Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by the arms, chin thrust out, and mouth open), nasal flaring, tachycardia, a high fever, and sore throat.
Familiar objects provide a sense of security for the child in a strange hospital environment. The child should be allowed to have a favorite toy or security blanket while in the mist tent.
The stinger from a bee should be carefully removed by scraping it out horizontally. The mother should be instructed to avoid squeezing the stinger because more venom will be released. Following removal of the stinger, the area is washed with soap and water and ice may be applied for discomfort.
Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for clients with Ménière’s disease.
Following mastoidectomy, the nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse should assess for signs of facial nerve injury to cranial nerve VII and assess the client for pain, dizziness, or nausea. The head of the bed should be elevated at least 30 degrees, and the client is instructed to lie on the unaffected side. The client would probably have sutures and an outer ear packing and a bulky dressing, which is removed on approximately the sixth postoperative day.
Unstable angina is triggered by an unpredictable amount of exertion or emotion, and may occur at night. The attacks increase in number, duration, and severity over time. Variant angina is triggered by coronary artery spasm, and the attacks are of longer duration than those of classic angina and tend to occur early in the day and at rest. Intractable angina is chronic and incapacitating, and is refractory to medical therapy. Nocturnal angina may be associated with dreaming that occurs with rapid eye movement (REM) sleep.
Bloody or clear watery drainage from the auditory canal indicates a cerebrospinal leak following trauma and suggests a basal skull fracture. This warrants immediate attention, and the physician should be notified.
Otoscopic examination of a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.
Hearing loss can occur in a client with an inner ear disorder. However, hearing loss is not the most common complaint of a client with an inner ear disorder. Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client’s thinking process and attention span.
A hallmark sign of pemphigus is Nikolsky’s sign. Nikolsky’s sign is when the epidermis can be rubbed off by slight friction or injury. Other characteristics of pemphigus include flaccid bullae that rupture easily and emit a foul-smelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, groin, and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin. Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Homans' sign, a sign of thrombosis in the leg, is discomfort behind the knee on forced dorsiflexion of the foot.
In severe cystic acne, isotretinoin is used to inhibit inflammation. Adverse effects include elevated triglycerides, skin dryness, eye discomfort such as dryness and burning, and cheilitis (lip inflammation). Close medical follow-up is required, and dry skin and cheilitis can be decreased by the use of emollients and lip balms. Vitamin A supplements are stopped during this treatment.
Scabies can be identified by the multiple straight or wavy threadlike lines noted beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the skin and lays its eggs. The eggs hatch in a few days and the baby mites find their way to the skin surface where they mate and complete the life cycle.
The client with any renal disorder, such as renal failure, may become angry and depressed because of the permanence of the alteration. Due to the physical change and the change in lifestyle that may be required to manage a severe renal condition, the client may experience Disturbed Body Image.
Athletes often have sinus bradycardia because exercise increases the stroke volume of the heart. Since the cardiac output is a product of stroke volume and heart rate, fewer beats are needed per minute at rest to maintain the normal cardiac output. The vital signs are normal for this client.
With classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. Herpes zoster is caused by a reactivation of the varicella zoster virus, the cause of the virus for chicken pox. In a Wood’s light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. A patch test is a skin test that involves the administration of an allergen to the skin’s surface to identify specific allergies.
The primary lesion of herpes zoster is a vesicle. The classic presentation consists of grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body’s midline.
Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and have a potential for metastasis. Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This type of skin cancer is highly metastatic, and a person’s survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures.
A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue-toned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry rough adherent yellow or brown scale.
Premature ventricular contractions are generally easily recognizable on the ECG. They occur early in relation to the timing of previous normal beats, have no visible P wave, and have a characteristically wide and bizarre QRS complex. There is a compensatory pause.
With onset of ventricular fibrillation, the client loses consciousness and becomes pulseless and apneic. There are no heart sounds or blood pressure. Death will occur if not treated.
Assessment findings in frostbite include a white or blue color, and the skin will be hard, cold, and insensitive to touch. As thawing occurs, the skin becomes flushed, blisters or blebs develop, or tissue edema appears. Gangrene develops in 9 to 15 days.
Acute frostbite is ideally treated with rapid and continuous rewarming of the tissue in a water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because this can contribute to increased cellular damage. Thawing can cause considerable pain, and the nurse administers analgesics as prescribed.
Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. A hallmark sign of pemphigus is Nikolsky’s sign. In Nikolsky’s sign, the epidermis can be rubbed off by slight friction or injury. Homans' sign, a sign of thrombosis in the leg, is discomfort behind the knee on forced dorsiflexion of the foot.
Histoplasmosis usually starts as a respiratory infection in the client with AIDS. It then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver.
The client who suffers a spinal cord injury experiences spinal shock at the time of the injury. The client loses all motor, bowel, bladder, and sexual function, and loses all reflexes below the level of the injury. Spinal shock resolves in 7 days to 3 months. Indications of resolving spinal shock include hyperreflexia and positive Babinski reflex.
As the first symptom, the client with Pneumocystis carinii infection usually has a cough that begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.
