No item should be placed inside a cast because of the risk for alteration in skin integrity. A cotton-tipped applicator with rubbing alcohol may be used near the cast edges to relieve itching. The skin around the cast edges should be checked for redness, irritation, or blistering. The extremity should be elevated as much as possible to minimize swelling. The physician should be notified for any unusual odor and/or sudden unexplained fever indicating infection, or if numbness, tingling, pallor, cyanosis, and/or pain unrelieved by medication occurs because these signs indicate neurovascular compromise.
Although signs of neglecting parents are not always easily identified, some behavioral characteristics emerge. These include a lack of concern for the child's well-being, unreasonable punishments, high demands and unrealistic expectations for the child, and a view of the child as a small adult who can meet their personal needs. Assessment of the parents in their role may provide the nurse with clues as to the family dynamics and assist in determining the educational needs of the parents.
Trauma, often due to falls, is the most common cause of spinal cord injury. Roller-blading, especially without a helmet, is a risk factor. Other risk factors include bicycling, motorcycling, horseback riding, diving into unknown waters, and occupations at elevations over 5 feet.
Constipation with ribbon-like, foul-smelling stools is particularly characteristic of Hirschsprung’s disease. A distended abdomen, poor feeding habits, irritability, and signs of undernutrition also are characteristic of Hirschsprung’s disease. Inguinal swelling indicates inguinal hernia. Projectile vomiting indicates pyloric stenosis. Intussusception is indicated by acute, colicky abdominal pain and currant jelly-like stool.
A “slapped face” appearance and circumoral paleness can be indicative of the presence of a communicable disease, specifically fifth disease. Therefore a complete and thorough assessment should be done before deciding on the appropriate nursing intervention.
Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. Before administering the medication, the nurse should assess the apical heart rate for 60 seconds. If the pulse rate is less than 60 beats per minute in an adult client, the nurse would withhold the medication and contact the physician, because a low pulse rate may be an indication of toxicity.
Allergy to seafood, iodine, or iodine contrast media in the preprocedure period may necessitate a skin test for allergy severity and the use of prophylactic antihistamines to prevent an allergic response to the contrast medium.
Progressive, gradual increases in activity should be done after MI. Gradual increases in activity prevent or minimize overtaxing of the heart and fatigue. The nurse’s role is to monitor and adjust the client’s activity level according to individual tolerance. Providing positive reinforcement and encouragement during physical activity and providing adequate fluid intake will not prevent or minimize activity intolerance.
Clients with polycystic kidney disease seem to waste rather than to retain sodium. Thus they need an increased sodium intake and fluid intake of 1500 mL to 2000 mL per day.
Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea, and vomiting. Neurological abnormalities also can occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, light flashes, halos around bright objects, yellow or green color perception) also are signs of toxicity but are not early signs.
The best initial action that begins the attachment process and promotes bonding is to encourage the parents to touch their infant. The parents’ initial need is to become acquainted with their newborn infant.
Ambulatory clients with visual field deficits do not distinguish between colors very well and therefore require bright (not pastel) colored doors, doorknobs, hallway corners, etc.
Photon absorptiometry uses two sources of radiation of different energies to measure the density of the bone, and a low dose of radiation is used. This diagnostic test requires no invasive technique such as an injection or placement of a scope and is painless. The test does not use a magnetic field, so no danger is associated with metal objects on or in the client.
Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided.
According to category-specific (respiratory) isolation precautions, acid-fast bacteria isolation always requires a private room. The room needs to be well ventilated and should have at least six exchanges of fresh air per hour and should be ventilated to the outside if possible.
The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene. Balloons are unsafe because of the potential aspiration of latex. The peak flow meter is used to assess vital capacity rather than to encourage breathing. Chest percussion and postural drainage will not affect depth of respiration.
A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities. If only one lower extremity is included, it is called a single hip spica; if two are included, it is called a double hip spica. Short and long leg casts are applied to the leg. A body jacket cast is applied to the upper torso.
The decrease in cortisol secretion that characterizes Addison’s disease can result in hypoglycemia. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of hyperkalemia.
General anesthesia depresses the gag reflex that, in turn, increases the risk for aspiration. Suction equipment must be available in the event the client aspirates
Florinef is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity that is used for long-term management of Addison’s disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. In small doses, fludrocortisone acetate causes sodium retention and increased urinary potassium excretion. Hypotension and fluid and electrolyte imbalance can develop rapidly if the medication is discontinued abruptly.
