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Unit 2

Advanced Procedures

Evaluation Final step in nursing process. Evaluates response to care. Includes judgment and effectiveness
Process vs Product Process - comparing actual outcomes vs predicted outcome. Act of making judgment. Product - state made about outcome. Ask questions to determine
Concurrent & Terminal Process Concurrent - continuous and ongoing b/c of receiving feedback/info. Even if you see pt not meeting initial goal continue to try to help pt reach it to best of of ability. Terminal - end point so make decision - set time frame - end
NI collecting data determine (5) Appropriation, alter/change NI, development of new problems, need for referral, need to rearrange priorities
Step in evaluation process (4) collect data, compare data, re-examine care plan, modify or terminate - if terminating have to be total meet to terminate
If goals not met ask questions & look at areas (6) realistic & appropriate, pt involved in setting goals?, important info overlooked, all interventions carried out in way & time specified?, new problems or adverse pt responses and appropriates changes made in pts plan of care, incorrect nursing dx
Modification involves (4) changing data, revise nursing dx, revise priorities, may need to change NI
Summary of evaluation process (5) individualizes approach to pt care, goal directed, interpersonal communication, constant cycle, universally applicable
Chest Physio Therapy (CPT) airways; sputum removal - mucus secretion from lungs, bronchi or trachea. Excess sputum could be irritating airway & can become problem for respiratory tract which could lead to infection because it would become thick and sticky.
CPT theory Theory is to clear airway, loosen secretion, move from smaller airway to larger airway (such as trachea) where they can be suctional
Problems leading to CPT Airway obstruction, prevention of gas exchange at alveoliar level, hypoxia, atelectasis, further respiratory disease
3 components of CPT postular drainage, percussion, vibration
Postural drainage drains by gravity, variety of positions if need to drain all lung fields. Done 2-4x/day ac meals, check to see if pt needs bronchodilator b5 treatment, monitor pt toleration,VS,palor,diaphoresis,fatigue,dyspnea
Percussion hands cupped position clapping on pt w/towel, gown, shirt - never directly on skin, bend elbows & alternate hands. Done 2-7 min then alternate vibration
Areas to avoid with percussion (4) spinal cord, sternum, breast tissue, lower kidney region
Vibration Downward vibrating pressure, done during exhalation, 1 - purse lips, over same area, use palm of hand,lock elbows & wiggle hands back & forth 3-4x, creates turbulance to help secretions come out, upright position & cough, listen to lungs for improvement
Suctioning types (3) and indications invasive treatment, oral, nasopharageal, enotracheal. Unable to swallow, unable to expectorate secretions, hear bubbling.Done as needed for airway, need order. done PRN & nursing judgment. Cath in the crinia in contact will trigger cough
Yankauer suctioning cleans out oral cavity, can be used for 24 hrs, dr order - PRN. Assess and determine when pt needs suctioning. Monitor for hypoxia, mental status and pt teaching. Semifowlers positions w/neck slightly hyperextended
Nasopharynxgeal thru nari's, 5 inches, nose to ear lobe for length. Intermittent suctioning, twisting, w/drawing, twisting, rotating, 10-15 seconds for suctioning. Preventing gas exchange both O2 and CO2, 3x max, 15sec or so
Oralpharynxgeal thru mouth, cheek & down throat, gag & difficult to get in, cant do oral than naso b/c sterility, clears respir tract, 5 inches
Endotracheal down deeper, ~8inches, tip of nose, around ear to adams apple, if congestion on left have turn head right, coughing is good - continue process, 10sec in and out, intermittent, rotating and twisting.
Sputum specimen Lukens trap - only sputum in it. No NS, water, rinsing agent. disconnect and reconnect suctioning, suctioning from wall onto tube.
CPT done for one of the following reasons (6) remove excess saliva or emesis from oral cavity, clear upper airway of secretions, promote adequate gas exchange, prevent pneumonia & atelectasis, obtain sputum sample, relieve respiratory distress
Created by: breinard