Semipermeable film dressings such as Op-Site or DuoDerm are used on superficial skin tears or ulcers. These dressings have the advantage of staying in place for several days, allowing tissues to heal underneath. Gelfoam sponge dressings are a type of enzyme dressing used in the treatment of necrotic tissue. Telfa dressings do not stick to a wound, but they are not as helpful as the semipermeable film dressing for healing. Dry sterile dressings would stick to the wound and are inappropriate.
Addisonian crisis is triggered by stressful events such as emotions, illness, injury, or surgery. The client should minimize risk of infection and illness whenever possible. If the client does become ill or develops an infection, adrenocortical replacement medication dosages are increased.
The client with adrenocorticosteroid (Cushing's) excess experiences hyperkalemia, hyperglycemia, an elevated WBC count, and elevated plasma cortisol and ACTH levels. These abnormalities result from the effects of excess glucocorticoids and mineralocorticoids on the body.
Addisonian crisis results from an acute insufficiency of corticosteroids. The client and his wife should be prepared to recognize the signs and symptoms, and to administer hydrocortisone intramuscularly. Epinephrine would be used in the emergency management of allergic reactions. Glucagon and glucose would be used to treat hypoglycemia.
Exercise of a body part increases the rate of absorption of the insulin from that site. For this reason, the client should inject insulin into an area that will not be exercised. This will help the client to avoid hypoglycemia from rapid insulin absorption.
Diabetic ketoacidosis is characterized by dry mouth, thirst, and other signs of dehydration. The pulse becomes rapid and weak, while the respirations become deep. The breath has a fruity or acetone odor to it. Laboratory studies reveal elevated serum glucose. The serum potassium level is also elevated, while the bicarbonate level is decreased.
Cardiovascular manifestations of hypothyroidism include a decreased pulse, distant heart sounds, anemia, variable changes in blood pressure, weak contractility, and increased likelihood of angina, myocardial infarction, and heart failure.
Diabetes insipidus inhibits water resorption in the kidneys, leading to large fluid losses from the body. The urine is large in amount and dilute.
Teaching session for a diabetic clients includes applying lotion to the feet to prevent dryness and cracking, but lotion should not be applied between the toes because of the risk of skin breakdown due to moisture. The client should cut the toenails straight across at the level of the contour of the toe. The client should wear shoes that are closed at the heel and toe to prevent injury to the feet, regardless of the season. The client should also avoid other potential sources of injury to the feet, such as application of direct heat to the feet, which could result in burns. The client should avoid exposure of the feet to excessive heat or cold.
Teaching plan for a client receiving external radiation therapy includes instructing client to avoid the use of lotions on the area being treated. The client needs to be instructed to avoid exposure to the sun. Deodorant should not be used during treatment to the chest area. The client should wear loose, not snug-fitting, clothing over the area.
The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 20 degrees for comfort. The nurse should avoid turning the client on the side. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment, the client is logrolled. Movement in bed is restricted to prevent dislodgement of the radioactive source.
Clients in thyroid storm are experiencing a life-threatening event, which is associated with uncontrolled hyperthyroidism. It is characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. The signs and symptoms of the disorder develop quickly, and therefore emergency measures must be taken to prevent death. These measures include maintaining hemodynamic status and patency of airway as well as providing adequate ventilation.
Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 3 describes the Trendelenburg test findings, which are indicative of varicose veins. In the test, the client lies down and elevates the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow.
During an acute exacerbation of COPD, the arterial blood gases deteriorate with a decreasing Po2 and an increasing Pco2. In the early stages of COPD, arterial blood gases demonstrate a mild to moderate hypoxemia with the Po2 in the high 60s to high 70s and normal arterial Pco2. As the condition advances, hypoxemia increases and hypercapnia may result.
Guided imagery involves the client’s creation of an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It does not require any adjuncts and does not need to be done in a quiet area only, although some clients may use other relaxation techniques or play music with it.
The nurse assesses vital signs and the level of fatigue with each activity. The client is not tolerating the activity if there is a drop in systolic BP greater than 20 mm Hg, changes in pulse rate of greater than 20 beats per minute, dyspnea, or chest pain. Cool, diaphoretic skin is a sign of some degree of cardiovascular compromise.
