Droperidol (Inapsine) may be administered by the intramuscular (IM) or intravenous (IV) routes. The IV route is the route used when relief of nausea is needed. The IM route may be used when the medication is used as an adjunct to anesthesia.
The purpose of Electrophysiology (EPS) is to study the heart’s electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test in order to study the dysrhythmias without the influence of medications. Because the client’s verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.
The inhalation of heated vapor helps the client to cough productively because the vapor condenses on the tracheobronchial mucosa and stimulates the production of secretions and a cough reflex. The client is told to lightly cover the mouthpiece with the lips and not to form a tight seal. The client inhales vaporized saline until coughing results.
If the client experiences air embolism, the immediate action is to place the client on the left side with the feet higher than the head. This position traps air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.
Physical or emotional stress triggers a sympathetic nervous system response. Responses that are reflected in the vital signs include an increased pulse, increased blood pressure, and increased respiratory rate. Stress reduction, then, returns these parameters to baseline.
Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thus reducing preload, afterload, and myocardial work. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.
When collecting a 24-hour urine specimen. The nurse asks the client to void at the beginning of the collection period and discards this urine sample. All subsequent voided urine is saved in a container, which is placed on ice or refrigerated. The client is asked to void at the finish time, and this sample is added to the collection. The container is labeled, placed on fresh ice, and sent to the laboratory immediately.
If a client’s nasogastric tube stops draining, the nurse would first check the functioning of the equipment. The nurse would ensure that there was an order for irrigating the tube and would then irrigate the tube with 30 to 60 mL of normal saline (or with another acceptable solution per agency procedure). There is no useful reason to clamp the tube because it is probably clogged. Pulling out the tube could displace the tube, placing the client at risk for aspiration. Replacement of the tube is the last step if other actions are unsuccessful.
Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic and contraindicated for tepid sponge or tub baths. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child’s body temperature. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results.
The TPN line is used only for the administration of the TPN solution. Any other IV medication must be administered though a separate IV access site
If the balloon is positioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther in order to provide sufficient space to inflate the balloon. The catheter’s balloon is behind the opening at the catheter insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra.
Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding, and implements the same precautions that are used for a client receiving anticoagulant therapy. Thus, venipuncture sites should be held for approximately 10 minutes. The medication does not have to be taken on an empty stomach. The medication may cause hypoglycemia, but not hyperglycemia.
Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler’s position. High-Fowler’s is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The supine position will increase the dyspnea that occurs with pulmonary embolism. The usual analgesic of choice is morphine sulfate administered IV. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilatation.
In PTCA a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall.
The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck’s extension traction (which is applied to a leg), the foot of the bed is elevated.
As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. Slow breathing helps the client relax to reduce the gag response. The tube may be advanced after the client relaxes.
The antidote to iron dextran is deferoxamine, which is a heavy metal antagonist. This medication chelates unbound iron in the circulation and forms a water-soluble complex that can be eliminated by the kidneys. Dirithromycin is a macrolide antiinfective. Ferrous sulfate and ferrous fumarate are forms of iron supplements.
An AV shunt is a less common form of access site, but carries a risk for bleeding when it is used. This is because two ends of a cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt should be checked at least every 4 hours.
Hypocalcemia is a potentially life-threatening complication following parathyroidectomy, and the nurse should ensure that intravenous calcium preparations are readily available.
Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance
Clients with low back pain are often more comfortable when placed in semi-Fowler’s position with the knees raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the foot of the bed flat will enhance extension of the spine. Keeping the bed flat with the knees raised would excessively stretch the lower back and would also put the client at risk for thrombophlebitis.
Ipecac is administered to induce vomiting in certain poisoning situations. In this situation, the child is conscious and the ingested substance (aspirin) will not damage the esophagus or lungs from vomiting. Activated charcoal may be prescribed as an antidote in some poisoning situations, but its action is to absorb ingested toxic substances.
Mestinon is an acetylcholinesterase inhibitor. Muscle cramps and small muscle contractions are side effects and occur as a result of overstimulation of neuromuscular receptors.
Leg elevation is important to increase venous return and decrease edema, which can cause compartment syndrome, a major complication of fractures and casting. Weight-bearing on a fractured extremity is prescribed by the physician during follow-up examination, after an x-ray is taken. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately.
Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Tricep muscle spasms may occur as a result of increased muscle use, but is not a complication of crutch walking. Weak biceps brachii is a common physical assessment finding in older adults and is not a complication of crutch walking.
A Tensilon test may be performed to determine whether increasing weakness in a previously diagnosed myasthenic client is a result of cholinergic crisis (overmedication with anticholinesterase drugs) or myasthenic crisis (under medication with cholinesterase inhibitors). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
As an isolated occurrence, the PVC is not life threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurred, the physician needs to be notified.
A sputum culture showing Mycobacterium tuberculosis confirms the diagnosis of tuberculosis. Usually three sputum samples are obtained for the acid-fast smear. After the initiation of medication therapy, sputum samples are obtained again to determine the effectiveness of therapy. A positive Tine or Mantoux test indicates exposure to tuberculosis but does not confirm the presence of Mycobacterium tuberculosis. A positive chest x-ray may indicate the presence of tuberculosis lesions, but again does not confirm active disease.
Up until the third trimester, the measurement of fundal height will, on average, correlate with the gestational age.
On inspection of the perineum, if the umbilical cord is noted, the nurse immediately places the client into the Trendelenburg position while pushing the presenting part upward to relieve the cord compression. This position is maintained and the physician is notified. The nurse monitors the fetal heart rate. The client is transferred to the delivery room when prescribed by the physician.
Intravenous pentamidine (Pentam-300) is infused over 1 hour with the client supine to minimize severe hypotension and dysrhythmias.
The nurse monitors for postoperative complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client’s calf could also indicate this complication.
Normal respiratory rate varies from 30 to 80 breaths per minute when the infant is not crying. Respirations should be counted for 1 full minute to ensure an accurate measurement because the newborn infant may be a periodic breather. Observing and palpating respirations while the infant is quiet promotes accurate assessment. Palpation aids observation in determining the respiratory rate.
Homans’ sign tests for venous thrombosis of the lower extremity. Pain in the calf during walking could indicate venous thrombosis.
When assessing an IV for signs and symptoms of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluid into the vein or surrounding tissues, which could cause more tissue damage. Increasing the IV flow rate can further damage the tissues if the IV has infiltrated. The IV site will feel cool if the IV fluid has infiltrated into the surrounding tissues. Redness and warmth may indicate phlebitis.
In suspected neck injuries, the appropriate way to open the airway is the jaw-thrust maneuver. If a neck injury is present, this maneuver will prevent further injury.
Intracranial pressure and encephalopathy are major problems associated with Reye’s syndrome.
A complication of pneumococcus pneumonia is pleural effusion, so the respiratory status of the child needs to be monitored.
Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling places pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.
The fasciotomy site is not sutured, but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require Betadine. Additionally, Betadine can be irritating to normal tissues.
Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on rigorous activities.
If there is leakage at the IV site, the nurse should first locate the source. The nurse should assess the site further to be certain that all connections are secure. The nurse should not increase the flow rate. Although it may leak more, it may also cause tissue damage if the IV was infiltrating. The infusion most likely will need to be stopped, but the physician would not need to be notified. Slowing and discontinuing the IV is also premature. The IV must first be assessed for the cause of the leaking.
The client is instructed to perform the Valsalva maneuver (take a deep breath, exhale, and bear down) for chest tube removal. This maneuver will increase intrathoracic pressure, thereby lessening the potential for air to enter the pleural space.
Electroconvulsive therapy is an effective treatment for depression that has not responded to medication. Psychosurgery is invasive, rarely performed, and would not treat depression. Seculsion is not used to treat depression. Neuroleptics are not effective in the treatment of depression.
The person whose anxiety is assessed as severe is unable to solve problems and has difficulty focusing on what is happening in the environment. Somatic symptoms are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.
Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever.
Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of a chronic tissue hypoxia and polycythemia.
The neurovascular status of the extremity of the client in Buck’s extension traction must be assessed frequently. Older clients are especially at risk for neurovascular compromise because many older clients already have disorders that affect the peripheral vascular system. Although the client’s temperature is monitored, it is not specific to the use of Buck’s extension traction. Although clients in some types of traction do become depressed after a few days or weeks, Buck’s extension traction is usually used preoperatively, which typically involves a few hours or 1 to 2 days at the most. Range of motion of the involved leg is contraindicated in hip fractures.
