Strict aseptic technique must be adhered to while performing endotracheal suctioning in order to prevent the introduction of pathogens into the lung field.
Myoglobinuria is a common finding after significant electrical injury or other significant muscular trauma and a potential complication of myoglobinuria is acute tubular necrosis. To prevent myoglobin from precipitating in the renal tubules, the IV rate is increased to maintain a urine output of 100 to 150 mL per hour until the urine is grossly clear of myoglobin.
Clients with Parkinson’s disease generally have resting tremors and the tremor can be reduced with voluntary activity. Grasping coins or another object or holding onto the arm of a chair will assist in reducing the tremors. Tremors diminish (not stop completely) with medication and voluntary activities. Tremors worsen at rest.
Permanent sterility for males is a side effect of radiation to the abdominopelvic region as a treatment for Hodgkin’s disease, and the nurse should plan to discuss sperm banking as a reproductive option with the client.
Warm packs applied to the affected side of the face can soothe the discomfort associated with Bell’s palsy. Vigorous massage can be harmful and will not resolve the paralysis. The client should chew on the unaffected side and lubricating eye drops should be used to prevent eye dryness and resultant injury.
Tooth brushing can cause pain with trigeminal neuralgia, so a water pick or warm mouth wash should be used instead. Massage and exposure to cold can increase pain. Morning care should be carried out when pain medication has had a chance to take effect.
A decrease in blood pressure and tachycardia could indicate post-operative bleeding. Bleeding is a complication of a parathyroidectomy. Often bleeding cannot be observed on the front of the dressing in a client who had a parathyroidectomy, since it trickles around the neck to the back. Therefore, it is important for the nurse to check the front, sides, back of the dressing, and the sheets underneath the neck.
Every effort should be made to maintain the infant in a neutral thermal environment. Oxygen consumption increases rapidly above or below the neutral thermal environment. Handling the infant stimulates movement and thus oxygen consumption. This includes auscultating breath sounds and performing heel sticks.
Health care professionals must use caution during the intrapartal period to reduce the risk of the transmission of HIV to the fetus. Any procedure that exposes blood or body fluids from the mother to the fetus should be avoided. It is important for nurses to guard against procedures that would result in a loss of skin integrity and expose the fetus to maternal blood or body fluids. Direct (internal) fetal monitoring is a procedure that may expose the fetus to maternal blood or body fluids and therefore should be avoided. Exposure to cervical and vaginal secretions is a likely mechanism of transmission to the newborn therefore a cesarean birth is warranted.
The nurse caring for a client with PIH demonstrating the potential for seizures should pad the side rails on the bed and initiate seizure precautions to provide a safe and effective care environment.
Checking pupillary responses to light is a component of a neurological assessment. Urine is not positive for glucose and protein with cerebral trauma. Specific gravity is maintained between 1.002 and 1.030 to ensure adequate fluid balance in the body. Syndrome of inappropriate antidiuretic hormone (SIADH) is a complication of head trauma and in this complication the specific gravity drops to 1.000. Orthostatic blood pressures are not assessed in the client with head trauma; the head of the bed should remain elevated to at least 30 degrees to decrease the amount of cerebral edema.
Tremors, rigidity, and bradykinesia are manifestations of Parkinson’s disease. Carbidopa-levodopa (Sinemet) is an antiparkinson agent and is used to control symptoms of Parkinson’s disease. Phenytoin (Dilantin) is an anticonvulsant and antidysrhythmic. Pyridostigmine (Mestinon) is a cholinergic medication often used to treat myasthenia gravis. Warfarin (Coumadin) is an anticoagulant.
Intubation should always precede gastric lavage to prevent pulmonary aspiration.
Phytonadione (vitamin K) is routinely given to every newborn as an injection. Any injection would need to wait until after the bath of the newborn infant and after the skin is thoroughly cleansed. Newborns are covered with amniotic fluid, vernix, mucus, and maternal blood. Any of these fluids could contain the virus. An injection would transmit the virus directly into the newborn’s system. Avoiding the use of forceps and vacuum extractions helps prevent lacerations to the infant’s scalp. A bath immediately after delivery removes the body fluid, and breastfeeding is discouraged because it can transmit the virus to the baby.
A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the physician if the cough becomes very troublesome to them.