Complications after insertion of an IVC filter are very rare. When they do occur, they include air embolism, improper placement, and filter migration. The percutaneous approach uses local anesthesia. There is no need for anticoagulant therapy after surgery; in fact, an indication for the procedure is an inability to tolerate anticoagulant therapy. Venous congestion can occur from accumulation of thrombi on the filter. The process usually occurs gradually, though.
The nurse must check nasogastric tubes regularly to maintain the tube’s patency and ensure that it is draining properly. Nasogastric tubes are used to decompress the stomach. The gastric distention will be relieved only if the tube drains properly. One cause of improper tube drainage is due to channels of gastric secretions forming along the walls of the stomach and bypassing the holes in the nasogastric tube. Turning the client regularly helps to collapse the channels and promotes gastric emptying. The tube has already been flushed, so it is unlikely that it is still blocked by thick secretions. Although this is a problem that requires attention and intervention, it is not a potentially serious complication.
The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, or the sudden development of bloody secretions. If they occur, the nurse stops suctioning and reports these signs to the physician immediately. Coughing is a normal response to suctioning for the client with an intact cough reflex, and does not indicate that the client cannot tolerate the procedure.
Furosemide depletes potassium, and a client on digoxin and furosemide needs to maintain normal potassium levels and moderate salt intake. Hypokalemia may make the client more susceptible to digoxin toxicity. The recommended daily intake for potassium is 2000 mg.
The client is taught before cardiac catheterization to report chest pain or any unusual sensations immediately. The client is taught that a warm, flushed feeling may accompany dye injection, and occasional palpitations and the urge to cough may occur as the catheter tip touches the cardiac muscle. The client may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client should feel pressure, but not pain, at the insertion site.
Buerger's disease (thromboangiitis obliterans), which affects men between 20 and 40 years of age, has an unknown etiology. It is a recurring inflammation of the small and medium-sized arteries and veins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels.
Peritoneal dialysis tubing is flushed to avoid introducing air into the peritoneal cavity. The dialysate solution should be warmed prior to use. With CAPD, there are usually four exchanges planned per day, with dwell times varying, depending on whether it is a daytime or nighttime exchange. The dialysate solution should be slightly warmed (37° C) prior to use.
The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and to provide good mechanical flushing of the kidney and tube. The nurse encourages the client to take in at least 2000 mL fluid per day, which is roughly equivalent to 6 to 8 glasses of water.
Most people, including the mildly and moderately obese, can lose only about 2 pounds per week of weight from fat loss. Weight loss beyond that level is probably due to protein and water loss alone.
Late manifestations of dumping syndrome after a gastrectomy occur 2 to 3 hours after eating and result from a rapid entry of increased carbohydrate food into the jejunum, a rise in blood glucose levels, and excessive insulin secretion. To monitor this, the nurse checks the blood glucose level 2 hours after meals.
Guillain-Barré syndrome is an inflammatory disease of unknown origin that involves degeneration of the myelin sheath of peripheral nerves.
The nurse evaluates the effectiveness of the suctioning procedure by auscultating breath sounds. This helps to determine if the respiratory tract is clear of secretions.
Asymmetrical breath sounds could indicate pneumothorax, and this should be reported to the physician. A weak cough and gag reflex 1 hour post-procedure is an expected finding, due to residual effects of intravenous sedation and local anesthesia. A respiratory rate of 22 breaths per minute and an oxygen saturation of 95% are acceptable measurements.
Clinical signs and symptoms of aspiration include fever, dyspnea, crackles or rhonchi, decreased arterial oxygen levels, and confusion. The client may exhibit difficulty in managing saliva, or may cough or choke while eating.
Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings from impaired peripheral perfusion.
Increased intrathoracic pressure contributes to rupturing of varices. Straining at stool, coughing, and vomiting all increase intrathoracic pressure. The nurse needs to implement measures that will prevent increased intrathoracic pressure.
Correct procedure for basic life support with two rescuers includes a compression-to-ventilation ratio of 15 to 2. With adults, compressions are performed at a depth of 1.5 to 2 inches. With effective compressions, carotid pulsations should be present. At its best, CPR produces only 30% of the normal cardiac output, so correct technique is vital.
Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation. Fluctuations of 5 to 10 cm (2 to 4 inches) during normal breathing are common. The absence of fluctuations could mean that the tubing is obstructed by a kink, the client is lying on the tubing, or dependent fluid has filled a loop of tubing. Expanded lung tissue can also block the chest-tube eyelets during expiration. The absence of fluctuations could also mean that air is no longer leaking into the pleural space.
Clients with Parkinson’s disease are at risk for aspiration. A congested cough and coarse rhonchi may be present after a client aspirates. Although constipation is a problem for clients with Parkinson’s disease, the concern is greater if the client has not had a bowel movement by the third day. Resting and pill-rolling tremors and shuffling, propulsive gait are characteristic findings in Parkinson’s disease.
A lead II rhythm strip displays a PQRST wave form. P-R interval range is 0.12 to 0.20 seconds. A P-R interval of 0.24 seconds indicates a conduction problem.
Speaking can exacerbate the pain that occurs with trigeminal neuralgia. Having the client record feelings in writing will help the nurse to gain an understanding of the client’s concerns without increasing the client’s pain.
The SA node is considered the primary pacemaker of the heart because it has the highest rate of automaticity of all potential pacemaker sites.
Continuous bubbling in the water seal chamber of a chest tube indicates that there is a leak somewhere in the system, and air is being sucked into the apparatus. The nurse needs to assess the system and initiate corrective action, which may include notifying the physician. Bubbling may occur intermittently with the evacuation of a pneumothorax, but it should not be continuous, especially with a client who had surgery 2 days earlier. Hemothorax results in accumulation of drainage in the collection chamber, but does not cause bubbling in the water seal chamber. Application of suction to the system causes bubbling in the suction control chamber, but not in the water seal chamber.
Pulmonary angiography involves minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle of the catheter that is used for dye injection.
Myocardial ischemia is expressed symptomatically as angina (chest pain). The pain is related to an imbalance of myocardial oxygen supply and demand. Oxygen administration would help to correct this imbalance.
The superior vena cava is the large vessel that accepts blood from the head, neck, and arms, returning it to the heart. Therefore, compression of this vessel by a tumor or by enlarged lymph nodes can cause decreased blood return from these areas, resulting in swelling.
A positive Mantoux skin test reading has an induration measuring 15 mm or more in clients at low risk, and is considered abnormal. An area of ecchymosis is insignificant, and is probably related to the injection technique. A Mantoux skin test result that shows no induration is negative.
Hypothyroid clients experience a slow metabolic rate, and its manifestation includes apathy, fatigue, sleepiness, and depression.
Abdominal pain is the predominant symptom of acute pancreatitis. Shock and hypovolemia can occur from hemorrhage, toxemia, or loss of fluid into the peritoneal space. Potassium and sodium can be lost due to gastric suction and frequent vomiting. Hyperglycemia can result from impaired carbohydrate metabolism.
Primary hyperaldosteronism refers to hypersecretion of aldosterone resulting from an adrenal lesion, which is usually benign. The disease, which produces secondary hypertension, hypokalemia in most individuals, and hypernatremia, is also known as Conn’s syndrome and produces sodium and water resorption.
An adrenalectomy is performed because of excess adrenal gland function. Excess cortisol production impairs the immune response, making the client at risk for infection. Because of this, the client needs to be protected from infection, and minor variations in normal vital sign values need to be reported so that infections are detected early and before they become overwhelming.
Fat embolism can result from a fracture, but the client is not experiencing any signs or symptoms of this complication. Venous thrombosis can occur after fractures, but would not affect sensation. Volkmann’s contracture is a result of compartment syndrome in an upper extremity following a fractured humerus.
If the client has sustained a craniocerebral injury or is recovering from a craniotomy, careful observation of any drainage from the eyes, ears, nose, or traumatic area is critical. Cerebrospinal fluid is colorless and generally nonpurulent, and its presence is indicative of a serious breach of cranial integrity. The nurse would check the drainage for the presence of glucose, indicative of the presence of cerebrospinal fluid, and would also report the presence of any suspicious drainage to the physician.