A significant advantage of an ultrasound is that it can differentiate a solid mass from a fluid-filled cyst. It is noninvasive, and does not require any special after care. Other diagnostic tests, such as magnetic resonance imaging and computed tomography scanning, are also noninvasive (unless contrast is used) and require no special after care either. However, the ultrasound can discriminate between solid and fluid masses most optimally.
The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses or parasites.
Creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. Levels begin to rise3 to 6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. Therefore, the client’s results are compatible with new-onset MI.
The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line. The client is placed in a sitting position.
An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus.
Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (Borborygmi) indicate hyperperistalsis. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit.
The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client’s activity level is adjusted according to the amount of edema and water retention. As edema increases, the client’s activity level should be restricted.
The pain of ureteral colic is caused by movement of a stone through the ureter, and is sharp, excruciating, and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because of its abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a deep ache in the costovertebral area. Renal colic is characterized by pain that is acute, with tenderness over the costovertebral area.
Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a “three-point” position while upright and use pillows to support the head and thorax at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.
The priority items in the management of sickle cell crisis are hydration therapy and pain relief. To achieve this goal, the client is given IV fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Narcotic analgesics may be given to relieve the pain that accompanies the crisis. Oxygen would be given based on individual need. Red blood cell transfusion may also be done in selected circumstances, such as aplastic crisis or when the episode is refractive to other therapy. Genetic counseling is recommended, but not during the acute phase of illness.
Classic signs of cardiogenic shock include increased pulse (weak and thready), decreased blood pressure, decreasing urinary output, signs of cerebral ischemia (confusion, agitation), and cool, clammy skin.
Chest tube drainage should not exceed 100 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after cardiac surgery. The nurse measures and records the drainage on an hourly basis. The drainage is initially dark red and becomes more serous over time.
The client undergoing radiation therapy should wash the site using mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools). The client should wear cotton clothing over the skin site and guard against irritation from tight or rough clothing such as belts or bras.
Iron is needed for RBC production. Otherwise, the body cannot produce sufficient erythrocytes. In either case, the client is not receiving the full benefit of epoetin alfa therapy if iron is not taken.
Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately in order to note any variation in the pulse rate or rhythm that may need to be reported to the physician. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the physician is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.
The symptoms of major depression include depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often, the client does not have the energy or interest to complete activities of daily living.
External fetal monitoring will allow the nurse to determine any change in the fetal heart rate and rhythm that would indicate that the fetus is in jeopardy. Internal monitoring is contraindicated when there is vaginal bleeding of an unstated cause, especially in preterm labor. Because fetal distress has not been determined at this time, oxygen administration is premature. The amount of bleeding described is insufficient to require intravenous fluid replacement.
A consistent finding of abnormally high sodium and chloride concentrations in the sweat is a unique characteristic of CF. Normally, the sweat chloride concentration is less than 40 mEq/L. A sweat chloride concentration greater than 60 mEq/L is diagnostic of CF.
The Cantor tube is an intestinal tube and is used for aspirating intestinal contents. For intestinal intubation the tube is threaded through the nose into the stomach and then through the pylorus, where peristaltic activity of the bowel carries it to the desired intestinal area. The nurse ensures intestinal placement by checking the pH of aspirate. A pH reading greater than 7 indicates intestinal contents; a reading less than 7 indicates gastric contents.
To assess for adequate circulation, the nail bed of each finger or toe is depressed until it blanches, and then the pressure is released. Optimally, the color will change from white to pink rapidly (less than 3 seconds). If this does not occur, the toes or fingers will require close observation and further evaluation. Palpable pulses and sensations distal to the cast are expected. However, if pulses could not be palpated or if the client complained of numbness or tingling, the physician should be notified.
Decerebrate posturing, which can occur with upper brain stem injury, is the extension of the extremities after a stimulus.
If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. The client should be positioned with the head in semi-Fowler’s position and the arm elevated on pillows to decrease edema. Edema is likely to occur because lymph drainage channels have been resected during the surgical procedure. Blood pressure measurement, venipuncture, and IV sites should not involve use of the operative arm.
Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, buttermilk, onions, peanut butter, and gelatin.
The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.
Mild diverticular disease is treated with a high-fiber diet and prevention of constipation with bran and bulk laxatives. A diet high in fat should be avoided because high-fat foods tend to be low in fiber. A low-roughage diet is similar to a low-fiber diet.
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