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Unit 2
Advanced Procedures
| Question | Answer |
|---|---|
| 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
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