THOSE TROUBLESOME THOSE TROUBLESOME TUBES:TUBES:

TUBE MANAGEMENT TUBE MANAGEMENT FOR THE NURSING TEAMFOR THE NURSING TEAM

KELLY JASZAROWSKI, MSN, RN, KELLY JASZAROWSKI, MSN, RN, CNS, CWOCN, ANPCNS, CWOCN, ANP

ObjectivesObjectives

Define percutaneous tubesDefine percutaneous tubes Identify percutaneous tubes frequently Identify percutaneous tubes frequently

encountered by the nursing teamencountered by the nursing team Explore conditions that may necessitate the Explore conditions that may necessitate the

need for tube placementneed for tube placement Describe patient care in relation to type of Describe patient care in relation to type of

percutaneous tubepercutaneous tube Describe skin care strategies to protect the Describe skin care strategies to protect the

peritube skinperitube skin

DefinedDefined

Percutaneous: effected or performed Percutaneous: effected or performed thru the skinthru the skin

Tube: a hollow cylindrical organ or Tube: a hollow cylindrical organ or instrumentinstrument

Examples of Percutaneous Examples of Percutaneous TubesTubes

Chest tubesChest tubes Gastrostomy tubesGastrostomy tubes Nephrostomy tubesNephrostomy tubes Biliary tubesBiliary tubes Cecostomy tubesCecostomy tubes Tracheostomy tubesTracheostomy tubes PIC linesPIC lines

General ObjectivesGeneral Objectives

Maintain patencyMaintain patency

Maintain peritube skin integrityMaintain peritube skin integrity

Eliminate/reduce painEliminate/reduce pain

Patient/significant other(s) educationPatient/significant other(s) education

General Nursing CareGeneral Nursing Care

Assess drainageAssess drainage Maintain closed systemMaintain closed system Assess and maintain skin integrityAssess and maintain skin integrity Promote patient comfortPromote patient comfort Provide educationProvide education

Chest tubesChest tubes

PurposePurpose

Maintain ventilation; negative pressureMaintain ventilation; negative pressure

Remove pathological collections of air Remove pathological collections of air or fluidor fluid

Enable lung expansionEnable lung expansion

Chest tube: IndicationsChest tube: Indications

PneumothoraxPneumothorax EmpyemaEmpyema HemothoraxHemothorax PleurodesisPleurodesis ThoracotomyThoracotomy

Chest tube: Nursing Chest tube: Nursing ManagementManagement

GeneralGeneral PositioningPositioning

Straight lineStraight line Semi-Fowler’sSemi-Fowler’s High-Fowler’sHigh-Fowler’s TurningTurning

Chest tube: Nursing Chest tube: Nursing ManagementManagement

DressingDressing Sterile versus aseptic techniqueSterile versus aseptic technique Insertion site air tight seal Insertion site air tight seal Split 4x4 dressingsSplit 4x4 dressings

Ranse, J (August 2003). “Nursing management of a patient with an: intercostal catheter and underwater drainage system” slideshare.netRanse, J (August 2003). “Nursing management of a patient with an: intercostal catheter and underwater drainage system” slideshare.net

Chest tube: Nursing Chest tube: Nursing ManagementManagement

OtherOther

SecurementSecurement

Ranse, J (August 2003). “Nursing management of a patient with an: intercostal catheter and underwater drainage system” slideshare.netRanse, J (August 2003). “Nursing management of a patient with an: intercostal catheter and underwater drainage system” slideshare.net

Tracheostomy TubesTracheostomy Tubes

PurposePurpose Airway maintenanceAirway maintenance Secretion removalSecretion removal

IndicationsIndications ObstructionObstruction Inability to breath on ownInability to breath on own AbnormalityAbnormality ParalysisParalysis TraumaTrauma

Tracheostomy TubeTracheostomy Tube

Tracheostomy tube: Nursing Tracheostomy tube: Nursing ManagementManagement

Site CareSite Care Promote skin integrityPromote skin integrity Prevent infectionPrevent infection

SecurementSecurement Evidence supports two person techniqueEvidence supports two person technique Trach tube holdersTrach tube holders

