GIVE THE INFORMATION. NOT TO MENTION YOUR BOOK'S NOT TOO BAD. SO...
- NO, NOT THAT.
- WHICH LEADS ME TO THIS, THE BOOK.
LAST NIGHT I READ THROUGH EVERYTHING.
I'M HAVING TO KEEP UP WITH THE READING WITH YOUR GROUP
BECAUSE YOU HAVE THE NEW EDITION OF THE BOOK
AND MAKING SURE EVERYTHING I'VE DONE MATCHES AND SO ON AND SO.
SO I READ THROUGH THE BOOK AND I READ THROUGH ALL THE ARTICLES AGAIN
AND I WANT TO SAY MY ARTICLES ARE BETTER THAN THE BOOK.
SO READ THE ARTICLES IF YOU'RE NOT GOING TO READ BOTH, OKAY?
READ THE ARTICLES, THEY'RE VERY GOOD.
ESPECIALLY THE CHEST TUBE ONE.
THEY TALK ABOUT EVERYTHING AND IT'S VALIDATED IN THE BOOK,
BUT IT'S VERY QUICK AND THEY DON'T EXPOUND ON IT.
AND THE ARTICLES GIVE IT IN CONTEXT OF A CLIENT AND IT'S JUST VERY READABLE
AND THEY'RE VERY, VERY GOOD.
THE SUCTION ARTICLE HAS -- LIKE, TEN STEPS.
TEN STEPS TO SAY FOR SUCTIONING.
MANY OF THE STEPS TALK ABOUT SUCTIONING WITH A RESPIRATOR,
AND YOU GUYS AREN'T GOING TO BE WORRYING ABOUT RESPIRATOR,
BUT THE STEPS AND THE TIPS ARE THE SAME.
SO READ THROUGH 'EM AND IF IT STARTS GOING OFF INTO RESPIRATOR JARGON, JUST LET THAT GO.
I'M NOT GOING TO HOLD YOU ACCOUNTABLE TO A RESPIRATOR.
YOU'LL BE DOING THAT WHEN YOU DO CRITICAL CARE,
SO I'D SAVE THAT ARTICLE BECAUSE IT'S EXCELLENT.
BUT LEARN THE TIPS AND LEARN THE TECHNIQUES
AND KNOW THAT WHAT I'M TELLING YOU, I'VE VALIDATED WITH THE LITERATURE.
SO, HOPEFULLY, THAT WILL HELP.
THE REASON THIS MODULE IS SO BIG. IT'S ALWAYS BEEN BIG.
WE'VE ALWAYS DONE CHEST TUBE, SUCTIONING AND TRACH CARE.
BUT I ADDED THE MODULE FROM LAST SEMESTER
SO THAT WE COULD HAVE A CRITICAL CARE MODULE.
SO WHAT I'VE ADDED TO YOURS IS AN INSPIROMETER,
SPUTUM COLLECTION, SUCTIONING A BABY,
OXYGEN AND POSTURAL DRAINAGE.
SO WHAT I'M GOING TO DO IS THESE QUICK PASS/FAIL THINGS FROM LAST SEMESTER.
IF WE HAVE TIME, I'LL DO POSTURAL DRAINAGE.
IF NOT, I'LL DO IT WITH THE CATHETER ONE NEXT SEMESTER.
IT'S VERY EASY AND IT'S ALSO A PASS/FAIL. IT'S NOTHING WE'RE TESTING ON.
AND THEN I'LL DO THE REGULAR MODULE, WHICH IN AND OF ITSELF IS RATHER HUGE.
OKAY, HERE WE GO.
OUR THEME FOR THIS WEEK IS RESPIRATORY CARE.
SO, THE FIRST THING WE WANT TO DO WITH ANY OF OUR CLIENTS IS WE WANT TO PREVENT ATELECTASIS.
WE WANT TO PREVENT PNEUMONIA. WE WANT TO PREVENT PROBLEMS.
SO YOUR POST-OP CLIENTS, PEOPLE THAT ARE HAVING DIFFICULTY BREATHING,
WE GIVE THEM WHAT'S CALLED AN INCENTIVE SPIROMETER.
AND THE IDEA IS THAT IT'S KIND OF A TOY
AND IT WILL GIVE THEM INCENTIVE TO WANT TO TAKE GOOD, DEEP BREATHS.
SO MOST OF 'EM LOOK SIMILAR TO THIS.
ALTHOUGH THEY DO HAVE SOME ELECTRONIC ONES AND I THINK THEY'RE PRETTY FUN.
THEY LOOK KIND OF LIKE IV PUMPS,
BUT THERE'S A LITTLE CLOWN FACE ON 'EM.
AND WHEN YOU BREATHE IN, IT STARTS BLINKING.
AND WHEN IF YOU GET TO THE CLOWN, THE VOLUME --
THE CLOWN BLINKS AT YOU AND THAT'S JUST GREAT FUN.
THESE ARE NOT SO HIGH-TECH, BUT THEY WORK LIKE THIS.
YOU TELL YOUR CLIENT, THAT THEY'RE GOING TO BE TAKING GOOD, DEEP BREATHS
AND IT'S THE INSPIRING THAT YOU WANT THEM TO DO, NOT BLOWING.
ANYBODY CAN DO THAT, BUT THAT'S CHESTY.
WHAT YOU WANT THEM TO DO IS TAKE GOOD, DEEP BREATHS THAT GO TO THE BASE OF THEIR LUNGS.
SO, IF YOU CAN, IT'S BEST IF YOU CAN TEACH THEM BEFORE THEY HAVE SURGERY
AND WHILE THEY'LL LISTEN TO YOU BEFORE THEY'RE HURTING.
SO YOU WANT TO TEACH THEM THAT THE IDEA
IS TO PUT THEIR INSPIROMETER TOGETHER.
THIS LITTLE TUBE COMES ON AND OFF AND THEY GET A MOUTHPIECE.
AND WHAT THEY NEED TO DO IS TAKE A GOOD, DEEP BREATH.
OUT.
PUT THEIR MOUTH ON HERE.
HOLD IT AND THEN BREATHE OUT.
WHEREVER THE BASE OF THIS IS, VENT,
THEN THAT'S WHERE YOU WANT TO MARK IT ON HERE,
SO THAT THEIR INCENTIVE AFTER SURGERY
IS TO GO TO THEIR MAXIMUM INSPIRATION.
SO, TELL 'EM TO DO ONE OR TWO AT A TIME.
IF THEY KEPT TAKING THOSE DEEP BREATHS ONE AFTER THE OTHER,
YOU KIND OF PASS OUT.
AND THE IDEA IS THAT YOU'RE NOT JUST GOING...
INSTEAD, YOU'RE TAKING THAT GOOD, DEEP BREATH IN AND HOLDING IT,
AND IT'S A SLOW BREATH IN.
SO, ONE MORE TIME.
YOUR LITTLE HEAD KIND OF GOES...WHOO!
AND THE IDEA IS THAT AFTER THAT,
THEN AFTER YOU TAKE A GOOD, DEEP BREATH AND OUT,
THAT YOU COUGH. [COUGHING]
NOW, NOT A CHESTY COUGH.
AND THEY'LL DO THAT BECAUSE IT HURTS TO COUGH,
BUT A GOOD ABDOMINAL DIAPHRAGM-TYPE COUGH.
IF THEY'VE HAD ABDOMINAL SURGERY, THEY MAY NOT WANT TO COUGH
SO YOU MAY HAVE TO TEACH THEM TO SPLINT THEIR STOMACH.
AND COUGH.
AND THEN TRY TO GET SPUTUM UP WHEN THEY'RE COUGHING.
YOU WANT THEM TO DO THIS ABOUT TEN TIMES AN HOUR.
SO A GOOD THING TO DO IS IF THEY'RE A TV WATCHER,
LIKE, DO A COUPLE BREATHS EVERY COMMERCIAL.
IF THEY'RE NOT, THEN JUST WITH THE CLOCK
OR EVERY TIME THEY TURN OR SOMETHING.
BUT YOU NEED TO GIVE 'EM SOME KIND OF A CUEING SYSTEM SO THAT THEY'LL GET IT.
ENCOURAGE THEM, "HEY! HEY! THAT'S SO GOOD." YOU KNOW?
AND BE THEIR CHEERLEADER ABOUT IT
AND THEN CHECK ON THEM FREQUENTLY.
THEY NEED TO DO IT WHILE AWAKE.
I MEAN, YOU DON'T WAKE PEOPLE USUALLY DURING THE NIGHT JUST TO TAKE A FEW DEEP BREATHS,
BUT WHEN THEY'RE AWAKE YOU WANT TO GO AHEAD AND ENCOURAGE 'EM WHILE,
YOU KNOW, WE'RE TAKING VITALS OR GIVING MEDS OR SOMETHING.
TAKE SOME DEEP BREATHS.
ALRIGHT. SPUTUM.
WE COLLECT SPUTUM.
AND IT'S EASIER IF THEY'RE TAKING GOOD, DEEP BREATHS
TO COUGH IT UP BECAUSE WHAT YOU WANT IS SPUTUM.
YOU WANT FROM THE LUNGS. YOU DON'T WANT SPIT AND SALIVA.
YOU NEED TO GET A CONTAINER. IT CAN BE SOMETHING LIKE THIS.
THIS IS USUALLY FOR TB
BECAUSE THAT ONE YOU DON'T WANT TO EXPOSE TO LIGHT
BECAUSE OF THE ACID-FAST BACILLI,
SO IT USUALLY COMES IN A CONTAINER LIKE THIS.
AND IT'S NICE BECAUSE IT HAS A FUNNEL, AND SO THEY CAN...
SPIT IT UP.
SPIT IS NOT MY BEST THING AND SPUTUM IS BY FAR NOT.
URGH. I CAN'T EVEN HARDLY WATCH BASEBALL,
FOR THOSE GUYS OUT THERE ARE JUST COUGHING ALL THE TIME.
ALRIGHT. SO WHAT YOU WANT 'EM TO DO IS THE SAME THING. GOOD, DEEP BREATHS.
AND THEN...
AND THEN THEY COUGH UP.
AND THEN YOU WANT ONE TEASPOON TO TWO TEASPOONS FULL,
DEPENDING AGAIN...ABOUT WHATEVER --
WHOSE SPECIMEN YOU'RE COLLECTING.
ONCE YOU'VE COLLECTED IT, THIS THING COMES APART.
AND THEN YOU PUT THE LID ON, LABEL IT AND IT GOES TO THE LAB LIKE THIS.
YOU DON'T HAVE TO SEND THIS WHOLE CONTRAPTION DOWN.
YOU CAN, BUT YOU WANT TO MAKE SURE IT'S SEALED WELL OR YOU'LL LOSE YOUR SPUTUM.
SO THAT'S THE POINT OF IT.
YOU CAN DO SPUTUMS IN JUST A REGULAR SPECIMEN CONTAINER.
JUST MAKE SURE THAT IT'S OKAY WITH THE LIGHT ISSUE.
OKAY.
SO LET'S START WITH -- LEAN 'EM OVER HERE. SO THAT WAS SPUTUM.
WE'RE GOING TO GET SPUTUM WITH A SUCTION AND THAT'S A LITTLE BIT DIFFERENT.
SOMETIMES PEOPLE CAN'T COUGH THEIR SPUTUM UP OR THEY CAN'T GET IT OUT
SO YOU MAY HAVE TO CALL RESPIRATORY THERAPY TO INDUCE THE SPUTUM.
AND SO THEY WILL PUT THEIR SUCTION CATHETER AND GET THEM COUGHING A LITTLE
OR PUT A LITTLE SOMETHING INTO THEIR MOUTH AND THAT WILL GET THEM COUGHING
AND THEN THEY'LL BE ABLE TO SUCTION THAT SPUTUM UP.
AND WE CAN GET THOSE AS WELL, WE CAN SUCTION SPUTUMS
AND I'LL SHOW YOU HOW TO DO THAT.
ALRIGHT. BABIES.
BABIES NEED SUCTIONING.
WHICH IS WHAT WE WERE SUPPOSED TO DO LAST WEEK.
THIS WAS THE BULB THAT THEY WERE TALKING ABOUT
TO SUCTION OUT BABIES' NOSES AND BABIES' MOUTHS.
AND SO WHAT YOU WANT TO DO IF A BABY IS CONGESTED IN THEIR MOUTH
OR THEY'RE CHOKING ON FLUIDS, YOU WANT TO BE ABLE TO GET THAT OUT.
YOU CAN DO IT SIMPLY WITH A BULB.
HERE -- EVERY NEWBORN SHOULD HAVE THIS IN THEIR CRIB
AND THEN PEOPLE THAT ARE ADMITTED, DEPENDING ON THE SIZE OF THE BABY.
USUALLY, UNDER A YEAR HAVE SOME KIND OF A BULB THERE FOR THEM.
THERE'S TWO THINGS WE NEED TO REMEMBER ABOUT BULBING A BABY.
ONE IS, THERE'S ON THE PERINEUM AND THERE'S ALREADY BORN.
AND SO I JUST WANT TO DISTINGUISH BETWEEN THE TWO
AND THAT WAS THE MAIN PURPOSE OF DOING THIS.
WHEN A CHILD IS BEING BORN, YOU'RE WATCHING THE BIRTH, YOU'RE IN OBSTETRICS.
AND THE BABY IS COMING OUT, AND THE HEAD COMES OUT,
AND THEY USUALLY STOP 'EM AT THAT POINT AND THEN THEY BULB THE BABY.
WHICH DO YOU SUPPOSE THEY DO FIRST? MOUTH OR NOSE?
- MOUTH FIRST. - MOUTH.
AND THE REASON IS BECAUSE IF YOU DO NOSE,
THEY HAVE AMNIOTIC FLUID IN THEIR MOUTH AND THEY MAY GO...
AND ASPIRATE AMNIOTIC FLUID.
AND SO THEY DO MOUTH FIRST ON THE PERINEUM AND THEN NOSE.
ONCE THEY'RE BORN, WE DO NOSE FIRST AND THEN MOUTH.
AND SO THAT'S THE DIFFERENCE BETWEEN THE TWO.
SO IF THEY HAD A LITTLE CONGESTED NOSE,
YOU WANT TO GET A LITTLE DIAPER OR SOMETHING TO WIPE THIS OFF ON.
YOU WANT TO SQUEEZE THIS FIRST, THEN PUT IT IN THE NOSTRIL.
GET YOUR STUFF AND THEN JUST SQUEEZE IT OUT ON THE LITTLE DIAPER OR ON A CLOTH.
SAME THING ON THIS SIDE. SQUEEZE IT OUT.
AND THEN YOU WANT TO GO OVER HERE AND THEN GO BETWEEN THE GUM -- GUMS AND CHEEK.
SQUEEZE FIRST, PUT IT IN... AND THEN SUCK IT UP.
OKAY?
THEY HAVE A NEW LITTLE THING, THIS IS ACTUALLY AN ADULT SIZE.
BUT THEY HAVE A NASO ASPIRATOR THAT YOU CAN HOOK TO SUCTION.
AND YOU CAN PUT THOSE TO THEIR LITTLE NOSES AND JUST GET NOSE SUCTION.
SAME IS IF SOMEONE HAS A TRACH OR SOMETHING, YOU COULD DO A NOSE.
AND I'LL TALK A LITTLE BIT MORE ABOUT HOW TO WORK THESE.
BUT THERE ARE LITTLE GADGETS FOR...
SEPARATE THINGS.
ALRIGHT.
I WANTED TO MENTION OXYGEN.
AND IN YOUR BOOK --
YOU'RE AVOIDING BOOK. I DON'T KNOW.
BUT THERE'S A WONDERFUL GRAPH OVER HERE
ON PAGE 749, I THINK.
YES. THAT TALKS ABOUT THE DIFFERENT DELIVERY SYSTEMS FOR OXYGEN.
AND WHAT YOU WANT TO DO IS REVIEW WHAT THESE ARE.
I'M GOING TO SHOW YOU WHAT THEY ARE AND WHY THE DIFFERENCE.
BUT THIS IS WHERE YOUR INFORMATION WILL BE.
THERE'S A LITTLE BIT OF INFORMATION ABOUT O2
AND SOME OF THE PERIMETERS. I'LL TALK ABOUT THAT IN A SECOND.
AND THEN THEY GIVE YOU SOME GOOD PICTURES ABOUT WHAT EACH OF THESE ARE.
BUT THEY'RE A LITTLE DIFFICULT TO DISTINGUISH
AS FAR AS THE PICTURES, SO I WANTED TO SHOW YOU.
OXYGEN THERAPY IS GIVEN TO PEOPLE
WHO USUALLY HAVE A O2 SATURATION BELOW 94%.
WE WANT PEOPLE TO BE ABOVE 94,
SO IF THEY ARE, THEN THERE'S USUALLY NOT MUCH NEED FOR THE OXYGEN.
BUT IF THEY AREN'T, THEN THAT'S WHAT WE'RE TRYING TO SUPPLEMENT.
AND SO WE'RE GOING TO DETERMINE -- ACTUALLY, WE AREN'T.
BUT THE DOCTORS ARE GOING TO DETERMINE HOW MUCH O2 THE CLIENT GETS,
BASED ON THEIR ARTERIAL BLOOD GASES, BASED ON THEIR CONDITION, DIAGNOSIS AND SO FORTH.
SO, HOW TO DO WE DELIVER ALL THESE DIFFERENT KINDS OF OXYGEN?
WELL, THE ONE YOU'RE PROBABLY THE MOST FAMILIAR WITH IS NASAL PRONGS.
NASAL PRONGS CAN DELIVER UP TO SIX LITERS OF OXYGEN
THROUGH THE PRONGS. ONE TO SIX.
ANYTHING OVER FOUR LITERS OF OXYGEN NEEDS TO BE HUMIDIFIED.
SO WE CAN GIVE DRY OXYGEN, BUT MOST OF THE TIME WE DON'T.
SO IF YOU JUST COULDN'T GET TO SOME DISTILLED WATER
TO PUT INTO YOUR O2 DISTRIBUTOR,
THEN IT'S OKAY FOR A LITTLE WHILE, BUT YOU DO WANT TO HUMIDIFY IT.
BECAUSE AIR JUST BLOWING UP THE NOSTRILS GETS REALLY DRYING.
TO WORK THE NASAL PRONGS, YOU WANT TO GET YOUR PRONGS
AND THEY KIND OF CURVE AND FORK THIS WAY.
SO THE FORK GOES TOWARDS THE CLIENT.
IT DOESN'T SHOOT OUT THIS WAY OR YOU'LL BE SHOOTING THE AIR OUT THEIR NOSTRIL.
OKAY? SO IT GOES UP LIKE THIS.
AND THEN THESE WRAP AROUND THE EARS.
AND KIND OF LIKE THOSE OLD-FASHIONED COWBOY HATS, IS WHAT IT REMINDS ME OF.
