Soft tissue injuries such as sprains are treated by RICE (Rest, Ice, Compression, Elevation) for the first 24 hours after the injury to prevent edema and pain at the injured site. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain.
Pyridostigmine is a cholinergic medication used to increase muscle strength for the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the client’s ability to eat.
To perform this screening test, the child should be asked to unclothe or wear underpants only so that the chest, back, and hips can be clearly seen. The child is asked to stand with weight equally on both feet with the legs straight, and the arms hanging loosely at both sides. The nurse assesses the child’s posture, spinal column, shoulder height, and leg lengths
Senna (Senokot) works by changing the transport of water and electrolytes in the large intestine, which causes the accumulation of water in the mass of stool and increased peristalsis.
Trigeminal neuralgia is characterized by spasms of pain in the face that start suddenly and last for seconds to minutes. The pain is often characterized as stabbing. It is accompanied by spasms of the facial muscles, which cause twitching of parts of the face or mouth, or closure of the eye. The other options are not accurate descriptions of the symptoms that accompany this disorder.
Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the priority action in this situation.
Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood.
The top of the cane should reach the level of the greater trochanter of the client’s femur.
Bone marrow transplantation is the treatment of choice for ALL after the child has come out of remission twice. The child faces almost certain death if bone marrow transplantation is not done. The child will have to have extensive radiation and medications before transplantation.
The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with CHF. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well.
Rheumatoid arthritis is a systemic disease and clinical manifestations may occur in various parts of the body. However, the joints are generally affected first. Stiffness occurs after inactivity, such as sleep or prolonged sitting. The client will have morning stiffness that lasts for at least 1 hour. It is an autoimmune connective tissue disease that most commonly causes inflammation of the joints and subsequent joint deformity.
Bleeding is an early sign of disseminated intravascular coagulation, a life-threatening complication, and needs to be reported to the health care provider.
Tracheostomy dressings should be changed whenever they get wet or damp. A soiled dressing promotes microorganism growth and enhances tissue irritation and breakdown. The oxygen mask may be cleaned if it becomes soiled between mask and tubing changes, which are usually done every 24 hours. Tracheostomy care should be done at least every 8 hours. It could be harmful to the client to limit fluids, because thicker secretions are harder to expectorate, and this could result in an increased chance of infection.
Upon removal, a sterile petrolatum gauze dressing is applied to the chest tube insertion site, followed by sterile gauze and adhesive tape. The entire dressing is securely taped to make sure it remains occlusive. The petrolatum dressing is the key element to make an airtight seal at the chest tube insertion site.
An EEG is a graphic recording of electrical activity of the brain. EEG electrodes are placed on the scalp over multiple areas of the brain to detect and record electrical impulses. Preprocedure care for EEG includes client teaching about the procedure, shampooing the client’s hair, and providing a full meal to prevent hypoglycemia, which could alter brain waves. Antidepressants, tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure, as are stimulants such as coffee, tea, cola, alcohol, and cigarettes.
Variable decelerations present on a fetal heart monitor suggest umbilical cord compression. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the difference between successive heartbeats identifying that the natural pacemaker activity of the fetal heart is working properly.
In ventricular septal defects, some defects may close spontaneously. If spontaneous closure does not occur, moderate or large defects require surgical closure before school age. If pulmonary hypertension is present, closure is necessary by age 1 year. Open heart surgery is done for closure.
Accelerations are transient increases in the fetal heart rate normally caused by fetal movement or often accompany contractions. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve.
The goal of labor augmentation is to achieve three good quality contractions (appropriate intensity and duration) in a 10 minute period. The uterus should return to resting tone between contractions and there should be no evidence of fetal distress. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia from excessive uterine activity. The nurse should also assure that the uterus maintains an adequate resting tone between contractions.
Fallopian tubes, also called oviducts, are 8 to 14 cm long and quite narrow. The fallopian tubes are a pathway for the ovum between the ovary and the uterus. Fertilization occurs in the fallopian tube.
An empty bladder contributes to a woman’s comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonogram but are not applicable to performing Leopold maneuvers. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones.
