ALRIGHT, WE'RE GOING
TO GET GOING

SO WE CAN GET TO THE TEST.

WE'RE GOING TO FINISH THE SECOND
WEEK OF THE MODULE.

SO NO BLACKBOARD THIS WEEK.

HOPEFULLY, YOU'VE GONE THROUGH
ALL YOUR MATERIAL

AND YOU'RE JUST READY TO GO ON
FEEDING TUBES BECAUSE THAT'S
WHAT WE'RE GOING TO DO.

OUR FOCUS THIS TIME WILL BE
NUTRITION BY NASOGASTRIC TUBE,

OR BY GASTRO --
GASTROSTOMY TUBE.

IN ONE YOUR BOOKS, IT TALKS
ABOUT ENTERIC TUBES.

THEY CALL IT A NET.
NASOENTERIC TUBE.

SO A NET TUBE IS ANOTHER PHRASE
YOU'LL HEAR. THERE'S A LOT.

SO SOMETIMES IT STARTS
BEING ALPHABET SOUP.

AND WHEN THERE'S JUST
A LOT OF ACRONYMS,

DON'T TRY TO FAKE IT LIKE
YOU KNOW WHAT IT IS.

EVERY HOSPITAL OR INSTITUTION
HAS TO HAVE A POLICY AND
PROCEDURE MANUAL

WITH ALL THEIR ABBREVIATIONS
IN THE FRONT.

SO RUN TO IT IF PEOPLE
DON'T KNOW.

AND IT'S SURPRISING TO SEE
ABBREVIATIONS THAT PEOPLE USE

THAT AREN'T IN THE BOOK,
THEY'RE NOT SUPPOSED TO.

SO DOUBLE CHECK,
YOU'RE NOT ALLOWED TO JUST
MAKE UP YOUR OWN.

YOU HAVE TO USE WHAT'S
OFFICIALLY BEEN BLESSED
BY THE INSTITUTION.

ALRIGHT, WHAT WE'RE GOING TO DO
IS HAVE YOU DO TWO DIFFERENT
DRILLS AT ONE STATION.

SO I WANT YOU TO COMPLETELY
DO YOUR HIGH FIVE.
DO THE PROCEDURE.

FINISH IT, PUT THE BED DOWN,
WASH YOUR HANDS, CLEAN UP
YOUR MESS AND BE DONE.

AND THEN DO THE NEXT PROCEDURE,
HIGH FIVE, GO THROUGH ALL THE
STEPS AND THEN FINISH UP.

PART OF THE POINT OF THIS ONE
IS YOU'RE ACTUALLY DOING TWO
VERY SIMILAR ACTIVITIES.

IT'S JUST -- WE'RE GIVING YOU
THE OPPORTUNITY TO DO IT TWICE

AND THAT WILL REALLY GET IT
INTO YOUR HEAD, SO.

THE PROCEDURE FOR THE BOTH,
THE NASO AND GASTRIC TUBE

AND THE GASTROINTESTINAL TUBE
ARE ALMOST IDENTICAL.

AND WHAT WE DO AS FAR AS
PROCEDURE GOES,

IS JUST THEIR LOCATION AND,
KIND OF, OUR MENTAL PHOBIAS

ABOUT HANDLING TUBES
COMING OUT OF STOMACHS

VERSUS TUBES IN NOSES
AND WHAT DO WE DO WITH THEM.

THIS SEMESTER
WHAT HAS WORKED WELL

IS IN THE NURSING HOMES
MOST OF THE TIME

THEY HAVE THEIR FEEDING TUBES
IN, THEY'RE A CHRONIC SITUATION.

AND SO YOU'LL SEE MORE FEEDING
TUBES THAN YOU PROBABLY WILL IN
THE ACUTE CARE SETTING.

IN THE ACUTE CARE SETTING,
YOU END UP PUTTING TUBES IN

TO USUALLY DRAIN THE STOMACH OR
TO GET BLOOD OUT OF THE STOMACH,

THEY'RE BLEEDING OR
SOMETHING LIKE THAT.

SO NEXT SEMESTER, OUR FOCUS
WILL BE PUTTING THEM IN,

AND PUTTING THEM TO SUCTION
AND DOING SOME DIFFERENT
THINGS WITH THE TUBES.

THIS SEMESTER, I JUST WANT TO
TEACH YOU HOW TO MANAGE THEM
HOW TO HANDLE FEEDINGS,

AND DO SOME BASIC NUTRITIONAL
MANAGEMENT OF YOUR CLIENT.

INTERESTINGLY, 40-55% OF
HOSPITALIZED CLIENTS
ARE MALNOURISHED.

THAT'S A LOT. 12% SEVERELY.

SO IT'S INTERESTING IF YOU CAN
START, KIND OF, PUTTING TOGETHER

THAT YOU NEED TO BE
CHECKING THEIR PROTEIN.

THE LAST TIME THEIR PROTEIN
ALBUMIN WAS CHECKED.

IT'S THEIR LAB VALUES.
WHO'S DONE A NUTRITIONAL
CONSULT WITH THEM.

HOW'S THEIR APPETITE? LOOKING AT
THOSE PERCENTAGE OF MEALS.

WHAT KINDS OF FOODS
ARE THEY EATING.

THAT'S WHY I DIDN'T MAKE
IT A CRITICAL STEP TO BE
LOOKING AT PERCENTAGE

BECAUSE PERCENTAGE DOESN'T
ALWAYS EQUATE WHAT?

THEY COULD HAVE EATEN, LIKE,
WHEN OUR REGULAR TRAY,

THEY COULD HAVE EATEN THE ROLL
AND THE COOKIE.

THAT'S 50%, LOOKS LIKE THEY'RE
DOING PRETTY GOOD.

NOT SO GOOD. SO IT'S WHAT
THEIR EATING, QUALITY OF FOOD
AND SO FORTH.

SO YOU WANT TO BE -- BEING
AWARE OF WHAT KIND OF FOODS
THE CLIENTS ARE EATING.

PEOPLE THAT WOULD
HAVE FEEDING TUBES,

USUALLY HAVE A REASON FOR A
FEEDING TUBE, RIGHT? WE DON'T
JUST PUT THEM IN.

AND MOST TYPICALLY, IT'S BECAUSE
THEY HAVE DIFFICULTY SWALLOWING.

WHAT ARE SOME SIGNS AND SYMPTOMS
OF DIFFICULT SWALLOWING?

- CHOKING.
- CHOKING.

- GAGGING.
- GAGGING, THE OBVIOUS.

THOSE ARE OBVIOUS SIGNS,
BUT WHAT ELSE MIGHT BE A SIGN?

- DROOLING.

- DROOLING. DROOLING IS HUGE.

AS I WAS DOING SOME
REVIEWING FOR INCLEX,

IT'S MAYBE SOMETHING
YOU DON'T THINK ABOUT.

BUT IF THEY'RE NOT ABLE
TO SWALLOW THEIR SALIVA,
THEIR LIQUIDS,

IF IT'S COMING OUT,
THERE'S A PROBLEM.

AND THEY'RE AT RISK FOR
CHOKING OR ASPIRATION.

AND SO THOSE ARE CLIENTS
THAT ALL OF A SUDDEN
BECOME HIGH RISK.

WE WANT TO BE AWARE OF THAT.

CHEWING FOREVER.

CHEWING, CHEWING,
CHEWING, CHEWING.

THERE'S OFTEN DIFFICULTY.

STROKES, HAVE DIFFICULTY
WHENEVER THERE'S ONE SIDED
WEAKNESS VERSUS THE OTHER SIDE.

YOU CAN ANTICIPATE THAT
THERE'S SOME DIFFICULTY.

INTERESTINGLY, THE PERSON
THAT EVALUATES FOR SWALLOWING
IS SPEECH THERAPY.

SOMETIMES PHYSICAL THERAPY WILL
BE THE ONE THAT MAKES THE
INITIAL CONSULTATION,

BUT SPEECH THERAPY IS THE ONE
DOES A LOT OF REFERRALS

AND A LOT OF TRAINING RELATED
TO SWALLOWING DISORDERS

TO HELP CLIENTS DO BETTER
WITH THEIR FOODS.

CLIENTS THAT HAVE DIFFICULTY
WITH SWALLOWING

AND YOU'RE STILL TRYING
TO GET THINGS IN ORALLY,

OFTEN DO BETTER WITH THICKER
FOODS THAN THINNER FOODS.

I THINK WE MIGHT HAVE MENTIONED
THAT OR I DON'T KNOW IF IT WAS
MENTIONED LAST WEEK OR NOT.

SO THAT'S IMPORTANT TO KNOW.

ALRIGHT, SO JUST A REVIEW OF
SOME BASIC NUTRITION THINGS.

OUR CLIENT HAS DIFFICULTY
SWALLOWING. WE DON'T KNOW
WHAT THE SCENARIO IS.

BUT IN THIS SETUP, ALL OF OUR
CLIENTS AND ALL OF
THE BEDS IN 179

HAVE A NASOGASTRIC TUBE THAT'S
ALREADY BEEN INSERTED

AND ALL OF THEM HAVE A
GASTROSTOMY TUBE THAT'S
BEEN INSERTED.

SO ALL THE BEDS HAVE BOTH
AND ALL OF THEM WILL
HAVE A FEEDING PUMP.

WHAT WE WANT TO DO
FOR THE FIRST TUBE

IS JUST UNDERSTAND A LITTLE BIT
ABOUT OUR NASOGASTRIC TUBE.

THE NASOGASTRIC TUBE GOES
IN THROUGH THE NOSE

DOWN THE BACK OF THE THROAT
INTO THE STOMACH

IS WHERE IT LANDS OBVIOUSLY
BECAUSE WE WANT TO PUT FOOD IN.

THIS ISN'T WHAT THEY CALL A
JEJUNOSTOMY TUBE.

IT'S A NOT A WEIGHTED
THIN FEEDING TUBE

THAT GOES ALL THE WAY DOWN TO
THE INTESTINES.
IT'S A FEEDING TUBE.

SO SOMETIMES KNOWING WHAT KIND
OF TUBE YOU HAVE IS HELPFUL TO
KNOW WHERE IT LANDS.

AND THE REASON I WANT
YOU TO KNOW THAT

IS BECAUSE WE'RE GOING TO
ASPIRATE FLUID CONTENTS

FROM THE STOMACH OR THE
INTESTINE TO MAKE SURE
IT IS INDEED THERE.

AND WE'RE GOING TO CHECK
THE PH OF THAT FLUID TO
VERIFY PLACEMENT.

YOU'RE NOT GOING TO JUST PUT
FOODS AND LIQUIDS INTO THESE

WITHOUT KNOWING WHERE
THE TUBE IS, RIGHT?

BECAUSE WHERE COULD IT POSSIBLY
BE IF IT'S NOT IN THE STOMACH?

- LUNGS.
- IN THE LUNGS.

THIS IS NOT GOOD. WE COULD COULD
BE CAUSING ASPIRATION PNEUMONIA

AND REALLY GET THEM INTO BAD
SHAPE AND POTENTIALLY DIE
FROM THAT.

SO IT'S SERIOUS THAT WE
DETERMINE CORRECT PLACEMENT.

THERE'S A COUPLE OF THINGS
THAT WE WANT TO DO

PRIOR TO PUTTING OUR
FEEDING TUBE IN

ASIDE FROM JUST CHECKING THAT,
THE FLUID IN THE STOMACH.

THAT IS WE WANT
TO CHECK THE LUNGS

TO SEE WHAT THE STATUS OF THE
LUNGS IS BEFORE OUR FEEDING

AND WE WANT TO
ASSESS THE ABDOMEN

TO SEE HOW THEY'RE
TOLERATING THEIR FOODS.

DO THEY HAVE BOWEL SOUNDS?
ARE THEY MOVING FOODS A LOT?

SO WE'RE GOING TO DO
TWO ASSESSMENTS THAT I
WANT TO INTRODUCE.

I'M NOT GOING TO INTRODUCE
'EM IN THEIR TOTALITY

BECAUSE YOU'RE GOING TO
DO THAT NEXT SEMESTER.

BUT I'M GOING TO GIVE
YOU THE BASICS

SO THAT YOU CAN JUST BEGIN
TO START ASSESSING

AND SO THAT YOU CAN BEGIN
TO START NOTICING NORMAL
FROM ABNORMAL.

OUR FOCUS THIS
SEMESTER IS NORMAL.

IF YOU KNOW IT'S NOT NORMAL,
YOU GET ATTENTION.

THAT'S ALL WE WANT
YOU TO DO, THOUGH.

THIS ISN'T NORMAL, ALRIGHT?

OKAY. SO LET'S JUST START FROM
THE BEGINNING WITH OUR NG TUBE,
NASOGASTRIC TUBE.

OUR CLIENT ORDER IS TO BE
GETTING INTERMITTENT FEEDINGS.

AND WE'RE ACTUALLY NOT GOING TO
BE DOING THE INTERMITTENT
FEEDING ON THIS TUBE.

WHAT WE'RE GOING TO DO
IS MAINTAIN THE TUBE.

SO LET ME DESCRIBE FOR A MINUTE.

IF I SAID THEY'RE GETTING
INTERMITTENT FEEDINGS,

THAT MEANS EVERY FOUR HOURS,
EVERY SIX HOURS

WHATEVER THE DOCTOR ORDERS,
WE WOULD PUT IN A FEEDING.

SO DEPENDING ON WHAT THE FOOD
IS LIKE ENSURE, OR LIKE --

OH, THEY HAVE ALL SORTS OF
STUFF. NESTLE MAKES A PRODUCT.

JUST ALL KINDS OF
DIFFERENT THINGS.

WHAT YOU WOULD DO IS YOU
WOULD PUT THE FEEDING IN HERE.

WE'RE GOING TO DO IT
WITH OUR OTHER THING.

JUST AS A GRAVITY, HOOK
IT UP TO THE TUBE

AND RUN IT IN OVER
20-30 MINUTES.

YOU DON'T USUALLY WANT TO GO
LESS THAT 30 MINUTES.

YOU CAN GO LONGER,
UP TO AN HOUR IS FINE,

BUT MOST PEOPLE DON'T JUST
GUZZLE A MEAL DOWN IN
FIVE MINUTES.

WELL, NURSES DO BECAUSE WE DON'T
GET LONG ENOUGH BREAKS.

BUT MOST PEOPLE TAKE
TIME TO CHEW THEY FOOD.

SO YOU'RE GOING TO TAKE
20-30 MINUTES MINIMUM
AND LONGER IF POSSIBLE.

SO ANYWHERE UP TO ABOUT AN HOUR.

GIVE THE FEED AND THEN
RINSE IT AND MOVE ON.

ONE OF THE THINGS
THAT HAPPENS WITH FEEDINGS,

IS IF WE JUST GAVE THE FEEDING
AND DIDN'T RINSE IT OUT,

THE FEEDING HAS A
HIGH SUGAR CONTENT,

THE FEEDING, KIND OF, BUILDS UP
AND THEN THE TUBES BLOCK OFF.

AND THEN WE CAN'T USE
THE TUBE, THAT'S NO GOOD.

YOU END UP HAVING TO PULL THE
TUBE OUT, PUT ANOTHER
ONE IN. TRAUMATIC.

SO WHAT WE WHAT TO DO
IS MAINTAIN THE TUBE.

THE BEST THING THAT WE CAN
DO TO KEEP A TUBE PATENT

IS TO FLUSH IT EVERY FOUR
HOURS WITH PLAIN OLD WATER.

SO WHAT YOU'RE GOING TO DO IS
JUST DO A FLUSH ON THIS NG TUBE.

NOT THE FEEDING. THAT MAYBE
HAPPENED A FEW HOURS AGO

AND THEY'RE NOT DUE
FOR THEIR FEEDING.

SO I JUST WANT YOU TO BE
THINKING ABOUT PLACEMENT
AND FLUSHING.

ALRIGHT, SO WE HAVE
OUR DOCTOR'S ORDER.

WE KNOW THAT THE CLIENT
GETS INTERMITTENT FEEDS,

AND THEN THE TUBE
NEEDS TO BE FLUSHED.

DID YOU KNOW THAT'S ONE OF THE
MOST NEGLECTED ACTIVITIES

THAT NURSES DO
RELATED TO FEEDINGS?

THEY JUST DON'T GO IN AND FLUSH
REGULARLY AND THEY SHOULD.

IT'S PART OF THE PROCEDURE,
THE DOCTOR DOES NOT HAVE
TO ORDER FLUSHING.

YOU JUST DO IT.

IF THEY'VE ORDERED THE NG
AND THEY'VE ORDERED THE
FEED, YOU CAN FLUSH.

AND YOU NEED TO FLUSH WITH --

I GAVE YOU, LIKE, FOUR ARTICLES.

ONE SAYS 30 CC ANOTHER
SAYS 50-100.

ANYWHERE IN THERE IS FINE AS
LONG AS IT'S KEEPING IT PATENT.