YOU HAVE THIS LITTLE PENDANT AND THAT TIGHTENS IT SO THAT IT'S SNUG.
YOU DON'T WANT IT TOO TIGHT,
BECAUSE IT CAN CAUSE PRESSURE SORES BEHIND THE EARS
AND LEAVE MARKS ON THEIR FACE.
SO JUST SNUG ENOUGH THAT IT'S NOT FALLING OFF OF 'EM ALL THE TIME.
I'VE SEEN SOME CLIENTS -- IN FACT, I VISITED A FRIEND THE OTHER DAY IN THE HOSPITAL.
SHE HAD HERS LIKE THIS BECAUSE IT WAS DRIVING HER CRAZY.
AND THEY ACTUALLY JUST TAPED IT TO HER CHEEKS
BECAUSE IT WAS JUST GETTING TO WEAR OUT THE BACK OF HER EARS.
AND SO ANYTHING, AS LONG AS THESE LITTLE PRONGS ARE HERE.
WHEN YOU'RE DOING YOUR O2, THESE COME IN A PACKAGE.
YOU GET 'EM FROM RESPIRATORY THERAPY.
AND THEY GET CONNECTED TO YOUR O2...
HERE.
THIS LITTLE PIECE AT THE BOTTOM IS THE HUMIDIFIER
AND YOU NEED TO PUT DISTILLED WATER IN THERE.
AND YOU CAN GET THAT ALSO FROM RESPIRATORY THERAPY.
SO YOU FILL THAT UP WITH DISTILLED WATER.
AND THEN YOU DO YOUR LITER FLOW BY TURNING THIS DIAL.
AND IF THAT WERE TO -- IT WOULD JUST RUN THROUGH THERE, THEY GET A LITTLE HUMIDITY.
WHEN YOU GET UP INTO THE HIGHER LITER FLOW,
SOMETIMES THE MOISTURE FROM THE HUMIDIFIER GETS INTO THE TUBING
AND YOU HAVE TO KIND OF DUMP IT OUT.
SO YOU WANT TO DISCONNECT, DUMP OUT THE FLUID
AND THEN RECONNECT LIKE THIS.
- BUT LEAVE IT FULL? - BUT LEAVE IT FULL. YEAH.
- FULL TO THE TOP?
- NO, TO THE TOP FULL LINE.
AND THERE'S A LINE THAT TELLS YOU ON HERE, HOW FAR TO FILL IT UP TO.
ONE OF THE REASONS WE HAD THESE INSTALLED
WAS BECAUSE I WANTED YOU TO PRACTICE TAKING THEM IN AND OUT OF THE WALL
BECAUSE YOU CAN HOOK UP OXYGEN
AND THAT'S KIND OF FUN TO DO.
I'M GOING TO GO AHEAD AND TURN THIS OFF.
BUT I DO WANT TO MENTION THAT THIS IS NOT REAL OXYGEN
AND IT'S NOT EVEN REAL COMPRESSED AIR,
IT'S A COMPRESSOR DOWN IN THE BASEMENT THAT'S AN OIL COMPRESSOR,
AND SO THIS IS NOT OXYGEN YOU WOULD WANT TO BREATHE.
URGH. SO THAT'S WHY WE HAVE OUR BIG RED SIGN.
IT'S JUST A GAS MACHINE DOWNSTAIRS THAT...
HAS AIR FOR US.
ALRIGHT. TO GET THIS OFF,
ALL YOU HAVE TO DO IS TWIST AND IT SHOOTS ITSELF OFF.
IT'S A LITTLE TWISTING DIAL RIGHT HERE.
AND THEN TO PUT IT IN, YOU WANT TO HOLD IT NICE AND FIRM,
GET IT IN THE RIGHT DIRECTION AND THEN JUST POP IT INTO THE WALL.
SO PRACTICE TAKING THOSE IN AND OUT OF THE WALL AND JUST TO GET THE FEEL OF IT.
ALRIGHT. NOW, I'LL JUST LOOK DOWN HERE.
NASAL PRONGS DELIVERS 24-44% CONCENTRATED O2.
WHICH IS DECENT ENOUGH, BUT SOMETIMES YOU NEED MORE.
SO YOU MAY NEED TO GO TO A MASK.
ESPECIALLY IF YOUR CLIENT'S NOT A MOUTH --
I MEAN, NOT A NOSE BREATHER. WHAT IF THEY'RE ARE A MOUTH BREATHER?
YOU KNOW? YOU NEED TO GET OXYGEN TO 'EM.
SO A MASK MAY BE WHAT YOU WANT.
THIS PARTICULAR MASK IS CALLED THE OXYMIZER.
IT JUST GETS 24-80%. A LITTLE BIT HIGHER THAN THE NASAL PRONGS,
BUT IT GETS IT TO THEIR MOUTH.
THERE'S SOME DISADVANTAGES TO THE MASK.
MOST OBVIOUS? CAN'T EAT.
THAT WOULD BE MY PRIORITY.
SO THESE ARE A LITTLE INCONVENIENT SO WHAT YOU DO --
YOU TRY TO GET THEM OVER YOUR EARS SO IT WON'T STAY ON AS WELL.
NOT FUN. MAYBE UP HERE.
BUT THEY HAVE TO BE SNUG OR THEY DON'T WORK.
AND PLUS, ISN'T IT KIND OF HARD TO HEAR ME?
IT'S HARD TO TALK TO YOUR PATIENTS TOO
AND THEN THEY'RE SHORT OF BREATH AS WELL.
SO THESE ARE A PROBLEM.
VERY HOT, VERY STUFFY AND VERY IRRITATING.
BECAUSE FOR THEM TO WORK, THEY HAVE TO BE SNUG, RIGHT?
SO, YOU DO GET A LITTLE MORE LITER FLOW, BUT THEY'RE A LITTLE IRRITATING.
THE NON-REBREATHER MASKS OR THE PARTIAL NON-REBREATHER MASK
GIVES US THE HIGHEST CONCENTRATION OF O2.
THEY NEED TO BE SET AT 6 TO 15...LITER FLOW.
AND WHEN THEY ARE -- SET IT AT 10.
AND WHEN THEY ARE, THE LITTLE BAG --
IT'S HARD TO TELL, CAN YOU TELL IT'S FULL A LITTLE BIT?
AIR'S GOING THROUGH HERE
AND IT'S CAUSING THEM NOT TO RE-BREATHE SO MUCH CARBON DIOXIDE.
A NON-REBREATHER CARBON DIOXIDE.
THERE'S LITTLE HOLES THERE SO THAT IT COMES OUT,
BUT IT TRAPS THE AIR AND IT ALLOWS THEM TO GET A HIGHER CONCENTRATION.
THIS IS A PARTIAL NON-REBREATHER AND I DON'T HAVE A TOTAL NON-REBREATHER.
BUT THE POINT IS THAT I WANT YOU TO APPRECIATE IS THIS BAG.
IT'S KIND OF LIKE WHEN YOU GO ON THE AIRPLANE
AND THE THING FALLS DOWN AND THEY SAY PUT IT ACROSS YOUR FACE.
AND THE BAG WON'T FILL UP, THIS WON'T EITHER.
IT'S JUST EVER SO SLIGHT, YOU CAN SENSE THE AIRS IN THERE.
BUT IT TRAPS THE CARBON DIOXIDE AND IT ALLOWS THEM
TO NOT RE-BREATHE THEIR OWN AIR AND GET OXYGEN.
SO YOU GET THE HIGHEST CONCENTRATION OF THAT.
THE OTHER ONE, THE VENTURA MASK, IS THE MOST ACCURATE.
THIS GIVES THE MOST, BUT THE VENTURI MASK IS THE MOST ACCURATE.
I DON'T HAVE A VENTURI MASK, BUT THERE'S A GOOD PICTURE OF IT
HERE ON PAGE 752.
AND WHAT IT DOES HERE, IS AT THIS POINT RIGHT HERE,
THERE'S A LITTLE DIAL THAT ACTUALLY DIALS THE LITER FLOW FROM THE MASK.
AND SO THAT'S WHAT ALLOWS IT TO BE A LITTLE MORE ACCURATE.
I'VE USED THEM IN THE PEDIATRIC ENVIRONMENT THE MOST,
WHEN WE NEEDED TO HAVE GOOD CONTROL OF OUR O2.
BUT THAT'S KIND OF THE DEAL ON HOW THOSE WORK.
ALL THE MASKS ARE A PROBLEM WHEN IT COMES TO EATING, TALKING AND FOR LONG-TERM WEAR,
BECAUSE THEY CAN CAUSE BREAKDOWN ON THE SKIN AND PEOPLE DO NEED TO EAT.
SO, USUALLY, WE HAVE PRONGS THAT WE SET ASIDE
AND WE PUT PRONGS ON FOR MEALS IF THEY CAN TOLERATE IT.
THEN THEY'RE JUST OFF FOR A LITTLE BIT OF TIME IF THEY CAN TOLERATE IT.
SO, YOU JUST HAVE TO FIND OUT WHAT'S GOING ON WITH YOUR CLIENT.
OKAY.
WENT THROUGH THAT PRETTY FAST.
I THINK WHAT I WANT TO DO IS...
I THINK I'M GOING TO DO SUCTION AND TRACH CARE FIRST,
AND THE THEN WE'LL DO THE TEST TUBE LAST.
YOU HAVE IN YOUR KITS, A SUCTION CATHETER KIT AND YOU HAVE A TRACH CARE KIT.
AND YOU CAN JUST APPRECIATE THAT YOUR CLIENT HAS A TRACH, TRACHEOSTOMY.
WHAT I WANT TO DO IS EXPLAIN A LITTLE ABOUT WHAT A TRACH IS, HOW IT WORKS
AND THEN SHOW YOU A LITTLE VIDEO CLIP
AND THEN WE'LL DO OUR CARE, SO THAT YOU KNOW WHAT'S GOING ON.
A TRACHEOTSOMY IS CREATED BY THE PHYSICIAN.
A LITTLE STOMA. AN INCISION IS MADE ON HERE AND A TRACH IS PUT IN
SO THAT THE CLIENT CAN PASS AIR THROUGH THIS TRACHEAL SPACE.
FOR SOME REASON, WE RELATE IT TO TRAUMA, WE RELATE IT TO DISEASE,
THAT THEY CAN'T PASS AIR OR GET A GOOD ENOUGH OXYGEN CONCENTRATION
THROUGH THEIR NOSE OR THROUGH THEIR MOUTH.
THESE MAYBE SHORT-TERM. THEY MAYBE LONG-TERM.
IT JUST DEPENDS AGAIN ON THE SITUATION.
YOU'LL SEE CANCER CLIENTS, FOR EXAMPLE, THAT HAVE --
THAT'S HOW THEY'RE GOING TO OUT OF THIS WORLD, IS WITH A TRACH.
AND SO YOU JUST NEED TO KNOW, IS THIS CHRONIC, IS THIS ACUTE, WHAT'S GOING ON?
TRACHS COME IN TWO DIFFERENT SIZES.
WE HAVE THE SHORT TRACH HERE THAT'S USUALLY FOR SHORT-TERM USE,
BUT IT JUST COMES DOWN PARTIALLY INTO THE TRACHEA.
AND THEN WE HAVE THE LONGER, AND THESE DON'T FIT.
BUT THESE ARE LONGER ENDOTRACH TUBES
THAT ARE EITHER ORAL OR CAN GO THROUGH THE TRACH.
BUT THEY CAN GO DEEPER INTO THE TRACH WHEN THEY'RE PUT ON TO A RESPIRATOR.
OUR'S IS JUST GOING TO BE A SHORT TRACH
AND WE'RE NOT GOING TO BE CONNECTED TO A RESPIRATOR.
A TRACH LOOKS --
WELL, LET ME TALK ABOUT THIS ONE, I THINK IS THE EASIEST. YOU CAN SEE IT BETTER.
A TRACH HAS AN INNER CANNULA, WHICH IS THIS PIECE RIGHT HERE,
THAT KEEPS THE SPUTUM FROM BUILDING UP.
WE'LL TALK ABOUT THAT IN A MINUTE.
AND IT HAS THE OUTER CANNULA WHICH IS WHAT MAINTAINS THE PATENT AIRWAYS,
WHAT GOES DOWN INTO THIS THROAT AREA.
THEY COME IN DIFFERENT SIZES BECAUSE WE CAN PUT A TRACH IN ANYONE FROM INFANT TO ADULT.
SO AN ADULT SIZE CUFF, TYPICALLY SIZE SIX OR ABOVE
WHICH IS WHAT THIS IS.
THE OUTER CANNULA INTO THE TRACHEA, CAN HAVE A CUFF OR CANNOT HAVE A CUFF.
IT JUST DEPENDS ON WHAT THE CLIENT'S STATUS OR DIAGNOSIS IS.
YOU'RE GOING TO GET MORE INTO THAT THEORY NEXT SEMESTER AND IN CRITICAL CARE,
BUT I NEED YOU TO APPRECIATE WHAT YOU'RE LOOKING AT WHEN WE'RE SUCTIONING.
THE CUFF ON HERE...
WHEN IT GOES INTO THE CLIENT -- I HAVE TO USE THIS ONE ON THE CLIENT.
WHEN THE CUFF IS DEFLATED, THEN THE CLIENT CAN PASS AIR
THROUGH THE MOUTH AND THE NOSE INTO THE TRACHEA.
BUT WHEN THE CUFF IS INFLATED,
THEN JUST SIMPLY INFLATE IT WITH THIS SYRINGE HERE.
THEN THE BALLOON GETS FILLED UP
AND THEN IT BLOCKS THE TRACHEA
SO THAT THE ONLY WAY YOU CAN PASS AIR IS THROUGH THE TRACHEA.
NO AIR EXCHANGE NOW HAPPENS FROM THESE UPPER ORIFICES.
THIS IS IMPORTANT FOR WHEN THEY'RE ON A RESPIRATOR
BECAUSE WHEN YOU'RE PUSHING AIR IN, YOU DON'T WANT THE AIR LEAKING OUT.
SO THAT WE CLOSE IT OFF, SO THAT THEY GET ALL OF THEIR AIR IN AND OUT.
WE ALSO CAN USE THIS BULB FOR PEOPLE
THAT MIGHT HAVE DIFFICULTY WITH CHOKING, FOR EXAMPLE.
LIKE WITH BRUSHING THEIR TEETH OR EATING,
YOU MIGHT CLOSE THIS OFF TO PREVENT ASPIRATION BECAUSE THAT'S A PROBLEM FOR THEM.
THEN THEY EXCHANGE AIR THROUGH HERE, BUT THEN THEY CAN EAT.
OR THAT YOU CAN BRUSH THEIR TEETH AND A LITTLE CAN GO DOWN
AND IT'LL GO DOWN THE RIGHT SLOT AND SO THAT'S THE PURPOSE.
THERE'S A LOT OF INFORMATION ABOUT CUFFS THAT I DON'T WANT TO GET INTO.
SUFFICE IT TO SAY YOU DON'T LEAVE THEM FULL ALL THE TIME
OR YOU CAN CAUSE EROSIONS ONTO THE ESOPHAGUS.
YOU HAVE TO RELEASE THEM SO THAT YOU DON'T BREAK DOWN --
NOT THE ESOPHAGUS, I'M SORRY, THE TRACHEA.
IT CAN CAUSE SCARRING, IT CAN CAUSE TRAUMA,
IT CAN CAUSE TISSUE DAMAGE, IT CAN CAUSE STENOSIS.
THERE'S A LOT OF THINGS THAT CAN HAPPEN RELATED TO POOR INFLATION OF THE CUFF.
BUT I WANT YOU TO APPRECIATE WHAT IT MEANS.
WHEN THE CUFF IS FULL, THE LITTLE BALLOON HERE IS FULL AND PUFFED UP.
WHEN THE BALLOON IS FLAT, THAT MEANS THE CUFF IS DEFLATED
AND SO YOU KNOW THAT THEY'RE ABLE TO PASS AIR FROM NOSE AND MOUTH DOWN TRACHEA.
AND PRIMARILY WE'RE ABLE THEN TO WORK
THROUGH THIS TRACHEA SPACE TO GIVE THEM OXYGEN.
ALRIGHT. NOW, WHEN THE CUFF --
THE INNER CANN-- OR THE OUTER CANNULA
STAYS IN ALL THE TIME TO MAINTAIN THE PATENT AIRWAY.
BUT IT'S BEEN MY EXPERIENCE BECAUSE I'VE WORKED HOSPITAL CARE,
NOT AS MUCH HOMECARE, ALTHOUGH SOME,
THAT PEOPLE THAT HAVE THESE THAT I'M HAVING TO TAKE CARE OF
ARE PRODUCING QUITE A BIT OF SPUTUM. THAT'S THE WHOLE POINT OF IT.
THEY WEREN'T ABLE TO CLEAR THEIR AIRWAYS. THEY'VE GOT THIS TRACHEA.
THEY'RE SPUTUM, SPUTUM, SPUTUM.
HOCKING IT, HOCKING IT OUT.
IF WE JUST LEFT THIS OUTER CANNULA IN THERE
WITHOUT A MECHANISM TO CLEAN THAT SPUTUM BUILD-UP,
THIS WOULD BLOCK OFF AND WE'D HAVE TO PUT ANOTHER ONE IN.
SO WE'D BE REPLACING THIS TUBE WHICH IS A LITTLE TRAUMATIC.
IT CAN BE DONE, I'M GOING TO SHOW YOU A VIDEOTAPE,
SO THAT YOU DON'T FREAK OUT ABOUT THE WHOLE THING.
BUT IT'S EASIER IF WE TAKE OUT
THE INNER CANNULA, CLEAN IT,
PUT IT BACK IN TO MAINTAIN THIS AIRWAY AS PATENT.
AND IT'S NOT AS TRAUMATIC FOR THE CLIENT.
THERE'S TWO KINDS OF INNER CANNULAS.
THERE'S A PERMANENT AND THEN THERE'S A DISPOSABLE.
TOO BAD FOR YOU, YOU HAVE THE PERMANENT.
AND SO WE'RE GOING TO HAVE TO CLEAN IT.
BUT IF THEY HAVE A DISPOSABLE INNER CANNULA.
LIKE THIS ONE. IT'S JUST A LITTLE FLIPPY.
IT COMES OUT, YOU THROW IT AWAY,
YOU OPEN UP YOUR NEW ONE IN THE LITTLE CASE AND YOU PUT IT IN
AND YOU DON'T HAVE TO PLAY IN THE SPUTUM AT ALL.
THAT'S GOOD. AND THEY'RE USING THEM A LOT MORE THAN THEY USED TO.