Denial is a failure to recognize what is occurring in a situation and generates inappropriate behavior. Projection is the disowning and attributing process that enables a person to remain blind to aspects of self and distant to the perception of others. Setting firm limits on unacceptable and inappropriate behaviors in a nondefensive manner is the initial nursing action in this situation.
The individual with retinopathy has varying degrees of visual impairment. Thus falls are a major concern, especially for the older client. Disturbed Body Image and Chronic Low Self-Esteem are psychosocial needs and are not the priority. Although Risk for Bathing/Hygiene Self-Care Deficit relates to a physiological need, for this client, the Risk for Injury presents the greatest threat.
Clients with hypothyroidism have Imbalanced Nutrition: More than Body Requirements due to their decreased metabolic need. They should consume foods from all food groups, which will provide them with the necessary nutrients; however, the foods should be low in calories.
Clients with Parkinson’s disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these individuals imagine lines on the floor to step over can keep them moving forward.
The halo vest is used to treat cervical fractures. The halo vest or jacket has a ring that is fixed to the skull with pins. This ring is then attached to the vest or jacket by rods. This device provides the traction required to maintain cervical alignment and allows early mobilization and rehabilitation. A body jacket cast is applied to the upper torso. Skull tong traction involves the use of one of a variety of tongs (Gardner-Wells, Crutchfield, Vinke, or Barton). These tongs are drilled into the skull or placed below the scalp and attached to ropes, pulleys, or weights. This type of traction is used for cervical vertebrae fractures and involves the use of special beds or turning frames to facilitate nursing care. A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities.
Hypocalcemia is the result of hypoparathyroidism because of either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence on tissue. Calcium is the major controlling factor of PTH secretion. Because of this, the diet needs to be high in calcium but low in phosphorus, because these two electrolytes must exist in inverse proportions in the body.
The vast majority of clients with Guillain-Barré syndrome recover from the paralysis because it affects peripheral nerves that have the capacity to remyelinate. Maximal paralysis can take up to 4 weeks to develop. Paralysis progresses distally to proximally. Rehabilitation can take from 6 months to 2 years.
Pyridostigmine bromide (Mestinon) is an anticholinesterase that is used to improve muscle strength in the client with myasthenia gravis. Taking the medication before activities such as working or eating helps lessen fatigue and dysphagia and improves muscle strength. The medication should be taken with food. Clients should avoid quinine, antacids, magnesium, and morphine sulfate and its derivatives, because these medications can reverse the action of the pyridostigmine bromide and increase weakness. The medication should be taken regularly and on time to prevent fluctuating blood levels, which can cause weakness.
Typically, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore excessive body growth (macrosomia) results from high maternal glucose. After birth, hypoglycemia may be a problem because the infant’s pancreas continues to produce large amounts of insulin (hyperinsulinemia), which quickly deplete the infant’s glucose supply. Infants of diabetic mothers are usually delivered just before or at term because of an increased risk of ketoacidosis and intrauterine fetal death after 36 weeks.
The tuberculin syringe has a long, thin barrel. The syringe, calibrated in sixteenths of a minim and hundredths of a milliliter, has a capacity of 1 mL. It is used to prepare small amounts of medication such as small, precise doses for infants or young children.
Erythromycin (Ilotycin) is effective in protecting the newborn from against both Neisseria gonorrhea and Chlamydia trachomatis. It is less irritating to the newborn’s eyes than silver nitrate, does not stain, and may be administered at any safe temperature.
Parents must give informed consent for treatment of a minor with three exceptions. The first is to give emergency treatment. The second is when the consent of the minor is sufficient, such as for treatment of a sexually transmitted disease. The third is when a court order or other legal authorization has been made.
A sign of an adverse effect of terbutaline (Brethine) is tachycardia. Therefore the nurse would instruct the mother to check her pulse rate before taking each medication dose. Side effects of the medication include tremors, shakiness, nervousness, drowsiness, headache, nausea, heartburn, dizziness, flushing, and weakness.