SO WE'RE GOING TO DO 30 BECAUSE
30 WON'T MAKE MY MANNEQUINS

FLOOD OUT QUITE
AS FAST AS 50 TO 100.

SO DON'T BE OVERZEALOUS
WITH PRACTICE

BECAUSE WE START
TO OH, GET REALLY FULL.

OKAY, SO WE CHECKED OUR
DOCTOR'S, INTERMITTENT FEED.

WE KNOW, BECAUSE
WE'RE GOOD NURSES,

IT NEEDS TO BE FLUSHED WITH
WATER EVERY FOUR HOURS.

IN BETWEEN FEEDINGS,
BEFORE AND AFTER FEEDINGS.

FLUSH, FLUSH, FLUSH, THAT'S
WHAT WE'RE ABOUT.

SO WE'RE GOING TO DO OUR FLUSH,
GATHER OUR EQUIPMENT.

THE EQUIPMENT IS GOING
TO BE A PISTON SYRINGE,

AND YOU NEED A PISTON BEING
THIS END VERSUS A LURE LOCK
WHICH IS A FLAT TIP.

SO YOU WANT THE PISTON END.
60 CC WORKS THE EASIEST.

YOU WANT A GRADUATE, A PITCHER
SOMETHING WITH WATER IN IT

SO THAT YOU CAN GET YOUR FLUID.

I ALMOST ALWAYS GET A CHUX FOR
GOOD LUCK BECAUSE IF I DON'T,

I END UP DRIBBLING STOMACH
CONTENTS ALL OVER THEIR CHEST.

AND THAT'S NO GOOD.
SO A CHUX.

I WANT PH PAPER SO THAT I CAN
CHECK THE STOMACH CONTENTS

TO MAKE SURE IT'S
IN THE RIGHT PLACE.

THERE'S SOME PH NUMBERS
THAT NEED TO KNOW.

HOPEFULLY, YOU'VE GOT THEM WHEN
YOU WERE DOING YOUR READING.

HOW WOULD YOU KNOW OR WHAT
IS THE PH PARAMETERS FOR
IN THE STOMACH?

- 2.
- 2.

- 2'S GOOD, PARAMETERS.

- 1 TO 6.

- 1.5 TO 6.

SO ANYTHING BELOW 6
IS INDICATIVE OF BEING
IN THE STOMACH.

HOW'S THAT? KIND OF SAFE.

ALRIGHT. ABOVE 6, BETWEEN
6 AND 8 USUALLY MEANS
IT'S IN THE LUNGS.

IF THE PH IS 7.5 TO 8ISH,
IT COULD BE IN THE INTESTINES.

SO THAT'S A LITTLE TRICKY,
AS FAR AS THAT HIGHER PH.

THAT'S WHEN YOU HAVE
TO KNOW WHAT KIND OF
FEEDING TUBE YOU HAVE.

AND ONE OF THE WAYS YOU'LL
KNOW, IT'S THE LITTLE
WHITE SOFT FEEDING TUBE

AND THEY CALL IT
A JEJUNOSTOMY TUBE.

OR -- OH, DEAR. IT SLIPPED
RIGHT OUT OF MY BRAIN.
STARTS WITH A 'D.'

DOBHOFF. BOY, IT CAME
BACK TO ME.

DOBHOFF TUBE AND IT'S A LITTLE
WHITE SOFT TUBE THAT COMES OUT.

AND IT'S GOT A WEIGHT. AND WHEN
IT GETS INSERTED, IT'S WEIGHTED.

AND IT TAKES IT ON DOWN
INTO THE INTESTINE.

IF THAT'S THE CASE, THEN YOU
KNOW IT'S IN AN INTESTINE AND
YOU'RE EXPECTING A HIGHER PH.

ALRIGHT, SO I'VE GOT MY
PH PAPER. I'M GOING
TO CHECK FOR THAT.

I DON'T NEED THIS FOR
THIS ONE YET.

PUT THAT ASIDE.

I'M GOING TO GET A
MEASURING TAPE OUT.

WHEN THE TUBE WAS INSERTED,
THE NURSE THAT INSERTED
THE TUBE,

SHOULD HAVE CHECKED
FOR PLACEMENT.

THEY SHOULD HAVE ASPIRATED TO
SEE IF IT WAS IN THE STOMACH,

THEY SHOULD HAVE TAKEN AN X-RAY.

IT SHOULD BE REQUIRED
AT EVERY FACILITY

THAT WHEN A TUBE IS INSERTED,
IT'S VERIFIED BY X-RAY.

THAT IS THE ONLY ABSOLUTE WAY TO
KNOW EXACTLY WHERE THAT TUBE IS.

AFTER THEY'VE VERIFIED
PLACEMENT, THEY NEED TO MEASURE

FROM THE END OF THE NOSE
TO THE END OF THE TUBE

TO MAKE SURE THAT THE TUBE ISN'T
MIGRATING IN OR OUT.

SO THAT'S ANOTHER GOOD
INDICATOR THAT THE TUBE
IS IN THE SAME PLACE.

SO I'M GOING TO GET A
MEASURING TAPE TO CHECK
THE LENGTH OF MY TUBE

JUST IN CASE I DON'T GET
ANYTHING OUT OF THE TUBE.

SOMETIMES YOU DON'T GET
STOMACH CONTENTS BACK,
THEN WHAT DO YOU DO?

PANIC? CALL THE DOCTOR?

HE'S GOING TO GO, "OH, PLEASE.
NEW NURSE." YOU KNOW?

THERE'S WAYS TO CHECK AND I'LL
TALK ABOUT THAT A LITTLE BIT

BECAUSE THINGS DON'T
ALWAYS GO PERFECTLY. THEY
SHOULD, BUT THEY DON'T.

SO WE'RE GOING TO BE READY
FOR IMPERFECTION.

ALRIGHT. SO I THINK I HAVE ALL
MY STUFF AND I'M READY TO GO.

I'VE WASHED MY HANDS. I'M GOING
TO GO INTO THE CLIENT'S ROOM,
IDENTIFY THE CLIENT.

OH, MRS. SMITH, YOU'VE
LOST YOUR NAME BAND.

WHAT'S YOUR NAME?
MRS. SMITH. OKAY, GOOD.

AND PROVIDE PRIVACY.
I DON'T KNOW WHAT HAPPENED
TO HER NAME BAND.

ALRIGHT, I'M GOING TO
PUT HER UP HERE.

AND MRS. SMITH, I'M GOING
TO FLUSH YOUR NG TUBE,

MAKE SURE THAT IT STAYS
PATENT, THAT IT STAYS
CLEAR WITHOUT BLOCKAGES

SO THAT THE FLUIDS
KEEP GOING IN.

BUT BEFORE, I DO THAT,
I WOULD LIKE TO ASSESS
A COUPLE OF THINGS.

I'D LIKE TO CHECK YOUR LUNGS AND
I'D LIKE TO CHECK YOUR STOMACH

BEFORE I GO AHEAD AND DO THIS...

FLUSH.

ALRIGHT, LUNG ASSESSMENT.

YOU NEED A STETHOSCOPE,
SO JUST FOR FAKEOUT.

WE MAY HAVE THE LUNG SOUNDS SO
THAT YOU CAN LISTEN TO THEM

ON THE ELECTRONICS BUT WE WON'T
HAVE THE STOMACH SOUNDS

BECAUSE WE HAD TO TAKE ANOTHER
STOMACH PART TO GIVE
YOU A G-TUBE.

SO WE DON'T HAVE ANY SOUNDS
RIGHT NOW ON THE STOMACHS.

TO DO ANY ASSESSMENT,
WHAT'S THE FIRST THING YOU DO?

ALWAYS. THIS IS AN ALWAYS RULE.
- INSPECT.

- INSPECT. YOU ALWAYS LOOK
FIRST. SO SAME THING.

WHEN WE DO LUNGS,
WE'RE GOING TO INSPECT.

AND WE'RE GOING TO INSPECT FOR
SOME BASIC THINGS.

WE'RE GOING TO INSPECT FOR EASE
OF RESPIRATIONS, COLOR,

SYMMETRY OF CHEST, WE'RE GOING
TO LOOK AT THE RATE, THE RHYTHM,
THE QUALITY OF RESPIRATION.

JUST TO SEE BASICALLY,
HOW THEY'RE DOING.

IT'S LIKE I LOOK AT YOU AND
NOBODY'S IN DISTRESS.

IT'S LIKE WE TAKE SOME
OF THAT FOR GRANTED.

SO WE'RE LOOKING FOR
ANYTHING ABNORMAL.

THEN WHAT I WANT TO DO IS I WANT
TO LISTEN FIRST.

SO ON THIS ONE IT'S
INSPECT AND OSCULTATE.

WE'RE GOING TO USE
THE DIAPHRAGM.

DI-HIGH SOUNDS,
RIGHT?

BEL-LOW SOUND.

AND THEN WE'RE GOING TO LISTEN.

WHEN YOU LISTEN
TO SOMEONE'S LUNGS,

IT'S BEST IF YOU LISTEN TO SKIN.

I DON'T WANT TO EXPOSE
POOR MRS. SMITH.

SO I'LL JUST SUFFICE IT TO SAY
I'LL HAVE THIS DOWN.

YOU'RE GOING TO LISTEN
TO THE UPPER LOBE

AND HAVE HER TAKE A GOOD DEEP
BREATH IN AND OUT OF HER MOUTH

SO YOU LISTEN TO THE FULL
INSPIRATION AND THE
FULL EXPIRATION.

FULL INSPIRATION.

FULL EXPIRATION.

ABOVE BREAST TISSUE
AND THEN TO THE SIDE.

AND THEN IF MRS. SMITH
WOULD SIT UP,

WE'RE GOING TO LISTEN ON THE
BACK AND YOU CAN'T SEE.

BUT ON THE BACK, I'M GOING TO
LISTEN TO THE TOP, THE MIDDLE
AND THE BASES.

BE CAREFUL THAT YOU DON'T SAY
YOU'RE LISTENING TO THE TOP, THE
MIDDLE AND THE LOWER LOBES.

WHICH LUNG ONLY HAS THREE LOBES?

THE RIGHT LUNG. SO IF YOU SAY
YOU'VE LISTENED TO THE MIDDLE
LUNG ON THE LEFT,

THEN THEY THINK THEY DON'T KNOW
WHAT THEY'RE TALKING ABOUT.

IT IS A MIDDLE AREA,
BUT IT'S NOT A MIDDLE LOBE.

AND IN ACTUALITY WHEN YOU LOOK
AT THE PHYSIOLOGY

AND THE PHYSICAL NATURE
OF THE LUNG,

THE LOWER LOBE TAKES UP THE
WHOLE BACK.

IT COMES UP THE BACK SIDE SO
YOU'RE REALLY LISTENING TO THE
LOWER LOBE.

ON THE MOST OF THE BACK, SO.

YOU'RE LISTENING FOR --

BASICALLY WHAT I JUST WANTED YOU
TO LISTEN NOW IS CLEAR LUNG.

SO CHECK EACH OTHER'S LUNGS THAT
DON'T HAVE SOUNDS.

THOSE GOOD, CLEAR...

YOU'RE GOING TO LEARN YOUR
ADVANTAGEOUS OR ABNORMAL SOUNDS
NEXT SEMESTER,

BUT JUST START LISTENING TO
WHAT'S CLEAR.

IF YOU HEAR A CRACKLING,
RUMBLING.

LIKE TAKE YOUR HAIR AND CRUNCH
IT TO YOUR EAR,
IT'S CALLED RAILS.

IF YOU HEAR WHEEZING.

THAT'S NOT NORMAL.

OKAY, SO ANYTHING THAT'S NOT...

IS ABNORMAL. OKAY, YOU'RE
LISTENING FOR NICE,
CLEAR SOUNDS.

AND THAT'S WHAT WE WANT TO DO
FOR THE LUNGS.

THE OTHER THING I WOULD LIKE TO
DO IS LISTEN TO HER STOMACH.

AND YOU KNOW WHAT, MRS. SMITH,

I'M GOING TO FLATTEN THE HEAD OF
THE BED OUT HERE A LITTLE BIT

BECAUSE IT'S A LITTLE EASIER TO
LOOK AT YOUR STOMACH
WHEN IT'S FLAT.

SO YOU WOULD EXPOSE YOUR
CLIENT'S ABDOMEN HERE.

AND THE FIRST THING WE WANT TO
DO WITH ABDOMEN IS?

- INSPECT.
- INSPECT.

SO WHAT WOULD YOU
BE LOOKING FOR?

- SYMMETRY.
- SYMMETRY.

AND THE BEST WAY TO SEE SYMMETRY
OF AN ABDOMEN IS TO COME DOWN TO
THE FOOT OF THE BED

AND LOOK TO SEE IF BOTH SIDES
ARE THE SAME.

YOU'RE LOOKING AT THE CONTOUR,
THE SHAPE.

IS IT ROUNDED? IS IT CONCAVE?
IS IT FLAT? WHAT'S GOING ON?

SOMETIMES YOU CAN SEE
PERISTALSIS.

YOU CAN SEE SOME MOVEMENT
GOING ON IN THE BOWELS,

AND SOMETIMES YOU CAN
SEE A BLOCKAGE.

LIKE THEY MAY HAVE STOOL THERE
SO YOU CAN SEE KIND OF A LUMP.

SO YOU CAN BEGIN TO SEE THAT'S
IT'S ASYMMETRICAL WHEN YOU'RE
LOOKING AT IT.

SO YOU'RE JUST LOOKING TO SEE
HOW THEY'RE DOING.

THINGS THAT MAKE YOU CAUTIONED
ARE, IS IT DISTENDED?

IS IT ROUNDED? IS IT FIRM?

ALRIGHT, BUT WE'RE NOT GOING TO
TOUCH FIRMNESS YET.

BECAUSE IT'S REAL IMPORTANT WHEN
YOU'RE ASSESSING AN ABDOMEN

THAT YOU GO IN THIS ORDER WHEN
WE'RE LOOKING THE MODES
OF ASSESSMENT.

INSPECTION FIRST, LOOK.

AND THEN SECOND YOU MUST DO
OSCULTATION BEFORE YOU PALPATE.

WE WANT TO LISTEN
TO BOWEL SOUNDS

TO SEE IF THEY HAVE SOUNDS GOING
ON IN THEIR BOWELS.

AND IF YOU TOUCH THE ABDOMEN TO
SEE IF IT'S SOFT OR FIRM FIRST,

IT STIMULATES BOWEL SOUNDS.

AND YOU DON'T WANT TO GET
FALSE BOWEL SOUNDS.

YOU WANT TO GET WHAT THEIR
BOWELS REALLY ARE AT REST.

SO, YOU KNOW, PEOPLE HAVE POOR
TECHNIQUE AND THEY GO...

AND THEN LISTEN BECAUSE
THEY'VE CREATED SOUNDS.

ALRIGHT, WHAT WE WANT TO DO IS
LISTEN TO THE FOUR QUADRANTS
OF THE ABDOMEN.

AND SO IF YOU JUST TAKE THE
ABDOMEN AND DIVIDE IT
AT THE UMBILICUS.

WE'RE GOING TO START AT THE
RIGHT LOWER QUADRANT.

THAT'S WHERE YOU'LL MOST LIKELY
HEAR BOWEL SOUNDS

BECAUSE THAT'S WHERE THE PYLORUS
EMPTIES DOWN THERE.

AND SO YOU'LL HEAR
SOME SOUNDS HERE

AND YOU'LL JUST MOVE AROUND
LIKE A CLOCK, VERY SYMMETRICAL
OR SYSTEMATIC.

SO YOU'RE GOING TO LISTEN.

AS SOON AS YOU HEAR
A BOWEL SOUND, MOVE.

LISTEN. MOVE.

LISTEN. MOVE.
LISTEN. MOVE.

IF YOU DON'T HEAR ANYTHING,
YOU STAY IN THAT QUADRANT
FOR ONE MINUTE.

AND THEN YOU MOVE TO THE NEXT
QUADRANT AND SO FORTH.

IF YOU HEAR NO BOWEL SOUNDS
AFTER FIVE MINUTES,

THEN YOU CAN ACTUALLY
SAY NO BOWEL SOUNDS.

BUT JUST BECAUSE YOU DIDN'T HEAR
THEM BECAUSE YOU LAID IT DOWN

AND IT DIDN'T RESPOND
TO YOU IMMEDIATELY.

NORMAL BOWEL SOUNDS, KIND OF,
DO A TINKLING SOUND.

OR RUMBLING KIND OF A SOUND
EVERY 15 TO 30 SECONDS,
EVEN EVERY MINUTE.

AND THAT'S JUST NORMAL.

HYPO-BOWEL SOUNDS
ARE LIKE ONE A MINUTE.

YOU'RE REALLY HAVING
TO GO TAKE YOURSELF

TO THE EXTREME OF LISTENING,
BUT YOU'RE HEARING SOMETHING.

HYPER-ACTIVE BOWEL
SOUNDS ARE LIKE...