BUT BECAUSE OF THE COST OF IT, PEOPLE THAT HAVE DIFFERENT INSURANCES,
AND PEOPLE THAT ARE GOING TO BE HOME WITH THEM FOR A LONG TIME
VERY OFTEN HAVE THE PERMANENT INNER CANNULA BECAUSE IT'S CHEAPER TO MAINTAIN IT
THAN IT IS TO KEEP BUYING THESE DISPOSABLES
THAT ARE "SINGLE USE ONLY" AND MAY NEED TO BE DISPOSED OFF TWO OR THREE TIMES A DAY
DEPENDING ON HOW MUCH SPUTUM YOU'RE PRODUCING.
SO, YOU'LL SEE BOTH AND YOU WANT TO KNOW WHICH ONE DO I HAVE.
DISPOSABLE OR THE PERMANENT THAT LOCKS INTO PLACE.
AND THE DISPOSABLES -- DID I SWITCH?
THIS DOESN'T FIT VERY GOOD.
OH, THAT'S BECAUSE IT'S THIS ONE.
THE DISPOSABLES SAY ON THEM "ONE TIME USE ONLY"
OR "SINGLE USE". SO THAT GIVES YOU A CLUE.
AND YOUR PERMANENT ONES LOCK IN PLACE.
YOU PUT 'EM IN, YOU POINT 'EM DOWN.
PUT 'EM IN AND THERE'S A DOT HERE THAT YOU NEED TO SCREW IT IN PLACE
AND THEN IT'LL LOCK AND YOU'LL SEE BY HAVING BOTH YOUR DOTS MATCHING UP.
BUT IT SHOULDN'T BE ABLE TO PULL OUT EITHER.
THE OTHER THING THAT'S IMPORTANT ABOUT THE TRACH
WHEN IT'S IN PLACE IS THAT YOU HAVE A PLATE.
AND THE PLATE ROTATES SO WHEN IT GOES INTO DIFFERENT ANATOMIES
THAT IT CAN LAY FLAT SO THAT THE TRACH IS IN THE RIGHT POSITION.
AND THEN WE SECURE IT WITH TIES
WHICH IS WHAT WE'RE GOING TO DO ON OUR CLIENT.
OKAY.
LET'S JUST GO DO SOME CARE HERE.
I THOUGHT IT WAS ABOUT TIME YOU EXPERIENCED A MAN
SINCE WE'RE DOING BREATHING THINGS AND HE CAN BREATHE.
HE'S HAVING TROUBLE.
FIRST THING YOU'RE GOING TO DO, YOUR ASSIGNMENT.
AND I WISH WE HAD SAME MANS FOR ALL THE BEDS.
BUT WHAT WE ARE GOING TO DO IS HOOK UP ALL OF THE MANNEQUINS
SO THAT YOU WILL HAVE BREATH SOUNDS.
AND I WANT YOU TO START LISTENING TO BREATH SOUNDS
BECAUSE YOU NEED TO DETERMINE IF THEY NEED TO BE SUCTIONED.
WE AREN'T WRITING ANY MORE ORDERS. IF WE GO BACK TO OUR HIGH-FIVE,
CHECK YOUR DOCTOR'S ORDERS AND NURSING CARE PLAN.
THE DOCTOR WILL SAY SUCTION.
BUT THE DOCTOR SHOULDN'T SAY SUCTION EVERY TWO HOURS
OR SUCTION EVERY FOUR HOURS. WE DON'T DO THAT ANY MORE.
FOR ONE, IT'S TOO TRAUMATIC FOR THE CLIENT
AND IT'S JUST NOT GOOD ENOUGH CARE.
YOU NEED TO SUCTION WHEN THEY NEED TO BE SUCTIONED
AND NOT JUST ON A ROUTINE SCHEDULE.
SO HOW DO YOU KNOW YOUR CLIENT NEEDS TO BE SUCTIONED?
THEY'RE COUGHING.
OH, I CLEARED THIS I HAD IT PRE-SET A MINUTE AGO.
THAT'S INTERESTING. BREATH SOUNDS.
O2 SAT HAS DROPPED...
BELOW 94. ANYTHING REALLY.
IF THEY'VE BEEN HOLDING AT A NORM THAT'S ACCEPTABLE FOR THEM AND IT THEM DROPS LOWER.
GURGLING RHONCHI, SO YOU'RE GOING TO OSCULTATE THEIR LUNGS.
DYSPNEA, THEIR RESPIRATORY RATE GOES UP.
AND THEN OF COURSE PRODUCTIVE SPUTUM.
YOU'RE SEEING THE SPUTUM AND THEY'RE STRUGGLING.
NOW, IF THEY'RE ABLE TO COUGH IT OUT
AND THEY CAN HANDLE IT, THAT'S ONE THING,
BUT IF THEY'RE JUST STRUGGLING AND HAVING DIFFICULTY, THEN THEY NEED TO BE SUCTIONED.
AND SO THAT'S WHEN WE'RE GOING TO SUCTION OUR CLIENT.
TO SUCTION YOUR CLIENT, YOU'RE GOING TO GATHER THE APPROPRIATE EQUIPMENT.
THERE'S A COUPLE OF THINGS THAT YOU'RE GOING TO GATHER.
YOURS -- I TRIED TO GET INTO SOMEONE'S BAG TODAY.
YOUR SUCTION...KIT LOOKS LIKE THIS.
IT'S A 12 FRENCH SUCTION CATHETER.
ONCE AGAIN, THESE ARE DIAMETERS MEASURED IN FRENCH,
SIMILAR TO THE NG TUBES.
SO IT'S GOING TO FEEL A LOT SIMILAR DOING THAT
BECAUSE WE'RE GOING TO PUT IT DOWN THEIR NOSE, MOUTH AND OR TRACH.
SO WE'RE GOING TO GET A SUCTION KIT DETERMINED BY THE FRENCH.
I HAPPEN TO HAVE A 14 FRENCH WHICH IS FINE.
BUT THESE TWO KITS ARE A LITTLE BIT DIFFERENT
AND THIS IS WHAT YOU'RE GOING TO SEE OUT IN THE FIELD.
I DON'T KNOW WHICH ONE BECAUSE THEY'RE DOING TWO DIFFERENT KINDS.
THE KIT THAT YOU HAVE IS PRE-PACKAGED WITH GLOVES,
A LITTLE CONTAINER FOR WATER AND YOUR SUCTION CATHETER.
AND THEN WE ARE GOING TO PUT THE SUCTION CATHETER IN WITH OUR STERILE GLOVES.
THEY'VE ALSO CREATED A NEW SUCTION CATHETER THAT HAS A SLEEVE ON IT.
AND I'LL SHOW YOU AFTER WE'VE DONE WHAT WE'VE DONE
SO YOU CAN APPRECIATE WHAT WE'RE DOING.
BUT THERE'S NO GLOVES IN THIS ONE
BECAUSE THE SLEEVE IS GOING TO MAINTAIN THE CATHETER AS STERILE.
ALRIGHT. SO I HAVE MY CATHETER KIT,
I HAVE SOME STERILE WATER OR STERILE SALINE,
IT DOESN'T REALLY MATTER.
THIS IS FOR IF I NEED TO GET...
A SPUTUM SPECIMEN. THIS IS A LUKENS-TRAP.
IT'S REALLY GOOD IF YOU HAVE AN 02 SAT MONITOR
AND IT'S REALLY EVEN BETTER IF YOU HAVE 'EM
ON A MONITOR ALL TOGETHER SO THAT YOU CAN SEE WHAT THEIR O2 IS.
SO RIGHT NOW THEY'RE AT 98,
BUT WHAT HAPPENS IF YOU LOOK OVER AND ALL OF A SUDDEN...
THEY DROP TO 88?
SOMETHING'S GOING ON. SO WE'RE GOING TO WANT TO SUCTION 'EM.
NOT TO MENTION THEY SOUND GURGLING WITH THEIR RHONCHI OVER HERE.
SO YOU'RE GOING TO PUT A SAT MONITOR ON.
YOU'VE PROBABLY WORKED WITH SOME OF THESE.
THIS ONE'S A PORTABLE ONE.
I'M GOING TO PASS IT AROUND SO THAT YOU CAN
CHECK OUT YOUR O2 SATS, SEE HOW YOU ARE DOING.
IF YOU'RE AWAKE, TAKING GOOD, DEEP BREATHS.
YOU WANT TO CLIP IT. IT TELLS YOU WHERE THE FINGERNAIL PART GOES.
PUT IT ON YOUR FINGERNAIL.
THIS WILL BE INTERESTING. I HAVE PLASTIC NAILS RIGHT NOW.
YOU'RE SUPPOSED TO TAKE OFF FINGERNAIL POLISH
AND YOU'RE SUPPOSED TO TAKE OFF ACRYLICS TO GET A GOOD READING.
AND INTERESTINGLY, THERE'S A TYPO IN YOUR BOOK.
IF YOU WANT TO CHECK CAPILLARY REFILL TO SEE HOW THEY'RE EXCHANGING THEIR BLOOD.
IF THEY'RE CAPILLARY REFILL IS MORE THAN THREE SECONDS,
THEN YOU'RE GOING TO WANT TO FIND ANOTHER METHOD OF CHECKING O2 SATS,
BECAUSE THEY'RE NOT CIRCULATING THEIR BLOOD.
AND YOUR TEXTBOOK ACTUALLY SAYS LESS THAN THREE,
WHICH WOULD BE A GOOD CAPILLARY REFILL.
I WAS READING THAT LAST NIGHT AND I WENT, "WELL, THAT'S BACKWARDS."
SOMEONE GOT THEIR GREATER THANS AND LESS THANS BACKWARDS OR SOMETHING IN THEIR MINDS.
SO THAT WOULDN'T MAKE ANY SENSE. OKAY. SO THIS IS NICE.
- WHAT DO YOU DO IF THE PATIENT HAS FINGERNAIL POLISH ON?
- THAT'S A TRICKY ONE BECAUSE THERE'S OTHER PLACES YOU CAN TAKE THEIR O2 SATS.
IF THEY'LL LET YOU TAKE IT OFF, THEN YOU CAN.
YOU JUST TAKE IT OFF WITH ACETONE AND THAT WILL ALSO REMOVE ACRYLICS.
BUT YOU CAN ALSO CHECK IT ON EAR LOBES.
AND SO EAR LOBES WILL GIVE YOU A NICE READING.
AND WHEN YOU DO EAR LOBES --
THIS DOESN'T WORK OBVIOUSLY, THE FINGER ADAPTOR.
I HAVE MY OTHER ONE, IT'S OVER ON THE CART.
BUT THERE'S A LITTLE TAPE ONE THAT YOU CAN PUT ONTO EAR LOBES,
A LITTLE DISPOSABLE ADAPTOR AND IT'LL READ THEIR O2 SATS FROM THEIR EARS.
AND THAT'S WHAT THEY TEND TO USE NOW IN ANESTHESIA
BECAUSE WOMEN JUST DON'T LIKE PARTING WITH THEIR NAILS.
THEY SPEND A LOT OF MONEY ON 'EM AND SO FORTH.
SO THESE ALSO GET OUR HEART RATES AND, BOY, I'M FLIPPING.
SO HERE YOU GO, CIRCULATING THAT BLOOD.
SO YOU CAN GIVE THAT A CHECK.
O2 SAT ISN'T ENOUGH WHEN YOU'RE DOING SUCTIONING.
YOU WANT TO BE CHECKING THEIR PULSE AND SEE HOW THEY'RE DOING
WHILE YOU'RE SUCTIONING AS WELL.
SO THAT'S WHEN IT'S REALLY NICE TO HAVE A MONITOR OR HAVE A MONITOR LIKE THAT
THAT'S GIVING YOU MORE THAN JUST THE O2 SAT READING.
BECAUSE A LOT OF THINGS CAN BE AFFECTED WHEN YOU SUCTION.
THE THING ABOUT SUCTIONING A CLIENT IS
THAT WHEN YOU SUCTION SPUTUM, YOU ALSO SUCTION O2.
AND IT IS A GIVEN THAT IF YOU'RE GOING TO SUCTION THEIR SPUTUM,
YOU'RE GOING TO LOWER THEIR O2 SATS.
SO WE HAVE TO BE PREPARED TO GIVE THEM MORE OXYGEN,
SO THAT WHEN WE SUCTION, WE DON'T DEPLETE THEM.
SO I'M GOING TO NEED HELP OVER HERE AS WELL.
BUT I HAVE HOOKED UP OVER HERE...
A BAG SO THAT I CAN GIVE THEM O2
WHICH IS CONNECTED, JUST LIKE MY OXYGEN WAS TO --
OR TO MY OXYGEN TUBING TO THIS O2.
AND I'M GOING TO TURN MY LITER FLOW UP TO BETWEEN 10 AND 15
WHENEVER YOU BAG TO GIVE 100% O2.
NOW, WHEN I'M SUCTIONING,
MY GOAL IS THAT I'M GOING TO GIVE 'EM SOME AIR
OR HAVE MY CLIENT TAKE THREE GOOD, DEEP BREATHS.
THEN I'M GOING TO SUCTION.
WHEN I'M DONE, I'M GOING TO GIVE 'EM MORE AIR
OR HAVE 'EM TAKE GOOD, DEEP BREATHS.
SO YOU'RE SANDWICHING THE SUCTION WITH AIR.
SO THAT YOU'RE HYPERVENTILATING 'EM A LITTLE BIT, SUCKING OUT SOME AIR
AND THEN RE-VENTILATING 'EM SO THAT YOU CAN GIVE THEM AIR.
ALRIGHT. WHEN YOU DO THE BAGGING TECHNIQUE...
AND I'M JUST SHOWING YOU NOW AND WE'LL DO IT RIGHT HERE IN A MINUTE.
BUT THE IDEA IS YOU ARE GOING TO PUT THE VALVE
THAT SHOOTS THE AIR TO THE CLIENT.
THEY SWITCH 'EM ON DIFFERENT BAGS.
THIS BAG, IT COMES OUT HERE,
BUT SOMETIMES THE AIR COMES OUT AT THE END.
AND THEN YOU HAVE TO HAVE AN EXHALE VALVE.
RIGHT? SO IF YOU HOOK THIS TO THE CLIENT,
WHICH I'M GOING TO DO HERE, STABILIZE THE PLATE,
HOOK IT TO THE CLIENT.
AND -- OH, I GOT TO MATCH HIS BREATHING HERE.
AND THEN SQUEEZE AND OUT.
YOU'VE GOT TO HAVE SOME PLACE TO EXHALE
BECAUSE I'M STAYING CONNECTED DURING THE BREATHING PART.
AND THAT'S WHAT THIS OTHER VALVE IS FOR, EXHALE.
SO YOU WANT TO COORDINATE YOUR BREATHS WITH HIS BREATHING
AND IT'S A FULL SQUEEZE...
OF...
THE BAG, COORDINATED WITH THEM.
OKAY? SO WHEN I --
ONE OF YOU GIRLS WHO LOOK OFFICIAL IN UNIFORM WANT TO BE MY BAGGER.
SHE'S LOOKING LIKE, "OKAY, I'LL DO IT."
ALRIGHT. YOU'RE GOING TO COME OVER HERE.
YOU'RE GOING TO PUT ON GLOVES, MASK AND A GOGGLE IN THEORY, OKAY?
BECAUSE THIS IS THE OTHER THING.
I HOPE YOU'LL TAKE SOME TIME TO WATCH THE MANUFACTURER'S VIDEOS,
BECAUSE IT'S REALLY IMPORTANT SOMETIMES TO SEE 'EM REALLY
DO SOMETHING ON SOMEONE AND THEY'RE VERY EXCELLENT VIDEOS.
THE ONLY PROBLEM WITH THE VIDEOS IS, LIKE I TOLD YOU,
THE CLIENTS THAT I'VE SUCTIONED
ALWAYS ARE PRODUCING COPIOUS AMOUNTS OF SPUTUM.
I MEAN, IT'S COMING OUT OF THEM.
IT'S SHOOTING OUT OF THEM.
AND THESE VIDEOS ARE PEOPLE THAT HAVE HAD TRACHS FOR A LONG TIME
AND THEY'RE VERY STABLE AND THEY DON'T HAVE SPUTUM. IT'S A FAKE OUT.
THEY'RE CLEANING AND SHOWING YOU HOW,
BUT THERE'S NO SPUTUM COMING OUT OF 'EM.
AND I'M LIKE, "TOO CLEAN."
SO YOU'RE NOT GETTING THAT PIECE OF THE REALISM,
BUT YOU'RE GETTING HOW IT WORKS TO REALLY DO IT ON SOMEONE.
AND THEY'RE REALLY VERY EXCELLENT VIDEOS.
SO WE WILL BE IN THE GATHERING UP OF EQUIPMENT.
GATHERING GOGGLES, MASK AND GLOVES
BECAUSE YOU HAVE TO GET SO CLOSE TO THE WORKING ENVIRONMENT.
ALRIGHT.
WELL, I THINK I'VE GATHERED MY EQUIPMENT FOR SUCTIONING.
AND WHAT I'M GOING TO BE DOING IS TRACHEAL SUCTION.
THERE ARE THREE KINDS OF SUCTIONING AND THIS IS SO IMPORTANT.
FOR SOME REASON, PEOPLE DON'T CAPTURE ON THIS
AND I NEED YOU TO CAPTURE ON THIS PIECE OF INFORMATION.
THERE'S NASOPHARYNGEAL SUCTIONING.
SO WHAT DOES THAT MEAN?
THAT THE TUBE GOES IN THE NOSE TO THE BACK OF THE THROAT.
NASOPHARYNGEAL. YOU'RE GETTING THE CONGESTION OUT OF NOSE BACK OF THROAT.
THERE'S ORAL PHARYNGEAL.
MOUTH TO BACK OF THROAT.
AND THEN THERE'S TRACHEAL, NASOTRACHEAL OR TRACHEAL.
WHICH MEANS YOU'RE GOING DOWN INTO THE TRACHEA AREA TO GET SPUTUM.
THE DOCTOR WILL WRITE THE KIND OF SUCTIONING HE WANTS YOU TO DO.
TRACHEAL SUCTIONING IS DEEP SUCTIONING
WHERE SOMETIMES THE CLIENT JUST HAS HEAVY CONGESTION AND HAS DIFFICULTY BREATHING.
YOU NEED TO KNOW WHICH ONE YOU DO.
WHEN YOU PUT A CATHETER DOWN FOR NASOPHARYNGEAL SUCTIONING,
HOW MUCH DO YOU PUT DOWN?
WELL, REMEMBER WHEN WE MEASURED FOR THE NG TUBE FROM EAR LOBE TO NOSE,
THAT'S ABOUT AS FAR AS YOU WOULD PUT IT DOWN TO DO NASOTRACHEALS.
SO YOU CAN JUST GET AN ESTIMATE OF ABOUT WHERE THAT IS AND THEN PUT IT DOWN.
ABOUT WHERE THEY GAG AND BACK UP.
NASOPHARYNGEAL. DID I SAY TRACHEAL? SORRY.
