ENDOTRACHEAL TUBE: PARTS, TYPES AND FUNCTIONS.

 

DESCRIPTION:
Endotracheal tube (ETT) is a flexible plastic tube, usually made of polyvinyl chloride (PVC), that is passed into trachea through the mouth (oral) or nose (nasal) to establish a patent airway and ensure adequate gaseous exchange or ventilation. It is also used to deliver or administer anaesthetic gases to patients during surgery.

DIAMETER AND LENGTH/DEPTH OF ENDOTRACHEAL TUBE.
Endotracheal tube has inner and outer diameter.  The inner diameter (ID) is the diameter of the tube lumen while the outer diameter (OD) measures the diameter of the lumen and the thickness of the tube. The size of the tube is determined by the inner diameter. For instance, if the inner diameter of a tube is 7.5mm, the tube is size 7.5.
The length/depth of the tube is how far the tube goes into the patient during intubation. The normal length for adult male is 21-22cm while that of adult female is 20-21cm. The landmark for setting the the tube at the appropriate length is the incisor or the lips. It is important to document the length used for the intubated patient. This helps to know if the tube is coming outwards or going inside, and appropriate actions taken.

PARTS OF ENDOTRACHEAL TUBE.
BEVEL: This is slant portion found at the tip/edge of the tube. The bevel is usually LEFT-FACING instead of RIGHT-FACING. This helps easy visualization of the vocal cords during intubation and easy access into the trachea.
MURPHY’S EYE: This is an extra opening at the tip of the tube that sustains ventilation or gaseous exchange peradventure the bevel becomes obstructed by secretions or tracheal wall.
CUFF: Endotracheal tube can either be cuffed or uncuffed. Paediatrics tubes are usually uncuffed because their tracheal is easily damaged by pressure. However, children above 6years can cope with cuffed ETT. The cuff (located proximal to the tip of the tube inside the patient) is inflated by injecting pressurized air in a syringe into the PILOT BALLOON. The air will not leak even after the inflating syringe has been removed because of the ONE-WAY VALVE in the the pilot balloon. The pilot balloon, which remains outside after patient has been intubated, shows the true condition/status of the cuff (inside the patient)- whether it is inflated or deflated or leaking.

TYPES OF CUFF.
High volume – low pressure cuff and Low volume – high pressure cuff.

IMPORTANCE OF INFLATING THE CUFF.
1. To ensure good positive pressure ventilation, especially for patients on mechanical ventilator. The inflated cuff forms a seal on the tracheal wall, thus preventing leakage of air during ventilation.
2. To prevent aspiration of regurgitated gastric content.

However, care must be taken to avoid too much or too little pressurized air. The tracheal cuff pressure must be maintained between 20-25cm of water. If the pressure exceeds 30cm of water, the cuff may burst! A MANUAL MANOMETER can be used to measure cuff pressure. In facilities where this instrument is not available, 5-10ml of air is usually injected into the pilot balloon to inflate cuff.
NOTE: “Centimetres of water” as used here, is the unit of measurement of PRESSURE. It doesn’t mean water will be used for inflation. ONLY AIR MUST BE USED TO INFLATE CUFF!

WHAT HAPPENS WHEN THE TRACHEAL CUFF PRESSURE IS TOO HIGH?
A very high tracheal cuff pressure impedes blood flow to the tracheal wall and causes tracheal ischemia or necrosis.

AND IF THE TRACHEAL CUFF PRESSURE IS TOO LOW?
Risk for aspiration is high and positive pressure ventilation will not be effective as there may be leakage of air.

RADIO-OPAQUE LINE:
The endotracheal tube is a colourless plastic tube which cannot be visible on X-ray. However, for this purpose, a radio-opaque blue line runs longitudinally throughout the length of the tube to make it visible or seen on chest X-ray.