Tracheostomy tube: Nursing Tracheostomy tube: Nursing ManagementManagement

Nephrostomy tubesNephrostomy tubes

Placed into renal pelvisPlaced into renal pelvis

Goal: Preserve kidney functionGoal: Preserve kidney function

Hautman, S.& Leveille, R. (Dec 2011). “Nephrostomy”. Hautman, S.& Leveille, R. (Dec 2011). “Nephrostomy”. emedicine.medscapre.com/articleemedicine.medscapre.com/article

Nephrostomy tube: IndicationsNephrostomy tube: Indications

BlockageBlockage AccessAccess Creatinine levelCreatinine level DisordersDisorders

Nephrostomy tube: Nursing Nephrostomy tube: Nursing managmentmanagment

Site careSite care

SecurementSecurement

Feeding tubesFeeding tubes

GoalGoal Enhance nutritionEnhance nutrition

HydrationHydration

Use of gutUse of gut

Feeding tube: IndicationsFeeding tube: Indications

StricturesStrictures Swallowing difficultiesSwallowing difficulties Disorders/diseaseDisorders/disease PediatricPediatric

Disorders/diseaseDisorders/disease DelaysDelays

Feeding tubes: TypesFeeding tubes: Types

Gastrostomy tubeGastrostomy tube

Low profile gastrostomy deviceLow profile gastrostomy device

GastrojejunostomyGastrojejunostomy

JejunostomyJejunostomy

Gastrostomy tubesGastrostomy tubes

Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Textbook of Medical Surgical Nursing. Lippincott Williams & Wilkins.

Feeding tube: GastrostomyFeeding tube: Gastrostomy

Feeding tube: LPGDFeeding tube: LPGD

Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Textbook of Medical Surgical Nursing. Lippincott Williams & Wilkins.

Feeding tubes: Feeding tubes: GastrojejunostomyGastrojejunostomy

www.stillmilestrip.com

Feeding tubes: JejunostomyFeeding tubes: Jejunostomy

Quilici, P. (Ed). (2002) Quilici, P. (Ed). (2002) Interventional laproscopy: the state of the art for the new millenniumInterventional laproscopy: the state of the art for the new millennium. Online laproscopic technical manual (2003), “Laproscopic . Online laproscopic technical manual (2003), “Laproscopic

placement of jejunostomy tube”.placement of jejunostomy tube”.

Feeding tubes: Feeding tubes: Nursing ManagementNursing Management

TractionTraction

RotationRotation

Site CareSite Care

Feeding tube: ComplicationsFeeding tube: Complications

DislodgementDislodgement MigrationMigration Skin irritationSkin irritation

HyperplasiaHyperplasia InfectionInfection

SecurementSecurement

Purpose:Purpose:

Allow movement without discomfortAllow movement without discomfort Goal:Goal:

Prevent displacementPrevent displacement Methods:Methods:

DressingsDressings

TapingTaping

DevicesDevices

Insertion site dressingsInsertion site dressings

ConsiderationsConsiderations DressingsDressings

TypeType TechniqueTechnique SolutionsSolutions

Insertion site dressingsInsertion site dressings

www.livingwithgp.comSoscia, J & Freidman,J. (May 2011). “A guide to the management of common gastrosotmy and gastrojejunostomy tube problems Pediatric

Child Health, 16(5).

TapingTaping

Factors to considerFactors to consider AgeAge ComplicationsComplications Risk factorsRisk factors

Tape selectionTape selection

Google imagesGoogle images

Tape selection considerationsTape selection considerations

Adhesive strengthAdhesive strength Pressure sensitivityPressure sensitivity Skin conditionSkin condition Tension freeTension free

Taping techniquesTaping techniques

Wrap methodWrap method TentingTenting Montgomery strapsMontgomery straps CreativeCreative

Ranse, J (August 2003). “Nursing management of a patient with an: intercostal catheter and underwater drainage system” slideshare.netRanse, J (August 2003). “Nursing management of a patient with an: intercostal catheter and underwater drainage system” slideshare.net

Taping techniquesTaping techniques

H or Goal PostH or Goal Post

Borkowski, S. (Aug 2004). “Similar Gastrostomy Peristomal Skin Irritation: three pediatric patients”. Journal Wound, Ostomy, & Continence Nursing, 31(4).