Nitroglycerin is a coronary vasodilator used in the management of angina pectoris. The client is generally advised to apply a new patch each morning and leave in place for 12 to 14 hours, as per physician directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client should avoid placing the system in skin folds or excoriated areas. The client can apply a new patch if it becomes dislodged because the dose is released continuously in small amounts through the skin.
Tissue plasminogen activator is a thrombolytic medication that is used to dissolve thrombi or emboli due to thrombus. A frequent and potentially severe side effect of therapy is bleeding. The nurse assesses for signs of bleeding in clients receiving this therapy. Equipment needed by the nurse would include occult blood-test strips to monitor for occult blood in the urine, stool, or nasogastric drainage.
Headache is a frequent side effect of nitroglycerin because of the vasodilating action of the medication. It usually diminishes in frequency as the client becomes accustomed to the medication and is effectively treated with acetaminophen (Tylenol).
Betaxolol is a ß-adrenergic blocking agent used to lower blood pressure, relieve angina, or decrease dysrhythmias. Side effects include bradycardia and symptoms of congestive heart failure, such as weight gain and increased edema.
Verapamil is a calcium channel–blocking agent that may be used to treat rapid-rate supraventricular tachydysrhythmias, such as atrial flutter or atrial fibrillation. The client must be placed on a cardiac monitor to evaluate the effectiveness of the medication. A noninvasive blood-pressure monitor also is helpful, but is not as essential as the cardiac monitor.
Cola, coffee, and chocolate contain xanthine and should be avoided by the client taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects.
The client taking a potassium-wasting diuretic, such as chlorothiazide (Diuril), must be monitored for decreased potassium levels. Other fluid and electrolyte imbalances that occur with use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia.
Amiloride is a potassium-sparing diuretic used to treat edema or hypertension. A daily dose should be taken in the morning to avoid nocturia. The dose should be taken with food to increase bioavailability. Sodium should be restricted if used as an antihypertensive.
Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle–relaxant properties. The nurse should institute safety measures before leaving the client’s room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse puts the side rails up on the bed before leaving the room to prevent falls.
Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely, more frequently at first and then once every several months after that. The client should be instructed to contact the physician immediately if excessive diarrhea, vomiting, or diaphoresis occurs. Lithium is irritating to the gastric mucosa; therefore lithium should be taken with food. A normal diet and normal salt and fluid intake (1500 to 3000 mL/day of fluid) should be maintained because lithium decreases sodium reabsorption in the renal tubules, which could cause sodium depletion. A low sodium intake causes an increase in lithium retention and could lead to toxicity.
Adverse effects of haloperidol include extrapyramidal symptoms noted as marked drowsiness and lethargy, excessive salivation, and a fixed stare. Hypotension, nausea, and blurred vision are occasional side effects.
Women who are postmenopausal are taught to do BSE on the same day of every month. Before menopause, women should do the procedure 7 days after the start of the menstrual cycle when the breasts are least tender. Each breast is examined with the opposite hand. The pads of the fingers should be used for palpation, and the client should press deeply feeling for lumps. The client may use a circular, up-and-down, or wedge method of assessment. Consistency of use of the same method is more important than the actual method used. The client would inspect the breasts while standing in front of a mirror. The client would palpate the breasts while in the shower because soapy wet skin makes it easy to slide the pads of the fingers across breast tissue, or the client would palpate the breasts while in the supine position.
Toxic shock syndrome is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse assesses the client for signs of this complication and notifies the physician promptly when a pattern of signs and symptoms is noted.
Testicular self-examination is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and twenties. The examination is performed once a month, as is breast self-examination (BSE). As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath) when the scrotum is relaxed.
The client with fibrocystic breast disorder experiences worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Clients should understand that this is part of the clinical picture of this disorder.
The client demonstrates the most difficulty adjusting to the loss of the breast by refusing to look at the wound or incisional drain. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery.
After a radical vulvectomy, discharge instructions include, resume activity slowly, but walking is a beneficial activity. The client should know to rest when fatigue occurs. Activities to be avoided include driving, heavy housework, strenuous exercise, wearing tight clothing, crossing the legs, and prolonged standing or sitting. Sexual activity is prohibited for 4 to 6 weeks after surgery.
Article copyright NurseReview.org - #1 source of information to update nurses all over the world. All rights reserved. No part of an article may be reproduced without the prior permission.