Signs of infection include fever (greater than 100° F), increased pulse and BP, high WBC count with a shift to the left (indicating rapid proliferation of WBCs), and positive cultures, such as from wound drainage, urine, sputum, or blood. If the client meets expected outcomes, the client is free of signs and symptoms of infection.
TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue.
The client taking isoniazid is at risk for hepatotoxicity. For this reason, the client’s hepatic enzymes are measured before and periodically during therapy with this medication. BUN and creatinine are measured during therapy with streptomycin, which is a nephrotoxic medication. Vision testing is done during treatment with ethambutol (Myambutol).
The most common symptom of Pulmonary embolism (PE) is a sudden-onset chest pain. The next most frequent symptoms are dyspnea and tachypnea. Other manifestations include tachycardia, diaphoresis, cough, fever, hemoptysis, and syncope.
When a client is severely depressed, the client should be involved in quiet one-to-one activities. Because concentration is impaired when the client is severely depressed, these types of activities maximize the potential for interacting and may minimize anxiety levels.
It is important to ask the client to identify preferred foods and drinks and to offer choices when possible. The client is more likely to eat the foods provided if choices are offered. The client should be offered high-calorie, high-protein fluids and snacks frequently throughout the day and evening. When possible, it is best to remain with the client during meals. This action reinforces the idea that someone cares, can raise the client’s self-esteem, and can serve as an incentive to eat.
In a depress client who has trouble sleeping, the client should be provided rest periods after activities during the day because fatigue can intensify feelings of depression. The nurse should spend more time with the client before bedtime to help allay anxiety and increase feelings of security. Reduced environmental and physical stimuli should be provided in the evening, such as soft lights, soft music, and quiet activities. Exercise should be avoided before bedtime. The client should be encouraged to get up and dress and stay out of bed during the day because this routine minimizes sleep during the day and increases the likelihood of sleep at night.
Eskalith is the medication of choice for treating the manic phase of a bipolar disorder. It is a mood stabilizer and is the prototypical antimanic medication. Often it can calm manic clients, prevent or modify future manic episodes, and prevent future depressive episodes.
A normal diet and normal salt and fluid intake should be maintained while the client is taking lithium. This agent decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention, which could lead to toxicity. The client should avoid taking any over-the-counter medications without checking first with the physician. Lithium is irritating to the gastric mucosa; therefore the client should take the medication with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely, more frequently at first, and then once every few months thereafter.
A flat affect is an immobile facial expression or blank look. A blunted affect is indicated by a minimal emotional response. An inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation. A bizarre affect is especially prominent in the disorganized form of schizophrenia and is characterized by grimacing, giggling, or mumbling to one’s self.
A bizarre affect is especially prominent in the disorganized form of schizophrenia. Grimacing, giggling, and mumbling to one’s self are included in this description. A bizarre affect is marked when the client is unable to relate logically to the environment. A flat affect is an immobile facial expression or blank look. A blunted affect is a minimal emotional response, commonly seen in schizophrenia. In schizophrenia, the client’s outward affect may not coincide with inner emotions. An inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation.
Thought-blocking occurs when a client stops talking in the middle of a sentence and remains quiet. Poverty of speech occurs when there is a restriction in the amount of speech and answers consist of brief, often monosyllabic or one-word answers. Speech that is adequate in amount but conveys little information because of vagueness, empty repetitions, or the use of stereotypes or obscure phrases is described as poverty of content of speech.
Accupril is an angiotensin-converting enzyme inhibitor. It suppresses the renal angiotensin-aldosterone system and reduces peripheral arterial resistance and blood pressure (BP). It is used in the treatment of hypertension, either alone or in combination with other antihypertensive agents.
Quinidine gluconate (Duraquin) is an antidysrhythmic medication. The BP should be monitored before administering the medication. Although pulse oximetry, temperature, and respirations may be components of the assessment, monitoring the BP is specific to the administration of this medication.
Quinine sulfate is an antimalarial, antimyotonic medication. Its antimalarial effect elevates the pH in intracellular organelles of parasites, producing parasitic death. It relaxes the skeletal muscle by increasing the refractory period, decreasing excitability of motor end plates, and affecting distribution of calcium within muscle fiber.
The catheter should be advanced for 1 to 2 more inches beyond the point where the flow of urine is first noted. This ensures that the balloon is fully in the bladder before it is inflated.
Anorexia nervosa is an eating disorder characterized by a determination to lose weight mainly by restricting food intake, even when emaciated. It generally occurs in young adults who have distorted views of the body’s shape and weight and the self. Through dieting and weight loss, these persons believe they will experience control, autonomy, and competence. Bulimia nervosa is characterized by eating binges followed by maladaptive or inappropriate reparative behaviors, such as dieting and purging, occurring at least two times each week for 3 or more months.
A desirable target weight should be discussed with the client with anorexia nervosa. A weekly weight gain of 1 pound is generally acceptable for the emaciated client. In the client with bulimia, a desirable goal is weight stabilization without binge-purge behavior.
Nitrofurantoin (Macrodantin) is specifically indicated for the treatment of urinary tract infections when due to susceptible strains of Escherichia coli, enterococci..
During the immediate postpartum period, vital signs are taken every 15 minutes during the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. Vital signs are monitored thereafter every 4 hours for the first 24 hours and every 8 to 12 hours for the remainder of the hospital stay.
During the first week after birth, transient episodes of bradycardia are common. The woman’s pulse may be as low as 40 to 50 BPM the first 1 to 2 days after delivery. It is not necessary to notify the physician.
The position of the fundus should be midline. Displacement to the side indicates that the bladder may be full. It is not necessary to notify the physician. Fundus massage is performed when the uterus is soft and boggy.
The presence of cyanosis can be best seen in the nailbeds, the conjunctivae, and the oral mucosa. Pallor is best seen in the buccal mucosa or the conjunctivae, particularly in dark-skinned clients. Jaundice can be best assessed in the sclera near the limbus at the junction of the hard and soft portions of the palate and over the palms.
After elbow arthroplasty, elbow-flexion and elbow-extension exercises are allowed as tolerated. The client should not lift more than 5 pounds and should not begin triceps- and biceps-strengthening exercises for 3 months. The client will not be able to lift heavy items or play sports with the operative arm.
To assess cutaneous nerve status, flexion of the biceps is checked by having the client raise the forearm. Poor biceps flexion may indicate compromise of the cutaneous nerve
The client is at risk for impairment of skin integrity owing to the presence of the catheter, exposure to moisture, and irritation from tape and cleansing solutions. The client should be instructed to use paper or nonallergenic tape to prevent skin irritation and breakdown. It is proper procedure for the client to use aseptic technique and to self-monitor vital signs and weight on a daily basis.
A client with anemia should be taught the basics of good nutrition and encouraged to consume a diet high in protein, iron, and vitamins. The nurse should encourage the client to consume foods cooked in iron pots and to ingest foods such as liver, which has the highest source of iron of the foods identified in the options. Other foods that may provide high sources of iron include oysters, lean meats, kidney beans, whole-wheat bread, kale, spinach, egg yolks, turnip tops, beet greens, carrots, apricots, and raisins.
One major risk factor for the development of pernicious anemia is gastric resection. Inadequate iron in the diet is not specifically associated with this type of anemia but is associated with iron-deficiency anemia. Central nervous system and musculoskeletal manifestations may occur as a result of pernicious anemia.
Polycythemia vera is defined as the increase in both the number of circulating erythrocytes and the concentration of hemoglobin within the blood. It is classified as a myeloproliferative disorder, meaning overgrowth of bone marrow. The cause remains unknown, although it is possibly a form of malignancy similar to leukemia and is often considered a premalignant condition, sometimes referred to as myeloproliferative dyscrasia. Iron-deficiency anemia occurs as a result of poor intake of iron. The lack of the intrinsic factor produces pernicious anemia.
