Summary
Summary NUR 463 Exam 3 Study Guide
- Institution
- University Of Rhode Island
This is a comprehensive and detailed study guide on Exam 3 for Nur 463. , Essential Study Material!!
[Show more]
Content preview
1NUR 463 - Study Guide for Exam 3
Laryngeal Cancer
o Postoperative plan of care and nursing diagnoses
● Communication
○ Voice rehab
○ Electrolarynx, hands free devices
○ Esophageal speech
○ Transesophageal puncture
● Stoma care
● Depression, sexuality
● Self-care management
Tracheostomy Care
● Provides an airway directly into the anterior portion of the neck - indicated for:
○ Long-term mechanical ventilation
○ Long-term secretion management
○ Protecting the airway from aspiration when the cough/gag reflexes are
impaired
○ Bypassing an upper airway obstruction that prevents placement of an
ETT
○ Reduces the WOB associated with an ETT
● Better tolerated than an ETT → less use of sedation/restraints
● Oral intake is allowed if swallowing studies demonstrate the absence of
aspiration; oral hygiene is more easily performed
● Speaking valve can be inserted
● NURSING IMPLICATIONS:
○ Suction the airway to remove secretions → suctioning is indicated
when the client needs it
○ Clean around the stoma with NS and H2O2 → prevents infection
○ Changing collar
○ Inner cannula care
○ Tube with inflated cuff is used for risk of aspiration or in mechanical
ventilation
■ Inflate cuff with minimum volume to create an airway seal
■ Should not exceed 20 mmHg or 25 cm H2O
○ Deflation
■ Performed to remove secretions accumulating above the cuff
■ Patient should always cough up secretions prior to deflation!!!
■ Suction mouth and tube
o Discharge teaching for a client with a tracheostomy
● Tube should be changed once a month → patient can be taught to change
the tube using clean technique at home
, 2
● When tube has been placed for several months, healed tract will be well
formed
o Client education about surgery and management
● Traditionally been a surgical technique performed in the OR, but a
percutaneous dilational tracheostomy (PDT) procedure may be performed
safely at the bedside by a trained physician
● Contraindications: inability to hyperextend the neck, pt inability to tolerate
transient hypoxemia and hypercarbia, morbid obesity, coagulopathy
● NURSING IMPLICATIONS:
○ Ensure that IV lines are accessible for administration of sedatives and
analgesic medications
○ Position the patient for the procedure and adjust the height of the bed
relative to the individual performing the procedure
○ Gather all supplies and ensure that sterility is maintained throughout
the procedure
○ Monitor physiologic parameters, document values at least every 15
minutes during PDT and at least 1 hour after
o Proper suctioning technique
● Only to be performed as indicated by physical assessment, not according to a
predetermined schedule
○ Indications include visible secretions in the tube, frequent coughing,
sawtooth pattern on the flow-time waveform on the ventilator,
presence of coarse crackles over the trachea, oxygen desaturation, a
change in vital signs, restlessness, increase in peak inspiratory
pressure, high pressure ventilator alarms, or when a sputum specimen
is indicated.
● Choose the proper size device - the diameter of the suction catheter should
be no more than half the diameter of the artificial airway
● Assemble equipment; set suction regulator at 80 - 120 mmHg; use sterile
technique
● Hyperoxygenate the client via the ventilator circuit before, between, and after
suctioning
● Gently insert the suction catheter; if resistance is met, pull back 1 cm before
applying suction
● Suction the patient NO LONGER THAN 10-15 seconds while applying constant
or intermittent suction
● Allow time for the patient to recover in between periods of suctioning; repeat
until the airway is clear
● Rinse the catheter with sterile saline after suctioning is performed
● Auscultate lungs to assess the effectiveness of suctioning
o Related emergencies
● Most significant post-procedure complication is accidental decannulation
, 3
○ PDT: trachea is not surgically attached to the skin; a mature tract takes
~2 weeks to form
○ Accidental decannulation and attempted reinsertion of the airway
during this time may result in difficulty securing the airway, bleeding,
tracheal injury, and death
○ Oral intubation may be required if the airway becomes dislodged or
needs to be replaced
○ NURSING IMPLICATIONS:
■ Immediately replace the tube
■ Retention sutures grasped and opening spread
o Psychological considerations and improvements
● Speech: fenestrated tracheostomies provide psychological benefit and
self-care
● Spontaneous breathing patient may be able to talk by deflating cuff, allowing
exhaled air to flow over the vocal cords
○ Use of a Passy-Muir valve to cap the trach
Acute Kidney Injury (AKI)
● 20-25% of cardiac output
● Clinical course:
○ Initiation phase
○ Oliguric/maintenance phase
○ Diuretic/recovery phase
● Most common sign is oliguria → UO < 0.5mL/kg/hr
o Possible etiologies
● Sepsis
● Hypoperfusion (prerenal)
○ Related to intravascular volume depletion, decreased cardiac output,
renal vasoconstriction, or pharmacological agents that impair
autoregulation and GFR
○ Ex. Major abdominal surgery → hypoperfusion of kidney d/t blood loss
during surgery or excessive vomiting or NG suctioning → body
attempts to normalize by reabsorbing sodium and water → adequate
blood flow is restored to kidney → normal renal function resumes
○ Most forms of prerenal AKI can be reversed by treating the cause
○ Urine osmolality > 500
○ Urine sodium < 10
○ Can progress to intrarenal damage → Acute tubular necrosis (ATN)
● Direct nephron injury (intra-renal)
○ ATN is the most common intrarenal condition
○ Occurs after prolonged ischemia, exposure to nephrotoxic substances,
or a combination
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller anyiamgeorge19. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
50155 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now