You are on page 1of 7

HLTEN505B Contribute to the complex nursing care of the client

HLTEN505B Contribute to the Complex Nursing Care of the Client

Nilesh Prasad 02

HLTEN505B Contribute to the complex nursing care of the client

Introduction Urinary incontinence (UI) is the complaint of any (Reynard, Brewster, Biers2 2006, p114) involuntary leakage of urine. It results from a failure to store urine during the filling phase of the bladder due to abnormality of bladder smooth muscle or the urethral sphincter. There are many factors which contribute to UI such as age, childbirth, overactive bladder, spinal cord injury, surgery such as (radical hysterectomy; radical prostatectomy) and is generally more common in women than men. An indwelling urinary catheter, also commonly referred to as a Foley catheter, is inserted into the bladder by way of the urethra and remains in situ by inflating a balloon at the catheter drainage tubing junction, which then secures it inside the bladder. The tubing is further secured around the thigh usually with a Velcro strap and the drainage bag is secured around the ankles. 1. What are the potential complications for a patient with an IDC? Catheter-associated urinary tract infection is the most frequent (Longo4, 2012, c 288) healthcare-associated infectionUrinary catheter use is common, with approximately one in every five Pt. admitted to an acute care hospital receiving an indwelling catheter. Bacteria move upward inside the catheter drainage system after contamination of the drainage bag through the outflow tap or disconnection of the catheter. Some of the complications associated with catheterization include; Trauma or introduction of bacteria into the urinary system, resulting in infection and, consequently, possible septicaemia or death Trauma to the urethra or bladder from incorrect insertion or attempts to remove the catheter without deflating the balloon Accidental catheter dislodgement Urine bypassing the bladder Urethral perforation Urinary stones Chronic renal inflammation Profound effects on a patient's social, work, and psychological well-being

2. Outline how you will provide effective IDC care? Management of a patient who has an IDC has to incorporate all different aspects of excellent nursing care, from effective pain relief or numbing agent before procedure usually required for men, choosing the right sized catheter, hand washing and aseptic technique when inserting the catheter, maintaining a closed drainage system, ensure there are no kinks in the tubing as they could obstruct the flow of urine, the correct positioning of the drainage bag, emptying of the bag on a regular basis in a clean container, recording of output on a fluid balance chart, bladder scan in acute setting to monitor levels and educating the client as to the proper hygiene while catheter remains in situ. 3. Where would you Document the patients fluid balance? Why is this important? Documenting would be on a fluid balance chart, it is important to record fluid input and output as these measurements will help assess a Pt.s hydration levels and electrolyte balance. If the patient is retaining fluid due to complications such as congestive cardiac failure or renal failure or losing fluid due to diarrhoea or excessive urination, interventions to correct imbalance can be implemented by reflecting back at the fluid balance charts to maintain homeostasis. Imbalance in fluid input and output can be signs of disease or illness and can lead to further deterioration if not detected promptly.

Nilesh Prasad 02

HLTEN505B Contribute to the complex nursing care of the client

A tracheostomy (Russell, Matta1, 2004, p 10) is an artificial opening made into the trachea, a curved tube, called a tracheostomy tube, is inserted through the opening. It is inserted in the operating room or intensive care unit under sterile conditions using local aesthesia, and can be temporary or permanent. 4. What are the potential complications of a patient with a Tracheostomy tube? As indicated by (Russell, Matta1, 2004, p 16) early complications that may arise during the tracheostomy procedure or soon thereafter include: Bleeding Air trapped around the lungs (pneumothorax) Air trapped in the deeper layers of the chest (pneumomediastinum) Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema) Damage to the swallowing tube (esophagus) Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve) Tracheostomy tube can be blocked by blood clots, mucus or pressure of the airway walls. Later Complications that may occur while the tracheostomy tube is in place include: Accidental removal of the tracheostomy tube Infection in the trachea and around the tracheostomy tube Thinning (erosion) of the trachea from the tube rubbing against it Narrowing or collapse of the airway above the site of the tracheostomy, possibly requiring an additional surgical procedure to repair it Blockages can be prevented by suctioning, humidifying the air, and selecting the appropriate tracheostomy tube. Furthermore these complications can usually be prevented or quickly dealt with if the nurse has proper knowledge of how to care for the tracheostomy site and can detect abnormalities quickly. A clean tracheostomy site, good tracheostomy tube care and regular examination of the airway should minimize the incidence of any of these complications. 5. What procedures will you implement for the dressing and safe management of the tracheostomy tube? Management of the tracheostomy would begin with regular monitoring of the site to ensure the airway remains patent and suctioning as necessary to clear any blockage, ensuring that adequate oxygen supply to the Pt. is maintained at all times, checking all necessary equipment is present in case of an emergency. Dressing care of the site is usually carried out by two staff members and will begin with assessing for pain before any procedure is carried out and appropriate pain medication is given, providing care of the insertion site with appropriate dressing changes using the correct aseptic technique and equipment, assessing the stoma site and reporting any abnormalities.

