Breath sounds are the best way to assess the onset of heart failure. The presence of crackles or rales or an increase in crackles is an indicator of fluid in the lungs caused by heart failure.
A positive reaction to a tuberculin skin test indicates exposure to tuberculosis infection. Because the response to tuberculin skin testing may be decreased in the immunosuppressed client, induration reactions more than 5 mm are considered positive. A reading of 6-mm induration is a positive result in a client who is HIV positive. A positive result indicates exposure to tuberculosis and possibly the development of tuberculin infection. Further diagnostic tests should be performed to confirm infection with tuberculosis.
The TNM classification system for staging tumors is widely used. T refers to the tumor size, with T0 indicating no primary tumor found and T1 to T4 referring to progressively larger tumors. TIS is used to indicate a carcinoma in situ. N refers to regional lymph node involvement. N0 indicates regional nodes were normal, and N1 to N4 indicates increasingly abnormal regional lymph nodes. M1 indicates that distant metastasis is present.
The complications associated with thoracic surgery include pulmonary edema, cardiac dysrhythmias, hemorrhage, hemothorax, hypovolemic shock, and thrombophlebitis. Signs of pulmonary edema include dyspnea, crackles, persistent cough, frothy sputum, and cyanosis. A urinary output of 45 mL/hour is an appropriate output. The nurse would become concerned if the output were below 30 mL/hour. Between 100 and 300 mL of drainage may accumulate during the first 2 hours after thoracic surgery. Normal arterial blood pH is 7.35 to 7.45. An arterial blood pH of 7.35 is not indicative of a complication.
The client with Raynaud’s disease suffers from body-image disturbance when physical changes begin to occur. Therapeutic nursing interventions are implemented to encourage verbalization about the body changes and to develop appropriate problem-solving techniques for coping with the changes.
Specific gravity is a measure of the concentration of particles in the urine. A normal range of urine specific gravity is approximately 1.005 to 1.030. Early in polycystic kidney disease, the ability of the kidneys to concentrate urine decreases. A urine specific gravity of 1.000 is lower than normal, indicating dilute urine.
Giving the client with chronic emphysema a high liter flow of oxygen could stop the hypoxic drive and cause apnea.
Assays of catecholamines are performed on single-voided urine specimens, 2- to 4-hour specimens, and 24-hour urine specimens. The normal range of urinary catecholamines is up to 14 mcg/100 mL of urine, with higher levels occurring in pheochromocytoma.
After a cerebrovascular accident, clients are often emotionally labile, confused, forgetful, and frustrated. Clients may use profanity, which is often termed “automatic language.”
The complications associated with severe scoliosis interfere with respiration. The lungs may not fully expand as a result of the severe curvature of the spine. Atelectasis and dyspnea are complications that can occur as a result of a decrease in lung expansion.
The purpose of a venogram is to assess the severity of venous obstruction. The test will locate obstructions and/or thrombi by x-ray films after a radiopaque dye is injected into a vein that has been previously emptied by gravity. This test is a diagnostic procedure and will not eliminate leg problems or determine whether the support stockings can be discontinued. Injections can cause discomfort.
The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, congestive heart failure (CHF), increased platelet aggregation, and cerebrovascular accident (CVA). Death can occur from shock, CVA, renal failure, dysrhythmias, and dissecting aortic aneurysm. Rales heard on auscultation are indicative of CHF.
In myxedema, the TSH level is elevated, and the T3 and T4 levels are decreased. Secretion of T3 and T4 is regulated by a hypothalamic-pituitary-thyroid gland feedback mechanism. TSH regulates the secretion of thyroid hormone from the thyroid gland. The circulating levels of thyroid hormone are the major factor regulating the release of TSH. If the thyroid levels are low, TSH release is increased, and if the thyroid levels are high, TSH is inhibited. In hyperthyroidism, T3 and T4 secretions are elevated because the normal regulatory controls of thyroid hormone are lost. Hypoparathyroidism is associated with a decrease in serum calcium and an increase in serum phosphate.
