Aerosolized pentamidine (Nebupent) is given prophylactically to clients with a T4 count below 200 to prevent Pneumocystis carinii pneumonia (PCP), which is the most common opportunistic infection that occurs in clients with AIDS. A respiratory rate and depth within normal limits for activity level would indicate that the client was not experiencing the respiratory difficulty that is associated with PCP. Standard precautions are always maintained on all clients.
Antidysrhythmic therapy may be prescribed for the treatment of premature ventricular contractions. PVCs are considered dangerous when they are frequent (greater than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave.
With right-sided heart failure, fluid pools in the interstitial spaces of the periphery of the body. At night, with the effects of gravity eliminated, fluid reenters the bloodstream and is eliminated by the kidneys, producing nocturia. This indicates that medical therapy is not yet effective. Diuretic therapy is administered in the morning and results in daytime diuresis.
Incoordination and drowsiness are common side effects resulting from diazepam.
Pitocin stimulates uterine contractions. An adverse effect associated with administration of the medication is hyperstimulation of uterine contractions. Therefore, pitocin infusion must be stopped when there are any signs of uterine hyperstimulation. Drowsiness and fatigue may be due to the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.
Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to central nervous system (CNS) depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, sudden drop in fetal heart rate and/or maternal heart rate and blood pressure. Therapeutic serum levels of magnesium are 4 to 7 mEq/L. Proteinuria of 3+ is likely to be noted in a client with preeclampsia.
Following a circumcision, the nurse should observe for bleeding, which is the most common complication. A common protocol is to assess the site every hour for 8 to 12 hours. Assessing for pain by looking at the infant’s facial expression, body movements, and character of crying will indicate the need to minimize or lessen pain. Nutrition is important. The consent is to be obtained before the procedure. Restraints are not necessary after the procedure.
It is critically important that ventilator alarms should never be shut off. The alarm indicates whether the system pressure has risen, whether other problems are occurring, or whether the client becomes disconnected from the ventilator. The client is suctioned as needed. Breath sounds are auscultated at least every 2 hours. The client is sedated on a prn basis to be able to tolerate the ventilator.
Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium restricted. Restricting potassium makes the client more prone to digoxin toxicity. Digoxin should be held and the physician notified when the client’s heart rate is less than 60 beats per minute, unless otherwise ordered. Heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. Resting after meals decreases the demands placed on the heart and should be encouraged.
Specific nursing management of the client undergoing treatment for Hodgkin’s disease focuses on the medication-induced side effects. Risk for infection is a significant consideration, and hand washing is the most effective means of decreasing risk of infection. Limiting visitors to immediate family only is not the best measure, because an immediate family member could transmit an infection.
Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit responsibilities. Other measures include increased fluid and fiber in the diet as prescribed, and antispasmodic or sedative medications as needed.
The medical treatment for AAA is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to be on bed rest. A low fiber diet is not helpful and will cause constipation.
In diabetes mellitus, the pancreas does not produce enough insulin for necessary carbohydrate metabolism. The physiological changes of pregnancy drastically alter insulin requirements. Pregnant diabetic clients should be taught to monitor themselves for hypoglycemia to minimize potential maternal and fetal effects that result from hypoglycemia. Testing for proteinuria is important for the mother with pregnancy-induced hypertension. Management of preterm bleeding is taught to the mother with placenta previa. Managing the discomforts of early labor is important for all pregnant women.
Because hospital stays are short, all contacts with the mother become teachable moments. A positive nurse-client relationship is a growth-fostering experience that will enhance the teaching/learning experience. Separation of the infant and mother decreases the chance of correct latch and suck in the immediate postpartum period. The infant should be placed at the breast immediately after delivery. The mother, not the physician, makes the decision regarding the method of feeding. Although previous breastfeeding experience is helpful, the most significant factor is the nurse-client relationship.
The nurse should petal the edges of the cast with tape to minimize skin irritation. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet, or if the client’s skin itches under a cast. Massaging the skin will not cure the problem. Powder should not be shaken under the cast, because it could clump, become moist, and cause skin breakdown.
The cast should be handled with the palms of the hands, not the fingertips, until fully dry, which takes up to 72 hours. Sheets or blankets should not cover the wet cast, because air should circulate freely around the cast to help it dry and because the cast gives off heat as it dries. The client should never scratch under the cast using any object; a cool hair dryer may be used to eliminate an itch. A plaster cast must remain dry to keep its strength. Wet cloths and soap could soften and damage a plaster cast.
The client should use only crutches measured for the client. Crutches belonging to another person should not be used unless they have been adjusted to fit the client. 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 tips should be inspected for wear, and spare crutches fitted to the client and tips should be available if needed.