With neurogenic bladder, vesicoureteral reflux can occur because of enlargement of the ureters and incomplete emptying of the neurogenic bladder. Urine flows back up into the ureters and eventually into the kidneys, causing hydronephrosis (enlarged kidneys). Protein, not blood, would be found in the urine at this time. Treatments include intermittent catheterization carried out around the clock and ureteral reimplantation surgery.
Autonomic dysreflexia (hyperreflexia) is a serious, potentially life-threatening complication of spinal cord injury. It results from an excessive autonomic response to normal stimuli and affects primarily clients with upper motor neuron lesions. The most frequent cause is bladder distention or feces in the rectum, although it can be triggered by visceral distention or stimulation of pain receptors in the skin. Clients are taught to perform self-catheterization regularly to prevent this problem, measures to prevent constipation, and other measures to prevent stimulation of pain receptors in the skin.
Digoxin (Lanoxin) is a cardiac glycoside that improves cardiac contraction, slows the heart rate, promotes diuresis, and increases cardiac output.
During the planning stage for client teaching, the nurse’s first action would be to determine what the client’s understanding of the topic is. This information provides the basis for planning further teaching. In this case, the nurse would determine the client’s knowledge and understanding of the ECG rhythm. Although the nurse also may identify any concerns that the client has about his condition, this information is not specifically related to client teaching as addressed in this question. Most clients would not know how to interpret an ECG rhythm strip; this activity is one that requires special training.
Propranolol (Inderal) is a beta-blocker that has side effects that could be disturbing to the client. These include decreased sexual ability, drowsiness, difficulty sleeping, and unusual tiredness and weakness. The client should know what these side effects are, so appropriate follow-up care can be sought.
Digoxin is a cardiac glycoside. The client is taught how to monitor his or her own pulse rate. The client is told to call the physician if the pulse rate is less than 60 beats/minute because bradycardia is a sign of medication toxicity. The client is not told to stop taking the medication. The medication must be taken daily and at the same time each day to ensure a consistent and stable blood level of the medication.
In cardiogenic shock, the nurse must take an active role in ensuring the client’s safety and physical comfort. A major role of the nurse is monitoring the client’s hemodynamic and cardiac status, and then planning care to maximize cardiac function and provide safety. Having the client sit on the side of the bed before the transfer allows the body’s baroreceptors to adjust and stabilize vital centers to position changes, thereby avoiding a fall due to postural hypotension. The nurse should remain with the client and assist in the transfer to the chair. Although a hydraulic lift may be appropriate for transferring a client from a bed to a chair, it is unrelated to this situation and the issue that the client experiences postural hypotension. A transfer (sliding) board is appropriate to use for transferring a client from a bed to a stretcher, not a chair.
Amitriptyline (Elavil), a tricyclic antidepressant, lowers the seizure threshold, increasing the risk of seizures. Therefore this medication is used with caution in the client with a history of seizures.
Client preparation for an oral glucose tolerance test includes ingestion of a diet with at least 150 grams of carbohydrates per day for 3 days before the test.
Chlorpropamide is a first-generation sulfonylurea (oral hypoglycemic agent) that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. Pioglitazone (Actos) is a thiazolidinedione, and miglitol and acarbose are glucosidase inhibitors used as oral hypoglycemic agents. These agents do not exert an antidiuretic effect.
To stimulate circulation as an aid in obtaining an adequate capillary blood sample, the client should wash the hands first by using warm water. The arm should be allowed to hang dependently, and the finger may be milked to promote obtaining an adequate size blood drop. The finger should be punctured near the side, not the center, because fewer nerve endings are found along the side of the finger. The puncture is only as deep as needed to obtain an adequate blood drop. Excessively deep punctures may lead to pain and bruising.
The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to the lowered pH. Once the client is treated with fluid replacement and insulin therapy, the potassium level begins to decrease quickly. This is because potassium is carried into the cells along with glucose and insulin, and also because potassium is excreted in the urine once rehydration has occurred. Thus the nurse must plan to monitor the results of serum potassium levels carefully and to report hypokalemia promptly.
