Warfarin sodium is an anticoagulant medication. Important teaching points include using safety measures to prevent bleeding, such as an electric razor and a soft toothbrush, and avoiding skin trauma whenever possible. The nurse should tell the client to take the medication only as prescribed and at the same time each day. The client should not drink alcohol, and should take other medications (including OTC medications) only with physician approval. Finally, the client should notify all caregivers about the medication, carry a Medic-Alert card, report any signs of bleeding (and prevent them whenever possible), and adhere to the schedule for follow-up blood work.
The antidote to warfarin sodium is vitamin K; it should be readily available for use if excessive bleeding or hemorrhage should occur, or if the client has taken excess medication (such as in overdose).
Thrombolytic agents dissolve existing clots, and bleeding can occur anywhere in the body as an adverse effect of the medication. The nurse monitors for any obvious signs of bleeding and also for occult signs of bleeding. The nurse would use materials such as Hematest cards, which will detect occult blood in body fluids, such as stool or nasogastric drainage. T
The client who has received a thrombolytic medication such as streptokinase is at risk for bleeding, and could suffer a hemorrhagic cerebrovascular accident (CVA) if a cerebral blood vessel ruptures following administration of this medication. The nurse carefully assesses the client for risk of bleeding, and reports this data to the physician at once
Once the thrombolytic therapy infusion is complete, a heparin infusion is started without a loading dose. This is initiated once the thrombin time has decreased to less than twice the control value, which usually occurs within 4 hours of the time the thrombolytic infusion ended. The nurse would look for injectable heparin sodium to prepare the solution.
Arterial leg ulcers tend to be deep and pale and are surrounded by tissue that is cool with trophic changes (dry friable skin, loss of hair). There is little granulation tissue at the base. The client usually has rest pain, and the ulcer site is painful. Surrounding skin has coloration consistent with peripheral arterial disease.
Standard intervention for arterial leg ulcers includes the use of wet-to-damp or damp-to-dry normal saline dressings. A damp-to-dry dressing is best when the wound needs mechanical debridement due to infection. Betadine is a strong agent that could cause further damage to friable underlying tissues. Dry sterile dressings do not keep the wound moist. Compression dressings are used for venous stasis ulcers.
With an arterial leg ulcer, the nurse applies tape only to the bandage itself. Tape is never used directly on the skin, because it could cause further tissue damage.
Rheumatic endocarditis occurs in many clients with rheumatic fever, which is a complication of infection with group A beta-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis, which is assessed by noting the presence of a sore throat and fever.
The client with a history of rheumatic heart disease is at risk for developing infective endocarditis. The client should notify all physicians and dentists about this past health problem. The physician or dentist will then initiate prophylactic antibiotic therapy before any procedure that is invasive or that could result in bleeding.
The client with infective endocarditis may experience both left- and right-sided heart failure, and thus the nurse assesses the client for both pulmonary and peripheral symptoms, such as crackles, peripheral edema, and weight gain.
Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling BP, accompanied by pulsus paradoxus (a drop in inspiratory BP by greater than 10 mm Hg).
The nurse is hearing wheezes, which are musical noises heard on inspiration, expiration, or both. They are the result of narrowed air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together near the ear, and indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is excessive production of mucus, which accumulates in the air passages. A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating in quality. These sounds are localized over an area of inflammation of the pleura, and may be heard in both the inspiratory and expiratory phases of the respiratory cycle.
Vesicular breath sounds are normal sounds that are heard over peripheral lung fields where the air enters the alveoli. Bronchophony is an abnormal finding with lung consolidation, and is identified if the nurse can clearly hear the client say “ninety-nine” through the stethoscope. (Normally words are unintelligible if heard through a stethoscope). Egophony occurs when the sound of the letter “e” is heard as an “a” with auscultation, and also indicates lung consolidation. Finally, whispered pectoriloquy is present if the nurse hears the client when “one-two-three” is whispered. This is an abnormal finding, again heard over an area of consolidation. Consolidation typically occurs with pneumonia.