OTHER TYPES OF ENDOTRACHEAL TUBE INCLUDE:
Armoured or reinforced endotracheal tube.
Laser-resistant endotracheal tube.
Double lumen endotracheal tube.
Preformed endotracheal tube e.g. RAE – Ring, Adair, and Elwyn.

 

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RE-AWAKENING THE ACT OF CLINICAL NURSING HANDOVER

In a clinical setting, the term “handover” may be used interchangeably with shift change, handoff, sign out, cross coverage or shift report.

According to Australian Medical Association (2006), clinical handover refers to the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.

Handover report (verbal and written) is a tradition in Nursing profession that must be sustained and emphasized from time to time. It is worthy of note that handover report must be communicated verbally alongside a well written documentation of the report (written). And one must not contradict the other. This usually takes place at the end of every shift or during patient transfer.

A good handover is centered on enhancing continuity of patient’s care and ensuring patient’s safety. The link/connection is that continuity of clinical information is vital to patient’s safety, hence a need to be deliberate and proactive about it.

Clinical nursing handover must be seen beyond just the transfer information, but also as the transfer of responsibility and accountability of patient’s care from the outgoing nurses to the incoming nurses. Thus, effective communication is a sine qua non to attaining a good handover practice. And effective communication in turn helps in the delivery of high quality care and ensures patient’s safety.

Evidence shows that ineffective shift handover increases the risk of medication error and sentinel events, delays the course of treatment, decreases patient satisfaction, prolongs the length of hospital stay, thus increases expenditure.

The nurse, being a major stakeholder in the healthcare team, is saddled with the responsibility of mastering the dynamics of effective communication in passing across vital clinical information about the patients to her professional colleagues as well as other professionals in the healthcare team involved in patient’s care.

It is important to note that the group of nurses who are just resuming duty do not know what has happened in the previous shift. Hence, a need to be proficient in communicating and transferring clinical information in a clear, simple and unambiguous manner. Rapt attention is needed so as not to miss out on the information being passed across. Handover time must be seen as sacrosanct for all nurses because it determines how the subsequent shift would go. Incomplete tasks that need to be completed, treatment plan that is yet to be executed, investigations that must be carried out, medications that have been discontinued, patients that have been discharged – these and many others are communicated during handover.

Handover report must be detailed yet concise. The nurse must avoid beating about the bush. A well structured tool (such as ISoBAR and the likes) must be devised to help cluster and organize information to be passed on. The nursing process is another very good tool that enhances a structured handover report, as it gives a step by step (systematic) approach to the report being given and helps in prioritizing the patient needs. When a report is detailed and organized, the listeners will not be bored. If it’s brief, it’ll be interesting too.

Also, a detailed report minimizes questions since almost all relevant information pertaining to patient has been given. There will be little or no question to be asked, except for clarification.

The nurse must also endeavour to be audible. It’s frustrating to keep straining the ears during handover report. It delays the report because the listeners will always demand that the nurse recapitulates. Some may decide to keep mute so as to avoid being tagged “troublesome”. And this will not benefit the patient.

During handover, the environment must be serene. Traffic must be well controlled to avoid distractions. Patients environment must look tidy and sparkling. It’s psychologically soothing! It is therapeutic too.

Questions should be asked and clarifications made. No assumption should be made about patient’s care. Any doubt or assumption must be clarified at the time of report. Remember, it’s patient life we are talking about here, not an object!

Lastly, unnecessary interruptions must be avoided and discouraged. It disrupts the flow in communication and may destabilize the person giving report. All comments and questions should wait till the end of the report. And if any interruption must come in, it must be relevant and be in consonance with the information being shared at that particular time. The incoming nurses are advised to jott down their questions and/or comments, and ask after the report of the patient is completed.

NOTE: ISoBAR means –
Identify
Situation
Observations
Background
Agree a plan
Read back

#davidthenurse

GLASGOW COMA SCALE (GCS) MADE EASY.

Graham Teasdale and Bryan J. Jennett developed the Glasgow coma scale/score in 1974. They were professors of neurosurgery in the University of Glasgow, Scotland, UK.