One of the biggest concerns for diabetics during air travel, especially for long-distance flights, is the availability of food at times that corresponds with the timing and peak action of the client’s insulin. For this reason, the nurse may suggest that the client have carbohydrate snacks on hand for use as needed. Insulin equipment and supplies should always be placed in carry-on luggage
The normal value for glycosylated hemoglobin is 6% to 7%, and this test result provides an indication of glycemic control over the previous 3-month period. With elevations in blood glucose, some of the glucose molecules attach to the red blood cell (RBC) and remain there for the life of the RBC. Therefore high values in this test correlate with high blood glucose levels, indicating poor long-term control of blood glucose. Poor control of blood glucose is thought to be related to the development of complications in the client with diabetes mellitus.
The client is exhibiting signs of shock and requires emergency intervention. The nurse would immediately place the client in a modified Trendelenburg position. This position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client’s volume status by assessing the urine output and whether the IV is infusing. The nurse should obtain all this information quickly and then call the physician. The nurse would also monitor the client’s blood pressure, but retaking the blood pressure as a first action would delay necessary and potentially lifesaving intervention.
Standard measures for control of morning sickness include eating crackers or toast before arising from bed in the morning, eating small frequent meals, avoiding fatty and spicy foods, and arising slowly to avoid orthostatic hypotension.
Proper skin care during radiation therapy is extremely important to prevent skin breakdown and resultant infection. The nurse teaches the client to wash the skin gently with lukewarm water and a mild soap and patting the skin dry. The skin should not be rubbed, nor should that area of skin be shaved. The client should use only mild soaps for cleansing to avoid chemical irritation of the skin and should avoid lotions, creams, powders, or perfumes in the affected area. Finally, the client should not remove any skin markings placed by the radiologist to guide the radiation therapy.
The nasal cannula provides for lower concentrations of oxygen and can even be used with mouth breathers because movement of air through the oropharynx creates the Bernoulli effect, pulling oxygen from the nasopharynx. It is not necessary to instruct a client to breathe only through the nose.
Determining what to teach a client begins with an assessment of the client’s own knowledge and learning needs. Once these have been determined, the nurse can effectively plan a teaching approach, the actual content, and resource materials that may be needed. The evaluation is done after teaching is completed.
Basic procedure for drawing up medication from an ampule involves tapping the top chamber until the medication lies in the lower area, placing an alcohol wipe around the neck of the ampule, snapping the top of the ampule toward the nurse so it opens away from the nurse, and withdrawing the medication without injecting air into the ampule. Shaking the ampule will cause medication to trap in the top of the ampule. Snapping the ampule so that it opens away from the nurse prevents injury from possible shattered glass fragments. The neck is not wiped with the gauze, because first, it is unnecessary and could contaminate the ampule or medication, and second, it could cause injury to the nurse’s fingers from sharp glass edges.
Suctioning is indicated when the client cannot expectorate mucus by using a variety of other assistive methods. The need for suctioning is best determined by listening for coarse gurgling or bubbling respirations, or by hearing adventitious breath sounds with auscultation.
The nurse removes the sleeves of the pneumatic compression device 3 times a day for 20 to 30 minutes so that hygiene may be performed and skin integrity and circulation can be checked. The circulation to the extremities and the placement of the sleeves should also be checked every 2 to 3 hours for client safety.
Wound irrigation with normal saline is done before obtaining a wound culture because it can remove substances such as proteins or exudate.
The most effective means of preventing irregularities in volume infusion for the pediatric client is the use of an infusion pump. This prevents both overhydration and underhydration. A small-bore catheter is used in the pediatric client because of the small vein size, and a microdrip infusion set is used, rather than a macrodrip set. An arm board may be helpful in certain instances to minimize movement of the extremity with the catheter but is not the most effective means for regulating IV flow rate.
Phenelzine (Nardil) is a monoamine oxidase inhibitor (MAOI) that produces an antidepressant effect. Hypertensive crisis is an adverse effect of the medication, and the client must be instructed in the signs of this adverse effect. The onset of a headache that is sudden, severe, or unusual may be a sign of hypertensive crisis. In addition to a headache, a stiff neck, vomiting, and a sudden increase in blood pressure are manifestations of hypertensive crisis. Hypertensive crisis can lead to intracranial bleeding and is one of the most threatening side effects of MAOIs. Hypertensive crisis can be caused by the ingestion of foods containing the amino acid tyramine, and the client is instructed to avoid foods that contain this amino acid. It is not necessary for the client to avoid high-carbohydrate foods, limit fluid intake, or eat bran every day.
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