YOU KNOW, THEY'RE JUST NOT
STOPPING. THERE IS CONSTANT,
CONSTANT SOUND.

THEY HAVE DIARRHEA. THEY HAVE
REALLY BAD GAS. THEY'RE
MISERABLE. THEY'RE DISTENDED.

AFTER YOU'VE LISTENED
TO BOWEL SOUNDS,
THEN YOU WANT TO PALPATE.

AND YOU TAKE THREE FINGERS
AND YOU JUST EVER SO GENTLY

ROTATE ON THE STOMACH

IN A GENTLE, PROBABLY,
ABOUT A QUARTER TO A
HALF AN INCH MOVEMENT.

AND YOU'RE JUST ASSESSING FOR
SOFTNESS, TENDERNESS, PAIN,

FIRMNESS AS YOU GO ALONG.

WE'RE NOT HUNTING FOR ORGANS,
WE'RE NOT DOING ANY DEEP
PALPATION RIGHT NOW.

JUST GENTLE, SOFT PALPATION TO
SEE IF THERE'S ANYTHING
SIGNIFICANT GOING ON THERE.

ALRIGHT, ONCE YOU'VE ASSESSED
AND YOU FEEL CONFIDENT

THERE'S GOOD BOWEL SOUNDS
AND THE LUNGS ARE CLEAR,

AT LEAST YOU HAVE A BASELINE FOR
STARTING YOUR FEEDING.

INTERESTINGLY, IN ONE OF THE
ARTICLES I GAVE YOU,

ONE OF THE MYTHS ABOUT
G-TUBE FEEDINGS

IS THAT IF THERE'S NO BOWELS
SOUNDS, WE SHOULD HOLD
THE FEEDING.

AND THEY SAY THAT'S NOT TRUE,

BECAUSE HOW DO THEY HAVE
ANYTHING TO HAVE THEIR
BOWELS MOVE WITH

IF WE DON'T GIVE THEM
SOME FOOD TO MOVE.

SO YOU, KIND OF, HAVE TO BE
WATCHING THE WHOLE PROCESS

TO SEE HOW THEY'RE
GOING TO TOLERATE IT.

ALRIGHT, ANYTIME YOU
DO A FEEDING OR HAVE
A FEEDING GOING IN,

THE HEAD OF THE BED NEEDS TO BE
UP AT LEAST 45 DEGREES,

BECAUSE THAT ALSO ASSISTS
AND PREVENTS ASPIRATION.

SO KEEP THEIR HEAD UP.

HOW'S THAT? ARE YOU COMFORTABLE?

ALRIGHT.

OKAY. THE FIRST THING I NEED TO
DO BEFORE I DO ANYTHING HERE,

IS GET SOME GLOVES ON NOW

BECAUSE I'M GOING TO START
MESSING WITH THIS TUBE AND I
WANT TO CHECK FOR PLACEMENT.

SO I'M LOOKING AT
A COUPLE OF THINGS.

BEFORE I EVER CHECK THAT
IT'S IN THE STOMACH,

I FEEL CONFIDENT ABOUT
A COUPLE OF THINGS.

ONE, IF THEY'RE
BREATHING EASILY,

THEN IT'S PROBABLY NOT DOWN
THE WRONG SLOT.

IT'S EITHER GOING TO BE DOWN THE
STOMACH OR DOWN INTO THE LUNGS.

IF IT'S DOWN INTO THE LUNGS,
THEY QUIT BREATHING
AND THEY TURN BLUE.

SO...LOOKING PRETTY GOOD, OKAY?

THE OTHER THING IS IT'S STILL AT
THE TAPE MARK FROM WHERE IT WAS
TAPED BEFORE.

AND ANOTHER GOOD INDICATION

THAT YOU'RE PROBABLY
IN A GOOD POSITION

IS YOU CAN LOOK IN THE BACK
OF THE THROAT

AND SEE THE TUBE DOWN
THE BACK OF THE THROAT.

IT'S NOT COILED UP,
COMING OUT OF THE MOUTH
OR GOING ANY PLACE WRONG.

SO WE'VE GOT SOME
GOOD SIGNS HERE,
BUT NOTHING THAT'S ABSOLUTE.

OUR BEST INDICATOR AGAIN IS PH.

SO WHAT I WANT TO DO
IS GET SOME PH PAPER.

NOW YOU NEED TO BE CAREFUL ABOUT
THE PH PAPER THAT YOU GET.

THERE'S A BUNCH OF
THESE MULTISTICKS

ON THE HOSPITAL'S
CENTRAL SUPPLY CARTS.

AND THEY'RE FOR CHECKING ALL
SORTS OF THINGS.

YOU CAN CHECK URINE, YOU CAN
CHECK PHS, YOU CAN CHECK SUGARS,

PROTEINS ALL KINDS OF STUFF
WITH THESE STICKS.

YOU PROBABLY USED
THEM IN CHEMISTRY.

THE INTERESTING THING HERE
IS THAT WHEN YOU GO
TO CHECK THE PH,

YOU'RE PARAMETERS...

ARE 5 TO 8.5.

IS THIS ANY GOOD?

THIS ISN'T HELPING US A BIT,

BECAUSE WE'RE HOPING TO GET
A PH OF 4 OR SO.

THAT'S REALLY VERY
REASSURING FOR US.

SO THESE ARE NOT GOOD STICKS.

WHAT YOU WANT IS A PH THAT
HAS A SCALE OF 0 TO 12.

SO THAT YOU GOT A REALLY
GOOD INDICATION OF WHAT
YOU GOT GOING.

WHERE DO YOU GET
THESE PH PAPERS?

FROM THE LAB.

SO CALL THEM AND SAY,
"I NEED PH."

I ACTUALLY CALLED THE PRESIDENT
OF COMMUNITY HOSPITAL

AND THE LAB DIDN'T
HAVE ANY IN STOCK,

SO I HAD TO GET THEIR LAB REP
TO GET ME SOME.

SO I HAVE SOME
AND I HAVE FAKE PEOPLE.

THEY HAVE REAL PEOPLE AND YOU'RE
GOING TO HAVE A HARD TIME
FINDING PH PAPER.

BUT HERE'S MY SPIEL.

I'VE BEEN TO ALL THE HOSPITALS,
I HAVE SENT LETTERS,

I HAVE SENT ARTICLES
TO SUPERVISORS,

I HAVE JUST DONE ABOUT
ALL I KNOW TO DO,

AND THEY STILL DON'T CHECK WELL
HERE IN THIS VALLEY.

SO YOU JUST HAVE TO GO AND BE
ADVOCATES FOR PH CHECKS AND
INSIST ON THE PAPER.

I MEAN, INSIST ON IT.

BE BRAVE. OUR INSTRUCTOR SAID --

THAT'S THE ONE TIME
I'LL TELL YOU TO TELL THEM.

THE INSTRUCTOR SAID,
"I HAVE LITERATURE."

YOU HAVE LITERATURE
THAT SUPPORTS.

I MEAN, HOW MANY ARTICLES DID I
GIVE YOU THAT TALK ABOUT THE PH?

AT LEAST THREE, PLUS YOUR TEXT.

OKAY, WE'VE GOT TO HAVE
SOME PH PAPER, SO.

GET YOURSELF A LITTLE STRIP
OF PH PAPER

AND THEN YOU CAN JUST SET IN
YOUR EMESIS BASIN.

ALRIGHT, THE OLD WAY TO CHECK
FOR PLACEMENT OF A TUBE

WAS TO PUT 10-15 CC OF AIR IN
THE SYRINGE,

PUSH THE AIR IN WHILE YOU
LISTENED AT THE ABDOMEN

TO SEE IF YOU'VE
HEARD THE SWISH.

WHAT THEY FOUND WAS THAT YOU
CAN HEAR REFERRED AIR
FROM EVERYWHERE.

SO IF THE AIR WENT IN THE LUNGS,
YOU STILL HEARD
IT IN THE STOMACH.

AND THE WORST SCENARIO AND WE'LL
TALK ABOUT IT NEXT SEMESTER

WAS ACTUALLY A NURSE CLAIMED
AFTER A TUBE HAD INADVERTENTLY

GOT COILED UP INTO THE BRAIN,
THAT SHE HAD HEARD
IT IN THE STOMACH.

SHE CLAIMED SHE DID, I DON'T
KNOW, I MEAN, WHATEVER.

AND THE PATIENT DIED FROM A TUBE
FEEDING TO THE BRAIN

BECAUSE OF THE TURBINATE,

PASSING THROUGH,
HAD A HEAD INJURY.

THIS IS NOT GOOD. NOW I'M
WONDERING, DID SHE LOOK IN
THE BACK OF THE THROAT?

I MEAN, THERE WERE SOME KEY
THINGS THAT WEREN'T
CHECKED EITHER.

YOU SHOULD SEE A TUBE GOING DOWN
THE BACK OF THE THROAT.

SO BE LOOKING FOR RIGHT SIGNS.

- NOW THE REASON THAT GOT COILED
IN THE BRAIN

WAS BECAUSE THE NASAL MEMBRANES
ARE SO THIN THAT THEY POKED
RIGHT THROUGH.

- THERE WAS A HEAD INJURY AFTER
A MOTOR VEHICLE ACCIDENT,

AND SO THERE WAS FACIAL TRAUMA.

AND THEY WEREN'T -- THEY JUST
DIDN'T APPRECIATE,

THE NEED OR A CONTRAINDICATION
OF AN NG TUBE FOR FACIAL TRAUMA.

AND I HAVE THE ARTICLE AND THE
X-RAY OF THE BRAIN,

SO YOU CAN SEE THE WHOLE THING
NEXT SEMESTER.

BUT THAT'S WHY THIS HAS BEEN
DEEMED NOT A GOOD TECHNIQUE
FOR CHECKING

BECAUSE OF REFERRED SOUNDS.

NOW I'VE DONE IT ALL MY LIFE.

UNTIL THE LAST FEW YEARS,
OBVIOUSLY.

BUT THAT'S WHAT THE OLDER NURSES
ARE GOING TO SAY.

THEY'RE GOING TO SAY,
"OH, WE JUST DO THIS."

I PROMISE YOU'RE GOING TO HEAR
THIS AND YOU'RE GOING TO GO,
"BUT YOU REALLY NEED TO DO PH."

AND I WOULD ENCOURAGE TO TAKE
YOUR LITTLE ARTICLES

AND POST THEM AROUND THOSE UNITS
AND SAY, "SEE."

YOU KNOW, REALLY.

OKAY. IT'S A MISSION,
IT'S A CAUSE.

AND WHEN SOMEONE CHANGES THE
WORLD, I'LL BE SO UPSET

OKAY, SO WHAT YOU'RE GOING TO DO
IS TAKE YOUR SYRINGE --

WELL, SO MUCH FOR MY LITTLE
GAUZE OR MY CHUX HERE
TO PROTECT MY TUBING.

YOU'RE GOING TO ASPIRATE
AND I'M SORRY, I FORGOT
TO BRING MY VINEGAR.

AND I CAN CREATE PHS FOR YOU
AND I'LL HOPEFULLY HAVE
YOUR STOMACH SET UP

SO THAT YOU'LL ACTUALLY GET A
LITTLE SOMETHING BACK,

YOU'LL GET A LITTLE PH,
BUT I DON'T KNOW.

I HAVE A LITTLE
ALZHEIMER'S TODAY.

OKAY, ASPIRATE AND WHAT YOU WANT
TO DO WHEN YOU ASPIRATE

IS NOT ONLY JUST ASPIRATE TO
CHECK PH, BUT YOU WANT TO GET
BACK ALL YOU CAN GET BACK

TO SEE WHAT KIND OF RESIDUAL'S
IN THERE ESPECIALLY
BEFORE A FEEDING.

HOW MUCH -- IS THEIR STOMACH
DIGESTING THIS FOOD.

SO WE'RE CHECKING FOR
RESIDUAL AND PH.

TAKE YOUR CONTENTS, PUT THEM
HERE ON THE PH PAPER.

NOTICE I CRIMPED IT OFF
JUST AUTOMATICALLY,

I FORGOT TO MENTION SOME OF
THOSE HABITS YOU HAVE.

RELEASE SO THAT YOU DON'T GET
STOMACH CONTENTS DRIBBLING
ON THE BED.

THEN RECONNECT AND THEN RE-IN
TILL THE STOMACH CONTENTS.

I KNOW IT'S GROSS,
BUT IT'S THEIR STOMACH

AND THEY'RE NOT GOING TO KNOW
OR TASTE IT OR ANYTHING.

THE THING IS IT'S THEIR STOMACH
AND IT HAS ALL THEIR
ELECTROLYTES IN IT.

AND SO IF WE PULL OFF THEIR
ELECTROLYTES, IT FOULS UP
THEIR BALANCE.

AND SO WE RETURN
THEIR STOMACH CONTENTS.

ONE OF THE THINGS THAT
CHECKING FOR RESIDUAL DOES
AND FEEDING DOES

IS IT PULLS THAT CONTENT
BACK IN HERE

WHICH MAKES ANOTHER REASON WHY
WE NEED TO FLUSH THIS

OR IT'S GOING TO GET THICK
AND TACKY IN HERE AND
IT'S GOING TO BLOCK OFF.

SO WE NEED TO FLUSH IT.
SO I'M GOING TO DISCONNECT.
I'M GOING TO PLUG.

AS LONG AS MY PH HERE WAS BELOW
6, HOPEFULLY AROUND 4, THEN
WE'RE IN GOOD SHAPE.

WHAT IF YOU DON'T GET
ANYTHING BACK?

YOU LOOK FOR EVERYTHING,
AGAIN, JUST LIKE I SAID.

THEN WE'RE GOING TO COME OVER
HERE AND WE'RE GOING TO UN-PIN
THIS FROM THE GOWN.

AND YOU WANT HIM TO BE PINNED TO
THAT LITTLE PIECE OF TAPE,

SO THEY'RE NOT FLOPPING
AND PULLING ON THE NOSE.

UN-PIN IT AND STRAIGHTEN IT OUT.

AND THEN MEASURE.

AND THEN IT JUST DEPENDS ON HOW
THEY MEASURE, WE DON'T HAVE ANY
HARD AND FAST RULE

ABOUT INCHES OR CENTIMETERS
OR ANYTHING LIKE THAT.

BUT MEASURE TO THE END.
AND I HAVE 34 INCHES.

AND HOPEFULLY, THEY WROTE
THAT ON THE CARDEX.

34 INCHES IS WHAT IT EXTENDS

AND THAT EVERYTHING
IS FINE AT THIS POINT,

AND I KNOW THAT PREVIOUSLY
THEY'VE BEEN CHECKED BY X-RAY,
THEN I'M OKAY WITH IT.

ALRIGHT. PIN THAT BACK
ONTO THE GOWN.

AND THEN WE'RE GOING TO GO AHEAD
AND DO THE FEEDING.

TAKE YOUR PISTON OUT, THIS IS --
I THINK THE BEST WAY.

I'LL SHOW YOU TWO WAYS, BUT I
PREFER YOU DO IT THIS WAY AND
IT'S JUST THE GRAVITY WAY.

CRIMP OFF THIS AND THAT JUST
KEEPS THE FLUIDS FROM DRIPPING.

YOU TAKE YOUR PLUG OUT,
PUT YOUR TUBE IN.

AND THEN WHAT WE WANT TO DO IS
JUST FLUSH WITH 30 CC OF FLUIDS.
SO CRIMP THIS OFF.

YOU COULD HAVE MEASURED 30 CC,
BUT I'VE GOT BOTH
MY FEEDINGS IN HERE.

SO I'M JUST GOING TO
GO AHEAD AND POUR,

A LITTLE ZEALOUS THERE, BUT IT
DOESN'T REALLY MATTER IN THE
SCHEME OF LIFE.

IF YOU DON'T CRIMP IT, AS YOU
POUR, IT KEEPS GOING IN.

AND SO YOU CAN OVER FEED THEM.

AND THEN YOU'RE JUST GOING TO --

YOU CAN LOWER IT
AND THAT SLOWS IT DOWN.

AND YOU CAN RAISE IT AND THAT
LET'S IT GO IN FASTER.

AND THEN GRAVITY
JUST ALLOWS IT FLOW IN

RATHER THAN YOU FORCING IT
INTO A SPACE.

NOW YOU CAN FORCE IT.

YOU COULD TAKE THIS
AND JUST DRAW IT UP.

GET YOUR 30 CC, I GOT QUITE A
BIT OF AIR IN HERE.

AND CONNECT IT AND PLUNGE IT IN.

AND THEN YOU CAN
HAVE GOOD CONTROL.

WHAT YOU CAN'T DO IS DECIDE THAT
AFTER YOU PUT YOUR PLUNGER IN

THAT NOW YOU WANT TO
TAKE THE PLUNGER OUT

SO THAT IN CAN GO BY GRAVITY.

BECAUSE THEN ALL YOU END UP
DOING IS SUCKING UP
THE CONTENTS,

AD IF YOU PINCH IT OFF,
IT CAUSES A NEGATIVE VACUUM

AND YOU CAN'T GET THE PLUG OUT.