Glasgow coma scale (GCS) is a tool commonly used by healthcare providers, especially nurses and doctors. It is a neurological scale or scoring system that helps to assess the level of consciousness of patients and the overall status of the central nervous system.

There are three areas of examination in GCS.
1. Eye opening – E
2. Verbal response -V
3. Motor response – M
The GCS is the cumulative score of three areas of examination. Eye opening is graded from 1 to 4; verbal response from 1 to 5; motor response from 1 to 6.

E-V-M = 4-5-6

EYE OPENING (E)
This comprises:
Spontaneous – 4
Command – 3
Pain – 2
No response – 1
INTERPRETATION.
Spontaneous: If patient opens eyes during assessment or by verbal arousal (for instance when his/her name is called), score 4.
Command: If patient opens eyes only when commanded to do so, score 3. For example, if the nurse says, “Mr K.B, please open your eyes” and the patient obeys the command by opening his eyes, score 3.
Pain: If patient opens eyes only to painful stimulation, score 2. This can be done through applying pressure to the nail bed or the supra-orbital notch, rubbing patient’s sternum firmly with the knuckles of closed fist, and pinching the trapezius muscles.
No response: If patient does not open eyes despite painful stimulation, score 1.

SPECIAL CONSIDERATION: Patients with peri-orbital oedema may not be able to open their eyes. In this case, the nurse scores 1 under eye opening, indicating the reason. For example:
E1 (oedema); V3; M4
GCS = 8.

VERBAL RESPONSE (V)
This comprises:
Converses and oriented – 5
Converses but disoriented or confused – 4
Inappropriate words – 3
Incomprehensible sound – 2
No response – 1

INTERPRETATION:
Questions that pertain to ascertaining patient’s orientation to time, place and person, should be asked. The nurse asks questions such as “Mrs R.M, where are you now?”. If patient says, “I am in the hospital”, it shows that patient converses and is oriented. So the patient scores 5.
If the same question is asked and the patient answers, “I am inside a bus”, it shows patient is disoriented or confused, though in a conversational manner. The patient scores 4.
If patient is asked, “Prof T.Y, what time of the day are we?”, and the patient gives a response that is completely out of tune, such as, “I won a visa lottery yesterday”, the patient scores 3 because the answer is inappropriate and out of context, that is, the response is not conversational.
If patient makes incomprehensible sounds such as groaning or moaning (with or without painful stimulation), score 2.
If there’s no verbal response at all despite painful stimulation, score 1.

SPECIAL CONSIDERATION:
Patients that are intubated (with endotracheal tube or tracheotomy tube) will be scored 1 under verbal response due to their inability to speak. The nurse must indicate this in her assessment. For example,
E4; V1 (intubated); M6
GCS = 11T

MOTOR RESPONSE.
This comprises:
Obeys command – 6
Localizes pain – 5
Flexion withdrawal – 4
Abnormal flexion (decorticate) – 3
Abnormal extension (decerebrate) – 2
No response – 1

INTERPRETATION:
If patient moves hands and legs in response to command, score 6. The nurse may put her hands in patient palm and ask patient to hold her tight.
If patient cannot obey command, the nurse inflicts pain on the patient by sternal rub or applying pressure on the nail bed or supra-orbital notch or pinching the trapezius muscles. If patient takes his hands directly to the source of pain and removes the nurses hand at the site of painful stimulation, score 5. It simply means patient is localizing pain.
In flexion withdrawal (score 4), the patient pulls the limb away (withdraws) from the painful stimulus.
Abnormal flexion is also called decortication or decorticate posturing (also called “mummy pose”). Here, the arms are adducted (drawn towards the body) and flexed. The fist is clenched and the wrist flexed and placed on the chest. This describes “mummy pose”. Also the legs are extended and internally rotated and planter-flexed. If a patient demonstrate these features, score 3. It’s a sign of damage to the cerebral cortex.
Abnormal extension is also called decerebration or decerebrate posturing. Here, the arms are extended, adducted and pronated. The wrists are flexed and the the fixed clenched and rotated outward. The legs are extended and plantar flexed. The teeth are also clenched. These features are signs of severe damage to the brain – irritation or excitation of the brainstem or lesion in the brainstem.