Cutting the blood glucose monitoring strips in half may affect the accuracy in reading the results.
Hydrocortisone is the topical treatment of choice for cutaneous inflammation and pruritus associated with contact dermatitis. If a rash does not respond to this over-the-counter medication, it should be evaluated by a health care provider.
The client should be taught to take the pulse in the wrist or neck every day at the same time, preferably in the morning, and to rest a full 5 minutes before taking the pulse. The pulse is counted for 1 full minute by using a watch or clock that has an accurate second hand. The pulse is recorded every day in a log that indicates a description of the rate, rhythm, and date and time of day. If a change in rate or rhythm is noted, the physician should be notified.
Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.
The normal random blood glucose level is 70 to 115 mg/dL but may vary depending on the time of the last meal.
On removal of a chest tube, an occlusive dressing consisting of petrolatum gauze covered by a dry sterile dressing is usually placed over the chest tube site dressing. This is maintained in place until the physician states it may be removed. Monitoring and reporting respiratory difficulty and increased temperature are appropriate client activities on discharge. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing.
Postoperative care after a parathyroidectomy includes instructing the client that the weight of the client’s head must be supported when the client flexes the neck or moves the head. This decreases the stress on the suture line, which prevents bleeding.
Boiling the vegetables and discarding the water can decrease the potassium content of vegetables. Bananas and oranges are high in potassium and should be avoided. Meats contain some potassium and are high in protein and should be limited to 6 oz/day. Salt substitutes are often high in potassium and are to be avoided.
Plasmapheresis is a process that separates the plasma from the blood elements, so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually three to five treatments are required. Improvement in vital (respiratory) capacity is an intended effect of this treatment.
The client with CAL should use energy-conservation techniques to conserve oxygen. These include sitting to perform many household chores or activities, and alternating activity with rest periods. The client should avoid raising the arms above the head, because use of the arms could increase dyspnea. The client should never hold the breath during an activity.
When a client is placed in pelvic traction, the foot end of the bed is raised to prevent the client from being pulled down in bed by the traction. The head of the bed is usually kept flat, and the client is maintained in good body alignment. The girdle or belt should be applied snugly so it does not slip off of the client, and therefore the skin should be checked for pressure sores.
Traditional treatment of a UTI involves 7 to 10 days administration of oral antimicrobial therapy. It is important to take antibiotics, even if the client is feeling better. While taking these medications, the client should drink at least eight glasses of fluid per day to keep urine dilute. Voiding regularly will flush bacteria out of the bladder and urethra. Teaching the client to cleanse the perineal area from front to back helps to prevent urinary tract infection.
The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through.
Older and immunocompromised clients may not have a positive reaction to the initial tuberculin skin test, even if they had prior exposure to the tubercle bacillus. If the test is negative (no reaction), the client may have a delayed reaction and should have a repeated tuberculin skin test in 1 to 2 weeks. The second test should reveal positive results if the client had prior exposure. The tuberculin skin test is read in 48 to 72 hours. Erythema or redness alone is not considered significant. The size of induration, if any, is what determines the significance of the test. A positive test does not indicate active disease. Persons with a positive reaction are followed up with a chest radiograph.
After restoring circulation to the affected limb, the nurse reinforces teaching that was done after the original surgery. This includes exercise and dietary recommendations, as well as instructions on foot care and prevention of injury to the limb. The client should check the condition of the leg and foot every day. Taking a baby aspirin every day does not ensure that further complications will not occur. Walking will be a component of the treatment plan.
Instructions to a client after a aorto-iliac bypass grafting about measures to improve circulation while in the hospital includes clot formation in the graft can result from any form of pressure that impairs blood flow through the graft, including bending at the hip or knee, crossing the knees or ankles, or use of the knee gatch or pillows. All of these actions are avoided in the postoperative period.
The presence of multiple organisms in a urine culture usually indicates that contamination has occurred. The urinary tract is normally sterile, and infection, if it occurs, is usually with one organism. A repeat of the urine culture is indicated.