The client is taught to hold the cane on the opposite side of the weakness. Therefore, a client with left-sided weakness would hold the cane in the right hand. The cane is placed 6 inches lateral to the fifth toe.
Oxygen saturation should be greater than 95%; 89% is low. Arterial oxygen levels should be 80 to 100 mm Hg; a level of 79 mm Hg is low. Dyspnea is a not a normal sign. When fat embolus occurs, there is a “snowstorm” appearance on chest x-ray. The normal chest x-ray report would be a “clear” chest x-ray.
The pain of compartment syndrome is aggravated by limb elevation, which further impairs blood supply. The compartment is painful even when passively moved. Paresthesias occur early in the syndrome and progress to paralysis unless pressure in the compartment is relieved. The pain of compartment syndrome is not relieved by narcotic analgesics.
A fasciotomy site is not sutured, but it is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings, since underlying tissue is exposed. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed.
Typical signs and symptoms following femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain, or pain in the medial side of the knee. Moving the fractured extremity significantly increases the pain.
The client who has had a TKR often has the leg put into a CPM machine while in the post-anesthesia care unit or shortly after surgery, depending on physician’s preference. The device increases circulation and movement of the knee joint. It should be used as much as possible, according to the tolerance of the client, and should be used at least 6 to 8 hours a day.
After TKR, the client must notify caregivers of the metal implant, because the client will need antibiotic prophylaxis for invasive procedures, and because the client will be ineligible for magnetic resonance imaging as a diagnostic procedure .The client should be taught to report any changes in the shape of the knee. This is not an expected event during recuperation from surgery. Fever, redness, or increased pain also are not expected and may indicate infection.
Clients with diabetes mellitus are more prone to wound infection and delayed wound healing. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative period that could apply to any client with an amputation. Hip contracture is a risk for any client with above-the-knee amputation, since the client does not have the weight of the lower extremity to keep the hip joint extended.
Uremia is a term used to loosely describe the illness accompanying kidney failure (also called renal failure).
Acute renal failure caused by glomerulonephritis is classified as intrarenal failure. This form of acute renal failure is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute renal failure from prerenal causes is characterized by decreased blood pressure (or a recent history of the same), tachycardia, and decreased cardiac output and central venous pressure.
Intrarenal failure is caused by damage to the kidney tissues and structures and includes tubular necrosis, nephrotoxicity, and alterations in renal blood flow. With intrarenal renal failure, there is a fixed specific gravity and the urine tests positive for proteinuria. Postrenal failure is generally caused by obstruction of urinary flow between the kidney and urethral meatus. In postrenal failure, there is a fixed specific gravity and little or no proteinuria. Prerenal failure is caused by intravascular volume depletion, decreased cardiac output, and vascular failure secondary to vasodilation or obstruction. In prerenal failure, the specific gravity is high, and there is very little or no proteinuria.
High-quality proteins come from animal sources and include such foods as eggs, chicken, meat, and fish. Low quality proteins derive from plant sources and include vegetables and foods made from grains. Since the renal diet is limited in protein, it is important that the proteins ingested are of high quality.
Of all of the electrolyte imbalances that accompany renal failure, hyperkalemia is the most serious, because it can lead to cardiac dysrhythmias and death. If the potassium level rises too high, Kayexalate may be given to cause excretion of potassium through the gastrointestinal (GI) tract.
Hypertension is commonly associated with chronic renal failure. This results from a number of mechanisms, including volume overload, renin-angiotensin system stimulation, vasoconstriction from sympathetic stimulation, and the absence of prostaglandins. Hypertension may also be the cause of the renal failure. It is an important item to assess because hypertension can lead to heart failure in the chronic renal failure client due to increased cardiac workload in conjunction with fluid overload.
The client with chronic renal failure may have several barriers to learning, including anxiety and the effects of uremia, such as short attention span and memory deficits. Uremic effects usually improve once hemodialysis has begun. The presence of family is helpful, since the family needs to understand the disease and treatment, and may help reinforce information with the client after the formal teaching session is over. Information should also be simple, direct, and at the educational level of the client to be most effective. Charts and diagrams may be helpful but are not the priority. Research articles will not be helpful.
Antihypertensive medications such as enalapril are given to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis, and also prevents the medication from being removed from the bloodstream during dialysis. There is no rationale to wait until bedtime to resume the medication.
Emotionally labile - also known as or related to emotional instability
The client with renal failure is almost certain to have a problem with constipation due to factors such as fluid restriction and dietary restrictions of most high-fiber foods (which have high potassium content). In addition, aluminum-based antacids such as aluminum hydroxide gel cause constipation as a side effect.
Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a conduit for bacteria to reach the catheter insertion site. The nurse teaches the client to keep the dressing dry at all times. Reinforcing the dressing is not a safe practice to prevent infection. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.
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