NASOPHARYNGEAL, BECAUSE THAT'S THE BACK HERE, THE PHARYNX AREA.
NASOTRACHEAL WILL GO DOWN UNTIL...IT STOPS, BASICALLY.
AND SOMETIMES THAT'S A LITTLE TRICKY TO HIT WHEN YOU GO NASO.
YOU REALLY HAVE YOUR BETTER LUCK GOING TRACHEAL TO TRACHEAL.
SO MOST OF THE TIME WE DO NASOPHARYNGEAL,
ORAL PHARYNGEAL AND THEN JUST TRACHEAL.
ALRIGHT? VERY IMPORTANT.
WHEN YOU DO ORAL PHARYNGEAL, THAT WAS WITH THE YANKER.
REMEMBER THE YANKER BACK FROM O2 -- I MEAN, FROM ORAL CARE.
WAY BACK WITH BED BATHS.
THIS IS CALLED THE YANKER.
WHAT IT DOES IS IT CONNECTS ONTO OUR SUCTION APPARATUS.
THIS IS OUR SUCTION APPARATUS.
TO TURN ON SUCTION WHICH IS NEGATIVE PRESSURE.
SUCKING, NEGATIVE PRESSURE.
YOU'RE GOING TO TURN YOUR MACHINE ON TO REGULATE.
TURN IT UP TO 80MM OF MERCURY.
WALL UNITS COME IN MILLIMETERS OF MERCURY,
WHEREAS PORTABLE UNITS COME IN CENTIMETERS OF MERCURY.
AND YOU GOT TO KNOW THE DIFFERENCE.
WHICH IS BIGGER? A MILLIMETER OR CENTIMETER?
- CENTIMETER. - CENTIMETER.
SO IF YOU HAVE CENTIMETERS, THEY ARE ON THE LITTLE PORTABLE UNITS
AND IT WILL BE 10 TO 15CM OF PRESSURE
VERSUS A WALL UNIT WHICH IS 80 TO 120.
SO WHEN WE'RE WORKING OFF A WALL UNIT,
YOU'RE GOING TO PUT THE SAME AMOUNT OF PRESSURE THAT THE DENTIST PUTS ON, BASICALLY.
RIGHT? TO GET THOSE POCKETS OF SALIVA.
AND IT WOULD JUST GO DOWN IN HERE
INTO THAT BACK POSTERIOR LINGUAL POCKET IN HERE.
AND THAT'S ORAL SUCTIONING.
ALRIGHT.
THAT'S NOT WHAT I'M GOING TO DO.
COS I'M STILL AT GATHERING MY EQUIPMENT.
SO I'M GOING TO COME INTO THE ROOM.
I'M GOING TO IDENTIFY -- I'VE WASHED MY HANDS,
I'M GOING TO IDENTIFY MY CLIENT WHICH IS...
SAM. GOOD MORNING, SAM. HOW ARE YOU DOING?
OH, I'M SORRY. I KNOW YOU CAN'T TALK.
RIGHT? THEY CAN'T TALK WHEN THEY HAVE A TRACH IN
BECAUSE IT'S RIGHT BELOW THEIR VOICE BOX.
AND THE AIR CAN'T PASS THROUGH SO THEY'RE ABLE TO VOCALIZE.
SO THEY STILL MAYBE VERY ALERT AND ORIENTED,
BUT THEY MAY BE UNABLE TO GIVE YOU VERBAL COMMENTS.
SO YOU MAY NEED TO GET A TABLET OF PAPER FOR THEM,
AN ETCH A SKETCH OR SOMETHING SO THAT THEY'RE ABLE --
ETCH A SKETCH, NO, THAT WOULDN'T WORK. WHAT'S THAT GOOGLE THING?
THOSE LITTLE BOARDS. MAGNETIC BOARDS THAT THEY WRITE ON, YOU KNOW?
KIDS HAVE 'EM NOW. I CAN'T REMEMBER THE NAME, BUT YOU KNOW WHAT I MEAN.
SOMETHING.
THEY GO, "YEAH."
WE ALL KNOW, HMM-HMM, CHARADES.
SOUNDS LIKE. I DON'T KNOW, I CAN'T REMEMBER.
BUT, ANYWAYS, SOMETHING THAT THEY CAN COMMUNICATE AND FLASH CARDS FOR SOME HELPS.
BUT YES-NO ANSWERS WILL WORK JUST AS WELL.
AND I'M GOING TO PROVIDE SOME PRIVACY HERE WHEN WE SUCTION.
IT LOOKS LIKE TO ME THAT YOU ARE PRODUCING A LOT OF SPUTUM OUT OF YOUR TRACH
AND I'M GOING TO GO AHEAD AND SUCTION YOU
AND SEE IF IT WILL MAKE IT A LITTLE EASIER FOR YOU TO BREATHE.
IN FACT, I'M ACTUALLY HEARING SOME GURGLING.
YOUR HEADS NICE AND HIGH, SO THAT'S GOOD.
ARE YOU COMFORTABLE LIKE THAT OR WOULD YOU LIKE IT TO BE HIGHER?
COMFORTABLE? GOOD.
CAN'T ASK TOO MANY QUESTIONS OR WHOO!
OKAY. THE FIRST THING I WANT TO DO PRIOR TO SUCTIONING
IS I WANT TO LISTEN TO THEM AND SEE AND HEAR...
AND I JUST KNOW THAT I WOULD DO THIS
BECAUSE I WOULD MASK -- FULL THING.
GOOD, DEEP BREATHS, IN AND OUT.
ARE YOU HAVING APNEA? AM I GOING TO HAVE TO DO A CODE? YES, YOU ARE. SORRY.
I DON'T KNOW WHY YOU PUKED IN THE APNEA HERE SOMETIMES
THERE. CURED.
LISTEN TO ALL THE LUNG FIELDS.
OH, HE'S KIND OF REALLY GURGLING.
WELL, I KNOW I DON'T HAVE MY STETHOSCOPE IN MY EARS,
BUT -- AND YOU CAN'T DO THAT.
OKAY. SO I'M GOING TO LISTEN TO THE FRONT,
I'M GOING TO LISTEN TO THE SIDES
AND I AM ALSO GOING TO HAVE HIM SIT UP IF HE CAN AND LISTEN TO THE BACK,
SO THAT I CAN LISTEN TO ALL OF HIS LUNG FIELDS
AND HAVE A GOOD IDEA OF WHAT'S GOING ON.
I ALSO, WHEN I'M LOOKING AND ASSESSING,
I'M LOOKING AT HIS COLOR. I'M LOOKING AT HIS RESPIRATORY RATE.
I'M LOOKING TO SEE WAS HIS BALLOON FILLED OR NOT.
AM I HEARING ANY LEAKING OR HISSING RELATED TO THE BALLOON.
IF THE BALLOON IS FILLED AND I'M HEARING A HISSING, THEN THE BALLOON'S NOT WORKING TOO GOOD.
SO I WANT TO BE LISTENING FOR THAT.
I'M LOOKING TO SEE IF THERE ARE DRIED SECRETIONS.
ARE WE DOING ENOUGH CARE FOR THIS CLIENT?
IT'S ONE THING TO DO ROUTINE CARE WHICH IS OKAY,
WE'LL CHANGE THE INNER CANNULA EVERY SHIFT,
BUT WHAT IF THINGS ARE GETTING ALL DRIED UP? WE NEED TO DO IT MORE.
SO I'M LOOKING TO SEE WHAT KIND OF SPUTUM, HOW MUCH SPUTUM,
COLOR OF SPUTUM AND IS THE CARE THAT I'M GIVING ADEQUATE.
SO SOME OF IT'S JUST PRACTICAL.
LOOKING AT THAT CLIENT, HOW DOES HE LOOK,
HOW DOES HE SOUND, DOES HE NEED TO BE SUCTIONED?
IT JUST SO HAPPENS THAT I'M ALSO GOING TO WORK ON YOUR TRACH A LITTLE TOO,
BUT WHAT I'D LIKE TO DO IS SUCTION YOU A FIRST
AND SEE IF WE CAN GET YOU BREATHING A LITTLE EASIER
AND THEN I'LL GO AHEAD AND CHANGE YOUR TRACH DRESSING.
SO I AM GOING TO GET MYSELF SET UP.
IN THE MEANTIME, COULD YOU BAG MY CLIENT?
AND THIS IS WHAT WE WANT TO DO.
YOU DON'T HAVE TO BAG YOUR CLIENTS.
ALL I WANT YOU TO DO IS TAKE A DEEP BREATH, HAVE 'EM TAKE DEEP BREATHS.
BUT I WANT YOU TO SEE WHAT THAT WOULD LOOK LIKE.
SHE HAS GOGGLES, MASKS AND GLOVES ON.
AND WHAT'S SHE'S GOING TO DO, SHE'S JUST GOING TO GIVE YOU A LITTLE EXTRA OXYGEN HERE
FOR A COUPLE OF MINUTES, WHILE I GET THE SUPPLIES READY.
BECAUSE WHEN I SUCTION YOU, I SUCTION OUT OXYGEN AS WELL AS SPUTUM
AND WE DON'T WANT YOU TO GET HYPOXIC OR GET HYPOXEMIA, RIGHT?
LOW OXYGEN LEVELS IN THE BLOOD, LOW O2 SATS.
SO THOSE ARE THE RISKS INVOLVED.
SO SHE'S GOING TO DO THIS.
NOW WHEN YOU DO THIS, THIS IS THE DEAL.
I WANT YOU TO DO THIS. TAKE ONE HAND AND SUPPORT THE PLATE.
DON'T PUSH THE PLATE OR IT MAKES THEM START COUGHING.
BECAUSE YOU STIMULATE THAT COUGH REFLEX.
BUT IF YOU'LL SUPPORT THE PLATE AND THEN PUT THIS ON
AND THEN COORDINATE THE SQUEEZE WITH HIS IN AND OUT.
AND IT'S A FULL SQUEEZE, WE'RE SET AT TEN, WE'RE GIVING 100% O2.
AND SO SHE'LL BE DIZZY OVER THERE IN A COUPLE OF MINUTES.
WHAT I'M GOING TO DO OVER HERE IS SET UP MY FIELD.
SO YOU WANT TO OPEN UP YOUR KIT.
AND ON THE TOP SHOULD BE STERILE GLOVES.
THEY GET VERY, VERY STICKY.
AND YOU'RE GOING TO PUT ON YOUR STERILE GLOVES FIRST.
OH, BUT BEFORE I DO THAT, I'M GOING TO OPEN THIS UP.
THEN I'M GOING TO PUT ON MY SECOND STERILE GLOVE.
YOU WANT TO HAVE YOUR WATER OPEN BECAUSE THEN YOU'RE GOING TO END UP
CONTAMINATING ONE OF YOUR HANDS TO OPEN YOUR BAG.
INSIDE...THIS KIT
IS MY SUCTION CATHETER.
I PICKED -- MINE IS A 14 FRENCH, I THINK.
12 OR 14. BECAUSE I KNOW IT'S ABOUT HALF THE SIZE OF THE DIAMETER OF MY TRACH.
AND REMEMBER, I TOLD YOU, WE HAD SIXES AND -- SIXES AND FOURS.
YOU GUYS ARE GOING TO HAVE MOSTLY FOURS ON THE MANNEQUINS IN THERE.
THAT'S THE SIZE OF THE TRACH.
AND YOU HAVE 12 CATHETERS WHICH WILL BE ABOUT HALF OF THE DIAMETER.
BECAUSE WE DON'T WANT TO CUT OFF ALL OF THEIR BREATHING WHEN WE GO DOWN.
INSIDE IS MY SUCTION CATHETER
WHICH I'M GOING TO LEAVE RIGHT HERE ON ITS LITTLE STERILE FIELD.
AND THEN THERE'S A CUP THAT I'M GOING TO PUT STERILE WATER IN,
SO THAT WHEN I SUCTION, I'M GOING TO BE ABLE
TO RINSE THE SPUTUM OUT OF THE CATHETER.
I'M GOING TO SET THIS HERE AND IT'S APPARENT AT THIS POINT
THAT I'M GOING TO HAVE TO SACRIFICE ONE OF THESE HANDS,
SO THAT I CAN HOLD EQUIPMENT AND POUR WATER.
SO I'M GOING TO LIFT MY WATER.
I'VE ALREADY CHECKED IT. I'VE CHECKED MY EXPIRATION DATES, EVERYTHING'S GOOD.
AND I'M GOING TO FILL UP THE LITTLE CUP AS MUCH AS POSSIBLE.
SOMETIMES IF YOU KIND OF TAP 'EM A LITTLE BIT, THE LITTLE BAG WILL SHIFT IN THE BOTTOM.
YOU CAN'T SEE, BUT...IT'S TRUE.
OKAY. NOW, WHAT I NEED TO DO IS GET TO THE SUCTION CATHETER.
SO YOU NEED TO SET YOURSELF UP CORRECTLY WHEN YOU RE-PACKAGE YOUR KITS.
I WANT YOU PRACTICING WITH YOUR KITS.
YOU'RE REALLY GOING TO POUR WATER FOR SUCTIONING
AND YOU'RE REALLY GOING TO SUCTION.
THIS HAND IS STERILE, THIS HAND IS NOT.
THIS HAND NEEDS TO TOUCH MY SUCTION EQUIPMENT
SO THAT I CAN HOOK 'EM TOGETHER.
YOU HAVE AN EXTENSION TUBING
THAT'S CONNECTED TO A WALL UNIT OVER HERE,
A BUCKET.
THAT'S WHAT'S GOING TO COLLECT THE SPUTUM.
CAN YOU KIND OF SEE THAT OTHER GREEN ONE OVER THERE?
THE BUCKET.
AND THEN THERE'S ANOTHER CONNECTION THAT GOES TO THE SPUTUM.
COULD YOU WIPE THAT WITH AN ALCOHOL SWAB? DO YOU HAVE A FREE HAND?
OH, I DO. ALL GOOD NURSES CARRY THEM IN THEIR POCKETS.
HERE. OKAY.
SO I'M GOING TO TURN MY SUCTION ON
AND I WANT IT TO BETWEEN 80 AND 120.
SO I'M GOING TO PICK A HAPPY MEDIUM OF 100 FOR NOW.
AND SHE'S CLEANED ME ALL UP
AND I AM GOING TO CONNECT THIS FINGER DEVICE
WHICH IS WHAT I'M GOING TO PUT MY SUCTION TOGETHER WITH.
WITH STERILE, NON-STERILE.
AND I CAN'T TOUCH MY STERILE HAND TO THIS PIECE.
OH, I'M OUT.
DID YOU SEE WHAT HAPPENED? IT SWUNG.
THIS SWUNG AND IT HIT HERE.
SO I'M CONTAMINATED, DONE DEAL.
BUT ALL GOOD NURSES BRING TWO.
DID I BRING TWO? OH, NO. I DID.
WHOO! OKAY. ALWAYS BRING TWO.
BECAUSE THINGS HAPPEN, LIFE HAPPENS.
AND THIS IS A DIFFERENT KIT. THIS IS WHAT YOURS LOOKS LIKE.
I NEED TO GET RID OF THAT.
SO THIS IS WHAT YOUR KIT LOOKS LIKE. YOUR GLOVES ARE HERE.
I OBVIOUSLY DON'T NEED MY WATER AGAIN,
BUT AT THE RATE I'M GOING, WHO KNOWS?
THIS IS TOTALLY SIDEWAYS.
SO PACK YOUR GLOVES UP GOOD AND YOU THEN CAN JUST PUT SOME NON-STERILE GLOVES IN THERE.
ALRIGHT.
OKAY. I'M GOING TO HAVE A LITTLE BETTER CONTROL HERE.
I'M GOING TO PUT THIS IN MY HAND SO IT'S NOT GOING TO GO FLYING EVERYWHERE.
CONTAMINATED. STERILE.
CONNECT.
OKAY. NOW I CAN HOLD LIKE THIS, I'M STILL STERILE
AND THAT LEAVES THIS HAND TO ADJUST OR TURN THINGS ON
OR MOVE THINGS THAT I FORGOT OR I CAN GRAB ON.
BUT SEE, I'M ALWAYS ABOVE MY WAIST AND ALWAYS OUT.
THIS IS WHAT GETS YOU YOUR SUCTION, IS WHEN YOUR THUMB IS ON --
I DON'T KNOW WHAT YOU CALL THIS. APPLICATOR.
AND THEN YOU'RE GOING TO STICK IT INTO THE WATER TO LUBRICATE IT.
BUT WHEN I STICK IT INTO THE WATER, I'M ALSO GOING TO PUT MY THUMB ON
AND SEE HOW HIGH THE PRESSURE GOES UP WHEN I PUT SUCTION ON.
AND IT ACTUALLY IS UP TO 130.
SO I'M GOING TO TURN IT DOWN JUST A LITTLE BIT.
TRY IT ONE MORE TIME.
AND I'M MUCH HAPPIER. 110.
SO CHECK TO SEE WHAT YOUR REAL SUCTION IS
BEFORE YOU GO SUCTIONING ONTO YOUR CLIENT.
ALRIGHT. THANK YOU SO MUCH.
ALRIGHT, HE'S NICE AND VENTILATED.
I AM GOING TO TAKE THIS AND I'M GOING TO PASS THIS DOWN.
I'VE NOTICED THAT YOUR O2 SAT IS 88,
SO HOPEFULLY, IT'S NOT GOING TO BE WORSE.
IT SHOULD'VE GONE UP AND IT SHOULD'VE -- WITH HER BAGGING IT.
I'M GOING TO PASS THIS DOWN INTO HIS TRACH
WITHOUT PUTTING MY THUMB ONTO THE CONNECTOR
OR ONTO THE ADAPTOR THERE.
I'M GOING TO PUT IT DOWN TILL IT STOPS
AND THEN I'M GOING TO PULL BACK A LITTLE BIT.
AND THEN I'M GOING TO PUT MY FINGER ON HERE
AND I'M GOING TO SUCTION FOR TEN SECONDS.
USUALLY THEY START COUGHING... [COUGHING]
WHILE YOU'RE SUCTIONING. OKAY? YOU ONLY HAVE TEN SECONDS TO DO IT.
GO AHEAD AND BAG HIM BECAUSE YOU BAG AFTERWARDS.
AND THEN I NEED TO RINSE THAT SPUTUM OUT.
OKAY? I NEED TO GIVE HIM ONE MINUTE BETWEEN SUCTIONS,
SO THAT HE CAN RECOMPOSE AND RE-OXYGENATE.
LET'S JUST GIVE HIM A LITTLE MORE.
WHOO! I CAN'T DO THIS STUFF ANYMORE.
- AND WHILE YOU'RE AT IT, COULD YOU TILT THAT MONITOR A LITTLE BIT SO IT'S NOT BLURRING.
- NO.
I CAN'T WITH ONE HAND.
- JUST TURN IT THE OTHER WAY.
