The primary symptom in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Passage of the mucus plug appears pink or as blood-tinged mucus. A ruptured amniotic sac would include findings such as a watery vaginal drainage. Findings of abruptio placenta include dark red vaginal bleeding and abdominal pain.
Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the continuation of the medication should be reassessed.
The symptoms of jitteriness and tachypnea (respiratory rate of 62 breaths per minute) in a 42-week-gestation newborn infant are indicative of hypoglycemia. Hypoglycemia may develop in a 42-week-gestation newborn infant because of the insufficient stores of glycogen, which may have been depleted during the post-term period. Insufficient amounts of glucose in the infant’s brain could possibly cause central nervous system damage.
A normal blood glucose level for newborn infants is 40 mg/dL and higher.
Rho(D) immune globulin is not administered if a client has experienced a severe reaction to its component, human globulin. Rho(D) immune globulin is indicated when Rh-negative clients are exposure to Rh-positive fetal blood cells in any way, including amniocentesis and abortion.
A person who lacks hope feels that life is too much to handle. By seeing no way out of the situation except death, the client meets the criteria for hopelessness.
Abdominal exercises should not be started after abdominal surgery until 3 to 4 postoperative weeks to allow healing of the incision.
Coagulation failure, particularly disseminated intravascular coagulopathy (DIC), is a common result of an amniotic fluid embolus. Manifestations are internal and external hemorrhage clinically determined by bleeding at the site of any trauma (pressure, needle prick, or incision), and petechiae resulting from slight to moderate touch. A postpartum woman who saturates a Peripad in 15 minutes or less is considered to be hemorrhaging, which in this case is caused by lack of coagulation at the placental site.
A pulsating rope-like object seen in the vagina indicates the presence of the umbilical cord. Each contraction will press the presenting part downward against the bony pelvis, applying pressure to the prolapsed cord, compressing it between the presenting part and the bony pelvis. The compression will shut off the fetal circulation at the point of compression, leading to impaired fetal tissue perfusion and hypoxia of the fetus.
Situational Low Self-Esteem represents temporary negative feelings about self in response to an event. This is a normal response to cesarean section.
Pregnancy taxes the circulating system of every woman because both the blood volume and cardiac output increase approximately 30%. This is especially important to monitor in the client whose heart may not tolerate this normal increase.
HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control.
HIV infection in a pregnant woman may cause both maternal and fetal complications. Fetal compromise can occur because of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk of opportunistic infections. Individuals in the later stages of HIV are further susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections.
The anterior fontanel is normally 2.5 to 5 cm in width and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could be indicative of increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated.
Clients with Cushing’s syndrome experience weight gain with truncal obesity. The extremities appear thin with the presence of muscle wasting and weakness. The skin is often described as being thin and translucent. A butterfly rash across the cheeks of the face is seen in systemic lupus erythematosus. Polydipsia and polyphagia are seen in diabetes mellitus. Weight loss and peripheral edema may be seen in a number of conditions.
Situations that precipitate sickle cell crisis include hypoxia, vascular stasis, low environmental and/or body temperature, acidosis, strenuous exercise, anesthesia, dehydration, and infections.
The client undergoing radiation therapy should avoid washing the site until instructed to do so. The client should then wash with mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools).
Prevention of recurrence of urinary stones is accomplished by drinking at least 3 L of fluid per day; voiding every 2 hours; following an acid ash diet if the stones are calcium oxalate stones; and notifying the physician promptly if symptoms of UTI occur.
The client with polycystic kidney disease should report any signs and symptoms of urinary tract infection so that treatment may begin promptly. The client should also report increases in blood pressure, because control of hypertension is essential. The client may experience heart failure as a result of hypertension, and thus any symptoms of heart failure, such as shortness of breath, also are reported.
The goal of therapy in nephrotic syndrome is to heal the leaking glomerular membrane. This would then control edema by stopping loss of protein in the urine. Fluid balance and albumin levels are monitored to determine effectiveness of therapy.
Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. The nurse assures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level.
The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. Clients often want to scrub the dead skin away, which irritates the skin. The client should avoid overexposing the skin to the sunlight.
Expected outcomes for Impaired Physical Mobility for the client in traction include absence of thrombophlebitis (measurable by negative Homans' sign), active baseline ROM to uninvolved joints, clear lung sounds, intact skin, and bowel movement every other day.
After three unsuccessful defibrillation attempts, CPR should be done for 1 minute, followed by three more shocks, each delivered at 360 joules.
Typical discharge activity instructions for the first 6 weeks include lifting nothing heavier than 5 pounds, not driving, and avoiding any activities that cause straining. The client is taught to use the arms for balance, but not weight support, to avoid the effects of straining. These limitations are to allow sternal healing, which takes approximately 6 weeks.
Clients can resume sexual activity on the advice of a physician, which generally occurs when the client can walk one block and climb two flights of stairs without discomfort. Suggestions to minimize potential problems include waiting for 2 hours after meals or alcohol consumption, making sure one feels well rested, using a comfortable position, and keeping the room at a mild (not chilly) temperature.
Expected outcomes for the client with pulmonary edema include improved cardiac output as evidenced by stable vital signs, and urine output of at least 30 mL/hour.
The client’s blood gas results indicate respiratory acidosis. Symptoms of respiratory acidosis include headache, irritability, muscle twitching, behavioral changes, confusion, lethargy, and coma.
When the carboxyhemoglobin levels are greater than 25% (acute toxicity), the respiratory center becomes depressed because of inadequate oxygenation, and hypoxia occurs.
A long-range approach to the prevention of pulmonary edema is to minimize any pulmonary congestion. During recumbent sleep, fluid (which has seeped into the interstitium by day with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed elevated helps prevent circulatory overload.
Complications after pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse notes indications of these complications, such as dyspnea, excessive pain, pallor, or diaphoresis. Mild pain is expected, because the procedure itself is painful.
The nurse teaches the client that the pain of fractured ribs generally lasts for about 5 to 7 days. Full healing takes about 6 weeks, after which full activity may be resumed.
Coughing and deep breathing will effectively promote lung expansion and clearance of mucus. Using an incentive spirometer is helpful, but it is most effective if the client uses it independently without coaching. The nurse may not need to suction the client if the client is not intubated
Prinzmetal’s angina results from spasm of the coronary vessels. The risk factors are unknown, and it is relatively unresponsive to nitrates. Beta blockers may worsen the spasm.
Exercise is most effective when done at least 3 times a week for a client with angina pectoris. Other positive habits include limiting salt and fat in the diet, using stress-management techniques, and knowing when and how to use medications.
Nosebleeds may occur during the winter because of decreased humidity in the home. The use of a humidifier helps to alleviate this problem.
If pulse oximeter values fall below a preset norm, which is usually 90% to 91%, the client should be instructed to take several deep breaths. This is especially true of a client without a respiratory history who is still under the effects of sedation. If the client did have a respiratory disease history, it might be an indication that supplemental oxygen should be put in place or increased if already in place.
A Gram stain classifies the organism as gram-negative or gram-positive, and may be done immediately by the laboratory. This gives initial information about the type of organism when initiation of antibiotic therapy is a high priority. The specimen is then incubated on a culture medium for at least 24 hours more to identify the specific organism(s). The sensitivity test gives the physician precise information about which antibiotics the organism is sensitive to.
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.