Spinal shock that occurs after spinal cord injury lasts 3 to 6 weeks after the injury and is characterized by a flaccid neurogenic bladder with urinary retention. Intermittent catheterization used to empty the bladder should be carried out in a manner that prevents urinary tract infection (UTI). Cloudy or blood-tinged urine may indicate the onset of infection. Because fluid is lost through the skin, lungs, and bowel, intake does not normally equal output. Sensations of the need to void require an intact cord, which would not be present in this client. Cholinergic action stimulates bladder emptying, so anticholinergics would produce the undesirable effect of relaxation of the bladder in this client.
First-degree heart block indicates a delayed conduction somewhere between the junctional tissue and the Purkinje network, causing a prolonged PR interval. Lying still will not relieve the problem. A pacemaker is not necessary for first-degree heart block. Medication may be prescribed to treat this condition.
The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it, and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation.
Within 2 or 3 days of surgery, a lung is generally fully re-expanded. The nurse notes an absence of fluctuation or bubbling in the water seal chamber or drainage from the chest tube. At this time, the client’s status is confirmed by chest x-ray. If the lung is fully re-expanded, the physician may remove the chest tube.
The irreversible stage of cardiogenic shock represents the point along the shock continuum when organ damage is so severe that the client does not respond to treatment and is unable to survive. Multiple organ failure has occurred, and death is imminent. As it becomes obvious that the client is unlikely to survive, the client’s family needs to be informed about the prognosis and outcome. Support to the grieving family members becomes an integral part of the nursing care plan.
The purpose of ECG monitoring is to record cardiac electrical activity during the depolarization and repolarization phases. The two types of single-lead monitoring are hardwire and telemetry. With a wireless battery-operated telemetry system, the client is afforded more freedom and mobility than with the hardwire system. The most common problems with ECG monitoring are related to client movement, electrical interference from equipment in the room, poor choice of monitoring leads, and poor contact between the skin and electrode.
Tracheostomy dressings should be changed whenever they get wet or damp. A soiled dressing promotes microorganism growth and enhances tissue irritation and skin breakdown. The oxygen collar may be cleaned if it becomes soiled between collar and tubing changes, which are done every 24 hours. Tracheostomy care should be done at least every 8 hours or per agency policy. It would not be beneficial to the client to limit fluids, because thicker secretions pose added problems with airway management.
Before discharging a ventilator-dependent client to home, the nurse determines that the family is able to perform CPR, including mouth-to-tracheostomy ventilation. The CPR course designed for lay people in the community does not include this element of care. The electrical service to the home must be sufficient for the equipment that will be used. The ventilator should have a built-in converter to battery power if the electrical power should fail. Otherwise, a generator must be installed. The home itself should be free of drafts and provide adequate air circulation.
Back pain after AAA repair may indicate a problem with the repair. It should be reported to the physician immediately.
Disease processes, such as cirrhosis, damage the blood flow through the liver, resulting in hypertension in the portal venous system. The increased portal pressure causes esophageal varices, which are swollen and distended veins. Factors such as increased intrathoracic pressure or irritations can cause these varices to rupture with subsequent hemorrhage.
Cryosurgery entails freezing cervical tissue with nitrous oxide. It is performed in an outpatient setting. Cryosurgery may result in cramping and a vasovagal response that may cause faintness. A watery discharge is normal for a few weeks after the procedure.
The client who experiences epididymitis from a urinary tract infection should increase the intake of fluids to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the urinary stream. Condom use can help to prevent epididymitis that can occur as a result of STDs. Antibiotics are always taken until the full course of therapy is completed.
Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The client also is taught to rest, increase fluid intake, and use sitz baths for comfort. Antimicrobial therapy is always continued until the prescription is completely finished.
The client with respiratory disease may have Ineffective Coping related to the inability to tolerate activity and social isolation. The client demonstrates adaptive responses by increasing the activity to the highest level possible before symptoms are triggered, using relaxation or other learned coping skills, or enrolling in a pulmonary rehabilitation program.
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