YEAH, THAT'S BETTER.
- ALRIGHT. HOW ARE YOU DOING?
IT'S BEEN A MINUTE, I'M GOING TO SUCTION YOU ONE MORE TIME.
AND I WANT YOU TO DO TWO PASSES.
I'M GOING TO LUBRICATE.
SHE'S HOLDING THAT SO NICELY, DID YOU SEE HOW IT KIND OF STUCK?
AND IF SHE JERKED WITHOUT HOLDING THAT,
THEN YOU CAN ALSO TRAUMATIZE THAT TRACHEA.
THAT'S WHY YOU WANT TO STABILIZE THIS PLATE.
I'M GOING TO PUT THIS DOWN AGAIN.
[COUGHING]
START COUGHING, COUGHING, COUGHING.
I'VE HIT BOTTOM. I PULLED BACK A LITTLE AND...
AND THAT'S WHAT IT SOUNDS LIKE.
THEIR EYES LOOK PANICKY AT YOU.
YES, THANK YOU. BAG. RINSE.
I THINK THAT WAS THE MOST FRIGHTENING THING
WHEN I FIRST STARTED SUCTIONING PEOPLE,
WAS THEIR EYES WERE PANICKY.
AND I DON'T KNOW, MAYBE I TRAUMATIZED THEM MORE THAN I SHOULD.
WE DIDN'T HAVE AS MANY RULES AS WE HAVE TO GIVE YOU WHEN WE SUCTION.
BECAUSE THEY CAN'T TALK AND THEY'RE KIND OF CHOKING IN SPUTUM
AND IT'S A PANICKY SITUATION.
THINK IF YOU COULDN'T BREATHE.
YOU KNOW? IT JUST -- IT FEELS PANICKY.
SO TRY TO HELP 'EM RELAX,
TRY TO JUST HELP THEM CATCH THEIR BREATH,
GIVE THEM THAT GOOD FULL MINUTE IN BETWEEN
AND NOT GETTING YOUR SUCTION UP TOO HIGH WILL HELP THEM NOT FEEL SO TRAUMATIZED.
ALRIGHT. WONDERFUL.
THE NEXT SUCTION, I WANT YOU TO DO TWO TRACH SUCTIONS
AND THEN I WANT YOUR THIRD PASS TO BE NASOPHARYNGEAL.
ALRIGHT? NOW NASOPHARYNGEAL DOESN'T HAVE TO BE STERILE,
BUT TRACH HAS TO BE STERILE.
SO YOU CAN DO THE TRACH FIRST AND THEN YOU CAN STOP.
YOU CAN DO NASO,
WHICH IS GOING TO BE ABOUT TO THE END OF MY HAND, RIGHT?
IF WE MEASURE FROM EAR LOBE TO NOSE AND PASS IT.
SO I'M JUST GOING TO PASS IT DOWN INTO HIS NOSE AND THEN...
WHEREVER YOU'RE GETTING THE SPUTUM OR IT'S CONNECTING,
THAT'S WHERE YOU WANT TO STAY AND GET THE SPUTUM AND THEN BE DONE.
AND THEN THE SAME THING. EITHER HAVE 'EM -- BAG THEM OR YOU CAN TAKE DEEP BREATHS.
AT LEAST THREE GOOD, DEEP BREATHS.
- TEN SECONDS OR LESS? - TEN. EVERYTHING IS TEN.
HOWEVER, I HAVE READ ONE TEXT WHERE IT WAS 15 SECONDS,
BUT IT'S STILL LIMITED. YOU JUST CAN'T STAY DOWN THERE FOREVER.
- DO YOU NEED TWO PEOPLE TO DO THIS?
- IF YOU'RE GOING TO BE BAGGING, YES.
I CAN'T DO IT BY MYSELF, IT'S IMPOSSIBLE.
BECAUSE YOU GOT TO HOLD THE PLATE, YOU GOT TO STAY STERILE.
SO IF YOU'RE IN A BAGGING SCENARIO, YOU'VE GOT TO HAVE HELP.
WHEN YOU'RE IN A JUST A DEEP BREATHE SCENARIO, YOU CAN DO IT ALL BY YOURSELF
AND THAT'S WHAT YOU'RE GOING TO HAVE TO DO TO TEST
BECAUSE WE DON'T HAVE ENOUGH TIME TO PAIR UP WITH EVERYONE.
THE FINAL PASS THAT YOU WOULD MAKE IS ORAL.
AND SO IF YOU WANTED TO GET ANYTHING OUT OF THE BACK OF THE THROAT,
ORAL PHARYNGEAL MOUTH, THEN YOU CAN DO YOUR FOURTH PASS THAT WAY.
ONCE YOU'RE DONE, RINSE, TAKE A FEW DEEP BREATHS AND NO MATTER WHAT --
WHENEVER YOU SUCTION, THEY HAVE TO BREATHE AFTER YOU'RE DONE.
ALRIGHT. WE CAN GO AHEAD AND TURN THE O2 OFF.
BECAUSE WE'RE NOT USING THAT ANY MORE.
AND I AM DONE WITH YOU. THANK YOU VERY MUCH.
THIS CAN GET BAGGED...
IN THE TRASH AND THIS THING CAN GET DISPOSED OFF.
AND THEN MY GLOVES REALLY ARE JUST THERE FOR ME,
AND I CAN CLEAN UP MY AREA.
I WANT TO SHOW YOU ONE OTHER THING THAT YOU CAN DO STERILE,
IF YOU NEED TO GET A SPUTUM SPECIMEN.
OKAY. LET'S SAY I JUST OPENED THIS UP AND I'M STERILE.
I NEED TO GET A SPUTUM SPECIMEN
AND ACTUALLY, I'M GOING TO DO IT THIS WAY.
THIS IS CALLED A LUKENS-TRAP
I'M GOING TO CONTAMINATE BOTH HANDS AND I'LL PUT THE STERILE GLOVES ON AGAIN.
I WANT TO CONNECT THIS PIECE TO THE SUCTION EQUIPMENT.
AND...STERILE GLOVES.
OKAY.
NOW WHAT I WANT TO DO IS PICK UP MY STERILE CATHETER AGAIN
AND I WANT TO CONNECT IT...
TO THIS LUKENS-TRAP.
NOW I CAN DO THIS WITHOUT SHOOTING IT OFF.
NOW I CAN LUBRICATE A LITTLE WITH WATER,
BUT I CAN'T SUCTION WITH WATER TO TEST IT.
BECAUSE IF I DO, THEN IT'S ALL GOING TO GO...
INTO THE TRAP.
SO WHAT YOU WOULD DO IS SAY, "OKAY. I'M GOING TO COME GET A SPECIMEN."
HAVE 'EM TAKE THEIR DEEP BREATHS, PUT IT IN...
THEN...
IT FALLS AND PLOPS INTO HERE.
YOU MAY NEED TO DO ONE OR TWO PASSES.
AND THEN WHEN YOU'RE DONE WITH THIS...
THIS GETS DISCONNECTED.
AND THEN IT'S COVERED LIKE THIS, LABELED AND SENT TO THE LAB
AS A SUCTION SPUTUM SPECIMEN.
OKAY? AND THAT'S WHAT A LUKENS-TRAP IS FOR GETTING A SPECIMEN.
ALRIGHT.
NOW, THAT'S WHAT YOU'RE GOING TO DO.
LET ME JUST SHOW YOU ONE OTHER THING.
OKAY, REMEMBER I TOLD YOU THEY CREATED THESE NEW SLEEVES.
THEY LOOK LIKE THIS,
IF YOU WOULD OPEN UP A KIT.
GET YOUR LITTLE BOX. YOU WANT TO HAVE THE INSIDE BE STERILE.
SO I'LL JUST TRADE THAT NOW SO I DON'T WRECK IT.
THEN I THINK I WOULD PUT REGULAR GLOVES ON.
WHERE ARE MY GLOVES?
OVER THERE.
WHEN YOU'RE WORKING WITH YOUR SLEEVE...
YOUR GLOVES DON'T HAVE TO BE STERILE ANY MORE
BECAUSE THE SLEEVE LOOKS LIKE THIS.
IT COMES IN A FRENCH JUST LIKE THE OTHERS DID,
AS FAR AS THE PACKAGE GOES.
BUT THIS IS HOW IT COMES NOW.
YOU'RE GOING TO CONNECT IT TO YOUR SUCTION.
STILL AT 81.10.
AND THEN I'M GOING TO...
PULL THE END OFF AND NOW THIS IS STERILE.
I SLIDE IT OUT.
SUCTION JUST THE SAME.
AND THEN I'M GOING TO PUT IT DOWN.
BUT FOR ME, IT TAKES TWO HANDS SO I'M GOING TO HOLD
AND THEN SLIDE IT DOWN INSIDE THAT SLEEVE.
AND THEN WHEN I SUCTION...
THIS COMES DOWN AND THAT'S WHAT MAINTAINS IT AS STERILE.
SO IT'S THE INSIDE THAT'S STERILE.
DEEP BREATHE AND SO FORTH AND THEN SLIDE IT BACK DOWN.
RINSE.
THEN THE SAME THING.
PUT IT IN. GET IT GOING. PRETTY COOL, HUH?
SO YOU DON'T HAVE TO WORRY SO MUCH ABOUT STERILE AND TOUCHING
BECAUSE THE CATHETER ITSELF IS GOING TO STAY STERILE.
YOU'RE -- YOU DON'T HAVE TO BE.
AND THEN THIS WHOLE THING GETS DISPOSED OFF.
ALRIGHT.
I WOULD NOTICE THE AMOUNT, COLOR, QUANTITY OF SPUTUM
AND THEN THIS BUCKET NEEDS TO BE EMPTIED AT THE END OF EVERY SHIFT.
AND ACTUALLY EMPTIED IS THE WRONG WORD.
IT JUST GETS DISPOSED OFF. YOU JUST TAKE IT AND THROW IT AWAY.
AND THEN PUT ANOTHER ONE IN ALL TOGETHER.
THERE'S A COUPLE OF THESE, YOU CAN PASS 'EM AROUND AND SEE HOW THEY FEEL.
I DON'T NEED THEM BACK.
ALRIGHT. WELL, MY CLIENT'S BEEN SUCTIONED.
BUT THE NEXT THING I NEED TO DO IS I NEED TO TAKE CARE OF THIS TRACH.
I NEED TO CLEAN THAT INNER CANNULA AND I NEED TO CHANGE THE TRACH TIES.
NO, I DID HAVE ONE OTHER PROP FOR SUCTIONING.
THIS IS THE COOLEST THING FOR ORAL CARE FOR SOME OF YOUR CLIENTS THAT ARE --
MAYBE COMATOSE OR MAYBE ON RESPIRATORS OR SOMETHING AND NEED TO BE SUCTIONED.
YOU CAN...HOOK THESE UP TO THE SUCTION.
AND THEN THESE CAN BE DIPPED IN MOUTHWASH OR DIPPED IN WATER.
AND THEN YOU USE THE LITTLE BRUSH TO SCRUB THEIR MOUTH AND SUCTION AT THE SAME TIME,
SO THAT THEY DON'T GET THE POOLING OF FLUID IN THEIR MOUTH.
AND YOU CAN REALLY GIVE NICE ORAL CARE, SO SCRUB, SCRUB, SCRUB.
AND THEN SUCTION BACK IN THOSE POCKETS. SCRUB, SCRUB, SCRUB.
AND THEN SUCTION BACK IN THE POCKETS.
AND WHAT'S IT GOING TO BE SET AT?
- 80. - 80?
- MILLIMETERS. - MILLIMETERS OF MERCURY
IF IT'S A WALL UNIT. WHAT IF IT'S PORTABLE?
- 10-15. - 10-15?
- CENTIMETERS. - CENTIMETERS.
- DO THEY HAVE TO BE ORDERED?
- USUALLY YOU CAN JUST GET THEM ON YOUR CENTRAL SUPPLY CART. THERE'S A CHARGE ITEM.
BUT YOU DON'T HAVE TO HAVE AN ORDER TO DO ORAL CARE.
- THEN YOU CAN DO SUCTIONS.
- YES, WHEN THEY'RE COMATOSE.
YOU HAVE TO HAVE SUCTION STANDBY.
IF YOU DIDN'T HAVE SUCTION AND SOMEONE ASPIRATED,
THEN YOU WOULDN'T BE DOING GOOD NURSING PRACTICE BECAUSE THAT'S --
WE ALWAYS HAVE SUCTION STANDBY FOR OUR CLIENT.
I CAN'T IMAGINE NOT EVEN ORDERING IT, BUT YOU WOULD ALWAYS HAVE IT.
OKAY. SO NOW WE'RE GOING TO MOVE ALONG AND WE'RE GOING TO DO OUR TRACH.
YOU'RE GOING TO HAVE GATHERED UP YOUR EQUIPMENT,
WHICH NOW IS GOING TO INCLUDE, YOUR TRACH KIT...
- WAS THERE A CHUX ON HERE?
- IT WAS OUTSIDE.
- OKAY. COMPLICATIONS OF SUCTIONING, THAT'S WHAT I WANTED TO TALK ABOUT.
I ALREADY TALKED ABOUT IT CAN LOWER
THE OXYGEN IN THE BLOOD AND OXYGEN SAT LEVELS,
BUT A TOO LONG, TOO HIGH A PRESSURE OR TOO LARGE A CATHETER
CAN ACTUALLY CAUSE ATELECTASIS.
- WHAT'S THAT? - COLLAPSED LUNG.
- COLLAPSED LUNG, OKAY?
IT CAN CAUSE BRONCHOSPASMS IF THE PRESSURE'S TOO HIGH,
YOU CAN CAUSE HEMODYNAMIC ALTERATIONS
AND THAT'S ESPECIALLY RELATED TO SOMEONE THAT'S ON A RESPIRATOR.
YOU CAN INCREASE INTRACRANIAL PRESSURE AND YOU CAN CAUSE AIRWAY TRAUMA.
SO THE BEST POSSIBLE CONSISTENT USE AND CONSISTENT SUCTIONING
IS THE BEST WAY TO PREVENT THOSE THINGS.
IS PEOPLE DOING IT RIGHT AND DOING IT RIGHT ALL THE TIME.
SO SOME OF THE RULES AND THESE ARE IN YOUR ARTICLE,
BUT I JUST WANT TO HIGHLIGHT WHAT I DIDN'T MISS.
SUCTION -- OR WHAT I MISSED. SUCTION ONLY WHEN NECESSARY.
I TALKED ABOUT O2.
OKAY.
EVERYTHING ELSE I DID.
THE OTHER THING I WANTED TO MENTION IS IT USED TO BE PRACTICED
AND I AM STILL HEARING 'EM DO IT SOMETIMES,
IS TO PUT SALINE INTO THE TRACHEA. OH, JUST A CC OR TWO.
SQUIRT IT IN BECAUSE THAT WILL HELP LOOSEN UP
THICK TENACIOUS SECRETIONS.
WELL, THEY FOUND OUT THAT IT'S NOT TRUE
AND IN FACT IT CAN ACTUALLY CAUSE INFECTION.
SO WE SHOULD NOT BE ADDING SALINE.
IT DOESN'T REALLY THIN THE MUCOSA AND IT'S --
JUST HARDLY, YOU'RE ABLE TO FIND SUPPORT FOR IT IN THE LITERATURE.
NOW THAT'S TRUE, BUT THEN THE LITERATURE SAYS
THERE'S DEBATE ABOUT IT AND IT SAYS SPARE IT.
SO YOU'RE GOING TO SEE IT OUT THERE,
BUT MOST OF THE RESEARCH RECENTLY HAS SAID
THAT IT'S NOT NECESSARY AND DON'T DO IT.
SO, DON'T WASTE YOUR TIME WITH IT.
- WHAT ABOUT THE BABIES, DON'T THEY --
- SAME THING. WE DON'T USUALLY PUT ANYTHING IN.
WE JUST PULL THEM. SPARE THE SALINE, DON'T USE IT.
ALRIGHT, I HAVE MY TRACH CARE KIT AND IT'S A STERILE KIT.
I HAVE SALINE AND I HAVE PEROXIDE.
AND WE'RE GOING TO GO AHEAD AND DO SOME CLEANING OF THAT INNER CANNULA.
I'M GOING TO OPEN UP MY KIT.
AND INSIDE THE KIT IS ALL YOUR SUPPLIES ONCE AGAIN.
I HAVE A LITTLE DRAPE IN HERE.
AND I AM GOING TO TAKE THIS DRAPE...
WHICH IS STERILE.
SO I AM GOING TO SET MY SELF UP A LITTLE STERILE FIELD.
I'M NOTICING I'VE GOT THAT ONE INCH BORDER AND I AM USING ALL OF IT.
I CAN'T SEEM TO GET MY HAND IN HERE.
ALRIGHT, AND THEN I'M GOING TO LAY THAT DOWN
ON THE CLIENT BELOW HIS TRACH.
NOT CROSSING OVER MY FIELD.
ALRIGHT, I WANT IT TOWARDS MYSELF.
OKAY, INSIDE MY TRACH KIT IS MY GLOVES.
AND BOY, ARE THEY STUFFED IN THERE PRETTY PITIFULLY.
I'M -- I NEED TO SET SOME SUPPLIES DOWN.
AND I THINK THE ONLY WAY I AM GOING TO BE ABLE TO DO IT
IS TO PEEL MY LID OFF AND USE IT AS A STERILE FIELD.
AND, BOY, IS THIS A TINY ONE. THIS IS A NEW KIT I'VE NEVER SEEN BEFORE.
THIS IS YOUR KIT, IT'S A LITTLE BIT BIGGER.
AND YOU HAVE THREE CONTAINERS IN YOUR KIT.
I HAVE THREE CONTAINERS, BUT MY CONTAINER IS IN --
MY THIRD CONTAINER IS INSIDE A CONTAINER IN HERE.
YOU WILL SEE WHAT I MEAN, BUT EVERYTHING ELSE WILL BE THE SAME.
WHAT I NEED TO DO IS DIG INTO THIS KIT
AND FIND THE CUP OF MY GLOVE
WITHOUT CONTAMINATING THIS CONTAINER.
BOY, OH BOY! OH BOY!
HMM!
[LAUGHTER]
FORGET IT. ALWAYS BRING EXTRA GLOVES.
THESE WERE TOO MANGLED TO DEAL WITH.
AND I JUST DON'T WANT TO DEAL WITH THAT.
SO I'M GOING TO GET RID OF 'EM AND JUST USE MY OWN GLOVES.
AND THAT'S WHY I WANTED YOU TO SAVE ONE MORE PAIR
FOR BACKUP FOR YOUR KITS.
SO PROBABLY AFTER YOU'VE RESET IT UP AND UNSTUCK YOUR GLOVES,
IT MIGHT NOT BE A PROBLEM. BUT YOU CAN SEE,
IT CAN BE A PROBLEM COS EVERYTHING IN THERE IS STERILE.
