers to human response to health conditions whereas the medical diagnosis focuses on health conditions.

Types of the nursing diagnosis:

1. Actual nursing diagnosis

These are presenting response to current health condition
The actual nursing diagnosis has three parts i.e. Diagnosis, relation to (pathophysiology) and evidence.

Scenario A: A patient complaining of fevers, on thermometer reading it indicates 38°C.
From NANDA 2024 – 2026 fevers have hyperthermia i.e.
Hyperthermia related to increased leukocyte activity evidenced by the thermometer reading of 38°C.

Scenario B: A patient complained of headache of the forehead since the last 2 days after a minor head injury following a fight. On examination the pain was at 3 on a 0 – 5 pain scale.
From NANDA 2024 – 2026 headache is described as Acute pain since it has been present less than 3 months.
-Acute pain related to trauma to the head evidenced by the patient’s verbalization of feeling headache of 3 on a 0 – 5 pain scale.

2. Potential Nursing diagnosis:

This is an issue that could occur incase the current symptoms is not properly managed.
The potential nursing diagnosis has two parts that is the nursing diagnosis and the relation (pathophysiology) only.

Scenario: A patient reported vomiting for 1 day after ingesting chips and chicken. On examination the patient had no signs of dehydration.
From NANDA 2024 – 2026 vomiting does not have an actual nursing diagnosis it only has a potential nursing diagnosis which is risk for inadequate fluid volume.
–Risk for inadequate fluid volume related to vomiting.

PLANNING PHASE

The planning stage is where goals and outcomes are formulated that directly impact patient care.
Planning phase is divided into
1. Goals
2. Expected outcomes

Goals

These are the aims of the nursing interventions to be provided.
Therefore they should be smart

Goals should be:

Specific or on point
Measurable or Meaningful
Attainable or Action-Oriented
Realistic: it should represent things in a way that is accurate and true to life
Timely or Time-Oriented

Goals are divided into 3 categories i.e.
1. Short term goals: these are goals having time limit ranging from minutes to 5 days.
2. Intermediate goals: these are goals having time limit ranging from 5 days to 30 days.
3. Long term goals: these are goals having time limit ranging from 30 days to years.

Expected Outcome

This what a nurse expects the patient to present after provision of the nursing interventions
Its divided into 2 i.e. short term and long term outcomes.

IMPLEMENTATION PHASE

The implementation phase of the nursing process is when the nurse puts the treatment plan into effect.

It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care.
The implementation phase is divided into two parts

Nursing Interventions
Rationale

EVALUATION

Evaluating is the fifth step of the nursing process. This final phase of the nursing process is vital to a positive patient outcome. Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. This is the past tense of the outcome if they have been
achieved.

Explain the importance of using a nursing process

The nursing process allows the nurse to provide effective care by prioritizing meaningful interventions based on their assessments and clinical diagnosis of the patient.
At the end of the nursing process, the nurse evaluates the success of their care to ensure that effective care is being prioritized.
It creates a standard of care where the nurse develops a nursing diagnosis and care plan based on their assessment of the patient.
The nursing process provides care that is centered around the individual patient which reduces the time the client spends in the health care facility, and optimizes their health by minimizing complications in care.
By setting defined goals with a clear timeline in the nursing process, the nurse can evaluate the effectiveness of the care they are providing and make changes to the care plan as needed.

SO IN BRIEF

Assessment:

Subjective Data (Symptoms): Patient complaining of fevers.
Objective Data (Signs): Thermometer reading indicates 38°C.

Diagnosis:

Actual Nursing Diagnosis: Hyperthermia related to increased leukocyte activity evidenced by the thermometer reading of 38°C.
Potential Nursing Diagnosis: Risk for fluid volume deficit related to vomiting.

Planning (Goals/Expected Outcomes):

Goals:

Short Term: Reduce temperature to between 36.0°C to 37.4°C within 30 minutes.
Intermediate Term: [Specify a goal if needed]
Long Term: [Specify a goal if needed]

Expected Outcomes:

The patient will verbalize that he no longer feels feverish. Thermometer reading will be between 36.0°C to 37.4°C.

Implementation:

[Specify nursing interventions here, e.g., tepid sponging.]

Rationale:

[Explain why you did the intervention, e.g., To allow evaporative cooling.]

