Beta-adrenergic blocking agents, such as timolol acetate (Timoptic), reduce intraocular pressure by decreasing the production of aqueous humor. Miotic agents (such as pilocarpine) increase contractions of the ciliary muscle and constrict the pupil, thereby increasing the outflow of aqueous humor.
Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis. A sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on the muscle.
When the client has suffered a chemical burn of the eye, the nurse immediately flushes the site with a sterile solution continuously for 15 minutes. If a sterile eye irrigation solution is not available, running water may be used. Performing an assessment may be helpful but is not the priority action. Applying compresses or bandages is incorrect, because they do not rid the eye of the damaging chemical. Cold compresses are used for blows to the eye, whereas light bandages may be placed over cuts of the eye or eyelid.
Urge incontinence occurs when the client has urinary incontinence soon after experiencing urgency. Reflex incontinence occurs when incontinence occurs at rather predictable times that correspond to when a certain bladder volume is attained. Stress incontinence occurs when the client voids in increments that are less than 50 mL and has increased abdominal pressure. Total incontinence occurs when there is an unpredictable and continuous loss of urine.
Levothyroxine sodium (Synthroid) is the medication of choice for hypothyroidism. The most significant factor adversely affecting the eventual intelligence of children born with congenital hypothyroidism is inadequate treatment. Therefore, compliance with the medication regimen is essential. If the infant or child vomits within 1 hour of taking medication, the dose should be administered again.
Catatonic excitement is manifested by a state of extreme psychomotor agitation. Clients urgently require physical and medical control because they are often destructive and violent to others, and their excitement can cause them to injure themselves or to collapse from complete exhaustion.
Ketonuria is an abnormal finding in the client with diabetes mellitus indicating ketosis. Ketosis is a metabolic effect from the lack of insulin on fat metabolism and occurs in type 1 diabetes mellitus. It is associated with the severe complication of diabetic ketoacidosis (hyperglycemia, ketosis, and acidosis).
Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the client is subject to the usual complications associated with insulin administration without the use of a pump.
Medical therapy for Graves’ disease does not help alleviate the clinical manifestation of exophthalmos. Because photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the problem. Tap water, which is hypotonic, could actually cause more swelling to the eye because it could pull fluid into the interstitial space. In addition, the client is at risk for developing an eye infection because the solution is not sterile. There is no need to avoid straining with exophthalmos. Methimazole inhibits the synthesis of thyroid hormone and is used to treat hyperthyroidism but will not alleviate exophthalmos or photophobia.
Clients with cholinergic crisis have experienced overdosage of medication. Tensilon will exacerbate symptoms in cholinergic crisis to the point where the client may need intubation and mechanical ventilation. Intravenous atropine sulfate is used to reverse the effects of these anticholinesterase medications. Morphine sulfate and pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Isuprel is not indicated for cholinergic crisis.
Tissue hypertrophy (lipodystrophy) involves thickening of the subcutaneous tissue at the injection sites. This can interfere with the absorption of insulin, resulting in erratic blood glucose levels. Because the client has been on insulin for many years, this is the most likely cause of poor control.
Theophylline is a bronchodilator used to treat bronchial asthma or to reverse bronchospasm caused by chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. To determine medication effectiveness, the nurse would auscultate lung sounds for the absence of rhonchi, crackles, or wheezes. Although the client’s temperature would be monitored for signs of respiratory infection in a client with a respiratory disorder, temperature is unrelated to medication effectiveness. Although the pulse rate would be monitored because tachycardia is a sign of toxicity, pulse rate is unrelated to medication effectiveness. Pupillary response is a neurological assessment and is unrelated to this medication.
Lidocaine can cause atrioventricular block with conduction defects. It can also cause paresthesia, numbness, disorientation, and agitation. Monitoring the vital signs, ECG, and neurological status is the priority.
Intravenous nitroprusside (Nipride) is a potent vasodilator that reduces preload and afterload. Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility. Morphine sulfate is a narcotic analgesic. Furosemide (Lasix) is a loop diuretic and can reduce preload by enhancing the renal excretion of sodium and water, which reduces circulating blood volume.
Streptokinase is a thrombolytic medication that causes lysis of blood clots. Anticoagulants prevent further clot formation. Beta-blockers, nitrates, and calcium channel blockers are used to reduce myocardial oxygen demand. Streptokinase does not prevent platelet aggregation.
The classic rash of erythema infectiosum, or fifth disease, is the erythema on the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule to papule rash is the rash of varicella (chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles).
Headache, hypertension, tachycardia, nausea, and vomiting are precursors to hypertensive crisis brought about by the ingestion of foods rich in tyramine and tryptophan while the client is taking an MAOI. These medications act by decreasing the amount of MAOI in the liver, which is necessary for the breakdown and utilization of tyramine and tryptophan. Hypertensive crisis may lead to circulatory collapse, intracranial hemorrhage, and death.
Catheter blockage or occlusion by clots following prostatectomy can result in urine backup and leakage around the urethral meatus. This would be accompanied by a stoppage of outflow through the catheter into the drainage bag. Drainage that is bright red indicates that the irrigant is running too slowly; drainage that is pale pink indicates sufficient flow. A true urine output of 50 mL per hr indicates catheter patency.
Bumetanide is a loop diuretic that is not potassium-sparing. The value given for potassium is below the therapeutic range of 3.5 to5.1 mEq/L for this electrolyte. The nurse should notify the physician before giving the dose so that potassium may be ordered.
Erythromycin is a macrolide antibiotic that should be taken with a full glass of water. Sufficient volume is needed to obtain the maximal effect of the medication. Depending on the specific type of erythromycin, it may need to be administered on an empty stomach, with meals, or regardless of timing of meals. The nurse should verify the best method of administration for the type of erythromycin ordered.
Hydralazine (Apresoline) is an antihypertensive medication used in the management of moderate to severe hypertension. It is a vasodilator medication that decreases afterload.
The diagnosis of carbon monoxide poisoning is confirmed by measurement of carboxyhemoglobin levels in the client’s blood. Pulse oximetry readings are unreliable because of the detection of CO-hemoglobin as oxyhemoglobin. The neurological system may be affected by carbon monoxide poisoning, but this will be detected by assessment of clinical manifestations. A CT scan of the head will not confirm the diagnosis or provide any useful information unless a structural defect or injury in the head is a concern. A complete blood cell count may provide useful information but will not confirm the diagnosis.
The client is experiencing signs and symptoms of what is called “red man” or “red neck” syndrome. This is a response caused by histamine release that occurs with rapid or bolus injection. The client may experience chills, fever, flushing of the face and/or trunk, tachycardia, syncope, tingling, and an unpleasant taste in the mouth. The corrective action is to administer the medication more slowly. An antihistamine such as diphenhydramine (Benadryl) may be administered as well.
The nasal decongestant should be administered 15 minutes before the beclomethasone (a glucocorticoid) to clear the nasal passages and enhance absorption of the glucocorticoid.
A myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single muscle group or multiple muscle groups. Absence seizures occur in childhood and adolescence and are characterized by a vacant facial expression. A clonic seizure is characterized by rhythmic muscular contraction and relaxation lasting several minutes. A tonic seizure is characterized by an abrupt increase in muscle tone and contraction and the presence of autonomic manifestations.
Lithium is used to treat manic disorders, not depression. Side effects of lithium are nausea, tremors, polyuria, and polydypsia. Serum lithium concentration is assessed approximately every 2 to 4 days during initial therapy and at longer intervals thereafter. Toxic levels of lithium may induce electrocardiogram changes, but there is no need to perform weekly ECGs if maintenance levels are maintained.
Aminophylline (Theophylline) is a bronchodilator. The therapeutic serum level range of theophylline is 10 to 20 mcg/mL. It is critical that the nurse monitor theophylline blood serum levels daily when a client is on this medication to ensure that a therapeutic range is present and to monitor for the potential for toxicity.
Pheochromocytoma is a catecholamine-secreting tumor that is usually located in the adrenal medulla. Hypertension is the principal manifestation associated with pheochromocytoma, and it can be persistent, fluctuating, intermittent, or paroxysmal. The blood pressure status would be assessed by taking the client’s blood pressure.
An increase in the rate of respirations and a decrease in the depth of respirations indicates a deterioration in ventilation.
The most rapid method used to calculate the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the Rule of Nines. This method divides the body into areas that are in multiples of 9%. Each leg is 18%, each arm is 9%, and the head is 9%. The trunk is 36% and the perineal area is 1%. Both legs and perineal area equal 37%.
On arrival of the client, 100% oxygen is administered at atmospheric pressure or hyperbaric pressure to speed up the elimination of carbon monoxide from the hemoglobin and to reverse hypoxia. The next most important action is assessment of the client. Then blood is drawn (initially and serially) to monitor carboxyhemoglobin levels; once they drop below 5%, oxygen may be discontinued. If the episode was unintentional and precipitated by conditions in a dwelling, the health department is notified.
This cardiac rhythm indicates coarse ventricular fibrillation. A defibrillator is needed to correct ventricular fibrillation.
Atrial fibrillation is characterized by rapid, chaotic atrial depolarization, with ventricular rates ranging from 160 to 180 BPM. The ECG reveals chaotic or no identifiable P waves and a baseline that is irregular. The PR interval is irregular. A sinus dysrhythmia has a normal P wave, PR interval, and QRS complex. In ventricular fibrillation, there are no identifiable P waves, QRS complexes, or T waves. In third-degree heart block, the atria and ventricles beat independently.
Assignment of tasks to the nursing assistant needs to be made based on job description, level of clinical competence, and state law.
If a client is exhibiting signs that indicate loss of control, the nurse’s immediate priority is to ensure safety for all clients
In an MRI, radio-frequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, watches, etc., should be removed. In addition, a history should be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, shrapnel, etc. For an abdominal MRI, the client is usually NPO. An NPO status is not necessary for an MRI of the head. The groin may be shaved for an angiogram, and inhalation of gas may be prescribed with a positron emission tomography (PET).
The family or a legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the physician writes the order. Generally, the family makes decisions in collaboration with physicians, other health care workers, and other trusted advisors. Although a written order by the physician is necessary, the nurse first checks for documentation of the family’s request. Unless special circumstances exist, a court order is not necessary. Although some health care agencies may require reviewing such requests via the Ethics Committee, this is not the nurse’s first action.
The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine, as in correcting a bowel obstruction. Initial insertion of the tube is a physician responsibility. The tube is inserted with the balloon deflated in a manner similar to the proper procedure for inserting a nasogastric tube. The client is usually given water to drink to facilitate passage of the tube through the nasopharynx and esophagus. A high-Fowler’s position decreases the risk of aspiration if vomiting occurs.
Clients receiving TPN are at high risk for developing infection. Concentrated glucose solutions are an excellent medium for bacterial growth. Using aseptic technique in handling all equipment and solutions is paramount to prevention of infection.
Safe pain control includes starting with low doses and working up to a dose of medication that relieves the pain.
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