SOME OF IT I NEED TO BE STERILE AND SOME OF IT I DON'T.
AND SINCE I AM USING THIS I'M GOING TO GO AHEAD AN OPEN THIS UP AND HAVE MORE STERILE FIELD.
I NEED MORE STERILE FIELD.
AND MORE STERILE FIELD.
THESE ARE GOOD STERILE FIELDS.
OH, MUCH BETTER GLOVES.
THOSE ONE SIZE FIT ALL. PUT IT ON.
OKAY, WELL THAT'S NOT GOING TO WORK BECAUSE I AM CROSSING OVER.
OKAY, WHAT I WANT TO DO IS GET MY SUPPLIES TOGETHER HERE.
AND I HAVE A BRUSH, TWO PIPE CLEANERS.
AN APPLICATOR, TWO APPLICATORS.
TIES TO CHANGE MY TRACH TIES WHICH DON'T NEED TO BE STERILE.
I'M JUST GOING TO SET THEM OVER THERE FOR NOW.
MY -- I CALL IT THE BIB.
BUT MY TRACH DRAPE HERE AND I AM GOING TO SET THAT ASIDE NOW.
IT DOESN'T NEED TO BE STERILE.
MY FOUR BY FOURS ACTUALLY SHOULD BE,
AND I'M GOING TO ALSO SET THEM ON THIS FIELD
OR YOU COULD SET THEM ON YOUR LITTLE PAPER TOP.
REMEMBER WHEN I PEELED THAT OFF, THE TOP WILL WORK.
AND I CAN'T USE THEM COS I THREW MY GLOVES DOWN.
THAT WAS LAZY OF ME.
OKAY, I HAVE THREE CONTAINERS.
AND THE INSIDES OF THE CONTAINERS ARE WHAT I AM CONCERNED WITH.
I AM ACTUALLY GOING TO SET THESE OVER HERE FOR NOW TOO.
MY BRUSH IS WHAT'S GOING TO DO MOST OF THE WORK.
I MAY NEED MY PIPE CLEANERS.
AND I AM ACTUALLY GOING TO USE THE EDGE OF MY BRUSH
WITH A NON-STERILE HAND.
SO I WANT IT TO STICK OUT SO I CAN GET TO IT.
I'M GOING TO SACRIFICE ONE HAND
TO POUR SOLUTION INTO MY BOTTLES.
THE IDEA IS THAT I'M GOING TO CLEAN THE SPUTUM...
OFF OF THE SUCTION CATHETER...
WITH HALF STRENGTH PEROXIDE, HALF STRENGTH SALINE SOLUTION.
SO I'M GOING TO POUR THAT IN TILL IT'S GOT HALF AND HALF.
IT DOESN'T HAVE TO BE PERFECT.
MY LIDS HAVE BEEN DOWN, AND I'LL JUST GO.
THIS HAND IS STILL STERILE.
ALRIGHT, THIS IS WHAT I NEED TO DO.
THIS ISN'T STERILE IN ITS PUREST FORM BECAUSE THIS TRACH ISN'T STERILE.
IT'S JUST INTO THE TRACHEA AND WE WANT IT TO BE AS STERILE AS POSSIBLE, THE OTHER END.
I'M GOING TO STABILIZE THE PLATE. I'M GOING TO COME OVER HERE
AND I'M GOING TO TWIST THE INNER CANNULA OFF
AND THEN JUST OPEN IT OUT LIKE THIS.
AND THROW IT INTO...
THE HALF STRENGTH PEROXIDE AND SALINE SOLUTION.
THEY'RE USUALLY SO FULL OF SPUTUM RIGHT NOW
THAT IT'S JUST FROTHING AND BUBBLING ALL UP IN THERE, FROTHING.
AND RIGHT NOW HE STARTS COUGHING.
AND SPUTUM STARTS SPITTING OUT OF THIS THING AND I'M THINKING,
"GREAT. NOW THAT'S ALL DIRTY, BUT I CAN'T CLEAN THAT ONE."
BUT THAT'S WHAT HAPPENS AND WE'RE GOING TO SLIDE
THE OTHER INNER CANNULA IN AND THAT WILL KEEP IT PATENT.
WHAT I WANT TO DO WITH MY LITTLE STERILE HAND
WHICH ISN'T THAT STERILE ANY MORE
COS I TOUCHED THAT OUTER CATHETER,
YOU CAN SEE THIS ISN'T PERFECT.
I'M JUST GOING TO DIP IT INTO THE WATER
AND I'M JUST GOING TO WIPE ALONG THE OUTSIDE EDGE HERE
AND CLEAN ANY CRUSTY SPUTUM RIGHT HERE
THAT'S GOING TO BE WHERE MY INNER CANNULA IS GOING TO GO BACK IN.
THE REST ISN'T STERILE
AND SO I'M GOING TO DO IT WITH CLEAN HANDS WHEN I AM DONE.
BUT I JUST WANT TO WORK AROUND THAT PIECE FOR NOW.
I'M JUST GOING TO LAY THAT RIGHT THERE.
NOW, I WANT TO HAVE MY MOST STERILE HAND
WHICH IS THIS ONE THAT ONLY TOUCHED THIS
TO COME HERE AND I'M GOING TO GRAB BY THE INNER CANNULA TOP.
AND I'M GOING TO GRAB MY BRUSH AND THEN I'M GOING TO SCRUB THE SPUTUM OFF OF HERE.
MAY I JUST SAY THIS IS VERY CLEAN WHAT YOU'RE LOOKING AT,
BUT WHEN IT'S ALL FULL OF SPUTUM, IT STARTS STICKING ONTO YOUR BRUSH
AND IT STICKS AND PLOPS AND --
AND I AM SO HAPPY THAT I AM BEHIND A MASK
BECAUSE I'M GOING, "URGH. THIS IS NOT MY BEST THING."
EVERYONE CAN HAVE THINGS AND THIS IS NOT MINE.
I DIDN'T KNOW NURSES COULD HAVE A THING.
I THOUGHT EVERYONE HAD TO LIKE EVERYTHING.
ALRIGHT, CLEAN, CLEAN, CLEAN.
CLEAN IT ALL OFF HERE. SCRUB, SCRUB.
IT MAY BE SO FROTHY, YOU CAN'T EVEN SEE WHAT YOU GOT OFF YET.
SO YOU MAY NEED TO DIP IT INTO YOUR PLAIN SALINE WATER
TO SEE IF YOU GOT ALL THE SPUTUM OFF.
WHAT IS THE POINT OF CLEANING IT IF YOU DON'T GET IT ALL OFF OF THERE?
DON'T THROW OUT YOUR BRUSH YET
BECAUSE YOU'RE GOING TO NEED THE BRUSH POSSIBLY
OR THIS IS WHEN YOU MIGHT NEED A PIPE CLEANER TO REALLY SCRAPE.
I DON'T WANT TO USE THAT END TO SCRAPE.
AND TRY TO GET THAT SPUTUM OFF THERE.
GET IT CLEAN AND THEN RINSE IT.
AND THEN ONCE IT'S CLEAN,
YOU WANT TO DRY IT OVER HERE ON YOUR 4 BY 4.
THEN I'M GOING TO STABILIZE THIS PLATE.
PUT THIS IN AND THAT'S WHEN THEY START COUGHING.
COS ANY KIND OF PRESSURE THAT GETS RIGHT THERE WHERE YOU COUGH.
I MEAN, YOU CAN PUSH YOUR OWN CRICOID A LITTLE BIT, IT JUST KIND OF...
OKAY, MAKE SURE IT'S LOCKED IN PLACE.
NOW, NOTHING IS STERILE ANY MORE.
I'M GOING TO REMOVE THIS LITTLE BIB OFF OF HERE
BECAUSE WHAT'S HAPPENING IS THEY'RE HOCKING UP SPUTUM HERE, RIGHT?
AND THIS IS CATCHING IT DOWN HERE
SO THAT ALL THAT WETNESS ISN'T MACERATING THEIR SKIN ON THEIR CHEST.
YOU'RE TRYING TO KEEP IT CLEAN AND DRY.
SO YOU CAN TAKE THIS OUT.
AND THEN I WANT TO GET THIS OTHER APPLICATOR THAT I HAVEN'T USED YET.
AND I WANT TO CLEAN ALONG THIS PLATE
AND I WANT TO CLEAN UNDER HERE AROUND THE STOMA, THE SKIN OPENING OF THE TRACH.
AND GET THAT NICE AND CLEAN.
YOU MAY NEED TO BRING ANOTHER PACKAGE OF APPLICATORS.
IF YOU SEE THAT IT'S LOOKING CRUSTED,
THEN YOU NEED TO GET MORE STUFF.
AND THEN I'M GOING TO LOOK UNDERNEATH THE PLATE.
I JUST WANTED TO DO THAT ONE DAY ON THE PLATE. AND IT WAS SO CRUSTY THERE.
NO ONE, I DON'T THINK HAD EVER CLEANED UNDER THE PLATE.
SO GET THAT NICE AND CLEAN.
AND I NEED TO REPLACE THAT LITTLE BIB.
BUT FOR NOW, I'M GOING TO WAIT BECAUSE I NEED TO CHANGE THE TRACH TIES.
THE TIES THAT HOLD THE TRACH IN PLACE STAY ON AT ALL TIMES.
AND THEY'RE ONLY CHANGED PER POLICY OR PER SOILING.
SO USUALLY EVERY THREE DAYS, EVERY FIVE DAYS
OR WHEN THEY'RE JUST GROSSLY SOILED.
YOU DON'T CHANGE THEM EVERYDAY, EVERY SHIFT, OR ANYTHING LIKE THAT.
SO YOU JUST NEED TO KNOW WHEN TRACH TIE DAY IS.
WHAT YOU WANT TO DO IS GET YOUR TRACH TIE.
IT'S A LONG PIECE OF TWILL TAPE LIKE THIS.
AND YOU'RE JUST GOING TO TAKE IT AND STICK IT THROUGH LEAVING THE OLD TIES ON.
STICK IT THROUGH HERE.
UP OR UNDER IT DOESN'T REALLY MATTER AS LONG AS YOU CAN GET TO IT.
AND OH, IT'S GOING TO MAKE HIM START COUGHING THE MORE YOU TRAUMATIZE THAT THING.
AND THAT'S WHEN I MAY USE MY APPLICATORS.
I MAY GET ONE OF THESE AND KIND OF STUFF IT A LITTLE BIT,
IF I CAN'T GET IT THROUGH THE HOLE.
BE CAREFUL THAT YOU DON'T GIVE 'EM ROPE BURNS WHEN YOU'RE PULLING THESE THROUGH.
PULL 'EM THROUGH SO THAT ONE SIDE IS LONGER THAN THE OTHER.
AND THEN WHAT I WANT HIM TO DO IS TO LIFT UP.
AND ACTUALLY, I JUST DO NOT LIKE LEANING OVER TRACHS LIKE THAT.
MM-MM. NOT GOOD. NOT GOOD AT ALL.
I'M GOING TO JUST WALK MY LITTLE SELF OVER HERE.
AND I WANT TO SLIP THIS THROUGH THE BOTTOM.
AND THEN...
LET ME LIFT YOUR HEAD UP A LITTLE, MR. SPADE.
BRING THAT THROUGH AND THEN YOU WANT TO TIE THIS
INTO A SQUARE KNOT FOR OUR PURPOSES
COS WE'RE GOING TO REUSE TWILL TAPE, JUST PUT IT IN A BUBBLE.
BUT YOU WANT IT IN A KNOT SO THAT IT DOESN'T COME UNDONE.
AND YOU WANT TO MAKE SURE...
THAT YOU CAN GET AT LEAST ONE FINGER...
IN HERE. THINK ABOUT THAT A MINUTE.
IF YOU DON'T -- IF YOU GET IT TOO TIGHT...IT'S THEIR NECK.
ALRIGHT, THEN THIS ONE CAN BE CUT OFF.
AND I MIGHT HAVE TO.
THEN TAKE THE OLD ONE OFF.
THAT WAY THE CLIENT'S NEVER AT RISK OF THIS THING FALLING OUT
OR SHOOTING OUT WHEN THEY COUGH.
COS THAT WOULD NOT BE A FUN THING TO HAVE THEM LOSE THEIR TRACH.
SO GO AHEAD AND PULL THIS OUT AND THEN PULL THE OLD ONE OUT
AND THEN THEY WILL HAVE THEIR CLEAN TRACH TIES ON THERE.
ALRIGHT.
ONCE HE'S ALL SET, THEN YOU CAN GO AHEAD AND PUT THIS NEW...
SPUTUM DRAPE HERE. AND IT NEEDS TO GO SO THAT THE SPLIT IS AT THE TOP.
HOPE THAT'S OBVIOUS.
BUT YOU'D BE SURPRISED HOW MANY DRESSINGS I SEE THE OPPOSITE WAY.
AND IT WOULDN'T SERVE ANY PURPOSE RIGHT?
BECAUSE THE SPUTUM IS COMING DOWN AND IT'S SUPPOSED TO GET CAUGHT HERE.
THESE CAN BE CHANGED. IN FACT I'D PROBABLY CHANGE --
I HAD A CLIENT THAT WAS JUST, OH, SO PRODUCTIVE.
AND I WAS CHANGING THIS EVERY TEN MINUTES ON HIM.
EVERY TIME I WALKED BY THE ROOM, THERE WAS JUST SPUTUM EVERYWHERE
AND IT WAS ON HIM ALL THE TIME. I COULDN'T KEEP UP WITH IT. IT WAS JUST TOO MUCH.
AT LEAST HE WAS GETTING IT OUT.
SO WHAT I DID WAS I JUST GAVE HIM A STACK OF DRAIN SPONGES.
I SAID, "HERE. CAN YOU CHANGE IT YOURSELF?"
AND HE DID, HE WAS PERFECTLY CAPABLE.
AND IT WAS, LIKE, WELL, BRAINSTORM.
I SHOULD HAVE THOUGHT OF THAT, YOU KNOW, THREE HOURS AGO.
BUT THAT GAVE HIM SOMETHING TO DO AND HE COULD KEEP HIMSELF DRY THAT WAY.
COS I HAD OTHER CLIENTS TO SEE AND SO FORTH.
SO THEY CAN TAKE CARE OF THAT.
AND THAT'S WHAT WE'RE TALKING ABOUT THIS ROUTINE CARE.
WHAT'S ROUTINE? IT'S WHAT YOUR CLIENT NEEDS TO KEEP 'EM DRY.
ALRIGHT, CLEAN UP YOUR MESS.
AT THIS POINT, YOU CAN RE-ASSESS VITAL SIGNS.
YOU CAN RE-ASSESS LUNG SOUNDS TO SEE HOW YOUR SUCTIONING AFFECT YOUR CLIENTS.
SEE WHAT THEIR O2 STATUS IS. MY CLIENT'S APNEAC AGAIN,
SO I'M PROBABLY GOING TO HAVE TO RESUSCITATE HIM.
AND HE'S STILL COUGHING.
BUT AT LEAST HE'S COUGHING AND THAT'S GOOD.
LUNGS SOUND BETTER. [COUGHING]
AND HE'S GOOD TO GO.
WASH YOUR HANDS AND DOCUMENT.
AND YOU'RE GOING TO DOCUMENT ALL OF THE THINGS WE JUST TALKED ABOUT.
YOUR SPUTUM, THE TYPE, THE AMOUNT, THE FREQUENCY,
HOW THEY TOLERATED THE SUCTIONING,
THE CARE YOU GAVE TO THE TRACH,
THE BIB, HIS O2 SATS, HIS VITAL SIGNS,
EVERYTHING THAT YOU DID GETS DOCUMENTED ON HERE.
PUT THIS UP.
AND YOU'RE LOOKING PRETTY GOOD THERE, MR. SPADE.
AND I'LL CLEAN THIS UP LATER.
ALRIGHT, I DID WANT -- OH!
THEY NEED GOOD ORAL HYGIENE AS WELL.
I WANT MY POINT BEFORE I LEAVE IF THEY HAVEN'T GRADED ME YET.
MAKE SURE THEY HAVE GOOD ORAL HYGIENE. DON'T FORGET THAT.
YOU KNOW, YOU CAN GET SO TRACH FOCUSED AND OVERWHELMED WITH ALL THAT SPUTUM AND STUFF,
THAT THE SAME THING, NASAL CARE AND ORAL HYGIENE.
I TALKED TO YOU BRIEFLY ABOUT WHAT HAPPENS
IF THEY HOCK THAT CATHETER OR THAT TRACH OUT?
OR WHAT -- DO YOU EVER CHANGE TRACHS?
I HAVE JUST A SHORT LITTLE THREE-FOUR MINUTE CLIP HERE
OF A MAN CHANGING HIS OWN TRACH.
AND I THOUGHT YOU MIGHT JUST LIKE TO SEE THIS.
SO MOST OF THE TIME THEY'RE OKAY,
BUT YOU WANT TO FILL IT PRETTY SOON BECAUSE THE STOMA WILL CLOSE.
AND SO THAT'S THE IDEA. BUT YEAH, YOU SHOULD HAVE PLENTY.
AND NOT ALL OF THEM HAVE A CUFF.
MANY ARE NON-CUFFED WHICH IS WHAT YOU USE --
I WORKED MOSTLY FLOOR NURSING AND SO MOST OF MINE
WERE UNCUFFED WHEN WE WORKED AROUND TRACHS.
- SO IF THIS THING FELL OUT AND THAT'S THE ONLY ONE YOU HAD,
YOU WOULD END UP CLEANING IT?
- THAT'S A GOOD QUESTION, I DON'T REALLY KNOW THE ANSWER TO.
BECAUSE THAT WOULD BE MY NIGHTMARE.
OH, I HAVE TO PICK ME UP OFF THE FLOOR?
I WOULDN'T PUT A DIRTY ONE IN, THAT'S FOR SURE.
I THINK IT WOULD JUST DEPEND ON THE CLIENT.
AND BOY, OH, BOY. YEAH, PROBABLY. 911.
BECAUSE YOU NEED A SPARE TRACH. THAT'S --
GOOD NURSES MAKE SURE THERE ARE SPARES.
I MEAN, THAT'S WHAT WE'RE ABOUT.
KIND OF LIKE A DIABETIC WITH ONLY ONE BOTTLE OF INSULIN. WHAT'S WITH THAT?
OKAY.
LAST BUT NOT LEAST. WE STILL GOT TIME.
SO THAT'S ONE DRILL AND THIS IS YOUR FINAL DRILL.
AND THIS ONE IS GOING TO BE A GROUP ACTIVITY.
AND I WANT TO PREP AS A GROUP ACTIVITY BY SAYING I HATE GROUP ACTIVITIES.
