Most clients experiencing chest discomfort use rationalization and deny that they are experiencing pain. Anger, depression, and hostility may occur, but denial and rationalization are the most common reactions.
Nitroglycerin tablets are administered one every five minutes, not exceeding three tablets for chest pain as long as the client maintains a systolic blood pressure of 100 mm Hg or above. The physician is notified if the chest pain is not relieved after administering the three tablets.
Morphine sulfate is administered to control pain in cardiac clients. The nurse assesses the client’s heart rhythm and vital signs, especially noting the client’s respirations. Signs of morphine sulfate toxicity include respiratory depression and hypotension. The client would be placed in the Trendelenburg position if a sudden drop in blood pressure occurs.
Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponin are released into the bloodstream when an infarction causes damage to the myocardium. A troponin I level greater than 1.5 ng/mL is consistent with a myocardial infarction. A troponin T level greater than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. Cardiac enzymes and isoenzymes may also be used to confirm myocardial infarction.
Constipation occurs as a result of inactivity and is an undesirable complication for cardiac clients because straining or bearing down triggers the Valsalva maneuver, which increases cardiac workload
Heparin is an anticoagulant, which decreases clotting time. The nurse monitors the client for signs of bleeding, such as bleeding gums, petechiae, hematoma formation, and blood in the stool and urine.
Activity restrictions are often a concern of clients following CABG. Resuming normal sexual relations will be allowed, but the physician decides when the client can safely resume this activity.
An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception.
Ribbon-like stool, bile-stained emesis, abdominal distension, and the absence of peristalsis are symptoms of congenital megacolon (Hirschsprung’s Disease)
Padded crib sides will protect the child from injury during seizure activity, if a seizure occurs. A padded tongue blade should never be used for a seizure and nothing should be placed in a child’s mouth during a seizure. During a seizure, the child should be placed in a side-lying position but should not be restrained. A code cart should be available but does not need to be placed at the bedside.
A 10 month old is in the Trust vs. Mistrust stage of psychosocial development (Erik Erikson) and in the sensorimotor period of cognitive development (Jean Piaget). Hospitalization may have an adverse effect and a consistent routine accompanied with touching, rocking, and cuddling will help the infant to develop trust and will provide sensory stimulation.
After a crush injury, myoglobin released from damaged muscle cells circulates in the bloodstream and can clog renal tubules. It is important to maintain an increased fluid intake to “flush” the kidneys and minimize this occurrence.
Homes that are older than 25 years may have lead paint and will most likely have lead pipes. Living close to high traffic areas can also contribute to lead poisoning as a result of inhaling exhaust. Hyperventilation and diaphoresis are signs of salicylate poisoning, not lead poisoning. A fruity breath odor is a symptom of ketoacidosis. Pencil lead is made of graphite so it does not present a hazard. Crayons are not toxic.
Bleeding into joints is a clinical manifestation of ALL, and cold applications will decrease joint discomfort. Aspirin has anticoagulant properties and would not be prescribed. Heat application will increase blood circulation to the site, which will increase pain and bleeding if it is present.
Proper dental care should be taught to a toddler.
Digitalis glycosides must be used cautiously in clients taking a loop diuretic because electrolyte imbalances such as hypokalemia can occur increasing the risk of toxicity. The risk for toxicity can also occur in clients with an impaired ability to metabolize medication, such as occurs in hypothyroidism.
Joint immobilization will assist in preventing bleeding. NSAIDs can prolong bleeding time, and increase the bleeding and the pain due to pressure of the confined fluid in the narrow joint space. Heat application will increase blood flow to the area and increase the bleeding. Physical therapy can be helpful after the bleeding episode is under control, but during the acute period, it can increase bleeding.
The most serious side effect of the phenothiazine antipsychotics is tardive dyskinesia. Early signs of this condition are lip sucking and smacking behaviors, tongue protrusion, facial grimacing, and choreiform movements.
A high probability of rheumatic fever is indicated when there is evidence of at least two of the major or one major and two minor manifestations of the Jones criteria and evidence of a streptococcal infection. The sedimentation rate is normally increased in rheumatic fever. An elevation in antistreptolysin-O antibodies indicates a recent streptococcal infection, but does not alone diagnose rheumatic fever.
Growth takes place at the epiphysis of the long bone. A fracture at this level can destroy the layer of germinal cells of the epiphysis, resulting in growth disturbance. Osteomyelitis is an infection of the bone and would be more likely to occur with a compound (open) fracture rather than an epiphyseal fracture. Muscle atrophy may result from immobility or casting, but will resolve as activity increases. Paresthesias and paralysis can result from edema and constriction by a cast, not specifically from fracture of the epiphysis.
An asthmatic child over the age of 4 should be able to measure the expiratory flow. A drop in expiratory flow is the most reliable early sign of an asthma episode. Medications would be administered by a metered-dose inhaler or by a hand-held nebulizer if an asthma attack actually occurs. Chest percussion and postural drainage are normally used to clear air passages for children with cystic fibrosis, not asthma.
Administering around the clock dosing provides increased pain relief and decreases stresses associated with pain, such as anxiety and fear. Opioid analgesics may be addictive but this is not the concern in a client with terminal cancer.
Numerous, frequent episodes of a child staring off into space and then quickly returning to conversation or activities are a classic sign of absence seizures that can be confirmed by an EEG. Classic symptoms of ADHD include easy distraction, fidgeting, and problems following directions. School phobia includes physical symptoms that usually occur at home and may prevent the child from attending school.
In an anorexia client, Until the client begins to take adequate nutrition and is physiologically stable, the nurse cannot work with the client on other levels.
The administration of magnesium-containing antacids can cause increased magnesium levels in the client with renal failure.
Warfarin (Coumadin) is an anticoagulant and is given to maintain an INR of 2.0 to 3.0 for most conditions requiring therapy.
Digoxin is a cardiac glycoside. One of the adverse effects of digoxin is slowing of the pulse rate that occurs due to a decreased conduction at the atrioventricular (AV) node. Therefore, the nurse would check the client’s apical pulse rate. Additionally, if the pulse was lower than 60 beats per minute, the medication would be withheld and the physician would be notified.
The use of a folk healer and home remedies is very common in the Hispanic cultural group.
Edema is a sign of gestational hypertension (pregnancy-induced hypertension or PIH) and should be investigated further. Other manifestations of gestational hypertension are proteinuria and hypertension.
Some cardiac medications, particularly the nitrates, dilate the body’s arteries, which can increase blood flow to the brain and cause headaches. These headaches are usually transient and treatable with over-the-counter pain relievers, such as acetaminophen.
Tetracyclines are deposited in the teeth and bones of the fetus. These medications can cause permanent tooth enamel discoloration and can depress bone growth. This medication does not induce labor.
In older clients, medications are metabolized and excreted more slowly; therefore the risk of adverse effects is increased. Halcion can cause confusion and dizziness leading to impaired mobility.
In normal sinus rhythm, the rhythm is regular, the rate is 60 to 100 beats per minute, and the P-R interval is 0.12 to 0.20 second. Sinus bradycardia occurs when the sinoatrial node fires at a rate of less than 60 times per minute. Sinus tachycardia is characterized by a rapid, regular rhythm at a rate of 100 to 180 beats per minute. In atrial fibrillation, the P waves are erratic or not identifiable.
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