Respiratory System Procedures

Respiratory System Procedures Carol Bailey, MSN, RN Introduction | Task | Process | Evaluation | Conclusion | Credits Introduction You are a nurse working in a PCU. Your clinical unit specializes in the care of patients who are undergoing treatment for pulmonary disease. You often provide care and patient teaching for patients having tests and procedures for pulmonary conditions. Your assignment today includes providing care and education support for 2 patients. You have a student nurse observing in your unit today. As you teach, please be sure to include rationales and answer the student’s questions. The Task Patient 1: Mr. Paul Monary, a 58 year old farmer, was admitted to your unit with complaint of progressive hoarseness, difficulty in swallowing, and loss of appetite over the past 3 months. The medical plan of care involves chemotherapy and radiation therapy. He will need a tracheostomy prior to beginning therapies. Objective data: He smokes 1 pack of cigarettes per day. His weight has decreased from 200 pounds to 180 pounds over the past 3 months. The results of a CT scan and MRI reveal that this patient has throat cancer. Subjective data: The doctor said I would have a tracheostomy, but I don’t really know what that means for me. I don’t know how I am going to manage my farm if I have to have surgery. The nursing diagnosis you must address is knowledge deficit related to lack of information regarding care of a tracheostomy as evidenced by patient’s verbal response. Patient 2: Ms. Flora Vack, a 25 year old female, is a bull rider in the â€Å"Riding Stars Rodeo† that is currently performing at the Civic Center. She was thrown from a bull in last night’s performance and received repeated kicks to her left posterior chest. She was seen in the emergency room and admitted for follow up care. Her chest X-ray reveals a large pleura effusion on the left. You are assigned to prepare the patient for a thoracentesis. Outcome: You assist with the thoracentesis. 1,500 ml of pink tinged pleural fluid is removed. The patient experiences a pneumothorax following the procedure and a chest tube is inserted and connected to an atrium ocean chest tube drain. You are assigned to prepare the patient for chest tube insertion and to manage the chest tubes after the procedure. The Process To accomplish the task, you will review information from the links provided for each patient to fill in the table below. Patient 1 Links: http://www.youtube.com/watch?v=DoSTehS7iq8 http://www.youtube.com/watch?v=Lo74zm3ULyk Tracheostomy regular manual approach http://www.youtube.com/watch?v=6TVOSb6sqL8feature=related Tracheostomy percutaneous insertion http://www.youtube.com/watch?v=SloXwGG2n-Q Tracheostomy – percutaneous view from inside the trachea http://www.youtube.com/watch?v=PhasybkUrzkfeature=related Laryngoscopy (this one was just cool!) http://www.youtube.com/watch?v=iYpDwhpILkQfeature=related effects of smoking: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/ effects all organs of the body http://www.tobaccofreekids.org/research/factsheets/pdf/0264.pdf immediate effects http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Smoking_effects_on_your_body http://www.quitsmoking.com/content/how-smoking-affects-your-body trach care http://www.youtube.com/watch?v=Wimw7bz0fLofeature=related suctioning trach http://www.youtube.com/watch?v=UVuPzhOWxRsfeature=related cleaning intercannula and trach dressing http://www.youtube.com/watch?v=ivUKHnnTKb4feature=related fenestrated trach tube http://www.youtube.com/watch?v=RzYPp5h_vx8feature=related passey-muir speaking valve http://www.hopkinsmedicine.org/tracheostomy/living/passey-muir_valve.html http://www.passy-muir.com/video_page Bottom of Form Click on â€Å"Videos† at the top of the home page. CEUs | Videos | News and Events | FAQs | Contact Us | International Then under – â€Å"Passy-Muir Animations† – There is a play list with 6 videos. View all videos except for the one on mechanical ventilation. Patient 2 Links: thoracentesis demo on real patient http://www.youtube.com/watch?v=noDxydboLrAfeature=related chest tube insertion http://www.youtube.com/watch?v=424M8L5Z_EQ http://www.youtube.com/watch?v=A_0K8o98SPw http://www.atriummed.com/EN/chest_drainage/education.asp Review â€Å"Managing chest drainage† ppt presentation for nursing educators (note: this ppt includes nursing assessment) Under the Product support tab: Along the left column under â€Å"Traditional Drainage† – click on â€Å"Ocean† Under education resources click on â€Å"Set up and Operation video†. Next click on Oasis, then pneumostat section. The video’s on ocean, oasis, and pneumostat are interesting and helpful to understand the function and assessment of a chest tube drainage system http://www.atriumu.com/ Click on the â€Å"Learning† tab Chest drainage 101 chapter 1 – 4 and Managing chest drainage part 1-6 are excellent resources of education developed by Atrium – a common brand of chest drainage system aking chest tube out / closing with a suture http://www.youtube.com/watch?v=4GTecWv5h6cfeature=related Nursing Assessment of the patient with a chest tube. Patient 1: Mr. Paul Monary NANDA: Knowledge deficit r/t lack of information regarding care of