I'VE BEEN IN GROUPS BEFORE. AND WHAT HAPPENS IN GROUPS
IS ONE OR TWO PEOPLE DO ALL THE WORK AND ALL THE TALKING
WHILE TWO OR THREE TAKE A RIDE.
WELL, SINCE I KNOW THAT. DON'T YOU KNOW, I'LL BE WATCHING FOR WHO'S RIDING,
BECAUSE YOU'RE THE ONES I AM GOING TO ASK THE QUESTIONS TO.
AND YOU'RE GOING TO HAVE INDIVIDUAL GRADES FOR EACH OF IT.
SO IF EVERYTHING IS GOING ALONG RIGHT AND YOU'RE IN AGREEMENT, EVERYONE GETS THE POINTS.
BUT IF SOMETHING IS AMISS, THEN I'LL GO AROUND THE GROUP AND TRY TO FIGURE OUT
WHO KNOWS WHAT'S RIGHT AND WHAT'S WRONG. AND I'LL GET IT ALL FIGURED OUT.
AND YOU CAN TRUST ME ON THAT.
AND I'M GOING TO GIVE EACH OF YOU YOUR OWN SCENARIO, A PROBLEM TO SOLVE.
AND YOU WILL SEE WHAT I MEAN WITH JUST YOU.
ALRIGHT, WE NEED TO TALK ABOUT CHEST TUBES.
WHO NEEDS A CHEST TUBE? WHAT KIND OF DIAGNOSES GO WITH CHEST TUBES AND SO FORTH.
THE CHEST TUBE IS JUST EXACTLY THAT.
A TUBE THAT GOES INTO THE CHEST, INTO THE THORAX, CALLED THE THORACOTOMY.
AND WHAT WE'RE TRYING TO DO IS RELIEVE PRESSURE
THAT'S HAPPENED IN THE PLEURAL SPACE THAT'S CAUSED LUNGS TO COLLAPSE.
TYPICALLY, IT'S CALLED A PNEUMOTHORAX WHICH IS AIR IN THE PLEURAL SPACE.
FOR A PNEUMOTHORAX TO HAVE A CHEST TUBE,
YOU HAVE TO HAVE MORE THAN 15% OF THE LUNG COLLAPSED.
THAT'S NOT FOR YOU TO DIAGNOSE, IT'S FOR THE PHYSICIANS TO DIAGNOSE.
BUT THEY WILL HAVE DONE THAT RELATED TO CHEST TRAUMA,
PROBABLY AND/OR CHEST X-RAY.
THERE ARE THREE KINDS OF DEFINITIONS.
THERE ARE THREE THINGS THAT CAN LEAD TO PNEUMOTHORAX AND THAT'S --
OR CAUSES AND THAT'S TRAUMATIC.
USUALLY, THAT HAS TO DO WITH SOMETHING BLUNT HITTING IT, A SUCKING CHEST WOUND.
IT'S USUALLY OPEN, BUT IT COULD BE CLOSED WOUND.
SOME KIND OF TRAUMA THAT'S CAUSED THE LUNG TO COLLAPSE
SO A TRAUMATIC PNEUMOTHORAX.
THERE COULD BE AN IATROGENIC PNEUMOTHORAX
WHICH IS SOMETHING THE IATRO, IS US CAUSING IT.
SO FOR EXAMPLE A PHYSICIAN PUTS IN A SUBCLAVIAN LINE
AND NICKS THE LUNG, WE CAUSED THE PNEUMOTHORAX.
AND FINALLY A SPONTANEOUS PNEUMOTHORAX.
AND IT COULD BE PRIMARY FOR REASONS WE DON'T KNOW,
IDIOPATHIC OR IT COULD BE SECONDARY TO A DISEASE PROCESS.
A FRIEND OF MINE LAST WEEK HAD PNEUMONIA
AND HAD A PNEUMOTHORAX, BUT LESS THAN 15%.
SO BECAUSE IT WAS DISEASE CAUSED AND NOT THE WHOLE LUNG,
SHE DIDN'T HAVE TO HAVE A CHEST TUBE AND THEY TREATED IT
WITH MEDICATION AND RESPIRATORY THERAPY AND SO FORTH.
SO IT VARIES, BUT THE KEY IS THAT GREATER THAN 15%, COLLAPSE OF LUNG.
THE FINAL KIND OF PNEUMOTHORAX YOU CAN HAVE
IS A TENSION PNEUMOTHORAX
WHICH IS REALLY THE VERY MOST SERIOUS KIND.
ALL THESE WORDS ARE DEFINED QUITE WELL IN ALL THE ARTICLES AND ALL THE BOOKS.
BUT A TENSION PNEUMOTHORAX IS INCREASED PRESSURE IN THAT PLEURAL SPACE
THAT CAUSES THE HEART TO SHIFT OVER AND CAUSES DIFFICULTY
IN BREATHING, POOR AIR EXCHANGE AND CAN BE FATAL.
AND SO THAT'S WHAT WE'RE TRYING TO PREVENT.
WE DON'T WANT IT TO GET WORSE THAN IT ALREADY IS IN THAT SPACE.
SO A CHEST TUBE IS PUT INTO THE THORACIC AREA
AND DEPENDING UPON WHAT KIND OF CHEST PROBLEM THERE IS
IS WHERE THE TUBE WILL BE PLACED.
IF IT'S A PNEUMOTHORAX, IT'S TYPICALLY PLACED HIGH
AROUND THE SECOND INTERCOSTAL SPACE, MID CLAVICULAR LINE.
BECAUSE AIR RISES,
AND SO THEY'RE TRYING TO GET THE AIR OUT OF THE SPACE.
BUT IF IT'S A HEMOTHORAX, OR...
WHAT ELSE? EMPYEMA, PUS IN THE LUNG.
FLUIDS GO TO THE BOTTOM OF THE LUNG,
SO WHAT THEY TEND TO DO IS PUT THAT IN THE FIFTH OR SIXTH INTERCOSTAL SPACE
ON THE POSTERIOR PART OF THE LUNG SO THAT THE TUBES WILL COME OUT FROM HERE.
SO PNEUMO IS USUALLY ANTERIOR HIGH,
AND FLUIDS ARE USUALLY POSTERIOR AND LOW.
THE ONLY EXCEPTION TO THAT IS WHEN THEY DO HEART SURGERY
AND TRYING TO PREVENT MEDIASTINAL SHIFT,
THEN THEY WILL PUT A CHEST TUBE, MAYBE EVEN IN TWO PLACES,
HIGH AND LOW WHEN YOU'VE GOT BLOOD AND AIR POST-OP.
OR AND EVEN WITH TRAUMA, YOU MAY HAVE TWO TUBES DRAINING 'EM BOTH OUT OF THAT SPACE.
SO IF YOU HAVE A CLIENT THAT'S GOING TO HAVE A CHEST TUBE,
THEY WILL HAVE DONE AN X-RAY, THEY WILL HAVE DONE AN ABG,
THEY WILL HAVE...
TAKEN VITAL SIGNS AND ASSESS
THAT THIS CLIENT IS HAVING DIFFICULTY BREATHING AND SO FORTH.
SO THAT IT'S INDICATIVE THAT THIS CHEST TUBE IS NEEDED.
SO IF A CLIENT COMES TO YOU
AND YOU HAVE TO GET EVERYTHING READY, THAT'S ONE SCENARIO.
OR THEY MAY ALREADY HAVE THE CHEST TUBE AND YOU HAVE TO MAINTAIN IT
BUT NEVERTHELESS YOU NEED TO KNOW THE WHOLE OF IT.
WHEN YOU COME WITH YOUR GROUP TO MY STATION,
I WILL GIVE YOU ONE OF FOUR SCENARIOS.
IT WILL EITHER BE A PNEUMOTHORAX OR A HEMOTHORAX.
ONE OR THE OTHER, SO YOU CAN THINK AIR OR FLUID.
AND IT WILL EITHER, THE CHEST TUBE WILL EITHER BE IN
OR YOU WILL HAVE TO HELP THE DOCTOR GET READY TO PUT IT IN.
I'M GOING TO START FROM THE BEGINNING OF HOW TO SET IT ALL UP
BECAUSE YOU NEED TO KNOW THAT INFORMATION.
BUT I MAY JUST SAY, "THE TUBE IS IN, WHAT ARE YOU GOING TO DO AS A NURSE
FOR THE SHIFT TO TAKE CARE OF YOUR CLIENT WITH THE CHEST TUBE?"
BECAUSE THAT'S WHAT LIFE IS LIKE FOR US WHEN WE'RE WORKING.
ALRIGHT, I WILL CHECK MY DOCTOR'S ORDERS.
I WILL GATHER MY EQUIPMENT AND THAT'S A HUGE JOB
IF THE DOCTOR'S GOING TO PUT A CHEST TUBE IN,
YOU HAVE TO GET A CHEST DRAINAGE UNIT.
AND IT COMES IN A PACK WITH THE CHEST TUBE ITSELF.
THERE'S THREE COMPARTMENTS.
AND IN THESE COMPARTMENTS ARE...
DIFFERENT FUNCTIONS THAT WILL BE TAKING PLACE.
THIS COMPARTMENT RIGHT HERE IS THE DRAINAGE COMPARTMENT.
SO IF THEY'RE GETTING -- IF THEY HAVE A HEMOTHORAX,
AND THERE'S BLOOD IN THEIR SPACE.
AND WE'RE DRAINING THE BLOOD OFF SO THAT THE LUNG CAN REINFLATE,
THEN WE NEED TO CAPTURE THAT BLOOD.
AND IT WILL COME INTO THE DRAINAGE PART OF THE UNIT.
BECAUSE THIS IS REALLY ALL OPEN, RIGHT?
IT'S AN OPEN -- THIS IS AN OPEN TUBE.
OPEN, OPEN, OPEN INTO THIS SPACE OPEN, RIGHT?
AT SOME POINT WHERE IS THE END OF THE TUBE?
ISN'T THAT A CURIOUS THING?
THAT'S THE WATER SEAL WHICH IS THE SECOND CONTAINER.
SO HERE'S THE DRAINAGE COMING OUT,
BUT WE'RE GOING TO SEAL THIS UP WITH A WATER SEAL.
IT'S THE END OF THE LINE, KIND OF, A THING.
I CAN'T TELL YOU EXACTLY HOW IT WORKS PHYSIOLOGICALLY,
BUT KNOW IT TO BE TRUTH LIKE THIS.
IF THIS WERE THE END OF THE TUBE
AND I PUT MY THUMB ON IT, THAT WOULD SEAL IT UP HARD.
NOTHING COULD ESCAPE AIR --
IF THERE GOT TOO MUCH AIR IN THE SPACE,
THE AIR COULDN'T ESCAPE OUT, IT'D BE TRAPPED.
BUT IF I CREATE A SOFT SEAL WITH WATER, YOU KNOW HOW YOU BLOW IN A STRAW
WHEN YOU'RE DRINKING OUT OF A CUP AND THE WATER BLURPS UP THE TOP?
THIS IS WHAT WE'RE TRYING TO CREATE, A SOFT SEAL.
SO THAT IF A PRESSURE BUILDS UP INTO THIS PLEURAL SPACE,
IT CAN BLURP OUT.
AND THE WATER HERE WILL MAINTAIN ENOUGH OF A SEAL
SO THAT WE KEEP THE RIGHT PRESSURE GOING INTO THE LUNG.
HOW DO WE KNOW WHAT THAT IS? WELL, THEY FIGURED IT ALL OUT.
AND WE NEED 2CM, SONAMETERS, WHATEVER I SAY AT THE TIME,
OF PRESSURE HERE IN THIS WATER SEAL.
OKAY? HOW DO YOU GET IT IN THERE?
WELL, ALL THE UNITS HAVE DIRECTIONS SO THAT'S ALWAYS HELPFUL.
BUT THIS PARTICULAR UNIT IS DESCRIBED IN YOUR BOOK
AND IT'S WHAT'S USED IN MANY OF THE FACILITIES IN THE VALLEY.
IT HAS THE WATER SEAL VALVE HERE,
AND YOU HAVE TO GET A SYRINGE AND CONNECT IT LIKE THIS.
AND THEN YOU HAVE A VALVE THAT TURNS IT OFF OR ON.
YOU NEED IT OPEN AND THEN YOU POUR YOUR WATER.
AND REALLY YOU NEED JUST STERILE WATER. SODIUM CHLORIDE ISN'T RECOMMENDED
BECAUSE SODIUM CHLORIDE, THE SALTS BUILD UP IF THEY HAVE IT FOR A WHILE.
SO JUST PLAIN OLD STERILE WATER, AND YOU JUST POUR A LITTLE IN HERE.
AND YOU WATCH THE LINE
UNTIL THE FLUID IS RIGHT AT THE 2CM LINE.
OKAY?
SO I HAVE MY...
UNITS SET AND I HAVE MY WATER SEAL SET.
BUT I MENTIONED THERE WERE THREE COMPARTMENTS.
THE THIRD COMPARTMENT IS THE SUCTION PRESSURE COMPARTMENT.
AND THEY FOUND THAT IF THEY HOOKED UP SUCTION
DIRECTLY TO THIS UNIT, IT WAS TOO STRONG.
BUT IF THEY PUT WATER IN AS A MEDIATOR
SO THAT IT DIDN'T PULL TOO HARD THAT THE RIGHT AMOUNT OF SUCTION
WOULD BE TO THAT PLEURAL SPACE AND WOULDN'T CAUSE DAMAGE.
SO WHAT THEY FOUND WAS THAT 27CM OF WATER IN THIS SPACE
WHEN WE HOOK IT TO SUCTION WOULD CREATE
THE RIGHT AMOUNT OF SUCTION INTO THIS PLEURAL SPACE
SO THAT IT WOULDN'T DAMAGE THE TISSUES AND THE LUNGS
AND YET IT WOULD DRAW OFF THE AIR AND THE FLUID
SO THAT THE CLIENT'S LUNG WOULD REFILL.
- DID YOU SAY 20?
- 20CM IS IN THE SUCTION.
SO THE SUCTION LINE IS HERE AT 20.
THE WATER SEAL LINE IS TWO,
AND THE DRAINAGE COMPARTMENT IS WHATEVER DRAINAGE NEEDS TO BE.
TO FILL IN THE SUCTION COMPARTMENT,
YOU JUST POUR IT INTO THIS TOP HOLE RIGHT HERE,
AND IT FILLS UP.
AND THEN YOU PLUG IT WITH THIS PLUG THAT'S GOT TWO HOLES IN IT.
YOU NEVER SEAL ANYTHING WITH A SOLID HARD SEAL.
NOT WITH TAPE, NOT WITH ANYTHING BECAUSE THEN IT CAN'T BURP OUT.
AND WE NEED IT TO BE ABLE TO FLUCTUATE A LITTLE BIT.
ALRIGHT, ONCE YOUR TUBE IS --
YOUR COMPARTMENT IS SET HERE, YOUR CHEST TUBE DRAINAGE UNIT.
IT NEEDS TO HANG AT LEAST A FOOT BELOW THE CLIENT'S LUNGS
WHERE THE INSERTION WILL BE.
SO IT USUALLY HANGS ON THE FOOT OF THE BED
OR IT SITS IN A STAND ON THE FLOOR
WHATEVER THE UNIT HAPPENS TO BE.
THE CHEST TUBE PIECE THEN WILL BE THIS PIECE RIGHT HERE.
AND -- OH, LET ME GRAB THIS AND SEE.
THEN YOU WOULD HAVE TO GET THE REST OF THE EQUIPMENT FROM THE PHYSICIAN.
THE PHYSICIAN IS GOING TO NEED A CHEST TUBE AND A CHEST TUBE INSERTION TRAY.
AND THOSE JUST COME OFF OF THE CENTRAL SUPPLY CART.
AND IT WILL HAVE EVERYTHING THE DOCTOR NEEDS EXCEPT FOR THE DRESSING.
AND YOU WILL NEED TO GET A DRESSING CART FOR YOUR DRESSING.
THEY WILL AT LEAST NEED AN ABD PAD, SOME GAUZE,
MAYBE SOME XEROFORM GAUZE
WHICH IS A VASELINE GAUZE AND ELASTOPLAST TAPE.
OH, MY DRESSING IS NOT DOING TOO GOOD, WHICH IS THIS THICKISH KIND OF TAPE HERE.
ALRIGHT.
SO YOU WILL HAVE GATHERED YOUR EQUIPMENT, WASHED YOUR HANDS,
YOU'RE GOING TO IDENTIFY YOUR CLIENT AND PROVIDE PRIVACY.
NOW EVEN BEFORE I WOULD GATHER UP MY EQUIPMENT IN TOTAL,
I WANT TO MENTION I WOULD TAKE CARE OF MY CLIENT FIRST.
AND THE FIRST THING YOU DO BEFORE YOU GET ALL ANAL ABOUT EQUIPMENT
IS MAKE SURE THAT YOUR CLIENT IS SITTING UP IN BED.
THEY NEED TO BE AT LEAST AT A 45 DEGREE ANGLE
OR HIGHER DEPENDING ON WHAT THE SCENARIO IS.
HIGH FOWLER'S IF IT IS A HEMOTHORAX
BECAUSE YOU NEED THE BLOOD TO GO DOWN.
AND PNEUMOTHORAX AT LEAST 45 DEGREES
COS YOU NEED THE AIR TO GO UP.
WHATEVER THE CASE, UP. THEY NEED TO BE SITTING UP.
YOU NEED A GOOD SET OF VITALS, YOU NEED TO LISTEN TO THEIR LUNG SOUNDS
AND YOU NEED TO KNOW HOW YOUR CLIENT IS DOING.
YOU MAY NEED TO PUT OXYGEN ON 'EM,
THEY MAY NEED TO HAVE AN IV STARTED.
MORE THAN LIKELY ALL OF THE ABOVE SO THAT THEY'LL BE STABLE.
SO MAKE SURE YOUR CLIENT IS SET FIRST
AND THEN BUSY ABOUT GETTING YOUR EQUIPMENT.
ALRIGHT. I HAVE MY CHEST DRAINAGE SET, I'VE GOT STUFF FROM MY DOCTOR.
BUT I ALSO KNOW THAT WHENEVER THERE IS A CHEST TUBE
THAT YOU NEED TO BE PREPARED FOR ANYTHING TO GO WRONG.
AND THAT IS THE CHEST TUBE TO COME OUT OR FOR A LEAK TO HAPPEN.
SO I AM ALSO GOING TO GATHER UP EMERGENCY SUPPLIES.
AND MY EMERGENCY SUPPLIES ARE GOING TO CONSIST OF MY RUBBER-TIP HEMOSTATS,
WHICH I'VE EITHER TAPED TO THE WALL OR TAPED TO THE FOOT OF THE BED.
I JUST PUT 'EM HERE SO YOU COULD SEE 'EM.
I ALSO NEED EMERGENCY SUPPLIES AT THE BEDSIDE.
