A client with a twin pregnancy is at increased risk for preterm labor. Preterm delivery has negative implications for the infant’s growth and development. With increased blood volume, cardiac output normally increases 30% to 50% in the second trimester of a twin pregnancy. Hyperglycemia and infection are not associated with a twin pregnancy.
Hyperactive clients receive insufficient nutrition because they are too involved mentally to attend to physiological signals. Offering frequent high-calorie snacks and finger foods will assist best in providing adequate nutrition during this period.
The client with depression experiences decreased energy and psychomotor retardation and requires assistance. Both the client and his family need to know that the nurse will assist the client until he can resume self-care activities.
Client safety always takes priority over other nursing care concerns.
The client with decreased cardiac output and possible dysrhythmias should be placed on continuous cardiac monitoring so myocardial perfusion can be most accurately assessed.
The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smooth ed as needed with a special cast knife. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.
Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides good isometric exercise to maintain muscle strength but will not prevent the left shoulder from becoming stiff. Range of motion of the affected fingers also is a useful general measure, but again will not prevent the left shoulder from becoming stiff. Lifting the right arm is of no particular value.
With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the victim, the site of fracture is immobilized to prevent further injury.
Home modifications to reduce the risk for falls includes the use of railings on all staircases, ample lighting, removing scatter rugs, and placing hand rails in the bathroom.
When the dialysate becomes cloudy, peritonitis is suspected. A culture and sensitivity of the peritoneal outflow is done, and broad-spectrum antibiotics are added to the dialysis solution, pending culture and sensitivity results. The dialysate also may be heparinized to prevent catheter occlusion. Some clients must switch to hemodialysis if peritonitis is severe or reoccurring, but it is not done on an emergency basis with this situation.
The client’s comfort is enhanced during insertion of the peritoneal dialysis catheter by premedicating the client and by use of a local anesthetic before introducing the catheter. The client is not placed in a side-lying position for insertion. Holding the breath will not promote comfort, but would increase tension on the abdominal wall, which is counterproductive. The client should be encouraged to speak as needed during the procedure.
To prevent bladder perforation during peritoneal dialysis catheter insertion, the client’s bladder should be emptied before the procedure. The client is positioned lying in bed, not standing for this procedure. An opioid analgesic may be prescribed, and a local anesthetic is used before catheter insertion. However, these interventions may not prevent complications of peritoneal catheter insertion. A baseline temperature is useful, but it also does not prevent complications from occurring.
The dialysate solution is warmed slightly before infusing it into the client. This prevents the client from becoming chilled and also helps to dilate the peritoneal blood vessels for better excretion of waste metabolites. Special warming pads or other devices specific for this use are used to warm the dialysate solution.
Compulsive rituals control the client’s anxiety. It is usually not productive to interfere prematurely with a ritual, unless it threatens the client’s health.
A client is at high risk for a barium impaction after a barium enema. To prevent this, the nurse should obtain a physician’s order for a laxative or enema to follow the procedure, encourage the intake of fluids, and monitor bowel movements.
Regurgitation with tracheal aspiration is a major complication of a hiatal hernia. Although antacids, avoidance of smoking, and losing weight will assist in alleviating the discomfort that can occur, these measures will not prevent aspiration.
Balloon tamponade is one method used to stop bleeding from esophageal varices, but the pressure may cause tissue necrosis. Scissors should be kept at the bedside to cut and remove the tube in an emergency. Saliva and secretions may accumulate above the tube, so to prevent aspiration, suction may be used. It is not necessary to elevate the head of the bed 90 degrees.
Antacids are medications used to relieve the symptoms of ulcers because they decrease gastric acidity and the acid content of chyme reaching the duodenum. In addition, some antacids bind to bile salts and decrease the harmful effects of acid on gastric mucosa. Because of its antiplatelet and irritating properties, enteric-coated aspirin is contraindicated in ulcer disease
Tuberculosis is spread by droplet nuclei; therefore, strict isolation is not required. A well-ventilated room with fresh-air exchange is important. The particulate respirator (not a simple, disposable facemask) is used in the care of clients with actual or suspected tuberculosis infection. A simple disposable facemask would not provide adequate protection for the health care worker.