In cardiogenic shock, the client’s heart is unable to generate cardiac output to meet the body’s demand. A major role for the nurse caring for the client experiencing cardiogenic shock is assessing and monitoring the client’s hemodynamic status in response to treatment. If the client is experiencing a decrease in cardiac output, the nurse would expect to see a decrease in urinary output (less than 30 mL per hour in an adult), a decrease in blood pressure, adventitious breath sounds, a decrease in the strength and quality of peripheral pulses, and cool, pale skin.
With severe respiratory acidosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell, forcing intracellular potassium out. This is an expected finding in this situation.
The primary symptom of GERD is heartburn, also called pyrosis. Another symptom is regurgitation. The client reports the feeling of warm fluid traveling up the throat. If the fluid reaches the level of the pharynx, the client notes a sour or bitter taste in the mouth. This effortless regurgitation frequently occurs when the client is in the upright position. If regurgitation occurs when the client is recumbent, the client is at risk for aspiration. Belching may be a symptom of the disease. Diarrhea and abdominal pain are not specifically associated with the disease.
Normal fasting blood glucose values range from 70 to 120 mg/dL. A 2-hour postprandial blood glucose level should be less than 140 mg/dL. In this situation, the blood glucose value was 180 mg/dL 2 hours after the client ate, which is an elevated value compared to normal. Although the result may be reported to the physician, it is not a dangerously high one.
The facial nerve (cranial nerve VII) has both motor and sensory divisions. Common abnormalities of this nerve include loss of the nasolabial fold, 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, contusions, or growths are often responsible for this dysfunction. The oculomotor nerve controls the following functions: raising the eyelids and extraocular movements (motor), and pupillary constriction (parasympathetic). The trigeminal nerve controls the following functions: jaw opening and clenching, chewing, and mastication (motor); and the sensory functions of sensation to the cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, and facial skin. The abducens controls lateral eye movement (motor).
The most common complications of peptic ulcer disease are hemorrhage, perforation, pyloric obstruction, and intractable disease. A low hemoglobin and hematocrit level will indicate bleeding. The normal hemoglobin range in females is 12 to 16 g/dL and in males is 14 to 18 g/dL. A white blood cell count is performed to indicate the presence of infection or inflammation. The normal white blood cell count is 5000 to 10,000 mcg/L. The normal platelet range is 150,000 to 400,000 cells mcg/L. The creatinine measures renal function. The normal value is 0.6 to 1.3 mg/dL.
Metabolic acidosis occurs when the pH is falls below 7.35, and the bicarbonate level falls below 22 mEq/L. With respiratory acidosis, the pH drops below 7.35 and the carbon dioxide level rises above 45 mm Hg. With respiratory alkalosis, the pH rises above 7.45 and the carbon dioxide level falls below 35 mm Hg. With metabolic alkalosis, the pH rises above 7.45 and the bicarbonate level rises above 26 mEq/L.
Myoglobin can be released from damaged muscles and precipitate out in the renal tubules, causing acute tubular necrosis. Carbonaceous sputum occurs as a result of inhalation of smoke, as during a fire; this finding would indicate an inhalation injury. Hyperkalemia commonly occurs after any cellular trauma or as a result of deteriorating renal function and cardiac dysrhythmias. Cloudy cerebrospinal fluid would indicate meningitis.
Postoperatively, pneumonia is a complication caused by atelectasis in the lungs. The blood gas results presented in the question are within normal range. Decreased breath sounds indicate possible atelectasis that may be cleared by coughing and deep breathing.
Hyperglycemia can develop into ketoacidosis in the client with type 1 diabetes mellitus. Polyuria develops as the body attempts to get rid of the excess glucose, and the client will lose large amounts of fluid. Because glucose is hyperosmotic, fluid is pulled from the tissue. Nausea and vomiting can occur as a result of hyperglycemia and can lead to a loss of sodium and water. Water is also lost from the lungs in an attempt to get rid of excess carbon dioxide. The severe dehydration that occurs can lead to hypovolemic shock. Of the nursing diagnoses listed, Deficient Fluid Volume deficit is considered first.
Clients newly diagnosed with diabetes mellitus may experience hypoglycemic reactions until the insulin dose is adjusted appropriately. The client may also experience the stages of grieving. Fear is the most common reason for the refusal to take insulin, and this issue must be addressed first.
SLE occurs primarily in females 10 to 35 years of age, and is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE.
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