a tracheostomy AEB by patient’s verbal response. Client outcomes: Patient will Describe what a tracheostomy is and why it is necessary Describe the purpose of suctioning Demonstrate clearning of the innercannula and trach dressing Identify the effects on cigarette smoking on his current state of health List safety precautions in the use of the Passey-Muir valve Note: Respond to the patient’s questions using terminology the patient can understand. Respond to the Student nurse’s questions using professional terminology. Patient teaching: explain to this patient what a tracheostomy is and why it is necessary for him while having radiation therapy Patient teaching: explain to this patient the purpose of suctioning the trach and how it is accomplished. (explain the in-hospital sterile procedure – in your own works as if you were telling the patient all the steps you are taking and why) Patient teaching: explain to this patient how the nurse will clean the innercannula and why it is done (in-hospital sterile procedure) Patient teaching: explain to this patient, the effect of smoking on the lungs and on oxygenation Patient teaching: explain to this patient, the effect of smoking on the body. Patient teaching: explain to this patient how the passey-muir valve works and list safety precautions Answering the student nurse’s questions: how does the percutaneous insertion of the trach differ from the regular manual insertion? Answering the student nurse’s questions: How is a fenestrated trach tube different from a regular tube? Is there any potential complications with the fenestrated tube? List 3 additional Nursing Diagnosis (in 3 part format) appropriate for Mr. Monary: 1. 2. 3. Note: must list actual nursing diagnosis in 3 part format – not â€Å"at risk for† Patient 2 Ms. Flora Vack Respond to the patient’s questions (using terminology the patient can understand) Respond to the Student nurse’s questions (using professional terminology. Patient question: What is a thoracentesis? A thoracentesis is when a needle is inserted through your chest wall and then into the pleural space (Lewis, 2014). The pleural space is the thin, but large lining of tissue that surrounds your lungs and lines your chest cavity (Lewis, 2014). We do this to take samples to perform some diagnostic testing, remove excess fluid or air and give medications directly to the pleural space (Lewis, 2014). In your situation we are using a thoracentesis to drain the fluid buildup from your lungs by inserting the large needle and letting it drain out (Thoracentesis to remove 1200cc of Pleural Fluid at Harborview). Answering the student nurse’s questions: How do you position the patient for a thoracentesis? What do I do to assist the doctor during this procedure? You need to position the patient with their elbows on over the bedside adjustable table, sitting in the upright position (Thoracentesis to remove 1200cc of Pleural Fluid at Harborview). Their feet should be supported and you can place a pillow across their abdomen for additional support (Thoracentesis to remove 1200cc of Pleural Fluid at Harborview). During a thoracentesis the nurse will assist the doctor by supporting the patient throughout the procedure and answering any questions she may have (Thoracentesis to remove 1200cc of Pleural Fluid at Harborview). Throughout the procedure you will need to ask assessment questions to determine how the patient is tolerating the procedure and to facilitate any alterations in body position, such as resting their head during the procedure if they feel light headed (Thoracentesis to remove 1200cc of Pleural Fluid at Harborview). You will also monitor vital signs throughout the procedure (Lewis, 2014). Also, make sure you ensure the patient is properly oxygenated by administering any supplemental oxygen that may be necessary (Lewis, 2014). After the procedure you will need to make sure you apply a sterile dressing to the puncture site (Lewis, 2014) Patient question: What is the purpose of a chest tube and drainage system? The purpose of a chest tube and drainage system is to drain the air or gas that has built up in the area around your lungs due to your pneumothorax (Chest Tube Insertion part 1/2). The space around your lungs is known as the pleural space (Chest Tube Insertion part 1/2). This is the lining of tissue that surrounds your lungs and lines your chest cavity (Chest Tube Insertion part 1/2). This reestablishes negative pressure in your lungs which allows your lungs to expand properly (Lewis, 2014). Answering the student nurse’s questions: What is the underwater seal of a chest drainage system and how does it work? The underwater seal of a chest drainage system is what allows the air or fluid to leave the pleural space but also prevents the backflow of air or fluid back into the pleural cavity (Chest Tube Insertion part 2/2). The way the underwater seal works is that is contains about 2 cm of water and when the air or gas enters up, or bubbles, through the water it acts as a one way valve (Lewis, 2014). Answering the student nurse’s questions: When do I expect to see bubbles in the underwater seal section of the chest tube drainage system? (what circumstances will cause bubbling in this chamber) Answering