Irrigation page 281 17th CPNE Study guide

Irrigations my be intermittent or continuous. Sterile technique is used to avoid introducing microorganism into a wound or body cavity such as the bladder.

determine the appropriate temperature of the solution
positions the patient
verifies the correct placement of the tube - ng instill 10-20 cc air if child 5 cc air and listen then aspirate gastric contents
instills the solution into the designated area
controls the flow rate
positions the receptacle
records the kind of irrigation solution  used and the amount of irrigation solution used, the patient's response or tolerance in the student pcs response form. check if irrigation solution is included in the i & o totals , ask what the hospital's policy is

Care Plan Question

My question:


If i write a "risk for" care plan, can I use it as my priority and evaluate it if it does not become an actual problem? I think I can but I thought it was not allowed.

I am reading the 17th Edition Study Guide page 280 answer for:
" #6 Write a care plan for a patient receiving enteral feeding via a peg tube following oral surgery for removal of a cancerous lesion of the mouth. What are the possible related factors?
Label: Risk for imbalanced nutrition: less than body requirements related to impaired swallowing
Outcome: Patient will be free of gastric distress during tube feedings
Interventions:
1. Position patient to a 45 degree angle for feeling
2. Administer enteral feeding as prescribed"

My thought on the evaluation all the components are here -
the nursing dx
with the RT aspect
no s/s since it is not an actual problem
Outcome is measurable - no gastric distress during the feeding
importance - According to maslow, nutrition is a basic human need, required for cell regeneration. Without adequate nutrition cell growth and repair can not occur. If an individual experiences gastric distress they may not tolerate adequate nutrition thus preventing tissue repair, strength, and increasing the susceptibility of infection, inadequate circulation, and tissue breakdown.

evaluation of interventions -
effective as the patient was positioned at 45 degrees
the feeding was administered as prescribed

the patient denied any gastric distress.

Enteral Feeding - 17 th Edition CPNE Study Guide - Excelsior pg 270-271

Feeding by bottle, tube or other device to infants, children or adults.

• For all feedings:
• select the correct formula
• position the patient
• deliver the feeding
• When assistance is designated:
• choose the appropriate device
• burp an infant under six months old periodically, as needed
• Administer the feeding at room temperature unless otherwise directed.
• intermittent Tube feeding:
• determine the amount of feeding
• calculate the gtts/min
• verify the location of a NG by:
• instilling 10-20 cc (5 mm for child <2) of air into the tube while listening to the abdomen
• aspirate amount of gastric contents
• record amount of gastric contents
• reinstill gastric contents
• initiate feeding within 30 minutes of scheduled time
• regulate the rate to be within the specified time by
• adjusting the flow rate to within 5 gtts/min
• or setting the icd to the prescribed flow rate.
• continuous tube feeding:
• within the first 20 minutes
• verify type of feeding
• verify rate either by gtt/min or icd setting
• regulate the flow if needed within 5 gtts/min
• or adjusting the rate on an ICD to the ordered rate.
• document same on the PCS recording form
• verify the position at least once during the PCS by
• instilling 10-20 cc (5cc for child <2) air and listening to abd and
• aspirating gastric contents
• when measurement of gastric residual is designated:
• measure gastric residual
• reinstill gastric residual unless contraindicated
• determines the amount of feeding to be administered
• Records the kind of oral feeding administered
• Records the name and strength of the feeding product for a  patient receiving a tube feeding
• Records the amount of feeding
• Records the volume of gastric residual measured

Interesting or Not

Vickie's Views

Other Selected Areas of Care page 265 CPNE 17th Edition Study Guide - Drainage and Specimen Collection

Removal of body secretions from a a body cavity or wound, includes care and protection of surrounding skin.
ID Patient
remember to wear gloves
explain procedure to patient

1. when drainage collection is assigned: (foley, hemovac, JP, NG)
1. assesses the amount and color of drainage
2. cleans surrounding skin or tissue - when assigned
3. insert the tube into the apropriate body cavity
4. when drainage is by tube
1. maintain or attach tube to container
2. maintain patency of tube
3. maintain drainage by suction or gravity
4. removes tube when assigned
2. when specimen collection is assigned: (urine, feces, sputum)
1. obtain designated specimen
2. place the specimen in the designated container or on the designated surface
3. ensures that the spicimen is labeled
4. places specimen in designated area for transport
3. record data related to drainage amount and color
4. record data related to specimen collection
5. document or report disposition of speciment

Documentation includes recording on the PCS recording form for the disposition of specimen. Additional data is to be written in "Other Observations" in the narrative note section.

Wound Management - Critical Element Selected Area of Care 17th Edition CPNE Study Guide

"Wound Management is the assessment of a wound and the implementation of measures to clean, irrigate, and protect the wound and surrounding skin." page 257

1. Assess the wound location, type,  (incision, contusion, abrasion, laceration, puncture, penetrating wound, pressure ulcer) appearance of the wound bed (granulation, necrotic), and presence or absence of drainage (purulent, serosangenous, bloody). Signs of infection - redness, odor, pain, warmth.
2. When irrigation is designated:
1. Selects the designated solution
2. Determines the appropriate temperature of the solution
3. Uses an appropriate irrigation delivery system
4. Positions a receptacle for return flow
5. Irrigates without contaminating the wound
6. Protects the surrounding skin from contact with the drainage
3. Cleanses the wound with the designated solution
4. When wound packing is assigned:
1. prepares gauze for application to wound bed
2. packs wound by applying a sterile moist dressing to wound bed surface
5. Applies the designated topical preparation
6. When wound protection is required:
1. removes the dressing without contaminating the wound
2. removes the dressing without injuring the surrounding skin
3. disposes of the soiled dressing in the designated container
4. applies the dressing without contaminating the wound
5. secures the dressing
6. labels the dressing with date, time, and their initials
7. Records data related to wound:
1. location
2. type
3. appearance
4. presence or absence of drainage

Care Plans found in the 17th edition Excelsior CPNE study guide

When writing a care plan use Kardex and what you are assigned.

• Respiratory Management:
• Ineffective airway clearance r/t retained secretions aeb ineffective cough, inability to move airway secretions, abnormal breath sound, abnormal respiratory rhythm, rate and depth
• goal: patient will perform respiration hygiene activities
• interventions - depend on assigned -
• Direct patient to perform IS x 10
• Instruct patient to perform deep breathing and coughing
• suction secretions
• assess respiratory status

 Oxygen Management:

• Impaired gas exchange r/t ventilation - perfusion imbalance aeb oxygen sturation of <93% on room air
• goal (Outcome) patient will have oxygen saturation equal to or < 93% during PCS
• monitor oxygen saturation
• position patient to facilitate respiration

Muscular Skeletal Management: