GI Stuff
Before initiating a feed via a client's NG tube we need to put a client into this position
What is semi or high fowlers (at least 30 degrees bed height)
2 types of passive drains
What are penrose & T-Tube
This closure device is used for deep and superficial layers of tissue and may be dissolvable or require removal by the nurse
What are sutures or stitches
What is healthy, viable tissue. Avoiding slough and eschar
You notice a loop of small intestine coming out of your clients incision. Your first action is...
What is getting the client into a semi-fowlers or low fowlers position with knees elevated
We do this prior to flushing an NG tube in order to ensure that we aren't suctioning the stomachs mucosal lining
instill 30 ml of air
What is a hemovac
True or False
Closing a wound with staples is a type of tertiary intention closure
Possible wound complication when a client coughs or vomits following an ABD surgery
What is dehiscence and possible evisceration
True or False
Abd sutures are likely to be ordered to be removed 7-10 days post-op
What is true
What are the steps to removal of an NG Tube
1.Verify the order
2.Explain the procedure to the client
3.Turn off the suction and disconnect the NG tube from the drainage bag or suction. Remove tape from the bridge of the nose and unpin the tube
4.Patient to sit in high fowlers. Stand on the client’s right side if you are right-handed, on the left side if you are left-handed.
5.Hand the client a facial tissue, place a clean towel across the chest. Instruct the client to take a deep breath and exhale slowly.
6.While the client exhales slowly (promotes comfort and ease of removal), clamp or kink the tubing securely and then pull the tube out steadily and smoothly into a towel held in your other hand.
7.Measure the amount of drainage and note the character of the contents. Dispose of the tube and drainage equipment into the proper container.
8.Clean the nares and provide mouth care.
9.Position the client comfortably
Drainage you expect to see when the client returns from a procedure and then 3-5 days post procedure
What is Sanguinous or sero-sanguinous initially followed by serous 3-5 days later
2 things the nurse should never do when removing sutures (suture no no's)
NEVER snip both sides of the external portion of the suture, or there will be no way to remove the portion of suture situated below the surface
NEVER pull exposed portion of suture into tissue below as this portion is considered contaminated
When a client is experiencing hypovolemic shock what does the nurse expect the pulse and BP to look like?
Definition of a chronic wound
Any wound present for more than 6 weeks.
Stalled through any one of the 4 stages of wound healing.
Does not show evidence of healing within 4 weeks.
Usually staged/described using universal classification. Stage 1,2,3,4,SDTI,& Unstageable
Ways to check placement of an NG Tube
Checking gastric contents (pH 5.5 or less)
xray
Insertion length
True or False
Hemovac Drainage should be disposed of into a biohazard container
What is False
OREEDA stands for..
Odour, redness, edema, ecchyomosis, drainage, approximation
The LPN notes that a wound should be packed only when these 3 criteria are present
Visible wound bed, at least 1 cm depth & all tunnels and undermining are assessed and have endings
Wounds should only be irrigated when these 2 criteria are present
What are
Being able to see where the fluid is going
Being able to drain instilled fluid from the wound (client able to reposition)
4 Main reasons a client might require an NG Tube
4 main reasons.
Decompression: Build up of gastric acid secretions due to a GI blockage such tumors, paralytic ileus, cancer.
Feeds: same type of feeding solutions students has seen in LTC. Levin tube
Compression: used to stop a bleed in the esophagus or stomach.
Lavage
Types of active drainage systems
What are hemovacs & JP drains
The type of sutures LPN's are able to remove (what are they called)
Intermittent or interrupted sutures
An alternative option or therapy to wound packing
What is VAC therapy
A client arrives back from the O.R with the report that they "lost a lot of blood"
What lab test do you expect to be ordered?
What is hgb