ARE YOU OKAY HERE WITH THIS? BUT
SOMETIMES I JUST SEE EVERYTHING,

AND SOMETIMES PEOPLE DON'T
APPRECIATE THE PLUNGER PIECE.

ALRIGHT, SO YOU CAN
GO AHEAD INSTILL.

BUT I THINK I WROTE ON YOUR
PAPER THAT I WANTED YOU
TO DO IT BY GRAVITY

JUST SO THAT YOU
GET THE SENSE OF IT.

BECAUSE YOU CAN DO A WHOLE
INTERMITTENT FEEDING...

AFTER I FLUSH, I CAN HOOK THIS
UP AND I CAN DO MY
FEEDING OF ENSURE

IN THE SYRINGE JUST LIKE THIS
AND POUR IT IN.

OKAY?

ALRIGHT, ONCE I'VE
RINSED IT THROUGH --

I CAN I CAN STILL SEE A LITTLE
FLUID IN THERE.

I CAN GIVE IT A LITTLE
PUSH HERE...

WITH AIR.

REMEMBER WE USED TO CHECK WITH
20 OR 30 CC OF AIR,

IT'S NOT GOING TO HURT THEM.

CRIMP IT OFF AND THEN PLUG IT

AND WE KNOW IT'S NICE AND PATENT
AND READY TO GO.

ALRIGHT, I THINK I SAID THAT
WHAT YOU WOULD DO IS FLUSH

AND THEN IT SAYS
INTERMITTENTFEED AND THEN FLUSH
AND I X-ED THOSE.

THAT MEANS DON'T DO IT.

THOSE ARE FREE, BUT THAT WOULD
BE THE PROCESS IF YOU WERE
DOING THE FEED.

SO FLUSH, FEED, FLUSH,

ALWAYS BEFORE AND AFTER TO KEEP
THAT TUBE PATENT.

ALRIGHT, I WOULD LEAVE MY CLIENT
SITTING UP FOR A LITTLE WHILE
IF THEY CAN TOLERATE IT.

OFFER ORAL HYGIENE.

PEOPLE THAT HAVE NG TUBES
IN THAT ARE NOT EATING

REALLY NEED GOOD,
FREQUENT ORAL HYGIENE.

AND I SAY AT LEAST EVERY FOUR
HOURS. I MEAN, AT LEAST ON YOUR
SHIFT A COUPLE TIMES.

HOW AWFUL TO HAVE THIS DRY,
TACKY MOUTH THAT'S NOT GETTING
ANY KIND OF FLUID OR MOISTURE.

SO MORE OFTEN IF YOU HAVE THE
TIME, OFFER THEM SOMETHING.

GIVE THEM THESE TOOTHETTES AND
THEY CAN JUST DO IT THEMSELVES

MAYBE EVEN DIP IT IN SOME WATER
OR SOMETHING SO THAT THEY'RE
GETTING A CLEAN MOUTH.

ALRIGHT.

GO AHEAD AND PUT THE BED DOWN,
CLEAN UP YOUR SUPPLIES.

IF THEY WERE GETTING FEEDINGS,
YOU WOULD --

I CAN'T REMEMBER IF IT'S ON THIS
ONE OR THE NEXT ONE SO I'LL JUST
SAY IT ANYWAYS.

YOU WOULD WANT TO BE CHECKING
FOR RESPIRATORY DISTRESS
AND DIARRHEA

RELATED TO THE TUBE FEEDINGS.

AGAIN, TUBE FEEDINGS USUALLY
HAVE A HIGH SUGAR CONTENT

SO IT CAN CAUSE SOME DIARRHEA.
SO YOU NEED TO WATCH THAT.

SOMETIMES WE NEED TO
CHANGE THE CONCENTRATION

AND MAKE IT A HALF-STRENGTH
CONCENTRATION FOR A LITTLE WHILE

TILL THEIR SYSTEMS ACCLIMATE
TO THE FEEDING.

TILL WE CAN GET THEM UP TO
A FULL STRENGTH.

AND RESPIRATORY DISTRESS AGAIN.

THEY'RE ALWAYS AT RISK
FOR ASPIRATION IF THEY
HAVE A TUBE FEED.

NG TUBES SHOULD BE
FOR SHORT TERM.

AND I MEAN, LIKE, NO LONGER
THAN TWO WEEKS.

SOMEONE'S HAD A STROKE OR
SOMEONE'S IN AN ACUTE PHASE
AND THEY HAVE THAT.

BECAUSE YOUR RISK OF ASPIRATION
IS MUCH HIGHER WITH AN NG TUBE
THAN IT IS WITH A G-TUBE.

THEY CAN BE DISLODGED.
CLIENTS THAT ARE CONFUSED,
PULL THEM OUT.

THEY CAN PULL THEM OUT WHILE
FEEDING'S CONTINUALLY GOING IN

AND THEN THEY GET THE ASPIRATION
PNEUMONIA AGAIN.

THEY'RE JUST -- THEY'RE NOT
YOUR BEST CHOICE.

THEY'RE FOR SHORT TERM
AND THEY NEED TO BE
WATCHED REALLY CAREFULLY.

ALRIGHT, WASH YOUR HANDS AND
THEN YOU WOULD DOCUMENT ON I&O

AND THAT WOULD BE, FINALLY,
IN THAT NG COLUMN, HOW MUCH
FLUID YOU PUT IN.

SO YOU DO YOUR FLUSHES AND THEN
YOU WOULD DO ANY KIND OF FEEDING

THAT WENT IN DURING THAT TIME
FRAME ON YOUR I&O.

YOU GUYS DID GREAT, BY THE WAY,
ON I&O. I WAS VERY PLEASED.

ALRIGHT. SO THAT'S ONE STATION.

YOU'VE WASHED YOUR HANDS,
YOU'VE DOCUMENTED
AND YOU'RE DONE.

ANY QUESTIONS ON FLUSHING?

- HOW DID YOU TEST FOR PH?

- JUST PUT A DROP AND I DIDN'T
HAVE A DROP, BUT I JUST
LAID IT IN HERE.

AND YOU WOULD DROP IT AND
COMPARE THE COLOR...

TO YOUR LITTLE LEGEND
SCALE THING.

SEE WHAT YOU GOT.
- AND A NURSE WOULD
PUT IT BACK, RIGHT?

- YEAH. SO A DROP OR TWO DOESN'T
MATTER, BUT IF YOU PULL UP 50 OR
100 CC RESIDUAL...

THEN YOU WANT TO MAKE SURE
AND PUT ALL THAT BACK.

WHAT IF THERE'S LOTS OF FLUID?

LIKE, IF YOU HAVE 50
OR 100 CC OF FLUID,
WHAT DO YOU DO WITH IT?

IT'S NOT STERILE, SO YOU COULD
MOVE YOUR LITTLE PH PAPER AND
YOU SQUIRT IT IN THERE.

SQUIRT IT IN THERE TO SEE
HOW MUCH YOU GOT,

OR YOU CAN HAVE A LITTLE
GRADUATE AND YOU CAN SUCK IT
BACK UP AND PUT IT IN THERE.

IT NEED IT TO BE A CLEAN THING.

AND MEASURE HOW MUCH YOU GOT.
WAS THAT YOUR QUESTION?

- NO. CAN I DO ORAL CARE WHILE
YOU'RE DOING THIS?

LIKE, DO WE HAVE TO WAIT
TILL THE VERY END.

- OH, LIKE WHILE THEIR GETTING
THEIR FEEDING. OH, YEAH.

YOU CAN DO IT ANY TIME.
BE VERY EFFICIENT.

BUT IF YOU'RE HOLDING, IT'S KIND
OF HARD TO HOLD THIS AND SCRUB.

- WELL, LIKE, IF THEY'RE GOING
TO DO IT ANYWAYS,

AND YOU'RE JUST -- BECAUSE
YOU'RE WORKING WITH THE TUBE FOR
MOST PART.

- IF YOU'RE ABLE TO
PULL ALL THAT OFF, YEAH.

THE MORE THINGS YOU CAN
MULTITASK, THE BETTER, BUT --

IF YOU'RE HOLDING THINGS,
IT'S A LOT.

- I WAS JUST CURIOUS
IF IT WAS ALLOWED.

IF THERE WAS SOME
INTERACTION THERE WITH --

- OH, NO. TUBE'S DOWN HERE.
SO, NO.

NOT AT ALL.

ALRIGHT. ANYTHING ELSE?

OKAY. G-TUBE IS VERY
SIMILAR TO NG

AS FAR AS PRACTICE AND
PROCEDURE, WHAT WE'RE GOING TO
BE CHECKING FOR.

BECAUSE WE STILL NEED TO
CHECK FOR PLACEMENT,

AND WE STILL NEED TO FLUSH IT
EVERY FOUR HOURS WITH WATER
TO MAKE SURE IT STAYS PATENT.

WHAT'S NICE ABOUT THE G-TUBE
IS IT'S BETTER FOR
THE CHRONIC PATIENT.

SOMEONE THAT HAS
CHRONIC FEEDING PROBLEMS,

CHRONIC DIFFICULTY WITH EATING,
SWALLOWING THAT KIND OF THING.

BECAUSE THE RISK OF DISLODGEMENT
AND HAVING IT PULLED OUT,

MISPLACED IS VERY, VERY MINIMAL.

BECAUSE ONE, IT'S OUT OF REACH,
IT'S IN THEIR STOMACH,

IT'S COVERED AND THERE'S REALLY
NOT MUCH PLACE FOR IT TO GO
EXCEPT FOR IN THE STOMACH.

LET ME JUST SHOW YOU HOW IT
WORKS HERE AND THEN WE'LL DO THE
PROCEDURE REAL QUICK.

IT'S IN THE STOMACH
AND IT LOOKS LIKE THIS.

IT'S SURGICALLY IMPLANTED.

SO IT'S JUST A PUNCTURE SPIKE
AND THEN THE DOCTOR
PUTS IN THE TUBE.

AND THEN IT'S VERY VASCULAR
THERE AND IT HEALS
UP FAIRLY FAST.

ALRIGHT, OF COURSE YOU WOULD
HAVE GLOVES,

BUT ON THIS, THE TUBE
IS VERY MUCH --

AND CAN BE EVEN
A FOLEY CATHETER.

SO YOU KNOW WHAT A FOLEY
CATHETER IS THAT TUBE

AND THEN THE BALLOON HOLDS
IT IN PLACE IN THE BLADDER.

IT'S THE SAME KIND OF
A THING HERE.

IN FACT, FOLEY TUBES HAVE BEEN
USED FOR FEEDING TUBES.

YOU CAN SEE BOTH.

THIS IS ACTUALLY CALLED
A MIC TUBE.

I'M NOT REALLY SURE
WHAT MIC STANDS FOR,
BUT IT'S A FEEDING TUBE.

AND IT'S A LITTLE STURDIER
OF A BALLOON.

IT DOESN'T SEEM TO BREAK DOWN
AS FAST WITH THE STOMACH ACIDS

WHEREAS THE FOLEY CATHETER TUBES
DO BREAK DOWN A LITTLE.

OH, CONNIE SAID -- DID SHE
ALREADY BRING ME A
LITTLE BIT HERE.

BECAUSE WE HAD ONE WHERE
OUR BALLOON BROKE,

SO MAYBE THIS IS THE ONE THAT
SHE HAD -- YEAH.
OUR BALLOON ROTTED.

OKAY, WELL, THIS WOULD NORMALLY
BE A BALLOON THAT HOLDS
IT IN PLACE.

WHAT YOU DO HAVE IS THIS SHIELD.

OKAY. SO THE DOCTOR
MAKES THE PUNCTURE
AND THE DOCTOR PUTS IT IN

AND THIS PORT RIGHT HERE FILLS
THE BALLOON JUST LIKE WITH THE
FOLEY CATHETER.

AND THIS PORT IS WHERE YOU PUT
IN YOUR FEEDINGS AND FLUSHES AND
MEDS AND SO FORTH.

THEN THIS LITTLE SHIELD IS WHAT
STABILIZES THE TUBE

SO THAT IT STAYS IN
ITS RIGHT PLACE.

WHERE THIS ONE WAS TAPED
TO HOLD IT, THE SHIELD HOLDS
THE TUBE IN PLACE.

SO WHAT YOU NEED TO DO IS EVERY
TIME YOU WORK WITH A TUBE

AND AT LEAST EVERY SHIFT,
LET'S SAY THAT.

YOU NEED TO CHECK IT
DOWN BELOW THE DRESSING.

YOU WANT IT CLEAN
AROUND THE SKIN.

IT'S CRUSTY AROUND HERE
BECAUSE IT'S NOT A SPHINCTER
OR ANYTHING.

IT'S JUST A SPIKE HOLE
THAT GETS A LITTLE STRETCHY,

AND SOMETIMES FLUID AND FOOD
LEAKS OUT OF IT.

IT'S BECAUSE IT'S JUST A HOLE
INTO THE STOMACH.

SO YOU WANT TO CLEAN IT REALLY
WELL, MAKE SURE THE SKIN IS GOOD
AND INTACT.

THEN WHAT YOU WANT TO DO IS YOU
WANT TO ROTATE THE TUBE,

SO THAT IT DOESN'T ADHERE
TO THE SKIN OR THE LINING
OF THE STOMACH.

AND IT'S CALLED --
YOU'RE TRYING TO PREVENT
BURIED BUMPER SYNDROME.

YOU DON'T WANT IT TO GET BURIED
INTO THE SKIN.

SO IT NEEDS TO BE ROTATED 360
DEGREES, THEN STABILIZED.

AND THEN --

YOU DON'T PUT THESE LITTLE TAPES
HERE. THIS IS JUST OUR LITTLE
JERRY RIGHT HERE.

THEN YOU HAVE THESE LITTLE SPLIT
-- THEY'RE CALLED DRAIN GAUZE.

SPLIT DRAINS, YOU DON'T WANT
TAKE A GAUZE AND CUT IT

BECAUSE THERE'S TOO MANY FIBERS
THAT WOULD GET THERE.

SO YOU WANT TO GET A DRAIN GAUZE
AND THEN PUT ONE, ONE DIRECTION
AND ONE THE OTHER.

AND THAT WILL HELP KEEP
THAT AREA DRY.

AND THEN JUST TAPE
ALL FOUR SIDES.

YOU DON'T NEED AN ORDER FOR A
DRESSING. YOU DON'T NEED AN
ORDER TO CLEAN IT.

THAT IS YOUR JOB. IF THEY HAVE A
G-TUBE, NURSES CLEAN IT.

SO GET DOWN AND MANAGE SKIN.

IF THERE'S A PROBLEM
AND THE SKIN'S BROKEN DOWN,

OR IT'S NOT HEALING
OR IT'S LEAKING TOO MUCH

THEN OF COURSE YOU WANT TO
NOTIFY THE PHYSICIAN.

BUT FOR JUST BASIC
MAINTENANCE AND SKINCARE,

OUR JOB.

ALRIGHT. AND SO THE REST IS JUST
MANAGING OF THE FEEDING.

YOU CAN SEE IT'S NOT LIKELY THAT
IT WOULD GO UP INTO THE LUNG
BECAUSE IT'S HERE.

BUT STILL THEY'RE AT RISK FOR
ASPIRATION BECAUSE OF FLUID
IN THE STOMACH.

SO YOU NEED THEIR HEAD TO BE UP
SO THAT THEY'RE AT LESS RISK...

FOR THAT AND SO FORTH.

ALRIGHT, SO THAT'S
WHERE THE G-TUBE IS

AND WE'LL GO THROUGH
OUR PROCEDURE HERE.

THIS PROCEDURE WHAT YOU'RE GOING
TO DO IS GIVE A CONTINUOUS
TUBE FEEDING.

- DO WE NEED TO GIVE THEM
PAIN MEDICATION WITH
THAT TUBE?

- NO.
- IT'S NOT GOING TO HURT THEM?

- I MEAN, IF SOMEONE COMPLAINS
OF IT, THEN, YES.

BUT AS A RULE IT
DOESN'T HURT AT ALL.

YEAH. NO. VERY
PAINLESS, YEAH.

ALRIGHT, THE DOCTOR'S
ORDERED THAT THIS CLIENT

GET CONTINUOUS TUBE FEEDING
AT 50 CC AN HOUR.

ALRIGHT. FOR DRAMA CLASS, WE GOT
TO DO A LITTLE PRETEND HERE.

WE'RE GOING TO DO
PRETEND FORMULA WATER.

OKAY. SO OUR WATER'S
GOING TO BE FORMULA.

AND IT'S -- OUR ORDER IS FOR
50 CC AN HOUR CONTINUOUS

WHICH MEANS WE'RE GOING TO
HAVE TO DO A PUMP.

YOU DON'T DO A CONTINUOUS
BY GRAVITY BECAUSE YOU
CAN'T REGULATE IT.