Nilesh Prasad 02

HLTEN505B Contribute to the complex nursing care of the client

6. Provide the tracheostomy nursing care plan that would be implemented for this client? Care of the Pt. with a tracheostomy involves all different aspects of nursing care, to provide exceptional care documentation of any variations e.g. excessive sputum production, should be communicated to other nursing or allied health staffs to ensure care is delivered and vigilance is maintained, use of aseptic technique during procedures such as suctioning or dressing changes, use of correct equipment; right sized suctioning catheter and technique; not suctioning while introducing the tube, following these guidelines will provide effective nursing care of a patient with a tracheostomy. It is also important to monitor the Pt.s vitals during any procedure and at regular interval, check the stoma site and monitor for dislodgement. As discussed by (Sim Portex5 1998) the three major factors which must be considered when caring for a Pt. with a tracheostomy are: 1. Humidification 2. Mobilization of secretions 3. Airway patency.

Humidification Usually inspired air is filtered, warmed and moistened by the nose and the upper respiratory tract. Humidification is needed to ensure that the upper respiratory pathways remain moist.

Action Explain the procedure to the patient. Fill reservoir of the humidifier with sterile water and attach to the oxygen supply. As prescribed set the oxygen rate at the required percentage, according to the patients needs (usually 1015 minutes of humidification every 4 hours) unless the patient has high oxygen demands. If the patient does not require oxygen, a room humidifier can be used. Replace the sterile water every 24 hours or when the reservoir is empty. Record procedure in patients care plan.

Rational To gain consent and co-operation. Humidification prevents formation of crusts which could block the airway. Sterile water reduces the risk of infection. This provides humidified air without the need for an oxygen supply.

To ensure continuity of care. To ensure validity of care.

Suction via a Tracheostomy Tube Suction is an essential component of secretion control and maintenance of tube patency. Frequency of suction will depend on the patients needs and should be assessed and documented accordingly.

Action Set the suction machine to the appropriate level. Place pulse oximeter on patients finger.

Rational If the suction is too low, it will be ineffective. If suction is too high, it will damage mucosa. To record oxygen saturation and heart rate throughout the procedure.
4

Nilesh Prasad 02

HLTEN505B Contribute to the complex nursing care of the client

Open the end of the suction catheter pack, keeping the rest of the tubing in the packet, apply sterile gloves. Insert suction catheter 10-15cm into tracheostomy tube advance until cough reflex/resistance is felt. Slowly withdraw the suction catheter with a swirling motion. The duration of suctioning should not exceed 10 seconds. Re-apply oxygen after each suctioning. Re-suctioning if required with the same suctioning tube up to 3 times then discard. The secretions should be observed for amount, colour and consistency.

To minimise the risk of infection. In order to minimise damage to the tracheal mucosa as this can lead to trauma and infection. To remove secretions from the mucosa membranes. The longer the duration increases the risk of mucosal damage and to prevent hypoxia. To oxygenate the patient. To ensure airway is completely clear. Document in patients notes.