Bone marrow aspiration biopsy is a key diagnostic tool for confirming the diagnosis of leukemia and for identifying malignant cell types. Lumbar puncture may determine the presence of blast cells in the central nervous system. Radiographic tests may detect lesions and sites of infection. A lymphangiogram may be performed to locate malignant lesions and accurately classify the disease.
When the neutrophil count is less than 500/mm3, the client is at risk for infection; therefore, monitoring the oral temperature is a critical nursing intervention.
When the neutrophil count is less than 1000/mm3, the client is at risk for infection. A platelet count less than 20,000/mm3 would place the client at risk for hemorrhage.
The breasts become tender early in pregnancy as a result of the increased levels of estrogen and progesterone. A self-care measure for breast tenderness includes wearing a well-fitting brassiere that provides support for the breasts and decreases discomfort.
Constipation may result from slowing of peristalsis, caused by increased levels of progesterone, displacement of the intestines by the expanding uterus, lack of activity, and inadequate fluid intake. Self-care measures for constipation include increasing daily fluid intake and whole grains and roughage in the diet and exercising regularly.
Vaginal discharge called leukorrhea is common in pregnant women because of the increased mucus production by the endocervical gland. The mucus should be clear or slightly whitish and mucoid in appearance.
Clinical manifestations indicative of alcohol abuse during the prenatal period include poor weight gain, hypoglycemia, tremors at rest, nausea, weakness, anxiety, slurred speech, unsteady gait, and sweating, especially of the palms and forehead, as well as generalized sweating.
After assessment of pitting edema, if the nurse notes a slight indentation, it is documented as a 1+ edema. A 2+ edema is an indentation approximately 1/4-inch deep. A 3+ edema is an indentation approximately 1/2-inch deep, and a 4+ edema is an indentation approximately 1-inch deep.
To evaluate the deep tendon reflexes, the client’s lower leg is exposed, and one hand is placed under the knee to raise it slightly off the bed. A percussion hammer is used to strike the patellar tendon just below the patella. The normal response is extension and thrusting of the foot upward.
The normal response is extension and thrusting of the foot forward. A 1+ response indicates a diminished response, 2+ indicates normal, 3+ indicates increased, or brisker than average, and 4+ indicates very brisk, or hyperactive.
The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be useful in transferring a client who cannot move from a bed to a stretcher or a wheelchair.
The facial nerve (CN VII) has both motor and sensory divisions. Common symptoms of dysfunction of this nerve include an inability to close the eye and to blink automatically, facial asymmetry, drooling and inability to swallow secretions, loss of the ability to form tears, and possible loss of taste on the anterior two thirds of the tongue. Bell’s palsy, fracture of the temporal bone, and parotid lacerations or contusions are often responsible for these symptoms.
The vestibulocochlear nerve (CN VIII) is responsible for auditory acuity as well as bone and air conduction. The audiometer assesses the client’s hearing, whereas the tuning fork tests bone and air conduction.
Nystagmus is characterized by fine involuntary eye movements. Ataxia is a disturbance in gait. Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed. This assessment technique may be done to detect small changes in muscle strength that might not otherwise be noted. Hyperreflexia is an excessive reflex action.
With an impaired corneal (blink) reflex, the client is at risk for the eyes becoming dry and also for corneal abrasions if foreign matter comes in contact with the eye. Use of sterile saline drops helps keep the eyes lubricated. An eye patch would have to be used carefully because corneal abrasion could result if the cornea comes in contact with the patch. Introduction of a foreign object (a cotton ball) inside the lower eyelid also risks corneal abrasion. Taping the eye shut could impair the client’s vision, putting the client at risk for another injury, such as a fall.
Clients with confusion from neurological dysfunction respond best to a stable environment, which is limited in the amount and types of sensory input. The family can provide sensory cues and give clear, simple directions in a positive manner. Confusion and agitation are reduced when environmental stimuli (television and multiple visitors) are minimized and when personal articles are visible to the client.
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