AND IF YOU DON'T -- IF YOU JUST
DO IT BY A GRIP -- DRIP

IT GOES TOO SLOW AND THEN IT
GOES FAST AND THEN IT GOES SLOW.

AND WHEN IT GETS INTO THOSE SLOW
MODES, IT STARTS BLOCKING UP

BECAUSE OF THOSE HIGH SUGAR
CONTENT AGAIN IN THOSE TUBES.

SO YOU NEED SOMETHING THAT
CONTINUOUSLY, AT THE SAME RATE,

KEEPS THAT STUFF MOVING ALONG
AND THAT'S WHY WE'RE GOING TO
HAVE A PUMP.

ALRIGHT, I'M GATHERING UP
MY SU-- SUPPLIES.

I KNOW MY ORDERS AND MY ORDER
SAID 50 CC AN HOUR OF FORMULA.

A COUPLE OF SCENARIOS WILL
HAPPEN IN YOUR INSTITUTIONS.

ONE, THE KITCHEN WILL
SEND YOU UP CANS OF ENSURE

OR SOME KIND OF CONTAINER WITH
YOUR FLUID AND YOU JUST
PUT IT INTO BAGS.

OR TWO, IT COMES IN A
PRE-PACKAGED SOLUTION.

NESTLE SEEMS TO BE WHO'S TAKING
CARE OF THE VA RIGHT NOW

AND SAINT AGNES', IT'S THE WHO
I'VE HEARD.

AND THEY PRE-PACKAGE THIS
24-HOUR FORMULA.

YOU HANG THE WHOLE BAG
AND IT'S GOOD FOR 24 HOURS.

IF IT COMES IN A CAN OR IF IT
COMES IN A SOLUTION
THAT YOU POUR IN,

YOU CAN ONLY PUT IN UP TO 8
HOURS WORTH OF SOLUTION
AT ONE TIME.

IF IT COMES IN A
PRE-MANUFACTURED CONTAINER,

YOU HAVE TO GO BY THEIR
DIRECTIONS, MANY OF THEM
UP TO 24 HOURS.

THEN I CAN'T GIVE YOU AN
ABSOLUTE ANSWER,

YOU HAVE TO GO BY WHATEVER THE
MANUFACTURER SAYS.

SO OURS IS COMING OUT OF A CAN
OR SOME SOLUTION,

AND SO WE'RE GOING TO
WORK WITH THE RULE.

8 HOURS.

IF OUR SOLUTION IS GOING AT
50 CC AN HOUR,

AND WE CAN ONLY HANG EIGHT HOURS
WORTH, HOW MUCH CAN WE HANG AT
THE MOST?

400.

AND WOULDN'T WE WANT TO HANG AS
MUCH AS POSSIBLE

INSTEAD OF HAVING TO RUN INTO
THE ROOM EVERY TWO HOURS

AND MISSING IT AND SO ON,
SO FORTH.

SO WE'RE GOING TO GET FOUR HOURS
WORTH OF SOLUTION...

IN HERE. SO I HAVE MY 400 CC
OF SOLUTION ACTUALLY
IN A LITTLE WATER.

I HAVE MY KANGAROO BAG WHICH
YOU'RE GOING TO NEED A BAG TO
FIT THE PUMP.

THIS PARTICULAR TUBING HAS A BAG
THAT HOLDS 500 CC.

SO IF IT WAS GOING
MUCH FASTER THAN THAT,

I WOULDN'T BE ABLE TO PUT IN
A FULL 8 HOURS.

YOU CAN ONLY PUT IN AS MUCH
AS IT CAN HOLD.

AND THEN I HAVE THIS FUN LITTLE
TUBING THAT I NEED TO GET
HOOKED UP AND GOING.

SO I HAVE MY TUBING,
I HAVE CHUX, I HAVE GLOVES,

I HAVE PH PAPER, I HAVE SYRINGE,
I HAVE MEASURING TAPES,
I HAVE EVERYTHING.

BECAUSE IT'S THE SAME SUPPLIES
AS YOU DID BEFORE.

ALRIGHT, SO I'M ALL GATHERED UP,
READY TO GO.

I WASHED MY HANDS, I'M GOING TO
IDENTIFY MY CLIENT.

ACTUALLY, I COULD PREPARE
SOME OF MY STUFF AT
THE NURSING STATION,

BUT WE'LL DO IT ALL HERE.
ALRIGHT.

BEFORE I GET GOING, WHY DON'T I
JUST ASSESS MY CLIENT.

IDENTIFY MY CLIENT. MRS. SMITH,
YOU STILL DON'T HAVE
YOUR NAME BAND.

CAN YOU TELL ME YOUR
FULL NAME? GOOD.

AND PROVIDE PRIVACY.

I WANT TO DO THE SAME CHECKS
THAT I DID BEFORE.

I WANT TO CHECK WHAT?

- INSPECT.

- I WANT TO CHECK LUNGS
AND ABDOMEN, FIRST THING
I'M GOING TO DO INSPECT.

SO I'M GOING TO LOOK.
I'M LOOKING FOR COLOR,
RESPIRATION, RATE, QUALITY...

ANY KIND OF DISTRESS, SYMMETRY
OF LUNG MOVEMENTS AND SO FORT.

LISTEN, 1, 2, 3, 4.

AND 6 ON THE BACK.

OKAY, AND THEN I WANT TO DO
STOMACH AND STOMACH AGAIN
IS BEST FLAT.

ONE OF THE THINGS I WANTED TO
MENTION AND THE LITTLE
THOUGHT ELUDED ME.

WHEN YOU DO A STOMACH
ASSESSMENT,

IT'S BETTER IF THEY'RE KNEES ARE
BENT UP A LITTLE BIT

BECAUSE IT TAKES THE TENSION OF
THE STOMACH RATHER THAN PULLING
THEM FLAT.

SO...

JUST KIND OF A RELAXED...
LITTLE POSITION HERE.

SORRY, I FLASHED YOU.

SAME THING. INSPECT, COLOR,
CONTOUR, SYMMETRY...

HAIR DISTRIBUTION, BRUISES,
DISCOLORATIONS,
ANY SKIN MARKINGS.

OSCULATE RIGHT
LOWER QUADRANT.

ALL FOUR QUADS AND THEN
LIGHT PALPATION.

ALL FOUR QUADS, OKAY.

GOOD BOWEL MOVEMENTS.
FEELING ANY NAUSEA?

ANY TROUBLE? ANY VOMITING?

WHEN WAS YOUR
LAST BOWEL MOVEMENT?

YOU NEED TO KNOW HOW MANY BOWEL
MOVEMENTS THEY'VE HAD.

AND THEN I WANT TO PUT THEIR
HEAD UP AT LEAST 45 DEGREES.

PROBABLY A LITTLE PREMATURE
HERE, SO I GOT TO STILL SET UP.

ALRIGHT.

I WANT TO GET MY TUBING SET UP.

SO THE FIRST THING I WANT TO DO
BEFORE I POUR MY FORMULA IN

IS FIND THE ROLLER CLAMP
AND TURN IT OFF.

OKAY. ROLL IT DOWN.

SO THAT WHEN YOU PUT THE FEEDING
IN, IT DOESN'T ALL ROLL OUT
ONTO THE FLOOR

AND ONTO YOUR SHOES AND MAKE A
STICKY ICKINESS.

ALRIGHT, YOU WANT TO MAKE SURE
THAT YOU MEASURE

THE CORRECT VOLUME IN YOUR
GRADUATE BEFORE YOU
MEASURE HERE.

DON'T GO BY THE MEASUREMENTS
ON THE BAG,

THEY'RE JUST NOT CLEAR ENOUGH...

TO GIVE YOU RIGHT MEASUREMENTS.
SO I'M GOING TO POUR IN...

MY 400 CC AND I KNOW I'M
50 HEAVY HERE, SO.

OKAY, THESE ARE CALLED
KANGAROO BAGS.

AND I THINK IT'S KIND
OF FUNNY BECAUSE I JUST
GOT THESE NEW BAGS,

AND WHAT THEY DON'T HAVE
IS THE WONDERFUL FEATURE

OF THE KANGAROO
AND THAT'S THE POUCH.

THERE'S USUALLY A LITTLE POUCH
THAT GOES ON HERE

THAT YOU CAN PUT ICE INTO SO
THAT YOU CAN KEEP THIS FRESH.

I DON'T KNOW WHY THEY GOT RID
OF THE POUCH IN THIS
NEW BATCH I GOT.

BUT ANYWAYS IF YOU SEE THE
LITTLE POUCH, THAT'S THE POINT.

YOU PUT A LITTLE ICE PACK IN A
LITTLE BAGGY. DON'T JUST PUT
LOOSE ICE IN THERE,

THEN YOU HAVE A DRIPPY MESS.
BUT THEN THAT KEEPS IT
KIND OF COOL AND FRESH.

THESE TUBINGS ARE GOOD
FOR A WEEK...

OR WHATEVER YOUR
INSTITUTION SAYS.

SO ONCE YOU'VE OPENED
A NEW TUBING,

YOU WANT TO TAKE A
LITTLE LABEL LIKE THIS.

AND PUT THE DATE AND TIME AND
THEN STICK IT ON HERE

SO THAT YOU KNOW HOW OLD IT IS.

THE TUBING IS WASHED OUT EVERY
24 HOURS WITH SOAP AND WATER.

JUST LIKE YOU'RE WASHING DISHES.
SO YOU WOULD PUT A LITTLE
SOAPY WATER IN,

THEN RUN IT THROUGH,
THEN RINSE IT THROUGH.

AND THEN YOU KEEP USING THAT
SAME BAG AND TUBING FOR A WEEK.

AND THEN AFTER A WEEK THEN,
IT GETS THROWN AWAY.

ALRIGHT, WHAT WE WANT
TO DO NOW IS WHAT'S CALLED
PRIME THE TUBING.

SO WE WANT TO TAKE AND MAKE SURE
WE GET FLUID THROUGH HERE

INSTEAD OF PUTTING AIR
INTO THE CLIENT.

IT WON'T KILL THEM.
IT'S NOT AN IV.

IT'S NOT INTO THE BLOOD SYSTEM.
IT'S JUST INTO THEIR STOMACHS.

SO, BUT IT CAN MAKE 'EM
BURP AND STUFF.

YOU CAN GIVE 'EM
A LOT OF EXTRA AIR.

SO GO AHEAD AND LET
THE FLUID RUN THROUGH.

AND THEN PINCH IT OFF.

AND IF YOU HAVE
AN UNCOORDINATED MOMENT
AND YOU EMPTY TOO MUCH OUT,

THEN YOU CAN ALWAYS JUST
DUMP IT BACK IN THE TOP.

ALRIGHT. ONE OF THE THINGS
THAT'S REAL IMPORTANT WHEN
YOU'RE PRIMING YOUR TUBING

IS TO MAKE SURE THAT
YOUR DRIP CHAMBERS STAYS
FACING DOWN LIKE THIS.

I DON'T WANT MY DRIP CHAMBER
TO BE FULL OF FLUID

BECAUSE I'M GOING TO PUT
THE DRIP CHAMBER INTO HERE,

AND THERE'S WHAT I CALL
THE EYE RIGHT HERE,

AND IT READS HOW MANY
DRIPS COME THROUGH.

IF YOU FILL IT UP TO FULL, THEN
IT THINKS IT'S FULL ALL THE TIME

AND THEN IT THINKS FLUID'S GOING
INTO THE CLIENT ALL THE TIME.

IT HAS TO SEE DROPS DROPPING
DOWN TO BE ABLE TO CALCULATE
THE RATE CORRECTLY.

SO, LET'S TALK ABOUT
SOME TROUBLE SHOOTING.

SOMEONE ALWAYS JUST
DOESN'T PAY ATTENTION
AND THEY FLIP IT OVER.

SHOOT, YOU MAY KNOW NOT TO
AND ONE DAY YOU'LL JUST DO IT.

SO YOU'RE CLIPPING ALONG.

AND YOU DO THIS
AND YOU FILL IT UP SIDEWAYS

BECAUSE YOU ARE
BOTTOM-FOCUSED HERE.

WHOA!

OKAY. NOTICE I PINCH A LOT.

PINCHING IS SO MUCH EASIER
THAN ROLLER CLAMPING.

ROLLER CLAMPING TAKES A SECOND.

NOW WHAT DO YOU DO?
YOU'RE OVER FILLED.

HOW DO YOU GET IT OUT OF THERE?

WELL, IT WOULD SEEM LIKE
THE SIMPLEST WAY WOULD BE
JUST TO SQUIRT IT BACK,

BUT THIS PARTICULAR BRAND
DOESN'T SQUIRT BACK.

THE LITTLE DRIP CHAMBER
IS TOO STIFF.

SO YOU REALLY ONLY HAVE
A COUPLE OF OPTIONS.

ONE, TO EMPTY THIS WHOLE THING
OUT AND THEN GET AIR IN IT.

THAT'S A PAIN IN THE NECK.

OR GET THIS LID ON REALLY TIGHT

AND DISPLACE THE FLUID SO THAT
THERE IS AIR RIGHT HERE.

WELL, I GOT SUCH
A MESS GOING ON HERE.

OKAY. THAT WAS NOT GOOD.

AND THEN OPEN THIS UP
AND LET THE AIR COME DOWN.

SEE HOW AIR IS COMING.

AND AIR WILL DISPLACE
THAT FLUID.

AND NOW YOU ARE GOOD TO GO.

ALRIGHT. SO YOU UTILIZE
THE FLUID THAT'S IN YOUR BAG.

OKAY, WHAT A MESS,
BUT IT'S JUST FLUID. SO --

- DO WE HAVE TO RE-PRIME IT NOW
THAT WE DID THAT?

- NO. IT'LL ACTUALLY DISPLACE
ITSELF IN HERE

AND IT'S JUST A LITTLE
STRETCH OF AIR.

SO, NO, I WOULDN'T EVEN
WORRY ABOUT IT AT ALL.

ALRIGHT. THE NEXT THING
I NEED TO DO IS SET UP MY PUMP

AND GET IT READY TO CONNECT
TO THE CLIENT.

AND YOU'RE GOING TO PUT
YOUR TUBING IN HERE.

LIKE I SAID,
THE DRIP CHAMBER.

I AM GOING TO GET IT OUT HERE,
WHERE YOU GUYS CAN SEE IT.

AND THEN WHAT YOU HAVE IS
THIS LITTLE STRETCHY TUBING,

THAT'S GOING TO GO AROUND
THIS ROTATOR CUP.

IT STRETCHES AROUND
AND THEN THIS BLACK BUTTON

HAS TO COME UP HERE
AND SIT ON THE LEDGE.

VERY IMPORTANT.
IF YOU DON'T GET YOUR BLACK
BUTTON UP HIGH ENOUGH,

LIKE IF YOU DO IT LOOSE LIKE
THIS, IT'S NOT TIGHT ENOUGH.

AND YOU'LL SEE WHEN
I TURN THIS ON

THAT THIS ROTATOR IS WHAT
MOVES THE FLUID THROUGH.

SO IF IT'S TIGHT,
IT WON'T MOVE THE FLUID.

AND SO IT WILL SAY
AIR, AIR, AIR.

AND YOU'RE GOING,
"WHAT? I PUT IT THROUGH."

BUT IT'S GOT TO BE UP-STRETCHED

AND THEN LANDED INTO
ITS LITTLE BASE THERE, OKAY?

SO STRETCH AROUND.
THEN THIS LITTLE...

TAB GETS MOVED.

AND THAT JUST SETS THERE
TO KEEP THE TUBING
FROM GETTING COILED UP.

ALRIGHT, SO WE'RE SET THERE,
BUT I STILL NEED TO CHECK A
COUPLE OF THINGS ON MY CLIENT.

I NEED TO CHECK FOR PLACEMENT
OF MY TUBE BEFORE I GET GOING.

SO...

GET GLOVES ON
WHENEVER YOU ARE

GOING TO BE MESSING
WITH THE TUBE.

AND I WOULD COME OVER HERE
AND GET MY PH PAPER READY.

GET READY TO ASPIRATE.
PUT THIS HERE.

THIS IS WHERE
YOU CAN JUST MENTION.

WE'RE NOT GOING TO REALLY
BE CLEANING THE STOMACH.

BUT JUST KNOW THAT IF WERE
DOING OUR CRITICAL THINKING

OR YOU WERE DOING SOMETHING
WITH THE G-TUBE,

THAT YOU WOULD REALLY TAKE THIS
DRESSING DOWN TO THE SKIN,

CHECK THE SKIN,
CLEAN IT WITH SOAP AND WATER,

ROTATE THIS 360
TO PREVENT VERY BUMPER.

THEN WE'RE GOING TO CHECK
FOR PLACEMENT.

SO CRIMP THIS OFF, OPEN UP,

STICK YOUR SYRINGE IN
AND THEN PULL OFF.

RESIDUAL AND OR ANY FLUID
YOU CAN GET TO CHECK PH.

RESIDUAL, WHAT'S THAT?

WHAT'S LEFT IN THE STOMACH.