Tracheostomy Dressing The site should be assessed and cleaned daily using aseptic technique or more often if required, especially if the patient is expectorating secretions. Soiled, moist dressings can contribute to infection and breakdown of the stoma site.

Action Explain the procedure to the patient. Wash hands, apply sterile gloves, apron and eye protection. Loosen tracheostomy ties on one side with one assistant supporting the tracheostomy tube. Remove old dressing and place into clinical waste bag. Remove gloves and wash and dry hands, and apply new pair of non-sterile gloves Moisten a gauze swab with normal saline, gently wipe from the stoma outwards. Use a fresh piece of gauze each time. Let stoma dry and apply a new dressing. Re-attach tracheostomy ties (again two person technique). Ensuring it is not too tight. Ensure the new dressing is comfortable for the patient. Record action in patients care plan

Rational To gain consent and co-operation. To minimise the risk of infection. To gain access to dressing, to maintain placement of tracheostomy tube. To avoid patient discomfort and prevent infection from Occurring and to prevent cross infection. To prevent excoriation of the skin surrounding the tracheostomy and to minimise the risk of infection. To minimize infection and secure the tube.

Promote patient comfort at all times. To promote communication between staff and maintain community of care.

7. Describe 3 ways to determine the position of a NGT? To determine if the NGT is in the correct place, an x-ray could be preformed on the patient to see if the tube is in the correct place. Secondly gastric contents could be aspirated from the stomach, which would be then placed on litmus paper to check the contents as the litmus paper would turn blue if it is acidic, and thirdly the NG tube could be placed in a cup of water and if bubbling is present it would indicate that the tube is within the airway rather than its intended position within the stomach. 8. How do you manage a NGT? Serious (Morley, Tyler3 2011) adverse effects on the patients condition may be associated with the incorrect use of the tube once inserted. The patient must be observed for adverse signs and symptoms which may indicate

Nilesh Prasad 02

HLTEN505B Contribute to the complex nursing care of the client

misplacement or dislodgement. It is the responsibility of the EEN to check the NGT; On each occasion prior to the administration of fluid, nutrition or medications. Aspirations of gastric contents every six hours to confirm ph. levels. After vomiting or server bouts of coughing or respiratory distress. After suctioning. It the tube is accidently dislodged or appears displaced when checked. If there is any doubt that the tube may not be in the stomach. Drain tubes where a tube fails to drain.

Ongoing daily management Check the tape securing tube is intact and not in need of replacement Check around nostril for signs of pressure necrosis and if it appears sore, consider re-passing the tube using other nostril.

9. Are there any special precautions associated with a NGT? After placement of a NGT it is essential to complete all the necessary tests to confirm its correct placement and preferably countersigned by a second nurse or physician as to its correct placement. These checks ensure that the placement of the tube is in the correct place, within the stomach, rather than the lungs. Introduction of medication or supplements is to only begin after confirmation, as feeding into the lungs through a misplaced tube can cause harm or even death.

Nilesh Prasad 02

HLTEN505B Contribute to the complex nursing care of the client

Reference

[1]Claudia Russell, Basil Matta, Tracheostomy A Multi-professional Handbook, 2004, Oxford University Press, 198 Madison Avenue, New York, USA. pp, 10,16.

[2]John Reynard, Simon Brewster, Suzanne Biers, Oxford Handbook of Urology, 1st Edition, 2006 Oxford University Press, 198 Madison Avenue, New York, USA.p.114.

[3]Julie Morley, Emma Tyler, Adult Nasogastric Tube Insertion Procedures and Management Policy, 2011, Plymouth Hospital, UK. p.38.

[4]Longo D Dan, Kasper L Dennis, Jameson J Larry, Fauci S Anthony, Hauser L Stephen, Loscalzo Joseph, Harrisons Principal of Internal Medicine, 18th Edition 2012, The McGraw-Hill Companies, Inc, Printed in the United States of America,Chapter,395.

[5] SIMS Portex Inc. Tracheostomy Care Handbook, 1998, 10 Bowman Drive Keene, New Hampshire 03431, p.20.

Nilesh Prasad 02

You might also like