Chest Tubes: Management and Care
- Confirm suction order
- Crepitus
- Kinking
- Shortness of Breath (SOB)
- Infection
- Excessive bubbling
- If tube dislodges from patient, use petroleum gauze taped 3 ways
- If drainage system is damaged, place disconnected drainage tube in sterile water
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
Oxygen Delivery Methods
- Nasal Cannula
- Simple Face Mask
- Non-Rebreather Mask
- Venturi-Mask
- Oxygen In Use Sign
- No Electrical Sparks
- Six Feet Away from Open Flames
- Dry Nasal and Upper Airway Mucosa
- Skin Irritation
- Home Education
Tracheostomy Care
- Inner Cannula Removed and Cleaned
- Clean Q8 Hours Around Stoma
- One Finger Under Ties
- Speak with Deflated Cuff
- Can Eat with Tube in Place
- Keep Replacement Tube Nearby
- Immediately Replace if Dislodged
- Physician Does First Tube Change
Rule of 9's for Burns
- Total Body Surface Area (TBSA)
- Head
- Chest
- Abdomen
- Upper Back
- Lower Back
- Posterior Leg (each)
- Anterior Leg (each)
- Each Arm
- Genitalia 1%
Parkland Formula
- Burn victims
- 24 hours
- TBSA %
- x Weight (kg)
- x 4
- = Fluid Requirement (in first 24 hrs)
- 1/2 of fluid given in first 8 hours
Wound Drainage Types and Devices
- Serous
- Serosanguineous
- Sanguineous
- Purulent
- T-tube
- Penrose
- Jackson-Pratt (JP)
- Hemovac
- Record Drainage Amounts
- Check Device Function
Neurovascular Assessment 6 P's
- Pain
- Paresthesia
- Pulse
- Pallor
- Pressure
- Paralysis