The client being suctioned, who is awake, is placed in semi-Fowler’s position to increase ease of breathing. The nurse should explain the procedure to alleviate some of the client’s anxiety. The postoperative client benefits from pain medication to minimize pain that could occur with coughing during the procedure. The catheter size should be large enough to obtain secretions, but small enough to prevent inducing hypoxia for the client.
When transporting a client with portable oxygen, the nurse checks the amount of oxygen in the cylinder by turning the key counterclockwise and reading the pressure gauge and attaching a humidifier bottle between the flow-meter adapter and the client’s cannula. Any excess tubing is coiled and placed under the pillow or secured to the client’s gown. The nurse avoids putting the cylinder on the stretcher, so that the client does not experience injury. The cylinder is always secured in the proper holder.
Common allergens in the home include animal dander, dust, smoke, fumes, and mold. Animal dander can be eliminated by not having pets with hair. Use of a damp cloth will prevent dust from being dispersed in the air with dusting. Air conditioners and furnace humidifiers are sources of mold that could be allergenic. These should be cleaned periodically to prevent accumulation of mold. Use of a humidifier year round is of no particular benefit. It could be contraindicated in summer months when a dehumidifier is needed to reduce environmental moisture (and subsequent mold growth).
Clients with schizophrenia exhibit isolation from others as a result of mistrust. Trust must be established before therapeutic intervention can occur, and it lays the foundation of the nurse-client relationship.
Defense-oriented behavior is using mental mechanisms to lessen uncomfortable feelings of anxiety and to prevent pain regardless of cost. The person has little awareness of what is happening or has a lack of control over events. Initially, these reactions may help reduce anxiety, but they interfere with the ability to grow or cope successfully. The nurse must decrease the anxiety so that more constructive behavior occurs.
Neurapraxia is the interruption of nerve conduction without loss of continuity of the axon. It can occur if the nerves have been stretched by the traction force. The location of the nerves at the base of the skull (cervical region) makes them more susceptible to damage by the force of the traction. If identified early, the paralysis can be reversed. An Allen wrench is needed, not pliers, for vest removal for emergencies only, not for hygiene needs. The release screws must be brightly marked. Clients in halo-vest traction cannot turn their heads. The purpose of the traction is provide for complete immobilization of the head and neck while allowing client mobility. Halo-vest traction does not involve the use of weights, although cervical skin traction and Crutchfield tongs involve the use of weights.
The most important nursing diagnosis is to Ineffective Airway Clearance. Because of the copious, thick secretions that occur with pertussis and the small airway of an infant, air exchange is critical. Fluid volume would be possibly less than body requirements because of the thick secretions and vomiting that may occur. Sleep patterns may be disturbed because of the coughing, but it is not the most important issue. Risk problems are addressed after actual problems.
The pacemaker is shielded from interference from most electric devices. Radios, TVs, electric blankets, toasters, microwave ovens, heating pads, and hair dryers are considered to be safe. Devices to be forewarned about are those that have strong electric currents or magnetic fields and include antitheft devices in stores and metal detectors used in airports.
The procedure for using support stockings is as follows: apply the stockings every morning (before the development of edema) while lying down if able, from the foot to the ankle to the calf, checking for proper fit and comfort, and removing if cyanosis or discomfort occurs.
Treatment in Buerger’s disease is aimed toward slowing the progress of the disease, controlling the pain, protecting the extremity from extremes in temperature, elimination of tobacco use, performing foot care daily, and performing Buerger-Allen exercises. The disease does not necessarily have a poor prognosis if correct life-style measures are implemented. The disease cannot be eliminated. No need exists to move to a warmer climate; this will not arrest the disease.
Raynaud’s disease, occurring primarily in women in their teens or early 20s, causes vasospasm and pain in the digits with exposure to cold, vibration, or stress. Raynaud’s disease produces closure of the small arteries in the distal extremities. Diminished or absent peripheral pulses can occur.
HIV infection causes immunosuppression and is indicated by a T4 lymphocyte count of less than 200/mm3. Although bacterial, fungal, and protozoan infection can occur, these infections occur as opportunistic ones as a result of the immunosuppression.
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