Taping techniquesTaping techniques

Slit Tape MethodSlit Tape Method

Borkowski, S. (Aug 2004). “Similar Gastrostomy Peristomal Skin Irritation: three pediatric patients”. Journal Wound, Ostomy, & Continence Nursing, 31(4).

DevicesDevices

DevicesDevices

DevicesDevices

Baby bottle nipplesBaby bottle nipples

Medicine cupsMedicine cups

Skin irritationSkin irritation

LeakageLeakage Tube securement is keyTube securement is key ? infection? infection

Skin irritation managementSkin irritation management

Match treatment to assessmentMatch treatment to assessment Two foldTwo fold

Skin protectionSkin protection Leakage managementLeakage management

Skin irritation: Skin irritation: Skin ManagementSkin Management

Fleischer, I. & Bryant, D. (Nov/Dec 2010). “Techniques for preventing and managing tube-related complications.” Journal Wound, Ostomy, Continence Nursing, 36(6).

Skin irritation:Skin irritation:Leakage managementLeakage management

ReplacementReplacement Securement Securement Scant to small amount drainageScant to small amount drainage

SecurementSecurement DressingsDressings Skin barrier ointmentSkin barrier ointment

Skin irritation:Skin irritation:Leakage managementLeakage management

Moderate to larger amount drainageModerate to larger amount drainage

PouchingPouching

Hanlon, M. & Lochbaum, L. (Nov 2001). “Patient with a chest tube and Hanlon, M. & Lochbaum, L. (Nov 2001). “Patient with a chest tube and heimlich heimlich

valve”. valve”. Journal of Wound, Ostomy, & Continence NursingJournal of Wound, Ostomy, & Continence Nursing, 28 (6)., 28 (6).

Pouching with tube accessPouching with tube access

Skin irritation:Skin irritation:Leakage managementLeakage management

Skin irritation:Skin irritation:Leakage managementLeakage management

Google imagesFleischer, I. & Bryant, D. (Nov/Dec 2010). “Techniques for preventing and managing tube-related complications.” Journal Wound, Ostomy, Continence

Nursing, 36(6).

Skin irritation:Skin irritation:Leakage managementLeakage management

Carmel, J. & Scardillo, J. TubeCarmel, J. & Scardillo, J. Tube management. In Colwell, J., Goldberg, M., & Carmel, J. (Ed.) (2004). management. In Colwell, J., Goldberg, M., & Carmel, J. (Ed.) (2004). Fecal & Urinary DiversionsFecal & Urinary Diversions. Mosby: St. Louis.. Mosby: St. Louis.

Skin irritation:Skin irritation:Leakage managementLeakage management

Securement plus pouching

Fleischer, I. & Bryant, D. (Nov/Dec 2010). “Techniques for preventing and managing tube-related complications.” Journal Wound, Ostomy, Continence Nursing, 36(6).

HyperplasiaHyperplasia

Overgrowth of tissueOvergrowth of tissue Moisture relatedMoisture related Goal of treatment: remove/reduceGoal of treatment: remove/reduce

Soscia, J & Freidman,J. (May 2011). “A guide to the management of common gastrosotmy and gastrojejunostomy tube problems”. Soscia, J & Freidman,J. (May 2011). “A guide to the management of common gastrosotmy and gastrojejunostomy tube problems”. Pediatric ChildPediatric ChildHealthHealth, 16(5)., 16(5).

InfectionInfection

Candida or fungalCandida or fungal Rash with satellite lesionsRash with satellite lesions Anti-fungalAnti-fungal

Soscia, J & Freidman,J. (May 2011). “A guide to the management of common gastrosotmy and gastrojejunostomy tube problems”. Pediatric Child Health, 16(5).

TeachingTeaching

TypeType

PurposePurpose

CareCare

TeachingTeaching

Body ImageBody Image

www.livingwithgp.comwww.livingwithgp.com

Keys to ManagingKeys to Managing

Understanding typeUnderstanding type Tube securementTube securement Dressing selectionDressing selection Potential complicationsPotential complications TeachingTeaching

Thank YouThank You

Kelly Jaszarowski, MSN, RN, CNS, CWOCN, ANPKelly Jaszarowski, MSN, RN, CNS, CWOCN, ANP

jaszcwocn@yahoo.comjaszcwocn@yahoo.com

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