ALRIGHT. I'M GOING TO CHECK
MY PH. WHAT DO I WANT?

- 4.
- 4.

- BELOW 6.
4 MAKES ME REALLY HAPPY.

AND THEN I WANT TO CHECK
FOR RESIDUAL.

WHAT HAPPENS IF I GET
A RESIDUAL OVER 100?

I'M GOING TO HOLD
THE FEEDING, PROBABLY.

THOUGHT I GAVE YOU THIS ARTICLE.

THIS NEW ARTICLE AND I AM
REALLY LOVING THIS NEW ARTICLE

ABOUT DEBUNKING
THE MYTHS OF G-TUBE.

YOU NEED TO READ THROUGH THAT.
IT ACTUALLY SAID THAT THEY --

IT WAS A G-TUBE OR IT WAS A TUBE
FEEDING HOSPITAL OR FLOOR

AND THEY DID A BUNCH OF RESEARCH

AND THEY FOUND THAT PEOPLE
COULD ACTUALLY TOLERATE HAVING

300 TO 600 CC OF FLUID IN THEIR
STOMACH WITHOUT A PROBLEM.

SO HERE WE ARE JUST STOPPING
FEEDINGS, YOU KNOW,

BECAUSE THERE'S THIS 100 IN
AND IT MAY NOT BOTHER
THE CLIENT AT ALL.

IF THEY ARE HAVING
NAUSEA OR THROWING UP,
THAT'S ANOTHER SUBJECT.

BUT IF THEY'RE ASYMPTOMATIC,

MAYBE WE'RE STOPPING IT
TOO SOON.

BUT ANYWAYS, YOU CAN STILL SAY
YOU CHECKED FOR RESIDUAL

AND HOLD...OVER 100,
UNLESS OTHERWISE INDICATED.

OKAY, WE'RE GOING TO RETURN
THE STOMACH CONTENTS.

AND PLUG.

ALRIGHT, EVERYTHING LOOKS GOOD,

IT SEEMS TO BE IN
THE RIGHT PLACE HERE.

WE GOT GOOD BOWEL SOUNDS,
NOT TOO MUCH RESIDUAL,
THE PH WAS 4.

I'M VERY HAPPY ABOUT THAT
AND DOING GOOD.

SO WE'RE GOING TO SET YOU UP
WITH A CONTINUOUS FEED HERE.

I'M GOING TO CRIMP THIS OFF,

PUT THE FEEDING TUBE INTO
THE G-TUBE AND MAKE SURE
IT'S NICE AND SNUG.

ONLY THAT'S A DRAG WHEN THOSE
COME APART AND YOU'VE BEEN
FEEDING THE BED FOR A WHILE.

ALRIGHT. THEN WHAT WE NEED TO DO
IS START THIS THING.

YOUR ORDER IS TO INFUSE
THE FEEDING AT 50 CC AN HOUR.

SO WHAT IS YOU NEED TO DO
IS TURN THE MACHINE ON.

AND IT'S GOING TO GO THROUGH ALL
OF THESE CLEARING CHECKS.

AND WHEN IT FINALLY STOPS,

AND IT'S AT THE NUMBER,
THAT IS THE RATE.

THAT'S WHERE YOU'RE GOING TO SET
THE MILLILITERS PER HOUR

THAT YOU WANT THIS
TO INFUSE AT.

SO, I ACTUALLY, I KIND OF
GOOFED UP ON THE SYLLABUS.

IN THE PRACTICE AREA,
IT SAYS PRACTICE SETTING
YOUR IV AT 50 --

OR YOUR G-TUBE PUMP
AT 50 CC AN HOUR.

BUT WHEN I SAID WHAT WE'RE
GOING TO BE TESTING ON,

I DIDN'T SAY WHAT
WE'RE SETTING.

SO THAT WASN'T TOO GOOD.

WE'RE SETTING IT AT 50 CC
AN HOUR, SO THAT IS THE ORDER.

WHAT YOU WANT TO DO
IS JUST FIND THE ARROWS

AND THEN GO AHEAD AND PUT IT UP
TO 50 CC AN HOUR.

AND IT'LL GO FASTER, FASTER,
FASTER, TILL YOU GET 50.

OKAY? AND IF YOU GO PAST IT,
THEN YOU JUST ARROW DOWN
TILL YOU GET IT SET.

SO THAT'S THE RATE.

NOW, THE NEXT THING YOU
HAVE TO SET ON THIS MACHINE
AND THIS IS REALLY IMPORTANT,

IS HOW MUCH FLUID IS IN THIS BAG
SO IT KNOWS HOW TO GO IN.

BECAUSE IF WE TRY
TO START IT RIGHT NOW,
IT'S NOT GOING TO RUN

BECAUSE IT DOESN'T THINK
THERE'S ANY FLUID.

SO WE HAVE TO GO TO
THE DOSE BUTTON.

THE DOSE IS NOT THE RATE,

THE DOSE IS THE
VOLUME IN THE BAG.

SO HOW MUCH DID
I PUT IN THE BAG?

- 400.

- SO WHAT DO YOU THINK
I SHOULD PUT FOR MY DOSE?

- 400. 350.

- 350, 375, 380, SOMETHING
LIKE THAT. WHY?

- BECAUSE YOU DON'T
WANT IT TO GO --
YOU DON'T WANT IT TO BE --

- EMPTY.
- UH-HUH.

- AND THEN IT'S BEEPING
AND IT'S EMPTY

AND IT'S GOING TO TAKE ME
ANOTHER 20 MINUTES

TO GET IT FROM THE KITCHEN
AND ALL THE STUFF OF IT.

SO, OH, OUCH!
GIVE YOURSELF A LITTLE LEEWAY

TO GET YOUR SUPPLIES READY.

SO 350, SO THAT'S A WHOLE HOUR,
SO MAYBE I DON'T WANT THAT.

BUT MAYBE 375, 380,
SOMETHING LIKE THAT.

A GOOD HALF HOUR OF WARNING.

SO HIT DOSE.
IT'S GOING TO GIVE YOU 4 ZEROES.

AND YOU GOT TO HURRY,
BECAUSE ONCE THOSE ZEROES
CLEAR OFF AGAIN,

THEN YOU'RE CHANGING YOUR RATE.

AND THEN SET IT FOR YOUR --
OH, THAT WAS IT.

375.

THEN THERE'S ANOTHER BUTTON
CALLED VOLUME INFUSED.

OR JUST VOLUME.

AND THAT'S HOW MUCH
WENT IN FOR YOUR I&O.

SO IT WILL TELL YOU
EXACTLY WHAT THEY GOT.

YOU DON'T HAVE TO JUST LOOK
AT A BAG AND GUESS IT.

ALRIGHT. SO WE'RE GOING TO
GO AHEAD AND START.

AND YOU CAN SEE HOW
THE LITTLE ROTATOR NOW
IS ROTATING THAT CUP.

AND SO I SHOULD LOOK UP --

LOOK IN HERE AND SEE IF
DRIPS ARE COMING DOWN.

MAKE SURE IT'S WORKING GOOD.

SO I'M GOING TO GO AHEAD
AND GET RID OF MY SUPPLIES.

PUT MY CLIENT DOWN.

I'VE ACTUALLY SABOTAGED MYSELF,
AND I WANT IT TO BEEP,

SO THAT YOU CAN SEE
HOW TO DO AN ALARM.

- DO YOU KNOW WHAT I'VE DONE?
- HE'S LAYING DOWN.

NO, HE'S NOT LAYING DOWN.
HIS HEAD'S UP.

I HAVE A PROBLEM.
- THE TUBE.

- NO, THE TUBE'S BEAUTIFUL.

I HAVE ANOTHER PROBLEM.

- THE VALVE.

YEAH. OH, I WISH I HAD A PRIZE.

I FORGOT -- I DIDN'T FORGET.

BUT I DIDN'T OPEN MY CLAMP.

REMEMBER WHEN I CLOSED MY CLAMP
AFTER I PRIMED IT.

WE SO OFTEN GET SO FOCUSED ON,

YOU KNOW, NUMBERS
OR WHATEVER THAT, OH!

SO NOW THIS STARTS BEEPING.
[BEEPING]

OH, CLIENTS LOVE THAT.
IT'S MY FAVORITE SOUND.

SO, THE FIRST THING
YOU PROBABLY WANT TO DO,

AND REMEMBER I TOLD YOU
THE RULE IS ALWAYS
CLIENT BEFORE EQUIPMENT.

BUT I THINK IF YOU
DON'T TURN THIS OFF,

YOUR CLIENT MIGHT
LOSE THEIR MINDS.

SO THE FIRST THING YOU
WANT TO DO IS COME IN HERE
AND PUT THIS ON HOLD.

OKAY? AND JUST,
"OKAY, PROBLEM SOLVED."

AND IT SAYS FLOW AIR,
FLOW AIR, FLOW AIR.

ALRIGHT. WHENEVER YOU'RE PROBLEM
SOLVING, ALWAYS BE SYSTEMATIC.

WE ASSESS FROM HEAD TO TOE.

WE'RE GOING TO ASSESS
FROM BAG TO BOTTOM HERE.

SO JUST START LOOKING,
"DO I HAVE FLUID IN THE BAG?"

"DO I HAVE MY --
AH! MY CLAMP," OKAY?

OPEN UP YOUR CLAMP, SLIDE IT UP,
MAKE SURE IT'S GOOD.

IS THIS -- I CHECK THE WHOLE
THING OUT WHILE I'M HERE.

DO I HAVE FLUID?
IS IT THREADED RIGHT?

DO I HAVE ANY CRIMPS
IN THE TUBING?

IS IT STRAIGHT?
IS IT PLUGGED IN?

EVERYTHING LOOKS OKAY.
LET'S GIVE THIS ONE MORE SHOT.

AND I'M GOING TO START IT.

I SHOULD SEE GREEN
AND I SHOULD SEE FLUID MOVING.

GET IN THE HABIT OF LOOKING
AT YOUR STUFF.

IS IT COMING DOWN?

THE LITTLE DOT SHOULD GO ACROSS,
THE LITTLE GREEN,

AND IT'S MOVING AND IT'S GREAT.

OKAY?
FLOW AIR.

THERE WILL BE TWO THINGS
THAT WILL FLOW AI--

WELL, THREE THINGS POSSIBLY.

THE CLAMP,
YOU DIDN'T CLEAR YOUR EYE

OR YOU DIDN'T THREAD IT GOOD
AND IT'LL TELL YOU FLOW AIR.

SO BE PREPARED TO PROBLEM SOLVE.

WHAT DO YOU DO FLOW AIR?

HOLD.

HOLD AND START ARE THE SAME.

THEY JUST ALTERNATE
BETWEEN THE TWO.

SO IT'S HOLD, START,
HOLD, START.

AND THE OTHER THING
THAT'S REALLY IMPORTANT
IS JUST TO MAKE SURE

THAT YOU KNOW THE DIFFERENCE
BETWEEN RATE AND DOSE.

AT THE END OF YOUR SHIFT,
YOU CAN COME TO VOLUME

AND HIT THE VOLUME
THAT'S BEEN INSTILLED

AND THEN YOU CAN
CLEAR THE VOLUME.

AND THEN IT'LL BE A FRESH START
FOR THE NEXT SHIFT
TO DO THEIR I&O.

OKAY?

ALRIGHT. ONCE I GOT 'EM GOING,

I HAVE MY CLIENT SITTING UP
AT A NICE 45-DEGREE ANGLE.

I'M GOING TO BE ASSESSING
FOR RESPIRATORY DISTRESS,

DIARRHEA, I KNOW THAT'S
FOR SURE ON THIS ONE

BECAUSE THIS ONE'S GETTING
A CONTINUOUS TUBE FEED.

SO WE'RE GOING TO BE ALWAYS
WATCHING FOR THAT.

YOU WANT TO OFFER
GOOD ORAL CARE,

MAKE SURE THEY'RE
IN A GOOD POSITION.

I'VE ALREADY TALKED
ABOUT THE BAG.

THE BAG NEEDS TO BE CLEANED.
SOAP AND WATER EVERY 24 HOURS.

IT STILL NEEDS TO BE FLUSHED
EVERY FOUR HOURS.

SO YOU'RE GOING TO COME IN
AND IN FOUR HOURS,

YOU'RE GOING TO
PUT THIS ON HOLD,

YOU'RE GOING TO
DISCONNECT THE TUBE,

PUT IN YOUR 30-50-100 CC,
WHATEVER IS THE GOING THING.

CONNECT IT BACK UP
AND LET IT KEEP GOING.

OKAY? SO YOU INTERRUPT
THE FEEDING.

- WHAT PORTION DO WE
DISCONNECT ON THIS?

- RIGHT HERE.

- JUST RIGHT THERE.
- UH-HUH.

YEAH. SO STOP IT SO THE FOOD
DOESN'T GET ALL OVER.

FLUSH, THEN RECONNECT
AND JUST KEEP 'EM GOING.

OKAY?

MAKE SURE -- AND THIS IS
REALLY IMPORTANT TOO.

WE CAN'T REALLY FIX THOSE FUNNY
LITTLE THINGS AND DON'T --

REMEMBER THAT THIS CLIENT
NEEDS TO BE TURNED.

JUST BECAUSE THEIR HEAD'S UP,
DOESN'T MEAN THEY CAN'T MOVE.

IF THEY JUST SIT
IN THEIR BED LIKE THIS,

THEY'RE GOING TO GET
A PRESSURE SOURCE.

SO MAKE SURE THIS CLIENT MOVES
EVERY, YOU KNOW, TWO HOURS.

THEY CAN STILL GET UP
AND WALK TO THE BATHROOM.

THEY JUST TAKE
THEIR LITTLE POLE.

KEEP YOUR CLIENT MOVING.

OH, I HAVE ANOTHER
LITTLE THING I -- OH!

NO, I CAN'T REMEMBER.

OKAY. WASH YOUR HANDS
AND DOCUMENT THE FEEDING

AND YOUR CLIENT
IS READY TO GO.

SO AFTER YOU'RE DONE,
WE'LL JUST HAVE YOU DISCONNECT,
DUMP THE WATER.

EVERYONE'S GOING TO
POUR THEIR WATER IN

AND REALLY SET THIS UP
AS A REAL FEED.

- THE CLIENTS ON TUBE FEEDING
ARE THEY ALWAYS ON I&O?

- ALWAYS.
- ALWAYS.

- UH-HUH, YEAH.
ANYTIME THEY HAVE AN NG TUBE.

GO AHEAD AND TURN THIS OFF.

OKAY, SO THAT'S WHAT
YOU'RE GOING TO DO

FOR YOUR TWO STATIONS,
BUT WE HAVE ONE -- YES?

- DOES THE PATIENT ALWAYS HAVE
TO BE IN A 45 DEGREES ANGLE?

- YES. WHEN THEY HAVE A
CONTINUOUS FEED BECAUSE
OF RISK OF ASPIRATION.

SO THEY ALWAYS HAVE TO HAVE
THEIR HEAD UP. YEAH.

THERE'S ONE OTHER ASSIGNMENT
IN THIS MODULE,

AND IT'S GOING TO
TAKE OUR LITTLE TIME.

DON'T PANIC.
WE HAVE PLENTY OF TEST TIME.

IT'S ONLY 25 QUESTIONS.
NOT TOO BAD.

DID I DO ORAL HYGIENE?
- YES, YOU DID.

- I WANT MY POINTS.
I'M AS BAD AS YOU GUYS.

I WANT MY POINTS.
DID I DO THEM ALL?

OKAY. THERE'S A THIRD THING
WE'RE GOING TO DO

AND IT HAS NOTHING REALLY
TO DO WITH THIS MODULE.

THAT'S WHAT WE'RE DOING
FOR FEEDING, ARE THESE
TWO TUBE FEEDS.

BUT WE FOUND YOUR NEXT MODULE
IS A TWO-WEEK MODULE

AND WE'RE GOING TO START
MEDICATION ADMINISTRATION.

YOU'RE GOING TO START GIVING
YOUR PO IN TOPICAL MEDS.

AND THERE'S SO MUCH TO LEARN

THAT WE FOUND OUT THAT THE FIRST
WEEK WAS JUST TOO STRESSFUL

IF I DIDN'T SPLIT IT OUT
A LITTLE BIT.

AND THIS WEEK ISN'T
VERY STRESSFUL.

THESE TWO FEEDINGS
ARE JUST NOT THAT HARD.

HONESTLY, RIGHT? AREN'T THEY
A LITTLE REPETITIOUS?

SO, WHAT WE WANT YOU TO DO
IS GET PREPARED TO GIVE MEDS

FOR THE NEXT WEEK.

ALRIGHT. SO HERE'S HOW IT WORKS.

YOU GUYS KNOW THAT WHEN
YOU COME FOR YOUR TESTING,

HOW YOU'RE AN APPOINT --

YOUR APPOINTMENT LIKE 8 O'CLOCK
AND THERE'S PERSON NUMBER 1,

PERSON NUMBER 2, PERSON NUMBER 3
ON THAT LITTLE SHEET

THAT'S POSTED BY THE --
ON THE BULLETIN BOARD.

