Antihypertensive medications, such as enalapril, are administered to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis.
The sigmoid and descending colon are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colon. Acute flexion of the right leg allows for adequate exposure of the anus.
Respiratory distress can occur following thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. SSKI is typically administered preoperatively to block thyroid hormone synthesis and release, as well as place the client in a euthyroid state. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem post-thyroidectomy.
Sodium nitroprusside becomes unstable when exposed to light and must be protected.
The use of an incisional splint such as a “cough pillow” can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated.
All stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual, which is determined in order to evaluate whether undigested formula from a previous feeding remains. It is important to assess gastric residual because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. Assessing residual does not confirm placement, determine patency, or assess fluid and electrolyte status.
Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning, provide the level of poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen.
Breathing and relaxation techniques aid the client in coping with the discomfort of labor and in conserving energy. Intravenous or epidural pain relief can be useful. Intravenous hydration can increase perfusion and oxygenation of maternal and fetal tissues and provide glucose for energy needs. Noise from a TV or radio and light stimulation does not promote rest. A quiet, dim environment would be more advantageous.
Autonomic dysreflexia (hyperreflexia) is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. A client with autonomic dysreflexia would be hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.
IV nitroglycerin is prepared only in glass bottles, using the administration sets provided. Standard plastic (polyvinyl chloride) tubing will adsorb the nitroglycerin, thus reducing the potency and reliability of the medication. It should also be protected from extremes of light and temperature. It should be remixed every 4 hours.
The client with a significant pleural effusion is usually treated by thoracentesis. This procedure allows drainage of the fluid, which may then be analyzed to determine the precise cause of the effusion. The nurse ensures that a thoracentesis tray is readily available in case the client’s symptoms should rapidly become more severe. A paracentesis tray is needed for the removal of abdominal effusion.
Procainamide (Pronestyl) is an antidysrhythmic medication. Before the medication is administered, the client’s blood pressure and pulse are checked. This medication can cause toxic effects, and serum blood levels would be checked before administering the medication (therapeutic serum level is 3 to 10 mcg/mL).
Drainage from the ureteral catheter should be checked when the client returns from the recovery room and at least every 1 to 2 hours thereafter. The catheter drains urine from the renal pelvis, which has a capacity of 3 to 5 mL. If the volume of urine or fluid in the renal pelvis increases, tissue damage to the pelvis will result from pressure. Therefore, the ureteral tube is never clamped. Additionally, irrigation is not performed unless there is a specific physician’s order to do so.
After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) in order to maintain the client’s electrolyte balance. It does not need to be mixed with water, nor should it be discarded or mixed with formula.
Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring, administering oxygen at a rate of 2 to 4 liters per minute unless otherwise ordered, and ensuring an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep vein open rate to prevent fluid overload and heart failure. Thrombolytic therapy may or may not be prescribed by the physician. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event.
Standard ECG graph paper measurements are 0.04 seconds for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.
Anterior cord syndrome is a medical condition where the blood supply to the anterior portion of the spinal cord is interrupted. It is characterized by loss of motor function below the level of injury, loss of sensations carried by the anterior columns of the spinal cord (pain and temperature), and preservation of sensations carried by the posterior columns (fine touch and proprioception).
Fluid volume during pregnancy peaks between 18 to 32 weeks’ gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or CHF in the pregnant client. By assessing lung sounds in the lower lobes, the nurse may identify early symptoms of diminished oxygen exchange and potential CHF
Compartment syndrome is prevented by controlling edema. This is achieved most optimally with the use of elevation and the application of ice.
To treat hypotension during hemodialysis, the nurse raises the client’s feet and legs to enhance cardiac return. A normal saline bolus of up to 500 mL may be given to increase circulating volume. The nurse would check the client’s weight and reassess the blood pressure. Finally, the transmembrane hydrostatic pressure or the blood flow rate into the dialyzer may be decreased. All of these measures should improve the circulating volume and blood pressure.
Anterolateral paddle placement for external countershock involves placing one paddle at the right second intercostal space and the other at the fifth intercostal space at the anterior axillary line.