A primary characteristic of an effective nurse is a nonjudgmental approach to clients. Nonjudgmental nurses allow clients to talk about feelings, and they respect clients as responsible people capable of making their own decisions. This allows the client to communicate openly and does not imply that the nurse accepts or condones the behavior of the client.
The ovaries are the endocrine glands that produce estrogen and progesterone. The FSH and LH are produced by the anterior pituitary gland. Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions during labor.
Prolactin stimulates the secretion of milk, called lactogenesis. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. In the female, testosterone is produced by the adrenal glands and induces the growth of pubic and axillary hair at puberty. Progesterone stimulates the secretions of the endometrial glands causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation.
Progesterone maintains uterine lining for implantation and relaxes all smooth muscle including the uterus. Relaxin is the hormone that softens the muscles and joints of the pelvis. Thyroxine increases during pregnancy to stimulate basal metabolic rates, and prolactin is the primary hormone of milk production.
Valium, a benzodiazepine, can cause motor incoordination and ataxia and safety precautions should be instituted for clients taking this medication.
Pitocin produces uterine contractions. Uterine contractions can cause fetal anoxia. The nurse monitors the fetal heart rate and notifies the physician of any significant changes.
The liver is not fully developed in the newborn infant and the infant cannot detoxify many medications.
The client with mania exhibits an elated mood, increased activity, and reduced sleep. The client constantly goes from one activity to another, one place to another, and one project to another and demonstrates an inflated self-esteem and an inability to concentrate. The client typically is too busy to eat and therefore demonstrates a weight loss.
Russell’s traction uses skin traction to realign a fracture in the lower extremity and immobilize the hip and knee in a flexed position. It is important to keep the hip flexion at the prescribed angle to prevent fracture misalignment. The traction may also relieve pain by reducing muscle spasms, but this is not the primary reason for this traction. The child can still move in bed with some restriction as a result of the traction. Traction is never used to restrain a child.
A small amount of serosanguineous drainage may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose and if this is noted, the physician should be notified. The physician is also notified if signs of infection are present.
A complete neurological assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.
Buck’s extension traction is a form of skin traction. Skin traction is achieved by ace wraps, boots, and slings that apply a direct force on the client’s skin. Skin traction is usually removed and reapplied once a day. Traction is maintained with 5 to 8 lbs of weight (depending on the physician’s order) and this type of traction can cause skin breakdown. There are no pin sites with skin traction. Urinary incontinence is not related to the use of skin traction. Assessment of bowel sounds may be a component of the assessment because constipation can occur as a result of immobility. However, this is not the priority assessment.
The palms or the flat surface of the hand should be used when moving a client who has a wet cast to prevent indentations. Pillows are also used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. The client would not be asked to stand and bear weight on a wet cast. Additionally the client would not bear most of the body weight on a casted extremity. Supporting the cast with the fingertips and pulling on the cast with a sheet wrapped around the cast will cause indentations in the cast. Indentations can cause pressure on the skin under the cast and skin breakdown.
A limb encased in a cast is at risk for nerve damage and diminished circulation from increased pressure due to edema. Signs of increased pressure from the cast include numbness, tingling, and increased pain. A plaster of Paris cast can take up to 48 hours to dry and generates heat while drying. Some drainage may occur initially with a compound (open) fracture.
Vitamin K is associated with the production of prothrombin, which helps the blood properly clot. Vitamin A deficiency is associated with night blindness. Vitamin B2 (riboflavin) deficiency is associated with scaly skin. Vitamin D deficiency can cause skeletal pain.
An enlarged thyroid gland occurs in the client with goiter because excessive amounts of thyroxine in the thyroid gland cause it to enlarge.
Slow wound healing occurs with zinc deficiency.
Chronic fatigue occurs with iron deficiency.
Heart damage occurs with selenium deficiency. Additionally, heart damage would not likely be noted during the nursing assessment. Further diagnostic tests, in addition to the assessment, would be necessary to determine the heart damage.
