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.
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.
WHAT ABOUT PULSE?
- INCREASE. - INCREASE.
OKAY? SO START MAKING SENSE OF WHAT WOULD NATURALLY HAPPEN
BECAUSE OF A DIURETIC AND THEN MAKES SENSE HERE.
SO WE KNOW, DEHYDRATION. ELECTROLYTES ARE GOING TO DROP.
HYPOBULIMIA, LOW BLOOD PRESSURE.
BECAUSE OF THE SULFA COMPONENT, PHOTOSENSITIVITY, RASHES.
AND THEN IF THEY ARE TOXIC.
AND IT TELLS A LITTLE BIT LATER WHY I PICKED THESE,
BECAUSE THESE WEREN'T EVEN UNDERLINED.
BUT EVENTUALLY, IF YOU GOT TOXIC,
YOU CAN GET SOME TINNITUS AND HEARING LOSS.
SO I WOULD LIKE TO JUST MAKE SURE I REMEMBERING THAT.
WHEN YOU COME DOWN TO DOSE,
LOOK AT THE DOSE PERTINENT TO YOUR DIAGNOSIS.
FOR EXAMPLE, IF YOU'RE USING IT AS A DIURETIC --
WHICH ONE WOULD BE THE DIURETIC?
CHF OR HYPERTENSION?
- CHF. - PROBABLY CHF.
THEN YOU NEED A DOSE OF 20 TO 80MG PER DAY, UP TO 600MG PER DAY.
BECAUSE I'M GOING TO ASK YOU, "ARE YOU GIVING A SAFE DOSE?"
AND YOU'RE GOING TO COME OVER TO YOUR MAR AGAIN
AND GO, "OH, YES. I'M GIVING LASIX 40MG PO BID. IS THAT SAFE?"
- 40 BID. - WHAT'S THE 80?
- 80? - YES.
- 80 PER DAY, IT'S A SAFE DOSE.
NOW I'M JUST GOING TO TELL YOU RIGHT NOW,
I DON'T ORDER SAFE DOSES ALL THE TIME.
BECAUSE I WANT YOU TO PAY ATTENTION AND GO,
"OH, THIS ISN'T RECOMMENDED."
I'VE BUILT IT IN THAT WAY.
SO WE CAN TALK ABOUT WHAT TO DO WHEN THINGS AREN'T EXACTLY LIKE THEY'RE SUPPOSED TO BE.
HYPERTENSION, HERE'S YOUR DOSE RANGE.
AND THEN NURSING IMPLICATIONS.
PROBABLY ONE OF MY FAVORITE SECTION
IS "SO WHAT DO I DO? I'M THE NURSE, I'M IN CHARGE."
YOU HAVE SOME THINGS THAT YOU WILL -- YOU NEED TO DO.
AND THAT IS THAT YOU'RE GOING TO MAKE SOME ASSESSMENTS,
WHETHER THE DOCTOR ORDERS IT OR NOT.
HE WAS NICE. HE ORDERED A DAILY WEIGHT AND I&O.
BUT IF HE DIDN'T, YOU CAN DO THAT WITHOUT A DOCTOR'S ORDER.
IT'S NOT IN ANYWAY INVASIVE. IT'S GOOD NURSING.
SO YOU'RE GOING TO GET DAILY WEIGHTS, I&O,
CHECK FOR EDEMA, ASSESS LUNGS,
CHECK SKIN TURGOR. HE DIDN'T ORDER SKIN TURGOR.
YOU CAN GIVE A LITTLE PINCH, YOU KNOW, AND CHECK.
MUCOUS MEMBRANES, GET VITAL SIGNS, LABS.
THESE PARTICULAR THINGS MIGHT BE EFFECTIVE.
GIVE THE DRUG WITH FOOD, IT CAUSES NAUSEA.
GIVE IT IN THE MORNING, IT TOLD US THAT.
WATCH FOR ORTHOSTATIC CHANGES.
WHAT'S THAT? ORTHOSTATIC, HYPOTENSION.
- BLOOD PRESSURE. - BLOOD PRESSURE DROPS WITH?
- CHANGE IN POSITION. - CHANGE IN POSITION.
FROM? - SITTING FOR MORE THAN 5 YEARS.
- UH-HUH. AND SO THEIR BLOOD PRESSURE DROPS, HOW MUCH?
- 25. - 25 OR MORE.
DIET, HIGH IN POTASSIUM.
RIGHT? BECAUSE WHAT IS THIS DOING?
IT'S PULLING OFF POTASSIUM.
WE GOT TO REPLACE IT OR THEY GET INTO A HEART TROUBLE.
SUNSCREEN, RELATED TO THE PHOTOSENSITIVITY,
ALL SULFA DRUGS AND CALL DOCTOR IF MUSCLE CRAMPS.
SO THAT'S JUST A FEW OF THE THINGS THAT I HAVE CLEANED OUT
AND THAT'S WHAT I'M LOOKING FOR ON YOUR CARD.
- YOU CAN ORDER LABS WITHOUT A DOCTOR'S PRESCRIPTION?
- NO, BUT YOU WOULD WANT TO BE CHECKING.
HE ORDERED THE CBC AND LIGHTS AND YOU'RE GOING,
"THAT'S NICE. WHAT AM I LOOKING AT?"
YOU'RE LOOKING FOR THAT SODIUM AND POTASSIUM
AND THAT'S WHY I PULLED IT OFF FROM MY WORKSHEET. YES?
- IF WE CANNOT ADMINISTER A DRUG THAT WE DO NOT KNOW ANYTHING ABOUT,
WITHOUT A DOCTOR, THEN IT FALLS ON US.
- YEAH. OH, YEAH.
IT'S YOUR RESPONSIBILITY TO FOLLOW UP ON THE DRUG. I DON'T GET ANY --
OH, I TAKE THAT BACK. THERE'S HARDLY ANY ABSOLUTES.
I MAY HAVE GIVEN ONE THAT I DIDN'T KNOW.
THE CLIENT HAD BEEN TAKING IT ALL HER LIFE
AND I JUST COULDN'T FIND INFORMATION RIGHT AWAY.
SO I GAVE IT AND FOLLOWED UP. IT'S BAD NURSING. IT'S BAD.
I KNEW BETTER. I JUST WAS OUT OF TIME.
BUT MY RULE AND 99.9% OF THE TIME,
I LOOK UP MY DRUG AND THE DOSE BEFORE I GIVE IT.
BECAUSE IT'S MY RESPONSIBILITY.
SO THE WHOLE GOAL OF IT IS THAT YOU JUST GET INTO THE PAPERWORK OF IT,
PORTION AND BE A LITTLE FAMILIAR.
AND THEN YOU'RE GOING TO SHOW ME YOUR PAPERWORK.
I WANT TO SEE YOUR CARDS AND YOUR WORKSHEET
AND THAT MEANS, "OKAY, GOOD. THEY'VE BEEN AT THEIR CHART.
THEY'RE READY NOW TO HEAR ABOUT HOW WE'RE GOING TO GET THE DRUG."
OKAY? ALRIGHT, IF YOU NEED TO GO TO THE BATHROOM, WE'LL TAKE FIVE.