THOSE ARE THE BEDS THAT YOU'RE
GOING TO BE ASSIGNED

WHEN YOU GO TO TAKE CARE
OF YOUR CLIENTS.

SO IF YOU'RE PERSON NUMBER 1,

YOUR BED FOR THE NEXT
FEW WEEKS IS GOING TO BE
BED NUMBER 1, SALLY SMITH.

SHE'S YOUR CLIENT AND THAT'S WHO
YOU'RE GOING TO GIVE MEDS TO.

IF YOU'RE BED NUMBER 2, BETTY
JONES. BED NUMBER 3, ALAN SMITH.

BED NUMBER 4, CONRAD.
AND BED NUMBER 5 --

OH, I AM SORRY,
BED 4 IS OTIS.

HE WOULD BE SO OFFENDED.
OTIS SWEET.

AND THEN CONRAD CURRY
IS BED NUMBER 5.

AND THOSE ARE GOING TO BE YOUR
CLIENTS FOR THE NEXT 3 WEEKS
OF MED ADMINISTRATION.

WHY THAT'S IMPORTANT IS BECAUSE
I NEED YOU TO GET INTO
THE CHARTS THIS WEEK,

SEE WHAT THEIR DIAGNOSIS IS,
GET YOUR WORK SHEET TOGETHER

AND START GETTING
YOUR MED CARDS READY.

SO THAT YOU'LL BE
READY TO GIVE MEDS.

WE'RE GOING TO TEACH YOU HOW
TO GATHER YOUR INFORMATION,

AND THEN WE'RE GOING TO
TEACH YOU HOW TO GIVE THEM.

THERE'S TWO DIFFERENT THINGS.

IT'S NOT LIKE, YOU KNOW, YOU GO
HOME AND YOU TAKE A TYLENOL.

OH, THAT'S THE LAYMEN'S WAY.

YOU'RE ABOUT TO DO IT
THE NURSING WAY.

YOU HAVE TO KNOW EVERYTHING
THERE IS TO KNOW ABOUT TYLENOL.

YOU HAVE TO KNOW
ALL THE IMPLICATIONS,
ALL THE ASSESSMENTS

AND ALL THE STUFF NURSING
HAS TO DO TO FOLLOW UP.

AND THEN YOU HAVE TO MAKE SURE
THAT YOU'RE DOING IT

WITH A PROCEDURE
THAT MAKES YOU SAFE

SO THAT YOU DON'T MAKE ERRORS.

AND SO THAT'S WHAT
WE'RE GOING TO DO.

BUT THEY'RE ALL FAIRLY SIMPLE.
OKAY.

WHAT YOU'RE GOING TO DO
IS OUT ON THE --

I DON'T KNOW WHERE CONNIE PUT
THEM. I THINK IN OUR CHART RACK.

WE HAVE THIS ROLLING CHART-RACK
THING. HUNT FOR IT.

OUR CHARTS.
EVERY CLIENT HAS TWO CHARTS

THAT ARE EXACTLY THE SAME.

SO SALLY HAS TWO AND BETTY
HAS TWO AND SO FORTH.

BECAUSE WE HAVE LOTS OF STUDENTS
AND EVERYONE NEEDS TO GET TWO.

SO EVERYONE HAS A CHART.
ON THE CHART BACK HERE,

IT HAS THEIR NAME,
THE DOCTOR.

THEY'RE BED NUMBER
IS THEIR ROOM NUMBER.

THEY'RE KIND OF SYNONYMOUS.
WE DON'T HAVE ENOUGH ROOMS.

AND THEN THEIR ALLERGIES
ARE POSTED ON THEIR CHART.

AND THIS IS HOW A CHART
SHOULD LOOK IN A HOSPITAL.

ALLERGIES SHOULD ALWAYS
BE FLAGGED.

ALL OF OUR CLIENTS
HAVE ALLERGIES AND
GET USED TO HEARING

ABOUT PENICILLIN,
CODEINE AND SULFA,

ARE THE THREE COMMON
ALLERGIES FOR OUR CLIENTS.

INSIDE THE CHART IS JUST ORDERS.

AND THAT'S ALL WE
PUT IN HERE FOR NOW.

OKAY? SO YOU'RE GOING TO
GO TO THE CHART

AND YOU'RE GOING TO LOOK
AT THE ORDERS FOR YOUR CLIENT.

EVERYTHING STARTS WITH
THE DOCTOR'S ORDER.

WE CAN'T HARDLY DO A THING
WITHOUT A DOCTOR'S ORDER.

SO YOU'RE GOING TO BE
LOOKING AT THOSE ORDERS.

HOWEVER, IT'S ONE THING
TO READ THEM,

IT'S ANOTHER THING TO FIGURE OUT
WHAT TO DO WITH THEM

AND HOW TO GET
YOURSELF ORGANIZED.

SO WHAT IS DID WAS I
GAVE YOU A WORKSHEET

SO THAT YOU COULD
TRANSCRIBE THIS INFORMATION

TO A FORM THAT YOU
COULD WORK OFF OF,

TO DO YOUR ASSIGNMENTS FOR THE
DAY AND STAY ORGANIZED.

LIFE IS PRETTY SIMPLE
WHEN YOU'RE A STUDENT.

YOU HAVE ONE PATIENT
AND YOU PROBABLY

COULD MEMORIZE EVERYTHING
IN YOUR NEUROSIS OF,

YOU KNOW, CARING FOR THEM
FOR THAT DAY.

BUT REAL LIFE IS
SIX, EIGHT, TEN CLIENTS.

HOPEFULLY, BETTER BY THE TIME
YOU GRADUATE, BUT RIGHT NOW
THAT'S THE REALITY.

SO WE'VE GOT TO
GET OURSELVES ORGANIZED.

SO HERE'S THE DEAL.

YOU'RE GOING TO LOOK
AT CONRAD CURRY

AND SEE THAT CONRAD WAS ADMITTED
WITH ALL OF THESE DIAGNOSIS.

AND THESE DIAGNOSIS
ARE REALLY SIGNIFICANT,

BECAUSE YOU CAN'T
ADMINISTER A MEDICATION

IF THERE'S NOT A DIAGNOSIS
TO SUPPORT IT.

SO YOU NEED TO BE ABLE
TO ANSWER THE QUESTION,

WHY IS MY CLIENT
GETTING THIS MEDICATION?

BECAUSE OF SOME DIAGNOSIS THEY
HAVE. SO THAT'S WHY IT'S THERE.

YOU'RE GOING TO LOOK AT THEIR --
THEY HAVE A DIET ORDER.

THEY HAVE ACTIVITIES
LIKE DAILY WEIGHT, I&O.

VITAL SIGNS THEY WANT EVERY
FOURS HOURS. LABS, ALLERGIES.

WHY DID THAT SAY PENICILLIN?

I MUST HAVE HAD A
DIFFERENT CHART BACK --

OH, THIS IS SALLY SMITH'S.

SALLY SMITH HAS
A PENICILLIN ALLERGY.

CONRAD CURRY HAS
A SULFA ALLERGY.

WHAT I'VE DONE FOR MEDICATIONS

AND ALL I WANT YOU TO BE
RESPONSIBLE TO THIS WEEK

IS THESE FIRST THREE MEDS.

THAT'S WHAT WE'RE GOING TO
GIVE THE FIRST WEEK.

AND THAT'S ENOUGH, BELIEVE ME,
TO GET STARTED.

I WANT YOU TO UNDERSTAND
THESE MEDS.

YOU'RE GOING TO MAKE MED CARDS

AND THAT'S WHAT WE'RE
ACTUALLY PREPARING TO DO.

ALRIGHT. WHAT HAPPENS WHEN A
DOCTOR WRITES ORDERS LIKE THIS,

IS THE NURSE OR THE SECRETARY,
SOMEBODY TRANSCRIBES THEM

ONTO A CARDEX, AND ONTO THE
DIFFERENT CHART PAPER

SO THAT WE CAN DO OUR WORK.

WHAT WE WANT TO DO IS GET
OUR NURSING ACTIVITY SHEET.

AND I GAVE YOU A SHEET LIKE THIS
IN YOUR SYLLABUS,

SO THAT YOU CAN BEGIN
TO FILL IT OUT.

AND WHAT YOU WANT TO DO IS BEGIN
TO PUT THE INFORMATION IN

THAT YOU'VE CLEANED
FROM THE DOCTOR'S ORDERS.

EACH LINE IS FOR
A DIFFERENT CLIENT.
YOU HAVE ONE RIGHT NOW.

SO CONRAD CURRY IS THE CLIENT.

I WROTE IN ALL THE DIAGNOSIS.

HYPERTENSION, ASTHMA, DIABETES,
GLAUCOMA, OSTEOMYELITIS.

THE PHYSICIAN IS IM SMART
AND I'M IN ROOM 5 OR BED 5.

ALL THIS INFORMATION
I GOT FROM THE CHART.
DIDN'T MAKE UP A THING.

THE DIET I PUT ON HERE
IS LOW SODIUM.

SULFA. I CAN'T REALLY APPRECIATE
IT, BUT IT'S IN BIG RED PRINT.

I ALWAYS DO ALL OF WRITING
ON MY PAPER IN, LIKE, PENCIL

WHEN I TAKE IT OFF OF THE DOC --
THIS IS WORKSHEET.

THIS IS TRASH TO HELP ME
KEEP ORGANIZED FOR THE DAY.

HELP MY BRAIN, YOU KNOW?

I KEEP EVERYTHING ON THERE
AND I DO IT ALL IN PENCIL
WHEN I TAKE IT OFF THE CHART.

I PUT MY ALLERGIES ALWAYS IN RED
SO I DON'T MISS IT.

I CAN'T MISS ALLERGIES,
VERY CRITICAL.

AND THEN EVERYTHING I DO
FOR THE REST OF THE DAY,

I WRITE IN INK
ON MY LITTLE SHEET

SO THAT I HAVE A WAY OF
DISTINGUISHING MY ACTIVITIES

FROM WHAT I NEEDED TO DO
AND WHAT I NEED TO WRITE
IN THE CHART.

SO IT'S JUST A WAY
THAT I KEEP MY LIFE STRAIGHT.

WE KNOW ACTIVITY IS UP AD LIB.

WHY DOES THAT MATTER
FOR GIVING THAT MEDICATION?

LIKE, "SO WHAT?
I'M GOING TO GIVE HIM A PILL."

SO WHAT? REALLY BIG DEAL.

WE'RE GOING TO GIVE
OUR CLIENT LASIX.

DOES ANYONE KNOW WHAT LASIX IS?

- DIURETIC.
- DIURETIC.

WHAT DOES A DIURETIC DO?
- GOES OUT FOR A --

- MAKES YOU HAVE TO URINATE.

OH, THAT WAS SO PROFESSIONAL.

AND THEY'VE GOT TO GO
AND THEY'VE GOT TO GO FAST.

DON'T YOU WANT TO KNOW HOW
THEY'RE GOING TO GET THERE?

YEAH, DO I NEED TO HAVE
A BEDPAN, BEDSIDE COMMODE?

CAN THEY GET TO THE --
WHAT ARE MY OPTIONS?

THAT'S WHY ACTIVITY IS REALLY
IMPORTANT ON HERE.

VITAL SIGNS, I PUT A TIME DOWN
THAT I NEED TO GET IT.

THIS IS MY Q-SHEET.
AT 8 O'CLOCK, I NEED
VITALS AND AT 12 O'CLOCK.

YOU'RE THE DAY SHIFT. SO MARK
THE TIMES, DON'T JUST WRITE Q4.

WRITE IT DOWN
SO THAT YOU GET THERE.

IT'S LIKE MY GAME,
KIND OF, FILL IN THE BLANKS.

DID I DO EVERYTHING AT THE TIME
I NEEDED TO DO IT?

I NEEDED A WAKE OR I&O.

SO I DO MY "I" AND THAT
I'LL FILL IT IN AT THE
END OF THE DAY.

ANY TOTALS THAT I
NEED TO FILL IN IN "O".

WEIGHT, IF SOMEONE GOT IT
ON THE NIGHT SHIFT.

AND USUALLY, THEY DO WEIGHTS
AT SIX IN THE MORNINGS.

SO DOUBLE CHECK YOUR CHART,
BUT IF NOT, I'LL CATCH IT.

MY ACTIVITY I WROTE HERE.
I WROTE IT TWO PLACES.

IT'S NOT REALLY TREATMENT,
BUT IT CAN GO ANYWAY.

LABS. HE ORDERED
A CBC AND LIGHTS.

CBC IS PRETTY BIG.

AND SO THERE'S REALLY NOTHING
I NEED TO KNOW, EXCEPT I REALLY
LIKE TO KNOW THE H AND H.

I LIKE TO KEEP MYSELF
RESPONSIBLE TO WHAT
ARE THE LABS.

AND IT SEEMS LIKE EVERY TIME
THE LAB IS ORDERED,

I HAVE TO CALL THE DOCTOR
ABOUT SOMETHING ELSE.

LIKE, "OH, THE CLIENT'S
COMPLAINING. THEY HAVEN'T HAD
A BOWEL MOVEMENT FOR 3 DAYS."

SO I CALL THE DOCTOR AND HE
GOES, "YEAH. HOW'S THEIR LAB?
WHAT'S THEIR H AND H?"

EVERY TIME I'VE BEEN BURNED
BY THAT. NOT ANY MORE.

I ALWAYS GET TO THAT CHART
AND I PUT THE BASICS DOWN.

SO WHEN THEY'VE ORDERED A CBC
OR COMPLETE BLOOD COUNT,
ALWAYS CHECK THE H AND H.

AND ELECTROLYTES, ALWAYS GET
YOUR SODIUM AND POTASSIUM.

WHY WOULD SODIUM AND POTASSIUM
BE IMPORTANT?

BECAUSE THEY'RE ON A DIURETIC.

YOU KNOW, START PUTTING
THE PICTURE TOGETHER.

AND I'LL SHOW YOU A LITTLE
BIT MORE OF THE PICTURE
HERE IN A SECOND.

FINALLY, AND I'VE WORKED WITH
THIS SHEET A FEW TIMES,

I KNOW I NEED TO GIVE MEDS
AT PARTICULAR TIMES.

AND I'LL SHOW YOU HOW
I CAME UP WITH THAT.

OKAY. IT'S ONE THING TO
TRANSCRIBE ALL THE INFORMATION
FROM THE CHART,

AND I WANT YOU TO HAVE
THIS NURSE ACTIVITY SHEET

READY TO SHOW ME NEXT WEEK.

BUT WE ALSO NEED TO KNOW
WHEN OUR MEDS ARE DUE.

SO THERE ARE TWO MED BOOKS.

ONE'S ON THE MEDICATION CART
AND ONE'S ON THE COUNTER.

AND INSIDE THE MED BOOK --

WE HAVE IT DIVIDED
BY BED 1, 2, 3 AND 4.

AND INSIDE ARE GOING TO BE
TONS OF MED SHEETS.

TONS. THEY'RE ALL THE SAME.

AND THEY'LL LOOK LIKE THIS.

AFTER THE DOCTOR WROTE
THE ORDER FOR LASIX,

PHARMACY IS GOING TO
GENERATE WHAT'S CALLED

A MEDICATION ADMINISTRATION
RECORD, AN MAR.

ON THIS MEDICATION
ADMINISTRATION RECORD,

THE DRUGS THAT THE DOCTOR
HAS ORDERED SHOULD BE HERE

AND THE TIMES THEY
SHOULD BE GIVEN.

PHARMACY CAN DECIDE,
YOU CAN DECIDE

OR THE DOCTOR CAN DECIDE
WHAT TIMES TO GIVE 'EM.

OKAY? SO IF THE LASIX
WAS ORDERED "BID",

HOW DID THEY COME UP
WITH 8 AND 2?

I MEAN, DO YOU JUST PICK ANY OLD
TIME WILLY-NILLY KIND OF THING?

NO. MOST OF THE TIME
HOSPITALS DEFINE THEIR TIME

SO THAT THERE'S UNIFORMITY.

SO A DRUG THAT NEEDS
TO BE GIVEN EVERYDAY,

WE GIVE ALL OUR DAILIES
AT 8 O'CLOCK.

DRUGS THAT NEED TO BE
GIVEN TWICE A DAY,

WE MIGHT GIVE AT 8 AND 5.

DRUGS THAT NEED TO BE
GIVEN AT Q6 HOURS,

WE'LL GIVE IT 12, 6, 12, 6.

THEY'LL HAVE IT POSTED
IN THE MEDICATION ROOM,

SO START LOOKING FOR SOME
OF THOSE CLUES AS TO HOW
THEY DECIDE IT.

NOW I SAID TWICE-A-DAY DRUGS
ARE USUALLY GIVEN,

LIKE 8 AND 8 MAYBE.

WOULD YOU WANT TO GIVE LASIX AT
8 IN THE MORNING AND 8 AT NIGHT?