An enlarged thyroid gland occurs in the client with goiter because excessive amounts of thyroxine in the thyroid gland cause it to enlarge. Slow wound healing occurs with zinc deficiency. Chronic fatigue occurs with iron deficiency. Heart damage occurs with selenium deficiency. Additionally, heart damage would not likely be noted during the nursing assessment. Further diagnostic tests, in addition to the assessment, would be necessary to determine the heart damage.
Normal hemoglobin levels indicate that iron and protein intake is sufficient. Elevated creatinine levels indicate kidney problems, which are not considered a nutritional disorder. Elevated albumin levels may falsely indicate dehydration. Normal red blood cell levels indicates adequate vitamin B12 intake.
Prior to the gastroscopy procedure, medication is administered to prevent a gag reflex. Upon return from the procedure, the nurse must test the client’s gag reflex to determine that it is present. The client must be placed in a side-lying or semi-Fowler’s position to avoid aspiration. Vital signs should be taken every 30 minutes for 2 hours (or per agency procedure) to detect abnormalities and signs of complications. Saline gargles must only be administered when the presence of the gag reflex has been confirmed.
Stir-fried vegetables are allowed for strict vegetarians. A chocolate milkshake is not an appropriate choice because dairy products, such as milk, are not allowed. Because the wheat toast is buttered, it is also not allowed because butter is a dairy product. Strict vegetarians do not eat eggs. Foods that are eaten by a client who is a strict vegetarian include grains, fruits, and vegetables.
A high-protein, low-fat diet is recommended for an individual with heartburn. This type of diet allows the stomach valve to close, which prevents gastric secretions from upsetting the stomach. The client should not lie down after eating and should wait at least 2 hours after a meal before doing so. This time period would allow enough time for the stomach acid to decrease. Fruit juices should be avoided because of their high level of acidity, which would aggravate the heartburn. Clients should not be encouraged to overeat because it increases the production of acid and causes additional stomach pressure.
Room temperature or cold food items seem to be tolerated better in the client who has nausea. Hot items may increase the nausea because of the aromas emitted. Dry toast would be better tolerated by the client and additionally, if the client were on a clear liquid diet, buttered toast is not allowed.
Daily weights are the most accurate way to monitor the client’s progress who has malnutrition. It is important to weigh the client at the same time each day using the same scale. The client should have the same amount of clothes on each time the client is weighed and the client should urinate beforehand. It is also recommended that the client be weighed before breakfast. Measuring I&O, skinfold measurements, and calorie counts are also helpful but the most effective method to monitor the client’s progress is by daily weights.
Nateglinide (Starlix) is an antidiabetic medication used to treat type 2 diabetes mellitus in clients whose disease cannot be adequately controlled with diet and exercise. It stimulates the release of insulin from beta cells of the pancreas by depolarizing beta cells, leading to an opening of calcium channels. Resulting calcium influx induces insulin secretion.
Rifampin (Rifadin) is an antitubercular medication used in conjunction with at least one other antitubercular agent for initial treatment or retreatment of tuberculosis. Urine, feces, sputum, sweat, and tears may become red-orange in color. The client should also be told that soft contact lenses may become permanently stained as a result of this harmless side effect. There is no useful reason for the client to provide a urine sample. The client is not told to stop a medication. Antacids are not usually taken with a medication because of interactive effects.
A primary goal for the pregnant client with known cardiac disease is to prevent anemias that could limit the oxygen supply to the placenta and developing fetus, thus causing restrictions in fetal growth. An adequate dietary intake and supplementation of iron and folic acid during pregnancy can prevent most maternal anemias from occurring.
Toxoplasmosis is a systemic, usually asymptomatic illness caused by the protozoan parasite. Humans acquire the infection from inadequately cooked meat, eggs, or milk; ingesting or inhaling the oocyst excreted in feline feces, or from contaminated blood-product transmission. Other than transplacental infection, this disease is rarely transmitted from human to human. During pregnancy, the parasite may be transmitted across the placenta and cause severe infection to the developing embryo or fetus.
Pregnant HIV-positive clients are at risk for alterations in nutrition, especially less than body requirements. Monitoring for adequate weight gain throughout pregnancy will help to identify potential problems early on to support adequate fetal development. This measure also reassures the client that a safe environment is being promoted for her developing fetus.
