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Summary NUR 463 Exam 3 Study Guide
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This is a comprehensive and detailed study guide on Exam 3 for Nur 463. , Essential Study Material!!
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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
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