SPECIAL CONSIDERATION.

The motor response of patients with spinal cord injury, especially those who are paraplegic , cannot be assessed due to their motor response deficit. Therefore, it must be noted during assessment.

CLASSIFICATIONS OF HEAD INJURY.

Head injury can be classified into three groups using the Glasgow coma scale:

GCS 13-15 (Mild head injury)
GCS 9-12 (Moderate head injury)
GCS 3-8 (Severe head injury)

TWELVE (12) COMMON ANTIDOTES, AND HOW THEY WORK.

 

 

An antidote is a drug or a chelating substance that counteracts the effects of another drug or a poison

COMMON ANTIDOTES INCLUDE THE FOLLOWING:
ACETYLCYSTEINE: Has hepatoprotective effect. Used in acetaminophen (paracetamol) overdose/toxicity, thereby preventing liver damage or failure. Cysteine (an amino acid) helps in the synthesis of glutathione, an essential intracellular antioxidant, which protects the liver from free radicals and intracellular toxins. Acetylcysteine is also a mucolytic agent that loosens thick mucus secretions in patients with cystic fibrosis and chronic obstructive pulmonary disease (COPD).

ACTIVATED CHARCOAL: It is used to treat drug toxicity or poisoning. Due to its large surface area, it has the capacity to bind to toxins or poisons, thus reversing their adverse effects

ATROPINE: It is used to treat organophosphate pesticide poisoning.

DEFEROXAMINE: Used in iron or aluminum toxicity/overdose. It chelates or binds to excess iron and aluminum, thus causing their removal from the body.

DIGIBIND: Also known as Digoxin immune fab (antigen binding fragments) or Digoxin-specific antibody. It is used to treat digoxin toxicity, hence, reversing the adverse effects of digoxin overdose

DIMERCAPROL: For arsenic, gold, or inorganic mercury poisoning.

FLUMAZENIL: A selective benzodiazepines (diazepam, lorazepam, bromazepam, midazolam) antagonist. It is used in benzodiazepines overdose/toxicity.

GLUCAGON: Used to treat overdose or toxicity of beta-blockers (propranolol, metoprolol) and calcium channel blockers (nifedipine, nimodipine, amlodipine). It acts by directly increasing cardiac inotropy and increasing hepatic gluconeogenesis.

METHYLENE BLUE: For drug-induced methemoglobinemia.

NALOXONE: It is an opioid antagonist. It is used in opioid toxicity to reverse the adverse effects of opioid overdose by binding to opioid receptors.

PROTAMINE SULPHATE: Used to reverse the anticoagulant effect of heparin (that is, it is used in heparin overdose). It is derived from fish sperm, and it binds to heparin to form a stable salt.

VITAMIN K: Antidote for warfarin overdose/toxicity. It helps to reverse high INR (International Normalized Ratio) values in warfarin overdose.

 

TWELVE (12) COMMON ANTIDOTES, AND HOW THEY WORK.

An antidote is a drug or a chelating substance that counteracts the effects of another drug or a poison.

COMMON ANTIDOTES INCLUDE THE FOLLOWING:
ACETYLCYSTEINE: Has hepatoprotective effect. Used in acetaminophen (paracetamol) overdose/toxicity, thereby preventing liver damage or failure. Cysteine (an amino acid) helps in the synthesis of glutathione, an essential intracellular antioxidant, which protects the liver from free radicals and intracellular toxins. Acetylcysteine is also a mucolytic agent that loosens thick mucus secretions in patients with cystic fibrosis and chronic obstructive pulmonary disease (COPD).