A variety of factors can further complicate the potential maternal and fetal effects of iron deficiency anemia during pregnancy. Such factors would include geographic location, socioeconomic status, daily nutrition and fluid intake, compliance to supplemental medication regimes, and blood loss during pregnancy.
Endometritis is an acute infection of the mucous lining of the uterus that can occur immediately after delivery. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of the membranes, multiple vaginal exams, and an excessive length of labor.
Purulent drainage can indicate infection at the pin insertion sites, and the nurse would assess the client’s temperature because an elevation is an indication of the presence of infection. A small amount of serous oozing is expected at pin insertion sites. Serosanguineous drainage may be present in small amounts initially, but do not indicate infection. Sanguineous drainage is also of concern, and should be brought to the attention of the physician. However, it is not a sign of infection, and therefore the client’s temperature does not necessarily need to be assessed with this finding.
Clients with chronic venous insufficiency are advised to avoid crossing the legs, sitting in chairs where the feet don’t touch the floor, and wearing garters or sources of pressure above the legs (such as girdles). The client should also avoid prolonged standing or sitting. The client should wear elastic hose for 6 to 8 weeks, and perhaps for life. The client should sleep with the foot of the bed elevated to promote venous return during sleep.
Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries, and then removal of the vein with the use of hook and wires via multiple small incisions in the leg.
(Buerger’s disease) is a relatively uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young adult males who smoke. The cause is unknown, but is suspected to have an autoimmune component. The primary emphasis in treatment is smoking cessation, along with standard measures to increase circulation that are used in other peripheral arterial diseases.
The nurse should help parents adjust to the congenital disorder in their newborn and to foster infant-parent bonding. Failure to pass meconium within 24 hours is suggestive of Hirschsprung’s disease. A barium enema is a diagnostic tool, which would not be administered by parents.
Smoking is highly detrimental to the client with Buerger’s disease, and clients are recommended to stop completely. Since smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients, symptoms are relieved or alleviated once smoking stops. The other resources are unnecessary for this client.
Esophageal atresia and tracheoesophageal fistula (TEF) are congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural connection with the trachea.
Clinical manifestations associated with congenital diaphragmatic hernia include diminished or absent breath sounds on the affected side, bowel sounds heard over the chest, cardiac sounds heard on the right side of the chest, respiratory distress developing soon after birth including dyspnea, cyanosis, nasal flaring, tachypnea, and retractions, and a scaphoid abdomen.
To evaluate the presence of pitting edema, the fingertips of the index and middle finger are pressed against the shin and pressure is held for 2 to 3 seconds.
When evaluating the deep tendon reflex, the normal response should be an extension and thrusting of the foot upward. A 1+ response indicates a diminished response; 2+ indicates normal; 3+ indicates increased, brisker than average; and 4+ indicates a very brisk hyperactive response.
Oliguria indicates renal impairment and is a characteristic symptom of severe preeclampsia. Renal perfusion is reduced as vasospasm increases and therefore urine output will decrease. Deep tendon reflexes of +2 and a fluctuating fetal heart rate are normal and expected assessment findings. The presence of pedal and pretibial edema does not indicate an increasing severity of preeclampsia.
In placenta previa, the placenta is implanted in the lower uterine segment and does not contain the same intertwining musculature as the fundus of the uterus; however, this site is more prone to bleeding.
Disseminated intravascular coagulopathy is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. The presence of petechiae, oozing from injection sites, and hematuria are indicative of the presence of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation and are thus prolonged. Fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area, such as the calf of one leg.
With a client in shock, the goal is to increase perfusion to the placenta. The priority nursing action would be to turn the client on her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels.
Sensation is tested by pinching the skin or pushing on it with a dull object. The nurse starts at the shoulder level and works downward in a systematic manner. The client is asked at which level sensation is felt, and if it is sharp or dull. Motor function is tested by asking the client to spread the fingers, squeeze the nurse’s hands, or move the toes or feet.
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