Evaluation:

Patient verbalized that he no longer feels feverish, and the thermometer reading was 36.7 degrees Celsius after 30 minutes

Sample Care Plan

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Sample Nursing Care Plan for a patient with Malaria

Assessment	Diagnosis	Planning (Goals or Expected Outcomes)	Implementation/ Interventions	Rationale	Evaluation
Fever	Hyperthermia related to leucocyte activity as evidenced by an elevated temperature of 39° C.	Reduce fever to 37° C within 30 minutes.	– Administer antipyretic medication as prescribed. – Encourage adequate fluid intake. – Apply cooling measures (e.g., tepid sponging).	– Antipyretic medication helps lower the fever. Adequate fluid intake prevents dehydration. Cooling measures aid in reducing body temperature.	Fever reduced to 37° C
Headache	Acute Pain related to malarial infection evidenced by patient verbalizing headache.	Alleviate headache within 40 minutes.	– Administer analgesic medication as prescribed. – Provide a quiet and dimly lit environment. – Encourage relaxation techniques (e.g., deep breathing).	– Analgesic medication helps relieve pain. – A quiet environment reduces stimuli that may exacerbate the headache. – Relaxation techniques promote comfort.	Headache Alleviated with In 40 minutes With a pain Scale reading Of 1/10.
Myalgias	Impaired Physical Mobility related to muscle pain and weakness as evidenced by difficulty in movement.	Improve mobility and reduce muscle pain within 5 days.	– Encourage gentle stretching exercises. Administer analgesic medication as prescribed. – Provide warm compresses to affected areas.	– Gentle stretching improves flexibility and reduces muscle pain – Analgesic medication helps relieve pain. – Warm compresses promote muscle relaxation.	Improved mobility and reduced muscle pain After 5 days.
Nausea	Nausea related to changes in eating habits as evidenced by patient complaints and increased salivation	Alleviate nausea within 1 hour.	– Administer antiemetic medication as prescribed. – Encourage small, frequent meals. – Provide oral hygiene measures after vomiting episodes.	– Antiemetic medication helps alleviate nausea. – Small, frequent meals are easier to tolerate. – Oral hygiene measures prevent discomfort and promote a sense of well-being.	Patient vebalised That no nausea After 1 hour..
Vomiting	Risk for inadequate fluid volume related to unpleasant sensory stimuli	The client will report decreased severity or elimination of nausea and vomiting.	– Administer antiemetic medication as prescribed. – Monitor and record intake and output. – Provide oral rehydration solutions as needed.	– Antiemetic medication helps control vomiting. – Monitoring intake and output prevents dehydration. – Oral rehydration solutions restore fluid balance.	The client reported elimination of nausea and vomiting.
Diarrhea	Risk for inadequate Nutritional intake related to less food intake as evidenced by watery stool.	Achieve optimal nutritional intake.	– Administer antidiarrheal medication as prescribed. – Encourage a bland and easily digestible diet. – Monitor and record bowel movements.	– Antidiarrheal medication helps control diarrhea. – A bland diet is easier on the digestive system. – Monitoring bowel movements informs about the effectiveness of interventions.	Achieved optimal nutritional intake
Dehydration	Risk for impaired fluid volume balance related to diarrhea, nausea and vomiting.	Patient will maintain hydration as evidenced by adequate intake and output, vital signs, and skin turgor	Administer fluids intravenously as indicated. Offer high-water content foods like soups Administer antiemetics as indicated.	Fluids for fluid replacement To encourage rehydration and motility of the bowel. To reduce vomiting episoded	Patient maintained hydration.

Summary NANDA

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Expected outcomes:

Patients will demonstrate bowel sounds within normal limits.
Patients will exhibit normal eating habits without experiencing nausea, vomiting, abdominal discomfort, dyspepsia, bloating, and early satiety.
Patient will exhibit balanced nutrition as evidenced by the absence of malnutrition
Patient will regain and maintain adequate body weight for age and gender
Patient will verbalize two strategies to reduce nausea and improve comfort.
Patient will express improved comfort as evidenced by improved sleep and mood.
Patient will verbalize relief from nausea
Patient will be able to demonstrate strategies that prevent nausea
Patient will maintain hydration as evidenced by adequate intake and output, vital signs, and skin turgor

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