CU-PPT-23.pdf - • Ensure that supplies are available for...

This preview shows page 1 out of 1 page.

Unformatted text preview: • Ensure that supplies are available for the next suctioning (suction kit, gloves, water or normal saline). 13. Assess the effectiveness of suctioning. • Auscultate the client's breath sounds to ensure they are clear of secretions. Observe skin color, dyspnea, level of anxiety, and oxygen saturation levels. 14. Document relevant data. Record the procedure: the amount, ccnsistency, color, and odor of sputum (e.g., foamy, white mucus; thick, greentinged mucus; or blood-flecked mucus) and the client's respiratory status before and after the procedure. This may include lung sounds, rate and character of breathing, and oxygen saturation. If the procedure is carried out frequently (e.g., every hour), it may be appropriate to record only once, at the end of the shift; however, the frequency of the suctioning must be recorded. SAMPLE DOCUMENTATION @ A sputum collection trap. 12/12/2015 0830 Producing large amounts of thick, tenacious white mucus to back of oral pharynx but unable to expectorate into tissue. Uses Yankauer suction tube as needed. O sat increased from 89% before suctioning to 93% after suctioning. RR also decreased from 26 to 18-20 after suctioning. Lungs clear to auscultation throughout all lobes. Continuous O, at 2 L/min via n/c. Will continue to reassess q hour. ---------------L. Webb, RN EVALUATION • Conduct appropriate follow-up, such as appearance of secretions suctioned; breath sounds; respiratory rate, rhythm, and depth; pulse rate and rhythm; and skin color. • Compare findings to previous assessment data if available. Report significant deviations from normal to the primary care provider. I WORKSHEET Direction: Accomplish the worksheet. Johti Singh is a 39-year-old secretary who was admitted to the hospital with an elevated temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals that Ms. Singh has had a “bad cold” for several weeks that just wouldn’t go away. She has been dieting for several months and skipping meals. Ms. Singh mentions that in addition to her full-time job as a secretary she is attending college classes two evenings a week. She has smoked one package of cigarettes per day since she was 18 years old. Chest x-ray confirms pneumonia. Physical Examination Height: 167.6 cm (5960) Weight: 54.4 kg (120 lb) Temperature: 39.4°C (103°F) Pulse: 68 beats/min Respirations: 24/min Blood pressure: 118/70 mmHg ...
View Full Document

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture