Following pneumonectomy, the fluid status of the client is monitored closely to prevent fluid overload, because the size of the pulmonary vascular bed has been reduced as a result of the pneumonectomy. Complete lateral turning and positioning is avoided. The head of the bed should be elevated to promote lung expansion. The client should remain on bed rest in the immediate postoperative period.
Pleurisy, also known as pleuritis, is an inflammation of the pleura, the lining of the pleural cavity surrounding the lungs, which can cause painful respiration (also called pleuritic chest pain) and other symptoms.
The client should remain in bed for at least 3 hours following a parenteral dose of diazepam. The medication is a centrally acting skeletal muscle relaxant and also has antianxiety, sedative-hypnotic, and anticonvulsant properties. Cardiopulmonary side effects include apnea, hypotension, bradycardia, or cardiac arrest. For this reason, resuscitative equipment is also kept nearby.
Clonazepam (Klonopin) is a benzodiazepine that is used as an anticonvulsant. During initial therapy and during periods of dosage adjustment, the nurse should initiate seizure precautions for the client.
Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.
Insulin is administered via an infusion pump to prevent inadvertent overdose and subsequent hypoglycemia. Dextrose is added to the IV infusion once the serum glucose level reaches 250 mg/dL to prevent the occurrence of hypoglycemia. Administering dextrose to a client with a serum glucose level of 700 mg/dL would counteract the beneficial effects of insulin in reducing the glucose level.
The client with DKA may experience a decrease in the level of consciousness (LOC) secondary to acidosis. Safety becomes a priority for any client with a decreased LOC, thus requiring the use of side rails to prevent fall injuries. The client may be too ill to ambulate and will experience fluid loss (dehydration) rather than overload.
A tort is a wrongful act intentionally or unintentionally committed against a person or his or her property.
Discussing a client’s condition without client permission violates a client’s rights and places the nurse in legal jeopardy. This action by the nurse is both an invasion of privacy and affects the confidentiality issue with client rights.
For negligence to be proven, there must be a duty, and then a breach of duty; the breach of duty must cause the injury, and damages or injury must be experienced.
Passage of a normal brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the physician, who may choose to alter the diagnostic or therapeutic plan of care. Hydrostatic reduction and surgery may not be necessary. Although the nurse would note the child’s physical symptoms
Primary nursing is concerned with keeping the nurse at the bedside actively involved in direct care while planning goal-directed, individualized client care.
The client has the right to donate her or his own organs for transplantation. Any person 18 years of age 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.
Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of care. It manages client care by managing the client care environment.
Participative leadership suggests a compromise between the authoritarian and the democratic style. In participative leadership, the manager presents his or her own analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. A laissez faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. The autocratic style of leadership is task oriented and directive. The situational leadership style utilizes a style depending on the situation and events.
Ascorbic acid can interfere with the result of occult blood testing, causing false-negative findings. Colchicine and iodine can cause false-positive results.
The transition point for switching to the forward-facing position is defined by the manufacturer of the safety seat but is generally at a body weight of 9 kg (20 pounds). The car safety seat should be used until the child weighs at least 40 pounds regardless of age.
To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees.
Methergine is contraindicated for the hypertensive woman, individuals with severe hepatic or renal disease, and during the third stage of labor. A uterine fundus that is difficult to locate, excessive bleeding, and excessive lochia are clinical manifestations of uterine atony indicating the need for methylergonovine.
Clients who cannot write may sign an informed consent with an X. This is witnessed by two nurses. Nurses serve as a witness to the client’s signature and not to the fact that the client is informed. It is the physician’s responsibility to inform the client about a procedure. The nurse clarifies facts presented by the physician.
Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective in reducing mucosal edema. Cool mist humidifiers are recommended over steam vaporizers, which present a danger of scald burns. Taking the child outside to breathe the cool humid night air may also relieve mucosal swelling.
All pregnant women should be screened for prior rubella exposure during pregnancy. All children of pregnant women should receive their immunizations according to schedule. Additionally, no definitive evidence suggests that the rubella vaccine virus is transmitted from person to person. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to the rubivirus.
For optimal upper extremity leverage, the elbow should be at approximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch needs to be two to three fingerwidths lower than the axilla. When crutch walking, all weight needs to be on the hands to prevent nerve palsy from pressure on the axilla.
Restraints should never be applied tightly because it could impair circulation. The restraint should be applied securely (not tightly) to prevent the client from slipping through the restraint and endangering him or herself. A hitch knot may be used on the client because it can easily be released in an emergency. Restraints, especially limb restraints, must be released every 2 hours (or per agency policy) to inspect the skin for abnormalities. The call light must always be within the client’s reach in case the client needs assistance.
To correct an error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. An error is never erased and correction fluid is never used in a medical record.
Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to have a violent episode. Walking up behind the client may cause the client to become startled and react violently. Remaining at the entrance of the room may make the client feel alienated. If the client’s agitation is not addressed, it will only increase. Therefore, waiting for the agitation to subside is not an appropriate option.
Syringes should never be recapped in any circumstances because of the risk of getting pricked with a contaminated needle. Used syringes should always be placed in a sharps container immediately after use to avoid individuals from getting injured. A syringe should not be swept up because this action poses an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringe.
To achieve proper traction, weights need to be free-hanging with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.
When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on the hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it.
With the client’s elbows flexed 20 to 30 degrees, the shoulders in a relaxed position, and the crutches placed approximately 15 cm (6 inches) anterolateral from the toes, the nurse should be able to place two fingers comfortably between the axillae and the axillary bars. The crutches are adjusted if there is too much or too little space at the axillary area. The client is advised never to rest the axillae on the axillary bars because this could injure the brachial plexus (the nerves in the axillae that supply the arm and shoulder area). The nurse should terminate ambulation and recheck the crutch height if the client complains of numbness or tingling in the hands or arms.
Instructions to a client with conjuctivitis includes eye makeup should be replaced but can still be worn. Cool compresses decrease pain and irritation. Isolation for 24 hours after antibiotics are initiated is necessary. A new set of contact lenses should be obtained.
A quad-cane may be prescribed for the client who requires greater support and stability than is provided by a straight-leg cane. The quad-cane provides a four-point base of support and is indicated for use by clients with partial or complete hemiplegia.
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