Sepsis/Sepsis Bundle
This is the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and even death.
What is Sepsis
This is the primary purpose of a PleurX Catheter.
What is to drain recurrent fluid from the pleural or peritoneal space.
This is the expected nurse action if the urine appears red or with small clots.
What is increase irrigation rate.
This is when you should empty the pouch.
What is when the pouch is 1/3 full (of stool or gas)
When caring for a patient with a JP drain, this should be done at least every four hours.
What is strip and reactivate.
This should be collected BEFORE antibiotic administration.
What is Blood Cultures
Continuous bubbling in the water seal chamber usually signifies this problem.
What is an air leak.
When should you measure the output in the catheter bag?
What is when starting a new irrigation bag.
This is the best time to change the pouching system.
What is when the bowel is least active.
Morning before breakfast or at least a few hours after a meal (eating marshmallows 30 m -1 before)
This is where you should assess the color of drainage/urine.
What is in the catheter tubing.
Lactate, Blood Cultures, and Antibiotics should be done/started within this time frame of recognizing sepsis.
What is within 1 hour.
If the patient develops difficulty breathing during drainage of PleurX Catheter, you should do this immediately.
What is stop the drainage and notify provider.
This action can help clear a clot obstructing the catheter.
What is hand irrigating or flushing the catheter.
Post operatively, this type of diet may be recommended due to bowel edema.
What is low-residue.
Total Output = 3270mL
Total Irrigation In = 3000 mL
What is the total amount of urine produced?
What is 270 mL
Initial fluid bolus recommendation for adult sepsis patients in this mL/kg.
What is 30 mL/kg of a Crystalloid Fluid (examples: Normal Saline, LR, 5% Dextrose)
This term describes fluctuations in the water seal chamber that correlates with the patients breathing, indicting the system is working.
What is Tidaling
This is subtracted from the total output to determine true urine output.
What is the amount of irrigation fluid instilled.
These are good tips to decrease gas in a patient with an ostomy. (Name 2)
What is avoid carbonated beverages, sipping through a straw, smoking, gas-producing foods, skipping meals.
Name 2 indication for NG tube placement
What is:
Gastrointestinal Decompression (SBO, Prevent Vomiting After Major Surgery)
Medication Administration When Patient Unable to Swallow
Enteral Nutrition
Assessing and Treating Upper GI Bleed
Gastric Content Analysis
Gastric Lavage
This lab value may be elevated in septic patients indicating inadequate tissue perfusion.
What is Lactic Acid
By doing this you increase the patients risk of a tension pneumothorax by preventing air and fluid from escaping the patient pleural space.
What is clamping the chest tube.
What is check for kinks of clots in the tubing.
This is a medical emergency and results in stoma discoloration that is dark maroon, purple or black.
What stoma necrosis.
A midline is placed in the upper arm using US guidance. What kind of line is this considered?
What is a deep peripheral IV