In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client’s activities. Vigorous shoulder and arm movement on the affected side should be avoided. This is an important concept regarding the care of the client immediately after pacemaker insertion.
The term capture refers to the electrical and mechanical response of the heart to pacemaker stimulation. The pacemaker spike indicates pacemaker firing. The client should have a QRS complex that follows the spike. Failure to capture then would be the absence of a QRS after a pacemaker spike on the client’s rhythm strip.
The sensing device of a demand pacemaker senses the heart’s own electrical activity and allows the pacemaker to fire only when the client rate is less than the preset rate. Thus for the portion of time that the client’s rhythm is adequate, no pacemaker spikes should appear on the ECG. Failure to sense occurs when regular pacing artifact appears on the ECG regardless of the client’s own inherent rhythm.
The client who has been on bed rest for 7 days is at risk for all the complications of immobility. The peripheral vascular complication would most likely be deep vein thrombosis. If this occurs, the client would exhibit redness and/or warmth of the affected leg, tenderness at the site, possible dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and possible positive Homans' sign in the affected extremity.
Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. The nurse vigilantly assesses the client for the development of pulmonary embolism. Chest pain is the most common symptom, is sudden in onset, and may be aggravated by breathing. Other common signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.
The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this will resolve as the therapy progresses, and that the client should gradually increase activity as energy levels permit. Remember that medication therapy for the client with TB lasts for 6 to 9 months and may continue for up to a year.
Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Imipramine hydrochloride (Tofranil) blocks the reuptake of norepinephrine and serotonin. Donepezil hydrochloride (Aricept) inhibits the breakdown of released acetylcholine. Fluoxetine hydrochloride (Prozac) is a potent serotonin reuptake blocker.
Before mixing different types of insulin, the bottle should be rotated for at least 1 minute between both hands. This resuspends the insulin and helps warm the medication. Insulin may be maintained at room temperature. Additional bottles of insulin for future use should be stored in the refrigerator. Regular insulin is drawn up before NPH insulin. Air does not need to be removed from the insulin bottle.
Dimenhydrinate (Dramamine) is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness
Omeprazole (Prilosec) is a gastric pump inhibitor and is classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often referred to as heartburn by the client.
Droperidol may be administered by the intramuscular or intravenous (IV) routes. The IV route is used when relief of nausea is needed. The intramuscular route may be used when the medication is used as an adjunct to anesthesia. To administer this medication, the nurse should have a needle and syringe.
Propantheline (Pro-Banthine) is an antimuscarinic anticholinergic medication that decreases gastrointestinal (GI) secretions. It should be administered 30 minutes before meals.
In a client with tuberculosis (TB), the client is generally considered to be noncontagious after 2 to 3 weeks of medication therapy, although the client is continued on medication therapy for 9 to 12 months. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission.
The client with TB should wash the hands carefully after each contact with respiratory secretions. The client should cover the mouth and nose when laughing, sneezing, or coughing. Used tissues are discarded in a plastic bag.
The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the client will always test positive on Mantoux skin testing. This client should be evaluated for TB with a chest radiograph.
A client with AIDS has a nursing diagnosis of Fatigue, The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, ironing, etc. The client should also sit in a shower chair instead of standing while bathing. The client should prioritize activities such as eating breakfast before bathing and should intersperse each major activity with a period of rest. Frequent short rest periods are more effective than fewer, longer ones.
The convalescent phase of illnesses is not a contraindication for immunizations. The general contraindication for all immunizations is a severe febrile illness or immunocompromise. The normal schedule for immunizations is recommended for this infant to provide protection from life-threatening diseases.
Bicycle safety requires always wearing a helmet when riding. Most injuries occur near home, and a potential exists for falls on bike paths and off roads. Five years is also a young age to be riding in the street.
Instructions on feeding an infant with a cleft palate, The mother should be taught to maintain constant pressure to the bottom of the bottle to decrease the risk of choking. The mother should also be taught to expect noise from the baby while feeding and to watch facial expressions as a cue to stop the feeding.
Instructions given to a mother on measures to take to reduce the incidence of gastroesophageal reflux (GER) in a child includes the child’s formula will most likely be thickened with cereal. Cereal is added to the formula to increase the consistency and decrease the incidence of regurgitation. The nipple holes should be large to allow for easy flow of thicker formula. The child should receive small feedings throughout the day. Sucking on a pacifier in an upright position facilitates the flow of food through the esophagus.
The following outcome indicates that the infant receiving phototheraphy is improving is when the infant’s stools often become loose and bright green owing to the excretion of excessive bilirubin as a result of the phototherapy. The infant’s urine may become a dark color from urobilinogen formation. The normal reticulocyte count in an infant at 1 to 3 days of age is 1.8% to 4.6%. An increasing reticulocyte count indicates continued destruction of the infant’s red blood cells. Phototherapy works by a process of photoisomerization and photo-oxidation that results in more water-soluble bilirubin end products, which can then be more rapidly excreted in the urine and stool. Therefore the bilirubin level would decrease.