AND THAT IS I NEED SOME 4 BY 4S,
I NEED A CONTAINER TO CREATE A WATER SEAL IF IT WERE NECESSARY.
OH, I AM IN TROUBLE WITH TIME.
I NEED TWO INCH TAPE AND I NEED SOME WATER.
SO I HAVE EMERGENCY SUPPLIES HERE AND I HAVE MY SUCTION SET UP.
AND ON MY SUCTION...
I HAVE AN EXTENSION TO MY SUCTION BUCKET.
THIS ISN'T GOING TO COLLECT ANY SUCTION,
IT'S JUST GOING TO CREATE THE SUCTION ON TO MY UNIT HERE.
LET'S SAY WE HAVE A PNEUMOTHORAX.
THE PHYSICIAN'S GOING TO COME IN.
THE PHYSICIAN IS GOING TO PUT IN THE CHEST TUBE.
WHAT THEY DO IS THEY PUT IN A LITTLE XYLOCAINE, THEY MAKE A KNIFE CUT.
AND THEN THEY PROBE THE CUT WITH THEIR FINGER TO GET INTO THE SPACE THAT THEY NEED.
SO...AND THEN...IN.
ALL STERILE, THEN THEY PUT THE CHEST TUBE IN
WHILE THE CHEST TUBE IS CLAMPED.
WHERE DID I SET THAT LITTLE CHEST TUBE?
- ON THE TABLE.
- THEY PUT THE CHEST TUBE IN AND IT'S AN ENDING LIKE THIS.
LET'S ME SEE. FOUR...
THE SIZE IS 12 TO 40 FRENCH FOR A PNEUMOTHORAX.
THEY'RE BIG. THIS ONE IS A 32 FRENCH.
A PRETTY BIG SIZE. AND WHEN IT'S A HEMOTHORAX,
IT'S A 28 TO 40 FRENCH. IT'S GOT TO BE BIGGER
BECAUSE OF THE BLOOD AND THE CLOTTING THAT CAN HAPPEN
AND YOU WANT TO MAINTAIN THAT IT IS PATENT.
SO THEY'RE GOOD SIZED TUBES TO DRAIN OFF WHATEVER IS COMING OUT.
SO MAKE SURE THAT YOU HAVE ACQUIRED A SELECTION FORM TO PUT IN.
OKAY. WHEN THEY GO TO PUT IT IN,
HE WILL CLAMP IT, PUT IT IN
BECAUSE HE DOESN'T WANT AIR ESCAPING AND CAUSING
A TENSION PNEUMOTHORAX FOR THAT CLIENT OR FOR AIR GOING IN.
EITHER WAY, WHATEVER IS THE PROBLEM.
SO HE'LL HAVE IT CLAMPED. HE'LL PUT THE TEST TUBE IN.
HE WILL CONNECT THE CHEST TUBE TO THE DRAINAGE UNIT.
TAKE THE CLAMP OFF
AND THEN SUTURE THE CHEST TUBE IN PLACE AND DRESS IT.
THAT IS THE DOCTOR'S JOB, OKAY?
SO THEY SUTURE IT AND THEY STABILIZE IT.
YOU'RE JOB IS, AT THIS POINT --
I WOULD DO EVERYTHING WITH GLOVES BECAUSE WHO KNOWS, BODY FLUIDS.
IS THAT YOU WANT TO GET THINGS HOOKED UP AND RUNNING
AND YOU WANT TO MONITOR THE AMOUNT OF DRAINAGE THAT COMES OUT.
SO, THE DRESSING'S OKAY.
YOU WANT TO TAPE THE CONNECTION
TO MAKE SURE THAT IT DOESN'T COME APART.
THIS IS A HIGH-RISK AREA FOR LEAKING
AND IT CAN CAUSE PROBLEMS FOR THE CLIENT.
SO THIS NEEDS TO BE VERY STABLE AND TAPED
AND THEN DOWN HERE TO YOUR UNIT.
AT THIS POINT, I'M GOING TO TAKE THE SYRINGE OFF OF THE UNIT
AND THIS PIECE THAT'S COMING OFF WHERE I FILLED UP THE WATER SEAL,
I'M GOING TO CONNECT TO SUCTION.
IT'S HARD TO SEE WHEN I AM KEEPING IT ONE FOOT BELOW THE CHEST.
BUT I AM GOING TO CONNECT THIS PIECE THAT ACTUALLY FILLED UP THE WATER SEAL,
AND NOW IT'S CONNECTED HERE TO SUCTION
AND I AM GOING TO TURN THE SUCTION ON.
OKAY, I'M GOING TO TURN THE SUCTION ON...
SO THAT IT'S BUBBLING IN THE SUCTION SECTION.
ALRIGHT.
NOW THAT THE CLIENT IS HOOKED UP,
I WANT TO MAKE SURE AND ASSESS THE CLIENT.
I WANT TO MAKE SURE AND ASSESS THEIR BREATHING.
THEIR EASE OF BREATHING. I WANT TO MAKE SURE THE DRESSING IS INTACT.
I WANT TO NOTE THE TYPE, AMOUNT OF DRAINAGE THAT'S COMING OUT.
WHAT KIND OF DRAINAGE WOULD YOU EXPECT WITH A PNEUMOTHORAX?
- PNEUMO? - UH-HUH.
MAYBE NOTHING, IT'S AIR.
MAYBE A LITTLE BIT RELATED TO TRAUMA,
BUT IT'S SO HIGH THAT YOU'RE NOT GOING TO PICK UP MUCH FLUID.
JUST FROM MAYBE THE INCISION, BUT MOSTLY AIR.
SO YOU WILL EXPECT TO SEE NOT MUCH IN THE DRAINAGE UNIT,
WHEREAS IF IT'S A HEMOTHORAX, YOU'RE GOING TO EXPECT TO SEE BLOODY DRAINAGE
AND EACH SHIFT YOU'RE GOING TO HAVE TO MARK
THE AMOUNT OF DRAINAGE THAT'S IN THE CONTAINER.
YOU WANT TO NOTICE CREPITUS
WHICH IS AIR LEAKING INTO THE SKIN FROM THIS PUNCTURE SITE.
YOU WANT TO NOT THE PAIN THAT THEY'RE HAVING AND SO FORTH.
AND THE OTHER THING YOU WANT TO NOTICE IS,
YOU WANT TO MAKE SURE YOUR UNIT IS WORKING CORRECTLY.
THERE ARE SOME THINGS THAT CAN BE NOT SO GOOD HERE.
THIS IS WORKING CORRECTLY. EVERYTHING ABOUT THIS IS FINE, ALMOST.
I DO HAVE A LITTLE PROBLEM HERE, I THINK, WHICH IS GOOD.
PROBLEMS ARE GOOD WHEN WE'RE WORKING.
THE BUBBLING SHOULD ONLY OCCUR IN THIS CHAMBER.
THERE SHOULD BE NO BUBBLING IN THE WATER SEAL.
IF THERE IS...THEN WE GOT A LEAK SOMEWHERE.
SO I'VE GOT A LEAK SOMEWHERE AND I DON'T EVEN KNOW WHAT IT IS.
SO WE'LL HAVE TO JUST GO SEARCHING FOR IT.
THIS SHOULD NOT BUBBLE AT ALL.
WHAT IS MAY DO IS WHAT'S CALL TIDLING.
AND THAT MEANS THAT IF YOU BREATHE IN AND OUT...
IT RISES...AND FALLS
AS A UNIT, NOT JUST TOTAL BUBBLING.
IF IT BUBBLES LIKE THIS, SOMETHING IS LEAKING
AND WE GOT TO GO CHECK THEM FOR IT.
SO THIS IS WHAT WE'RE GOING TO DO.
PART OF IT IS BECAUSE I LIFTED IT HIGH.
IF YOU SUSPECT A LEAK, YOU HAVE EMERGENCY SUPPLIES.
AND WHAT YOU'RE GOING TO DO IS GET YOUR RUBBER-TIPPED HEMOSTATS,
AND THESE MEAN NO TEETH, BECAUSE YOU DON'T WANT ANY TEETH
CRIMPING IN AND PUTTING HOLES INTO YOUR LINE.
YOU'RE GOING TO COME UP EVER SO SYSTEMATICALLY
AND PINCH THIS TO SEE IF IT STOPS BUBBLING.
AND IF IT DOESN'T STOP BUBBLING,
THEN YOU GET YOUR OTHER SET OF HEMOSTATS
AND YOU CRIMP THEM OFF.
IT DIDN'T STOP BUBBLING.
THIS IS THE AREA I'M THINKING IS MOST AT RISK.
AND I AM ACTUALLY JUST GOING TO TURN THIS OFF AND SEE IF IT BUBBLES.
I DON'T HAVE A LEAK. IT'S JUST SO VIGOROUSLY BUBBLING.
I THINK THERE IS GOING TO BE SUCTION SET UP HERE.
OR I COULD HAVE A CRACK MAYBE, BUT ANYWAYS, YOU JUST KEEP WORKING ALONG.
SO, WHAT IF I COME TO HERE AND ALL OF A SUDDEN IT QUITS BUBBLING?
WHERE IS MY LEAK?
OKAY. SO WHAT IS THE PROBLEM?
I GOT A HOLE IN MY TUBING SOMEWHERE
AND THIS PIECE OF TUBING NEEDS TO BE REPLACED, OKAY?
SO -- ACTUALLY WHAT I NEED TO DO
IS LEAVE THIS CLAMP ON AND I AM GOING TO TAKE THIS CLAMP OFF.
NOW, YOU CANNOT LEAVE YOUR TUBINGS CLAMPED FOR A LONG TIME
OR IT CREATES A TENSION PNEUMOTHORAX.
COS WE'RE NOT ABLE TO HAVE THAT SOFT AIR EXCHANGE.
SO WHAT I WOULD NEED TO DO IS CREATE A SOFT SEAL.
I'M GOING TO TAKE MY STERILE CUP AND MY STERILE WATER.
PUT A COUPLE OF MILLILITERS.
PROBABLY A LITTLE MORE THAN THAT THERE.
HEMOSTATS, I'M GOING TO CLAMP,
SO THAT THIS IS NEVER EXPOSED.
I'M GOING TO UN-TAPE THIS,
WHICH WILL TAKE ABOUT A DAY TO GET UNDONE.
TAPPED IT WELL, DISCONNECT THIS
AND THEN I AM GOING TO PUT THIS IN A SOFT SEAL...
AND DISCONNECT.
AND NOW I'VE CREATED A WATER SEAL SO THAT MY FRIEND,
WHO I AM GOING TO PUT THE CALL LIGHT ON AND SAY,
"PLEASE, CAN YOU GO GET ME A NEW UNIT.
THIS HAS GOT A LEAK IN IT AND IT'S MESSED UP."
SO YOU CAN CREATE YOUR OWN SOFT SEAL.
THEY COME WITH A NEW UNIT.
I CLAMP IT.
TAKE THIS OUT. DON'T MOVE MR. SPADE.
I GOT WATER BETWEEN YOUR LEGS.
I'M GOING TO CONNECT IT.
DISCONNECT.
DISCONNECT...
AND THEN HOOK HIM TO HIS NEW UNIT.
ALRIGHT?
- IF IT'S ABOVE...
- IF IT'S IN THIS TUBE WE GOT PROBLEMS
AND IT'S PROBABLY TOO FULL.
IT COULD BE THE CONNECTION HERE, SO ALWAYS CHECK THIS FIRST.
THIS IS YOUR AT-RISK PLACE OR THIS HAS GOTTEN PULLED OUT.
AND ONE OF THESE EYELET HOLES THAT'S SUPPOSED TO BE
IN THE SKIN CAUSING A SEAL HAS GOTTEN PULLED OUT.
AND A PHYSICIAN NEEDS TO BE NOTIFIED.
WHEN THAT HAPPENS, THIS IS WHAT YOU DO.
YOU MAKE SURE THAT THE DRESSING IS OVER THE WOUND AND ONLY THREE SIDES OF IT ARE TAPPED DOWN,
SO THAT AIR CAN ESCAPE IF IT NEEDS TO ESCAPE.
SO YOU DON'T DO AN OCCLUSIVE DRESSING.
THE SAME TOKEN. IF THE WHOLE CHEST TUBE GOT PULLED OUT --
LET'S SAY IT WAS NIGHT SHIFT AND YOU STEPPED ON IT
AND IT ALL CAME OUT, THAT'S WHY YOU KEEP THESE SUPPLIES HERE.
YOU'RE GOING TO PULL OUT YOUR 4 BY 4S,
SLAP IT ON THERE AND TAPE THREE SIDES DOWN OVER THE HOLE
AND CALL THE PHYSICIAN IMMEDIATELY.
IF THE CLIENT NEEDS TO GO TO THE BATHROOM,
THEY CAN GET UP AND WALK WITH THEIR CHEST TUBE.
WHAT YOU WANT TO DO IS DISCONNECT THE SUCTION.
NEVER DISCONNECT THE TUBE, CLAMP OR ANYTHING LIKE THAT.
THE UNIT HAS TO STAY INTACT. SO THE UNIT IS ALTOGETHER.
ALL YOU WOULD DO IS COME DISCONNECT HERE, TURN THAT OFF
AND THEN THEY CAN WALK WITH THEIR UNIT
A FOOT BELOW THEIR LUNG.
I LIKE TO PUT IT ON THE BASE OF AN IV POLE AND THEN JUST TAPE IT TO THE POLE,
AND THAT WAY THERE IS NO TIPPING ACTION.
WHAT HAPPENS IF YOU GO TO THE BATHROOM
OR THEY GO TO THE BATHROOM AND IT FALLS OVER?
OH! IT'S HAPPENED.
SOME OF THE NEWER UNITS HAVE BAFFLES THAT KEEP THE DRAINAGE
FROM GOING FROM ONE SIDE TO THE OTHER, BUT SOME OF THEM DON'T.
IT JUST DEPENDS ON WHO THEIR DISTRIBUTOR IS.
YOU WANT TO FIRST MAKE SURE THAT IT'S INTACT AND THAT YOU GOT NO BUBBLING HAPPENING IN IT
AND THAT IT DIDN'T CRACK HERE BECAUSE IF IT DID,
YOU'RE GOING TO HAVE TO CREATE A SOFT SEAL
AND THEN YOU'RE GOING TO HAVE TO REPLACE THIS UNIT.
IF THE UNIT IS FINE, BUT YOU JUST HAVE --
THE DRAINAGE HAS JUST GOTTEN MESSED UP
THEN YOU'RE JUST GOING TO HAVE TO RE-LABEL THE DRAINAGE UNIT.
LET ME SPEAK TO THAT IN A MINUTE.
IF ON THE FIRST DAY, THEY HAD 750 CC OUT
AND THEN THE SECOND -- LATER, THE NEXT SHIFT THEY WERE UP TO 1000.
HOW MUCH WENT OUT ON THE NEXT SHIFT?
FIRST SHIFT HAD 750 AND THEN ON YOUR SHIFT THERE IS 1000. HOW MUCH ON YOUR SHIFT?
250 AND THAT'S HOW YOU FIGURE OUT THE I&O OF THE DRAINAGE.
AND WE MARK IT WITH TAPE AND A LINE, DATE AND TIME ON THE UNITS.
BUT IF IT FALLS OVER AND NOW SOME OF THE 750 AND ALL COMES OVER
AND NOW WE HAVE 1300 AND 500,
YOU HAVE TO RE-LABEL IT AND THEN YOU HAVE TO WATCH THE NEXT FLUID COME UP
AND KEEP TRACK OF IT FROM HERE AND FROM HERE.
IT GETS A LITTLE CONFUSING,
BUT YOU CAN KEEP THE UNIT WITHOUT HAVING TO CHARGE IT.
DOES THAT MAKE SENSE?
OKAY. I DON'T KNOW. CLEAR AS MUD.
NO. NO. TOTALLY DISPOSED OFF AND ALL THE BODY FLUIDS GO TO BIOHAZARDS.
YOU NEVER EMPTY ANYTHING OUT, UNLESS IT'S AN AUTO INFUSION UNIT
AND THEN THEY GET THEIR OWN BLOOD OUT OF IT TO RE-TRANSFUSE.
BUT THAT'S A DIFFERENT KIND OF UNIT.
ALRIGHT. I THINK I HANDLED MOST OF YOUR PROBLEMS.
YOU'RE GOING TO HAVE TO -- OH, SEE I AM WAY OVER.
WE JUST HAVE TO DC THIS CHEST TUBE AND I'LL DO IT THE SPEED VERSION.
OKAY. HIGH-FIVE IF IT'S TIME TO DC.
YOU NEED TO GET A DRESSING. THE TUBE'S GOT TO COME OUT.
YOU WANT TO INSTRUCT YOUR CLIENT THAT THIS IS A LITTLE UNCOMFORTABLE.
YOU WANT TO MEDICATE HIM 30-45 MINUTES PRIOR TO THE PROCEDURE IF POSSIBLE.
THE PHYSICIAN WILL COME IN. HE'LL HAVE HIS SUPPLIES
WHICH IS AN ADAPTEC, SOME 4 BY 4S, ABD.
YOU WANT TO TELL THE CLIENT THAT WHEN THE TUBE COMES OUT
THAT THEY NEED TO HOLD THEIR BREATH.
PULL THE TUBE OUT, THAT WILL KEEP THE LUNG INFLATED.
THE DOCTOR WILL PUT AN OCCLUSIVE DRESSING ON AT THAT TIME.
YOU WILL WANT TO GET A GOOD SET OF VITAL SIGNS
AND PROBABLY A CHEST X-RAY TO MAKE SURE THAT THE LUNG
IS STAYING RE-INFLATED, WHICH BY THE WAY, WE WOULD HAVE GOTTEN A CHEST X-RAY,
AFTER THE CHEST TUBE TO MAKE SURE THAT THE CHEST TUBE WAS IN PLACE.
WASH YOUR HANDS, DOCUMENT,
AND YOU'RE GOING TO KEEP AN EYE ON THAT CLIENT DOING POST-OP VITAL SIGNS
TO MAKE SURE THAT THEY'RE GOING TO BE STABLE
WITHOUT THE CHEST TUBE IN THEIR LUNG SPACE.
THAT WAS VERY FAST. YOU CAN READ THE DC PRETTY MUCH YOURSELF.
ALRIGHT. HUGE, HUGE, UNIT. READ, READ, READ.
SEE YOU NEXT WEEK. - WHERE IS CPT?
- I'M GOING TO DO CPT, THAT WAS THE POSTURAL DRAINAGE.
IT'S JUST PHYSIOTHERAPY AND I'LL DO IT NEXT WEEK WITH CATHETERS
BECAUSE WE JUST DON'T HAVE ENOUGH TIME. NO.
IT'S A PASS/FAIL AND WE'LL JUST DO IT LATER.
I KNEW WE WERE GOING TO HAVE TROUBLE GETTING IT ALL DONE TODAY.