Dyspnea is difficult to measure, as it tends to be subjective in nature. The client with aphasia may also have difficulty adequately communicating shortness of breath to the nurse. The nurse can use a visual analog scale (such as a 1 to 10 rating scale) and ask the client to point to the number corresponding to the amount of dyspnea felt.
To accurately assess breath sounds, the client is asked to sit up and breathe slowly and deeply through the mouth. Breath sounds are auscultated with the diaphragm of the stethoscope, which is warmed prior to use. The stethoscope is always placed directly on the client’s skin, and not over a gown or clothing. The nurse would intervene if the student used the bell of the stethoscope, which is best used to evaluate heart sounds, and if the student placed the stethoscope over the gown.
The nurse verifies placement of an ETT by auscultating breath sounds bilaterally, which assures ventilation of both lungs. Placement is then checked by x-ray. The nurse notes the ETT marking at the point where it enters the nose or mouth for ongoing monitoring of correct placement. The client may or may not be able to take a deep breath upon request in this situation. The best observation that could be made with this request is bilateral lung expansion, which could be accomplished more easily and effectively with the use of a manual resuscitation bag.
The client’s airway should be suctioned just before tube removal. This assures that the client has few if any secretions that must be managed as the client begins totally independent respiration. The cuff should have been deflated once tracheostomy plugging began. Oxygen and arterial blood gas measurements are useful indicators that may have contributed to the decision to remove the tracheostomy, but they are not most essential just prior to tube removal.
Equipment needed to perform tracheostomy care includes a tracheostomy care kit, sterile water and saline solutions for cleansing and rinsing, and a suction kit for client suctioning. As part of tracheostomy care, the client’s airway should be suctioned before cleansing of the actual tracheostomy. The solutions are changed once per 24 hours, which is often done at the beginning of the work day. A tracheostomy care kit contains the needed supplies for cleaning the tracheostomy and for changing the dressing and tapes.
The client who is unable to stop smoking independently may benefit from a resource group such as Smoke Enders or the American Cancer Society.
The purpose of PEEP is to allow alveoli to stay expanded at the end of expiration, allowing for better gas exchange and improved oxygenation. PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by a decreased blood pressure and increased pulse (compensatory). These are not the intended effects of this therapy, however. Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP. Expected benefits is an increase in arterial oxygen.
Antianxiety medications (such as lorazepam) and narcotic analgesics are used cautiously or withheld whenever possible in the client being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive.
The water seal chamber should be filled to the 2 cm mark to provide an adequate water seal between the external environment and the client’s pleural cavity. The water seal prevents air from reentering the pleural cavity. Since evaporation of water can occur, the nurse should remedy this problem by adding water until the level is again at the 2 cm mark.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically ordered. In most instances, clamping of the chest tube is contraindicated and forbidden by agency policy. The nurse keeps the drainage collection system below the level of the client’s waist to prevent fluid or air from reentering the pleural space. Water is added to the suction control chamber as needed to maintain the full suction level ordered. Connections between chest tube and system are taped to prevent accidental disconnection.
The reasons for tunneling the peritoneal dialysis catheter under the skin before inserting it into the peritoneal cavity are to stabilize the catheter and to reduce the likelihood of infection. These catheters have cuffs that allow ingrowth of fibroblasts and blood vessels, thereby preventing leakage of fluid and reducing bacterial invasion into the peritoneum.
Methenamine Mandelate (Mandelamine) exerts its effects by releasing acids and formaldehyde, and is ineffective in alkaline urine. Medications that produce alkaline urine should be avoided while taking this medication. These include calcium and magnesium antacids, carbonic anhydrase inhibitors, thiazide diuretics, citrates, and sodium bicarbonate.
The major symptom of PIH is increased blood pressure. As the disease progresses, it is possible that increased brachial reflexes, decreased fetal heart rate and variability, and decreased urine output will occur, particularly during labor.
An induration of 15 mm or more is considered positive for clients in low-risk groups. Erythema is not a positive reaction. The presence of a wheal would indicate that the skin test was administered appropriately. Itching is not an indication of a positive PPD.
Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation.
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