Between the ages of 1 and 3 months, the infant will produce cooing sounds. Babbling sounds are common between the ages of 3 and 4 months. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months.
The age-appropriate instruction that is most important to instruct a mother of a 1-month old infant is to instruct the mother not to shake or vigorously jiggle the baby’s head.
Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats, introduced one at a time can begin at 6 months of age. Self-feeding is not appropriate until approximately age 9 months.
In the preschooler, play is simple, imaginative, and creative, and dramatic play is prominent. The preschooler likes to build and create things. In the bedridden child, the nurse should provide an activity that provides this type of stimulation.
Celiac disease, also known as gluten enteropathy or tropical sprue, results from the inability to digest fully the protein part of wheat, barley, rye, and oats.
Elbow restraints are used after cleft palate repair to prevent the child from touching the repair site, which could cause accidental rupture and tearing of the sutures. One restraint can be removed only if a parent or nurse is in constant attendance.
In an adolescent, age 15 years to adulthood, the maximum volume of intramuscular medication that can be safely administered in the dorsal gluteal muscle is 2 mL.
Care of a child with rubella involves contact isolation. Contact isolation requires the use of masks, gowns, and gloves for contact with any infectious material. Contaminated articles must be bagged and labeled before reprocessing.
Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology.
HIV is an acquired cell-mediated immunodeficiency disorder
Rheumatic fever is an inflammatory autoimmunune disease that affects the connective tissue of the heart, joints and subcutaneous tissues
Systemic lupus erythematosus is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue.
Human immune globulin is obtained from the pooled blood of many people. This type of vaccine provides antibodies to a variety of diseases such as measles, rubella, and infectious hepatitis. Its disadvantage is that it offers only temporary passive immunity. Some immune globulin can be disease specific and is derived from individuals with a specific disease.
Dietary sources of vitamin B12 are primarily from meat, eggs, milk, and milk products. Plant foods do not provide this vitamin. Leafy green vegetables, whole-grain cereals, wheat germ, and legumes are dietary sources of folate.
Dietary sources of folate include leafy green vegetables, whole-grain cereals, wheat germ, and legumes. Meat, eggs, milk, and milk products are dietary sources of vitamin B12.
Fifth disease is transmitted via airborne particles, respiratory droplets, blood, blood products, or by transplacental means.
Epstein-Barr virus (Infectious mononucleosis) is transmitted via saliva, close intimate contact, or via blood. It is not transmitted via airborne particles, contact with sweat, or by the fecal-oral route.
The parents should be taught to wipe the child from front to back after urination or a bowel movement to avoid moving bacteria from the anus to the urethra. Fluid intake including water should be encouraged. The child should be encouraged to avoid holding urine and to urinate at least 4 times a day. Additionally, the bladder should be emptied with each void to avoid residual urine. Hand washing is necessary to prevent the spread of infection. Bubble baths also are avoided because they may cause possible urethral irritation.
In poststreptococcal glomerulonephritis, a urinalysis will reveal hematuria with red cell casts. Proteinuria also is present. If renal insufficiency is severe, the BUN and creatinine levels will be elevated. The WBC is usually within normal limits, and mild anemia is common.
Clinical manifestation associated with nephrotic syndrome include edema, anorexia, fatigue, abdominal pain from the presence of extra fluid in the peritoneal cavity, diarrhea due to edema of the bowel caused by decreased absorption of nutrients, increased weight, and a normal blood pressure.
Cryptorchidism occurs when one or both testes fail to descend through the inguinal canal into the scrotal sac.
After tonsillectomy, the child should be placed in a prone or side-lying position to facilitate drainage. The supine position is contraindicated because of the drainage that may occur and the risk of aspiration
Acute laryngotracheobronchitis (LTB) usually has a gradual onset and usually occurs at night.
Respiratory syncytial Virus (RSV) can live on paper or skin for up to 1 hour and on cribs or other nonporous surfaces for up to 6 hours. Although it is not airborne, it is highly communicable, and it is usually transferred by the hands. Meticulous hand washing decreases the spread of organisms. Personnel who care for these children should maintain contact precautions including wearing gloves and gowns and practicing good hand washing.
The therapeutic management for viral pneumonia is supportive. Antibiotics are not prescribed. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids.
A patent ductus arteriosus is a left-to-right shunt. Blood is shunted to the right side of the heart because the left side is normally functioning at a higher pressure than the right side. This shunting allows oxygenated and unoxygenated blood to mix. It results in increased pulmonary blood flow because the abnormal communication or opening sends more blood to the right side of the heart than normal.
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