THAT WOULD BE CRUEL.
THEY COULDN'T SLEEP.

THEY WOULD BE GETTING UP
PEEING ALL NIGHT LONG.

SO WE'RE GOING TO SWITCH IT
AND SOMETIMES WE GIVE IT,

LIKE AT 6 AND NOON, 8 AND 2,

BUT BEFORE THE EVENING MEAL.

I MEAN, EARLY ENOUGH IN THE DAY
THAT THEY ARE DONE URINATING

SO THEY CAN GET
A GOOD NIGHT'S REST.

AND SO THAT WAS THE TIME
THAT THIS INSTITUTION
PICKED 8 AND 2.

ALRIGHT? AND THEN POTASSIUM
CHLORIDE WAS ORDERED "BID".

AND WE KNOW THAT WE'RE GOING TO
GIVE POTASSIUM WITH LASIX

BECAUSE LASIX IS A DIURETIC
AND IT IS GOING TO
PULL OFF POTASSIUM.

I'M GOING TO SHOW YOU HOW YOU
FIND THAT INFORMATION
IN A SECOND.

SO WE'RE GOING TO GIVE IT
AT THE SAME TIMES.

ALRIGHT. WHAT HAPPENS
ONCE YOU COME TO THE CHART

AND YOU CHECK THE CHART
AGAINST THE DOCTOR'S ORDERS.

THIS IS SAINT AGNES' SHEET.

I HAVE TO PUT MY INITIALS
ON HERE.

IT SAYS RN CHECKED.
THAT MEANS THAT I HAVE CHECKED

THAT THE ORDERS WRITTEN
ON THIS SHEET

MATCH THE ORDERS WRITTEN
ON THIS SHEET.

YOU CAN'T JUST GIVE SOMETHING.

JUST BECAUSE IT'S WRITTEN
ON THE MAR,

IT DOESN'T MAKE IT RIGHT.

IT'S RIGHT BECAUSE WE CHECK IT
AGAINST THE ORDERS.

THEN IT GOT TRANSCRIBED RIGHT.

WE'RE JUST PEOPLE.
PEOPLE DOUBLE-CHECKING PEOPLE

TO MAKE SURE THAT
WE GET IT STRAIGHT, ALRIGHT?

SO ON YOUR WORKSHEET NOW, I WANT
YOU TO BE MENTALLY THINKING,

NO MATTER WHAT TIME
YOUR APPOINTMENT IS,

YOU'RE GIVING 8 O'CLOCK MEDS.

THAT'S YOUR ASSIGNMENT
FOR THE DAY.

SO ON MY LITTLE ACTIVITY SHEET
THAT I'VE BEEN CREATING,

I AM GOING TO COME OVER HERE AND
GIVE MYSELF A COUPLE OF CLUES.

I'M GOING TO GIVE
TWO 8 O'CLOCK MEDS.

THAT'S GOING TO HELP ME KNOW
THAT AT 8 O'CLOCK,

I HAVE GOT MEDS TO GIVE.

I'VE GOT THINGS TO DO,
PLACES TO GO.

OKAY? SO GIVE YOURSELF
SOME CLUES.

THIS IS FOR MY OTHER DAYS.

WE'RE GOING TO KEEP THE SAME
SHEET FOR THREE WEEKS

AND WE'RE KEEP GIVING
DIFFERENT TIMES AND MEDS.

ALRIGHT, SO MY TWO 8S UP HERE.

YOU CAN ALSO WRITE LASIX
ACROSS HERE TO REMIND YOURSELF.

AND YOU CAN SAY POTASSIUM
TO, KIND OF, GIVE YOURSELF
A HEADS UP IF YOU WANT

OR YOU CAN JUST PUT TIMES
FOR YOUR WORKSHEET.

THIS IS TO HELP YOU GET
INTO RIGHT PLACES.

NOW, IS THE SHEET THAT THEY
HAVE AT EVERY HOSPITAL?

NO. THIS IS MY WORKSHEET
THAT I CREATED OVER THE YEARS.

I DEVELOPED IT JUST BECAUSE I --

OTHER NURSES HAD SOME GOOD STUFF
AND I HAD SOME GOOD STUFF

AND I MADE A GOOD THING
THAT I LIKE WORKING WITH.

SO USE IT, TRY IT, YOU MAY
LIKE IT AFTER YOU GRADUATE.

YOU MAY FIND SOMETHING BETTER.
YOU MAY WANT TO SWITCH IT UP
FOR YOURSELF.

BUT WE'LL WORK WITH A LITTLE
SO YOU HAVE SOMETHING TO DO.

ALRIGHT.
YOU HAVE YOUR WORKSHEET.

I WANT YOU TO BE PREPARED TO
JUST HAVE YOUR ACTIVITIES
IN YOUR MIND.

WHAT ARE YOU GOING TO DO?

YOU'VE CHECKED YOUR ORDERS.
YOU'VE CHECKED YOUR MARS.

DID YOU NOTICE THERE WERE THREE
DRUGS ON THE DOCTOR'S ORDERS

THAT YOU'RE SUPPOSED TO GIVE...

THIS FIRST WEEK.

LASIX, POTASSIUM AND DARVOCET.

BUT ONLY TWO WERE ON THIS SHEET.

BECAUSE LASIX AND --

TOO MANY SHEETS.

LASIX AND POTASSIUM
ARE ROUTINE MEDS.

THEY'RE ORDERED REGULARLY
AT "BID", REGULAR INTERVALS.

BUT DARVOCET IS A PRN MED.
WHAT DOES PRN MEAN?

- AS NEEDED.
- AS NEEDED.

AND IT'S AS NEEDED FOR PAIN.

SO IT'S GOING TO BE
ON A DIFFERENT SHEET.

IT'S GOING TO BE
ON THE PRN SHEET.

THEY'RE USUALLY A
COLORED SHEET, LIKE PINK.

AND SO THAT WE
KEEP THEM SEPARATE.

SO ROUTINE MEDS GO ON ONE SHEET,
SO THAT THEY DON'T GET MESSED.

AND PRN MEDS GO ON
THEIR OWN SHEET,

SO THAT WE CAN LOOK
AND SEE WHAT'S AS NEEDED.

WHAT'S AVAILABLE FOR THE CLIENT
AS THEY NEED IT.

LIKE LAXATIVES, PAIN MEDS,
THAT KIND OF STUFF.

SO MAKE SURE YOU CHECK
BOTH SHEETS FOR YOUR DRUGS.

ALRIGHT. SO YOU HAVE AN
ACTIVITY SHEET READY TO GO,

YOU'VE BEEN IN THE CHART,
YOU'VE CHECKED YOUR ORDERS.

THERE'S ONE OTHER THING
YOU NEED TO DO TO GET READY

BEFORE WE EVEN TALK
ABOUT HOW TO GIVE MEDS

AND THAT IS MAKE A MED CARD.

AND YOU GUYS WANT TO HIT THE
LIGHTS AND TURN THEM ON AGAIN.

AND I'LL SHOW YOU
A SAMPLE MED CARD.

WE'RE FINALLY GOING TO GET
TO YOUR MED BOOK.

DID YOU ALL GET THIS WONDERFUL
-- DAVE IS MY FAVORITE.

LOUISE LIKES MOSBY,
BUT SHE LETS ME GET DAVIS.

DAVIS BOOK.

I DON'T REALLY HAVE
A LOT OF TIME TO EXPLAIN
HOW THE BOOK WORKS,

BUT I'M JUST GOING TO GIVE YOU
THE, KIND OF, DOWN AND DIRTY
ON THE BOOK.

YOU CAN FIGURE OUT BOOKS.

BUT A COUPLE FEATURES
OF THE BOOK THAT I THINK
ARE REAL IMPORTANT

IS THE VERY FIRST FEW PAGES.
IT SAYS HOW TO USE THE BOOK.

OKAY? I LIKE IT.
IT'S PRETTY STRAIGHTFORWARD.

BUT IT TELLS YOU
WHAT BOLD PRINT MEANS,

WHAT ITALICS MEANS,
WHAT HEADINGS MEANS.

HOW TO FIND DRUGS
BY GENERIC NAME.

HOW TO FIND THEM BY TRADE NAME.

HOW TO FIND THEM
BY CLASSIFICATION.

WHAT'S THE DIFFERENCE
IN DRUG CLASSIFICATION
VERSUS A DRUG NAME.

IT GIVES YOU SOME GOOD
DEFINITION OF YOUR DRUGS.

OKAY? WHAT WE'RE GOING TO
DO IS MAKE A DRUG CARD
FOR EVERY DRUG YOU GIVE.

YOU NEVER GIVE A DRUG IF YOU
DON'T KNOW ANYTHING ABOUT IT.

NEVER.
DON'T DO IT.

YOU'RE GOING TO ALWAYS KNOW
SOMETHING ABOUT A DRUG.

YOU CAN ALWAYS MAKE A QUICK
CHECK IN THE HOSPITAL.

GRAB A PDR, A PHYSICIAN'S DESK
REFERENCE OR A NURSING BOOK

TO FIND OUT WHAT
IS THIS DRUG ALL ABOUT.

WHAT I WANT YOU TO DO
IS MAKE CARDS

AND I WANT THE CARDS
TO BE AT LEAST 5 BY 7.

DON'T GET THOSE LITTLE,
YOU KNOW,

3 BY 5 TEENY, TINY CARDS AND
WRITE IN YOUR TINIEST PRINT.

GET SOMETHING THAT'S USABLE.
5 BY 7.

I DON'T WANT YOU TO USE
THE PRE-PRINTED CARDS.

YOU'RE GOING,
"WHAT'S THE POINT THEN?"

THE POINT IS I WANT YOU TO
LEAN OUT THE RIGHT INFORMATION
OUT OF THE BOOK.

YOU DON'T NEED EVERYTHING
OUT OF THE BOOK,

YOU NEED WHAT'S PERTINENT
FOR YOUR CLIENT.

SO I WANT YOU TO GET
INTO THE BOOK AND WRITE A CARD

WITH INFORMATION THAT YOU NEED
TO KNOW AS A LEARNING EXERCISE.

I DON'T EVEN WANT YOU TO COPY
A CARD AND HIGHLIGHT IT.

I WANT YOU TO WRITE OR TYPE
THE INFORMATION YOURSELF

THAT YOU WOULD WANT
FOR THIS MED.

ALL OF YOUR DRUG CARDS NEED TO
HAVE THIS BASIC INFORMATION

AND I LISTED IT
IN YOUR SYLLABUS.

YOU NEED TO HAVE THE DRUG.

AND I TRY TO LIST
ALL MY DRUG CARDS.

GET 'EM UNIFORMED BECAUSE YOU'RE
GOING TO BE USING DRUG CARDS FOR
THE REST OF YOUR LIFE.

SO START, KIND OF, FINDING
YOURSELF AND A STYLE THAT GIVES
YOU GOOD INFORMATION.

BUT IF YOU GET THE HABIT
OF PUTTING YOUR GENERIC FIRST
AND YOUR TRADE SECOND,

IT'S JUST --
IT WILL KEEP YOU STRAIGHT.

BECAUSE DOCTORS USE BOTH
WHEN THEY REFER TO DRUGS.

THEY WILL USE THE GENERIC NAME.
YOU'RE FAMILIAR WITH GENERICS.

IT'S THE CHEMICAL
COMPLEX NAME VERSUS THE
MANUFACTURER'S NAME.

YOU KNOW THE DOCTOR, IF YOU BUY
GENERICS, THEY'RE CHEAPER,

THAN IF YOU BUY ELI LILLY'S
SPECIALTY DRUG,

IT'S ALWAYS MORE EXPENSIVE.

AND SO YOU NEED TO KNOW
BOTH NAMES.

WE NEED TO KNOW
WHAT THE DRUG IS FOR.

I ADDED --
THIS WASN'T ON YOUR SHEET,

BUT THIS IS AN IMPORTANT TITLE,
CONTRAINDICATIONS.

YOU NEED TO KNOW ADVERSE
REACTIONS OR SIDE EFFECTS.

YOU NEED TO KNOW THE DOSE

AND YOU NEED TO KNOW
NURSING IMPLICATIONS.

SO LET'S JUST TALK
ABOUT THESE BRIEFLY.

WHEN YOU GET INTO YOUR BOOK,
YOU CAN FIND IN THE BACK
OF THE INDEX,

MOST OF YOUR DRUGS ARE LISTED
BY TRADE OR GENERIC.

EITHER NAME IS IN HERE.

SO ONCE YOU FIND IT,
THEN YOU GO TO THE PAGES.

THE DRUGS ARE THEN ACTUALLY
ALPHABETICAL BY CLASSIFICATION.

SO START NOTICING WHAT'S
THE CLASSIFICATION OF DRUG

WHEN YOU GET IN HERE.

OKAY. WELL, I'M IN THE
LOOP DIURETIC SECTION.

AND THAT'S IMPORTANT. THAT'S THE
CLASSIFICATION OF DRUGS.

SO ONCE YOU FIND YOUR DRUG,
IT TELLS YOU YOU'VE GOT
A LOOP DIURETIC.

IT TELLS YOU HOW TO
PRONOUNCE ALL THESE NAMES.

BUT WHEN YOU'RE LOOKING HERE
IN THIS RED BOX,

THERE'S BUTAMIDE, FUROSEMIDE
AND TORSEMIDE.

YOU NEED TO MAKE SURE THAT
YOU'RE FINDING SPECIFIC
INFORMATION RELATED TO YOUR DRUG

BECAUSE IT'S GOING TO HAVE
SPECIFICS ABOUT EACH
OF THESE DRUGS

AND YOU DON'T WANT TO BE
IN THE WRONG COLUMN.

OKAY. SO WE HAVE OUR GENERIC,
WE HAVE OUR TRADE,
INDICATION AND ACTION.

THIS IS WHAT I PUT DOWN.
USE A LOT OF ABBREVIATIONS,

YOU DON'T HAVE TO WRITE
ALL THOSE WORDS OUT.

IT'S YOUR CARD
SO MAKE IT WORK FOR YOU.

IT'S PRETTY STRAIGHTFORWARD
OVER HERE.

IT TELLS YOU NEED TO KNOW.

I DIDN'T BOTHER WITH WRITING
UNLABELLED USES.

I'M NOT DOING IT FOR MANAGEMENT
OF HYPERCALCEMIA OF MALIGNANCY.

SO, I'M --
THAT'S NOT MY PROBLEM.

WHAT WAS MY CLIENT'S DIAGNOSIS,
DO YOU REMEMBER?

- HYPERTENSION.
- HYPERTENSION.

SOME OF YOU ARE GOING TO
HAVE HYPERTENSION

AND SOME OF YOU
ARE GOING TO HAVE CHF
FOR YOUR CLIENT'S DIAGNOSIS.

SO FIND THEIR DIAGNOSIS
AND FIND INFORMATION AND GO,

"OH, MY CLIENT'S GETTING IT
FOR HYPERTENSION.

IT'S A DIURETIC IT INHABITS
THE REABSORPTION OF SODIUM
AND POTASSIUM.

IT'S A LOOP OF HENLEY DRUG.
THAT'S REALLY IMPORTANT.

IT'S A KIDNEY DRUG.
YOU'LL STUDY MORE OF THAT LATER.

BUT IT INCREASES THE SECRETION.

IT HELPS TO MOVE OUT WATER,
SODIUM AND SO FORTH.

OKAY. SO WE KNOW, KIND OF,
HOW IT WORKS.

IT KEEPS -- IT KEEPS THEM
FROM ABSORBING SODIUM.

WHAT DOES SODIUM DO?

DRAWS WATER TO ITSELF
AND THAT HELPS TO RETAIN WATER.

SO WE NEED SOMETHING
THAT GETS RID OF SODIUM,

SO THEY'LL LOSE WATER.
THAT'S THE PROBLEM.

OKAY. CONTRAINDICATION.

HYPERSENSITIVITY TO A COUPLE
OF DRUG TYPES.

THIAZIDES AND SULFONAMIDES.

WHAT DID I SAY WAS
AN ALLERGY IN OUR...

- SULFA.
- IN OUR INSTITUTION?

SULFA. MAKE SURE YOU KNOW
IF YOUR CLIENT CAN TAKE
THIS DRUG OR NOT.

OKAY? SO LOOK AT THAT.

ADVERSE REACTIONS.
OH, MY GOODNESS, THERE'S TONS.

SO DON'T WASTE YOUR TIME WITH
NAUSEA, VOMITING AND DIARRHEA.

EVERYONE CAN HAVE THAT.
LOOK AT WHAT'S PERTINENT
TO A DIURETIC.

WHAT DO YOU THINK WOULD HAPPEN
JUST NATURALLY?

- DEHYDRATION.
- DEHYDRATION.

WHAT ABOUT VITAL SIGNS?

- LOW AND LOW. DROP.

- DROP OF WHAT?
- BLOOD PRESSURE.

- BLOOD PRESSURE.
WHAT ABOUT PULSE?