NURSING NUR 3227 Compiled study guide_ Already Graded A+
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Final Exam Study Guide Respiratory Normal values pH: 7.35-7.45 PCO2: 35-45 PO2: >80 mm Hg HCO3-: 22-26 mEq/L Assessing: 1. First note pH: 2. Determine primary cause of disturbance a. Alkalo sis b. Aci... dosis 3. Determine if compensation has begun Chest Tubes- 1. Procedure: a. Fill water-seal chamber with sterile water to the 2-cm level b. If suction is to be used, fill the suction control chamber with sterile water to the 20-cm level, or as ordered by the health care provider c. Encourage the client to change position frequently d. The drainage system must be maintained below the level of insertion e. Chest tubes are clamped only momentarily to check for air leaks and to change the drainage apparatus f. Observe for fluctuations of fluid in water-seal chamber g. Gently milk tubing in the direction of drainage as needed if agency policy allows h. When the health care provider removes the chest tubes, the nurse should instruct the client to do the Valsalva maneuver (forcibly bearing down while holding breath); the chest tube is clamped and quickly removed by the health care provider; an occlusive dressing is applied to the site 2. Complicaitons: a. Observe for constant bubbling in the water-seal chamber; this indicates a leak in the drainage system b. If the chest tube becomes dislodged, apply pressure over the insertion site with a dressing that is tented on one side to allow for escape of air c. If the tube becomes disconnected from the drainage system, cut the contaminated tip off the tubing, insert a sterile connector, reattach to the drainage system; or immerse the end of the chest tube in 2 cm of sterile water until the system can be reestablished Cystic Fibrosis-Hereditary dysfunction of exocrine glands, causing production of abnormally thick mucus secretions [Show More]
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