Venography is similar to arteriography, except it evaluates the venous system. A radiopaque dye is injected into selected veins to evaluate patency and blood flow characteristics. The client signs an informed consent because it is an invasive procedure. Allergies to shellfish or iodine must be noted. Peripheral pulses are assessed so comparisons can be made after the procedure. The client is usually given clear liquids for 3 to 4 hours before the procedure to help with dye excretion afterward.
Good contact between the skin and electrodes are necessary to obtain a clear 12-lead ECG tracing. Therefore, the electrodes are placed on the flat surfaces of the skin just above the ankles and wrists. Movement may cause a disruption in that contact. The client does not need to hold the breath or take a deep breath during the procedure. The client needs to be reassured that a shock will not be received.
Long, firm strokes in the direction of venous flow promote venous return when bathing the extremities. Circular strokes are used on the face. Short, patting strokes and light strokes are not as comfortable for the client and they do not promote venous return.
The Z-track variation of the standard intramuscular technique is used to administer intramuscular medications that are highly irritating to subcutaneous and skin tissues. The nurse selects an intramuscular site for injection, preferably in a large deep muscle such as the ventrogluteal muscle. A new sterile needle is attached because the new needle will not have any medication adhering to the outside that could be irritating to the tissues. Retracting the skin provides a seal over the injected medication to prevent tracking through the subcutaneous tissues. The medication is injected slowly after aspiration, if there is no blood return on aspiration. The needle remains inserted for 10 seconds to allow the medication to disperse evenly. The nurse then releases the skin after withdrawing the needle.
General recommendations for managing extravasation of a chemotherapeutic agent include stopping the infusion, leaving the needle in place and attempting to aspirate any residual medication from the site, administering an antidote if available, and assessing the site for complications. Direct pressure is not applied to the site because it could further injure tissues exposed to the chemotherapeutic agent.
Intravenous pyelography is a contrast study of the kidneys to determine a variety of disorders of the kidneys, ureters, and bladder. Normal sensations during injection of the iodine-based radiopaque dye include a warm, flushed feeling, salty taste in the mouth, and transient nausea. Difficulty breathing, wheezing, hives, or itching indicate an allergic response and should be reported immediately. This complication is prevented by inquiring about allergies to iodine or shellfish before the procedure.
Tetracycline use during pregnancy may lead to discoloration of the child’s teeth when they erupt. This treatment for acne is contraindicated during pregnancy.
When doing a indium imaging, a sample of the client’s blood is collected, and the leukocytes are tagged with indium. The leukocytes are then reinjected into the client. They accumulate in infected areas of bone and can be detected with scanning. No special preparation or after care is necessary.
Penicillin is frequently the medication of choice for treating endocarditis of bacterial origin. The standard duration of therapy is 4 to 6 weeks, with home care support after hospital discharge, which is usually in 7 to 10 days.
The use of wet-to-dry saline dressings provides a nonselective mechanical debridement, whereby both devitalized and viable tissue are removed. This method should not be used on a clean, granulating wound. Granulation tissue in a venous stasis ulcer is protected through the use of wet-to-wet saline dressings, Vaseline gauze, or moist occlusive dressings, such as hydrocolloid dressings.
Digoxin immune fab is an antidote for severe digitalis toxicity. It contains an antibody produced in sheep, which antigenically binds any unbound digitalis in the serum and removes it. As more digoxin reenters the bloodstream from the tissues, it binds that also for excretion by the kidneys.
The classic signs and symptoms of intussusception are acute, colicky abdominal pain with currant jelly-like stools. Clinical manifestations of Hirschsprung’s disease include constipation, abdominal distention, and ribbon-like, foul-smelling stools. Peritonitis is a serious complication that may follow intestinal obstruction and perforation. The most common symptom of appendicitis is colicky, periumbilical or lower abdominal pain in the right quadrant.
The client in seclusion is assessed continuously or at least every 15 minutes, or according to agency protocol. Vital signs, food and fluid intake, and toileting needs are assessed.
In this situation, the nurse is performing one test of cerebellar function and is testing for ataxia. Alterations in the cerebellar function are noted by alterations in balance and coordination.
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