With subcutaneous injection of enoxaprin, the administration technique is the same as for heparin. The smallest gauge needle available (25 to 27 gauge) is used to prevent injection site hematoma; a “bunching” technique or Z-track technique is used; and the medication is injected deep into fatty abdominal tissue. Aspiration before injecting is not done and the injection site is not massaged. The needle is withdrawn gently to minimize bleeding, and injection sites are rotated systematically.
A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, normal (isotonic) saline should be used rather than sterile or tap water (hypotonic) for gastrointestinal or urinary tract irrigations. It is not ordinary clinical practice to irrigate with 5% dextrose solution.
Bone fragments and tissue edema associated with a fracture can cause nerve damage. The nurse would assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Although the blood pressure measurement provides an overall indication of circulatory status, it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury. Checking pin sites for drainage provides information about infection. The client should not be encouraged to perform active range of motion to an extremity that is fractured and in traction.
In the Asian (Chinese) culture, direct eye contact is often viewed as being rude. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Asking the client if he or she can hear the nurse or leaving the room and returning later to continue with the discussion may be viewed as a rude gesture by the client.
The nurse should instruct the nursing assistant to assess restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of restraints should always be followed.
Any person 18 or older may become an organ donor by written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent’s organs, if this is the case.
Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, the nurse should discuss any anxieties and concerns about floating with the nursing supervisor.
When a corneal donation is anticipated, the client’s eyes are closed and gauze pads with a small ice pack are placed on the client’s eyes. The head of the bed should also be elevated. Antibiotic eye drops may also be prescribed. These actions will assist in preventing infection and edema. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours.
The nurse should not hang a fat emulsion that has visible fat globules. Another solution should be obtained and used instead. In a container that has TPN plus fat emulsion in one solution (three-in-one solution), the solution should not be used if there is a visible “ring” noted. Fat emulsion is white and is supplied in a glass container. It does not need to be discarded if it is cool in temperature.
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution stops. The corrective action is to remove the catheter and start a new IV line
The injection cap should be discarded and a new one applied once it has been removed from the actual lumen. It is removed whenever blood work is drawn from the port. This is done to reduce systemic infection, which has been shown to be caused by contaminated caps. In addition, each agency has a policy that guides the frequency of routine cap changes (often every 48 hours).
The client should be asked to perform the Valsalva maneuver during tubing changes. This helps to avoid air embolism during tubing changes. This is commonly achieved by asking the client to take a deep breath and hold it.
Chinese Americans believe that illness is due to an imbalance between yin and yang and due to prolonged sitting or lying, or to overexertion. In the African American culture, illness is viewed as a disharmonious state that may be caused by demons and spirits. Hispanic Americans believe that illness occurs as a result of punishment for sins. Native Americans believe that illness is caused by supernatural forces.
Following cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is enforced for 6 to 12 hours or per agency procedure. The client may turn from side to side. The affected leg is kept straight and the head is elevated no more than 30 degrees until hemostasis is adequately achieved.
Sodium chloride 0.9% is isotonic and is frequently used for intravenous infusion because it does not affect the plasma osmolarity.
The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. Other causes of excess fluid volume include heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt.
Bumetanide (Bumex) is a loop diuretic, which places this client at risk for hypokalemia. The nurse assesses this client carefully for signs of hypokalemia, monitors serum potassium levels, and encourages intake of potassium sources in the diet. Spironolactone, triamterene, and amiloride HCL are potassium-sparing diuretics.
A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, which is the most common electrolyte imbalance, and which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, depressed ST segment, and prominent U waves.
The usual concentration of IV potassium chloride is 20 to 40 mEq/L in a peripheral IV line, and up to 60 mEq/L with a central IV line. Potassium chloride administered IV must always be diluted in IV fluid. Saline dilution is recommended; dextrose is avoided because it increases intracellular potassium shifting. Potassium chloride should be administered using a controlled IV infusion device to avoid bolus infusion and possible cardiac arrest. The IV site is monitored carefully because of the risk of phlebitis from vein irritation. The urine output is monitored during administration, and the physician is notified if the urinary output is less than 30 mL/hr.
Total parenteral nutrition solutions contain amino acid and dextrose solutions with electrolyte and trace elements added. The physician uses the electrolyte values to determine if changes are needed in the composition of the total parenteral nutrition solutions that will be administered over the next 24 hours. This prevents the client from developing electrolyte imbalance.
The surgeon has the ultimate responsibility for the safety of the client and can stop the surgery until the sponge is found. Although documenting is necessary, this is not the most important action.
Emergency treatment can be provided under the emergency doctrine. This doctrine implies that the client would have consented to treatment if able because the alternative would have been death or disability. The emergency doctrine removes the need for obtaining informed consent before emergency treatment and care is initiated.
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