ACTIVATED CHARCOAL: It is used to treat drug toxicity or poisoning. Due to its large surface area, it has the capacity to bind to toxins or poisons, thus reversing their adverse effects.

ATROPINE: It is used to treat organophosphate pesticide poisoning.

DEFEROXAMINE: Used in iron or aluminum toxicity/overdose. It chelates or binds to excess iron and aluminum, thus causing their removal from the body.

DIGIBIND: Also known as Digoxin immune fab (antigen binding fragments) or Digoxin-specific antibody. It is used to treat digoxin toxicity, hence, reversing the adverse effects of digoxin overdose.

DIMERCAPROL: For arsenic, gold, or inorganic mercury poisoning.

FLUMAZENIL: A selective benzodiazepines (diazepam, lorazepam, bromazepam, midazolam) antagonist. It is used in benzodiazepines overdose/toxicity.

GLUCAGON: Used to treat overdose or toxicity of beta-blockers (propranolol, metoprolol) and calcium channel blockers (nifedipine, nimodipine, amlodipine). It acts by directly increasing cardiac inotropy and increasing hepatic gluconeogenesis.

METHYLENE BLUE: For drug-induced methemoglobinemia.

NALOXONE: It is an opioid antagonist. It is used in opioid toxicity to reverse the adverse effects of opioid overdose by binding to opioid receptors.

PROTAMINE SULPHATE: Used to reverse the anticoagulant effect of heparin (that is, it is used in heparin overdose). It is derived from fish sperm, and it binds to heparin to form a stable salt.

VITAMIN K: Antidote for warfarin overdose/toxicity. It helps to reverse high INR (International Normalized Ratio) values in warfarin overdose.

 

REHYDRATING A SICK CHILD

.Fluid loss, especially in children, can be fatal if prompt intervention is not taken to rehydrate the sick child. Cardinal signs that make children vulnerable to dehydration or fluid loss include: Diarrhoea, vomiting, fever, and some other disease conditions that further increase the metabolic rate in children.

Therefore, fluid and electrolyte therapy constitute a vital component of the care given to a sick child.

Fluid requirements for children are higher than those for adults for the following reasons:
1. Children have higher metabolic rates than adults. High metabolic rate is directly proportional to high caloric demand or expenditure. This translates into high fluid requirement.
2. The surface area to weight ratio is high in children. Increased surface area leads to increase insensible water loss through the skin.
3. Children have higher respiratory rates, and this equates to higher insensible losses from the respiratory tract.

ESTIMATING THE PERCENTAGE OF DEHYDRATION.
It is important to first estimate or calculate the percentage of fluid loss in children in order to know the amount of fluid deficit to be given for replacement.

METHOD 1:
IF THE PRE-ILLNESS WEIGHT OF THE SICK CHILD IS KNOWN, THE ILLNESS WEIGHT (PRESENT WEIGHT) IS MEASURED. THE DIFFERENCE BETWEEN THE PRE-ILLNESS WEIGHT AND ILLNESS WEIGHT IS DIVIDED BY THE PRE-ILLNESS WEIGHT AND THE RESULT IS MULTIPLIED BY 100.

For example:
A child weighed 10kg in the last visit to the clinic. The child was rushed to the clinic due to frequent passage of watery stool. His weight is now 9kg.

To calculate the percentage of dehydration:
(10kg – 9kg) divided by 10kg, then multiply by 100%
= (1kg divided by 10kg) times 100%
= 10%
FLUID DEFICIT = %DEHYDRATION * WEIGHT * 10
In the example given above;
Fluid deficit = 10% * 10kg * 10
= 1000ml
Therefore, the child requires 1000ml for replacement.
NOTE: The pre-illness weight is used in the formula for Fluid deficit.
THE RULE HERE IS THAT EVERY 1KG DROP IN WEIGHT REQUIRES 1L (1000ML) FLUID REPLACEMENT.