If the results of two ELISA tests are positive, the Western Blot is done to confirm the findings. If the result of the Western Blot is positive, then the client is considered to be positive for HIV, and infected with the HIV virus. The CD4 count identifies the T-helper lymphocyte count and is performed to determine progression and treatment.
Hyperglycemia is characteristic of newly diagnosed diabetes mellitus. Newly diagnosed diabetics present a variety of symptoms, which may include polydipsia, polyuria, polyphagia, weakness, weight loss, dehydration. The definitive diagnosis is verified by hyperglycemia.
Renal biopsy is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system. While some types of cancer grow more quickly than others, it is not possible to determine this by biopsy.
Radiation therapy to the brain can cause cerebral edema. Clients may also experience nausea and vomiting because of the effects of the radiation on the brain’s chemoreceptor trigger zone. Because hair follicles are destroyed by radiation, clients receiving radiation to the head may also experience hair loss.
Anxiety varies with an individual's perception, which in turn depends on a person's psychosocial makeup, education, degree of maturity, and life experiences. The nurse should know that anxiety is exhibited in many various forms. People can communicate their anxiety both verbally and nonverbally. The nurse needs to identify cues, interpret them, and seek to validate them.
Oral, subcutaneous, and intramuscular routes for administering medications are contraindicated for the burned client because of the poor absorption. When fluid balance is stabilized, oral narcotic agents can be used.
A hydrocele is an abnormal collection of fluid within the layers of the tunica vaginalis that surrounds the testis. It may be unilateral or bilateral and can occur in an infant or adult. Hydrocelectomy is the excision of the fluid filled sac in the tunica vaginalis. The client needs to be instructed that the sutures used during the hydrocelectomy are absorbable.
The client undergoing a radioactive iodine uptake test needs to be reassured that the amount of radioactive iodine used is very small, that it is not harmful to the client, and that the client will not be radioactive.
Since tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is important to perform proper hand washing after contact with body substances, tissues, or facemasks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing, and dispose of tissues carefully.
The client with tuberculosis usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.
The signs identified in the question indicate an occlusion of the femoral artery. Prior to the procedure, the nurse should mark the peripheral pulses distal to the catheter insertion site with a felt-tipped pen, and record the quality of the pulses in the chart. This will aid in locating the pulses after the procedure. Pulses are checked before the procedure for post-procedure comparisons and to detect possible occlusion of the vessel undergoing cannulation. The physician is notified immediately if the client experiences numbness or tingling in the affected extremity, if the extremity becomes cool, pale, or cyanotic, or if sudden loss of peripheral pulses occurs. These manifestations represent serious impairment of circulation.
Vaccines for hepatitis A using live activated and inactivated virus have been tested and seem safe and effective. Havrix, a vaccine containing the inactive virus of hepatitis A, is available and can replace gamma globulin for travelers. A single dose of this vaccine is given intramuscularly. For maximum antibody titer, a booster dose is recommended 6 to 12 months after the initial injection. The hepatitis B vaccine (Engerix-B, Recombivax-HB) provides active immunity to hepatitis B.
Subcutaneous emphysema can follow a thoracentesis, because air in the pleural cavity leaks into subcutaneous tissues. The tissues feel like lumpy paper and crackle when palpated (crepitus). Usually, subcutaneous emphysema causes no problem unless it is increasing and constricting vital organs, such as the trachea.
In Bell’s palsy, the client experiences weakness on an entire half of the face. The client is unable to close the eye on the affected side and experiences paralysis of the ipsilateral facial muscles. The client also experiences pain, drooling, decreased taste, and increased tearing. Tinnitus, vertigo, and deafness are not associated with Bell’s palsy but can be seen in Ménière’s disease. Muscle spasms in the jaw and cheek area are most likely associated with trigeminal neuralgia.
Therapeutic management for the client with Bell’s palsy includes providing moist heat packs to the affected area. The client is instructed to eat small meals and soft foods frequently, and to protect the affected eye by using an eye patch. The client is also instructed to use artificial tears four times daily and to manually close the affected eye from time to time.
For the first 24 hours postoperatively, the nurse should elevate the stump as prescribed to decrease swelling and promote comfort. Stumps with compromised circulation must not be elevated. A lower extremity stump is elevated at intervals, because elevation for long periods of time can cause flexion contractures of the hip. To prevent flexion hip contractures, the client should be positioned on the abdomen for a 30-minute period every 4 to 6 hours.
In general, only the area in the treatment field is affected by radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to any site, whereas other side effects occur only when specific areas are involved in treatment. A client receiving radiation to the neck is most likely to experience a sore throat.
Pallor is best seen in the buccal mucosa or conjunctiva, particularly in dark-skinned clients. Cyanosis is best seen in the nail beds, conjunctiva, and oral mucosa. Jaundice is best seen in the sclera, the junction of the hard and soft palate, and over the palms.
Abdominal pain is the most prominent symptom of acute pancreatitis. The main focus of nursing care is aimed at reducing discomfort and pain by the use of measures that decrease gastrointestinal tract activity, thereby decreasing pancreatic stimulation.
Article copyright NurseReview.org - #1 source of information to update nurses all over the world. All rights reserved. No part of an article may be reproduced without the prior permission.