the student nurse’s questions: The atrium pleura drain uses the same concepts at the 3 bottle system of chest tube bottles. What is the main function of each of the bottles? Bottle 1 = Bottle 2 = Bottle 3 = Answering the student nurse’s questions: What should I include in the assessment and care of a patient who has a chest tube? (include assessment of the patient as well as the drainage system) Answering the student nurse’s questions: Describe to the student nurse how the chest tube will be removed, how the nurse will assist, and observation and care of the site. Evaluation Your grade for this exercise will be 2% of your grade for this course. Grading will use the rubric below. Maximum points = 36. This webquest is due to be submitted by 1:00 PM, October 17, 2014. Learning Objectives Beginning 1 point Developing 2 points Accomplished 3 points Score Describes the purpose of a tracheostomy including the difference between a regular tube and a fenestrated tube Response reflects limited knowledge of this objective Limited explanation Effectively explains the purpose of a tracheostomy and the fenestrated tube Explains the purpose and steps of trach suctioning and cleaning of the inner cannula Response reflects limited knowledge of this objective Limited explanation Effectively explains trach suctioning and cleaning of the inner cannula using terms appropriate for patient education Identifies the effects of smoking on the respiratory system Response reflects limited knowledge of this objective Identifies only 3 smoking risks on the respiratory system (lungs) Explains effectively to the patient the effect smoking has on their lungs. Identifies the effects of smoking on the body Response reflects limited knowledge of this objective Identifies only 3 smoking risks to the body Explains effectively to the patient the effect smoking has on their body. Explains the purpose of the passey-muir valve and how it works. Response reflects limited knowledge of this objective Limited explanation Effectively explains purpose of a passey-muir valve and how it works using terms appropriate for patient education Identifies safety precautions for use of a passey-muir valve. Response reflects limited knowledge of this objective Identifies only 3 safety precautions Explains safety precautions effectively to the patient. Critiques the difference between the surgical insertion and the percutaneous insertion of the tracheostomy tube Response reflects limited knowledge of this objective Limited explanation Clearly critiques the difference in the 2 insertion techniques for tracheostomy insertion. Identifies 3 actual nursing diagnosis using the 3 part format (diagnosis / related to / AEB) Response reflects limited knowledge of this objective Nursing diagnoses do not include pertinent diagnoses or format is not followed Identifies 3 actual nursing diagnosis pertinent to this patient in proper format Describes the procedure, performing a thoracentesis Response reflects limited knowledge of this objective Limited Explains the procedure effectively including patient positioning Recognizes normal versus abnormal function of the chest tube system Response reflects limited knowledge of this objective Limited explanation Recognizes which chambers bubbling may occur and what that means Describes the function of the 3 bottle chest tube system Response reflects limited knowledge of this objective Limited explanation Fully explains the function of each of the 3 bottles Demonstrates knowledge in the care of the patient with a chest tube drain and chest tube removal. Response reflects limited knowledge of this objective Limited explanation Explains effectively to the student nurse, how to care for a chest tube drain, including assessment of the patient Conclusion This WebQuest will support learning and application of materials covered in Lewis, Chapters 26, 27, and 28. I hope you found the exercise to be a fun, interesting way to learn. In addition to Web links, you may use your NANDA and Lewis books as needed to support your answers. You must cite references for your answers using APA format. Credits References Ackley, B. J. Ladwig, G. B. (2008). Nursing diagnosis handbook: A guide to planning care (8th ed.). St. Louis, MO: Mosby-Elsevier Atrium Chest Drainage Education. www.atriummed.com/Products/Chest_Drains/education.asp Chest Tube Insertion part 1/2. (2012, July 13). Retrieved March 11, 2015, from https://www.youtube.com/watch?v=424M8L5Z_EQ Chest Tube Insertion part 2/2. (2012, July 13). Retrieved March 11, 2015, from https://www.youtube.com/watch?v=424M8L5Z_EQ Lewis, S.M., Heitkemper, M.M., Dirksen, S.R., O’Brien, P.G., Giddens, J.F, Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St.Louis: Mosby-Elsevier. Lewis, S. M., Dirksen, S. R. (2014). Medical-surgical nursing: assessment and management of clinical problems (Ninth ed.). St. Louis: Elsevier. Ocean Drain Education Video. (n.d.). Retrieved March 11, 2015, from http://www.atriummed.com/EN/chest_drainage/edu-files/ocean-video1.asp Thoracentesis to remove 1200cc of Pleural Fluid at Harborview. (2007, November 2). Retrieved March 11, 2015, from https://www.youtube.com/watch?v=noDxydboLrAfeature=related Based on a template from The WebQuest Page