METHOD 2:
Percentage of dehydration can also be estimated through diligent clinical assessment. The signs to look out for include: Dry mucous membrane, decreases skin turgor, sunken eyes, depressed fontanels, increased thirst, low urinary output, low blood pressure, fatigue, and other signs of dehydration.

This method is applicable IF THE PRE-ILLNESS WEIGHT IS NOT KNOWN.

The nurse makes clinical judgment based on her assessment and concludes on the appropriate percentage to give to the sick child.

MILD DEHYDRATION (<3%)
Dry mucous membranes.
MODERATE DEHYDRATION (4-10%)
Dry mucous membranes, sunken eyes, decreased skin turgor, depressed fontanel.
SEVERE DEHYDRATION (>10%)
Dry mucous membranes, sunken eyes, decreased skin turgor, depressed fontanels, low urinary output, low blood pressure, delay in capillary refill time, fatigue, increased thirst.

For example:
After a diligent and careful clinical assessment of a dehydrated patient, a percentage dehydration of 12% was given. If the patient weighs 8kg, calculate the amount of fluid replacement required.

FLUID DEFICIT = %DEHYDRATION * WEIGHT * 10
= 12 * 8 * 10
= 960ml
Amount of fluid to be replaced = 960ml

NOTE:
For a sick child or hospitalized child, total fluid requirement will be the sum of MAINTENANCE FLUID AND THE DEFICIT.

#davidthenurse

HOLLIDAY-SEGAR METHOD OF CALCULATING MAINTENANCE FLUID.

 

Fluid therapy is divided into MAINTENANCE, DEFICIT, and REPLACEMENT requirements. Our focus for this week is MAINTENANCE REQUIREMENTS.

Maintenance fluid can be defined as the amount of fluid required to compensate for ongoing fluid losses, thus maintaining steady state in the body.

It can be given by intravenous routes or oral routes (if patient can tolerate orally) or both.

Water losses in the body are classified into SENSIBLE LOSS (urine and faecal water) and INSENSIBLE LOSS (perspiration and respiration).

Holliday segar method is a widely acceptable method of calculating maintenance fluid, especially in children. It helps to estimate the fluid requirement in 24 hours. The method is based on the weight of patient in kilogram.

This formula relates water loss to the caloric expenditure. That is, for every 100 kilocalories burned, the patient utilizes 100ml.

HOLLIDAY-SEGAR METHOD:
First 10kg = 100ml per kg in 24 hrs
Second 10kg = 50ml per kg in 24hrs
Other kg (or remaining kg) = 20ml per kg in 24 hrs.

Example 1:
What will be the maintenance fluid requirement for a child weighing 6kg?

Wt= 6kg (this falls within first 10kg)
=100ml per kg
= 100ml*6 = 600ml
Therefore, the child requires 600ml of fluid in 24hrs (per day).
To express it in ml per hour, divide 600ml by 24hrs
= 25mls per hour

Example 2:
A child weighing 14kg was rushed to the emergency department. Calculate the daily maintenance fluid of the child.

Wt = 14kg (10kg + 4kg)
First 10kg = 100ml per kg
= 100ml*10= 1000ml
Second 10kg (which is 4kg) = 50ml per kg
= 50ml*4 = 200ml
Daily maintenance fluid for the child of 14kg = 1000ml + 200ml = 1200ml.

To express it in ml per hour, divide 1200ml by 24
= 50mls per hour

Example 3:
Calculate the maintenance fluid to be given to a patient weighing 22kg.

Wt = 10kg + 10kg + 2kg
First 10kg = 100ml per kg
= 100ml*10 = 1000ml
Second 10kg = 50ml per kg
= 50ml*10 = 500ml
Remaining kg (2kg) = 20ml per kg
= 20ml*2 = 40ml
Maintenance fluid = 1000ml + 500ml + 40ml
= 1540ml in 24hrs (per day).
To express it in ml per hour, divide 1540ml by 24
= 64.2ml per hour.

#davidthenurse