A Sengstaken-Blakemore tube is inserted in clients with cirrhosis who have ruptured esophageal varices. It has esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in correct position and prevents migration of the esophageal balloon.
Pursed-lip breathing allows the client to slowly exhale carbon dioxide while keeping the airways open. Abdominal breathing is recommended for clients with dyspnea.
Rebreathing masks have a reservoir bag that conserves oxygen and requires a high liter flow to achieve concentrations of 40% to 60%. It does not deliver accurate Fio2 to the client. The bag should not deflate during inspiration. Rebreathing bags conserve oxygen by having the client rebreathe his or her own exhaled air.
A normal P wave indicates that the impulse that depolarized the atrium was initiated in the SA node. A change in the form or the absence of a P wave can indicate a problem at this part of the conduction system, with the resulting impulse originating from an alternate site lower in the conduction pathway.
The effectiveness of heparin therapy is monitored by the results of the partial thromboplastin time (PTT). Desired ranges for therapeutic anticoagulation are 1.5 to 2.5 times the control. A PTT of 65 seconds is within the therapeutic range.
Nitroglycerin dilates both arteries and veins, causing blood to pool in the periphery. This causes a reduced preload and therefore a drop in cardiac output. This vasodilation causes the blood pressure to fall. The drop in cardiac output causes the sympathetic nervous system to respond and attempt to maintain cardiac output by increasing the pulse. Beta-blockers, such as propranolol (Inderal), are often used in conjunction with nitroglycerin to prevent this rise in heart rate.
After an abdominal aortic aneurysm repair bowel sounds may be absent for 3 to 4 days postoperative due to bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds.
The major complication of PIH is seizures.
Dyspnea and angina are signs of altered cardiac output. The absence of these with activity indicates that cardiac output is adequate. Normal adult cardiac output is 4 to 8 liters per minute. Free from angina pain with activiy.
For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the physician if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. One week after testicular surgery, the client may drive. Often, a prosthesis is inserted during surgery. Sitting needs to be avoided with prostrate surgery because of the risk of hemorrhage, but this risk is not as high with testicular surgery.
Changes in level of consciousness are a potential indicator of narcotic overdose, as well as an indicator of fluid, electrolyte, and oxygenation deficits. It is important to teach the spouse the differences between sleep related to relief of pain and changes in neurological status related to a deficit.
Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include low socioeconomic status, poor prenatal care and nutrition, and a history of substance abuse during pregnancy. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection.
The first trimester, “organogenesis,” is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this critical period depend not only on the amount of alcohol consumed, but also on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman. Eliminating consumption of alcohol during this time may promote normal fetal organ development.
Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and the blank expression that are characteristic of myxedema.
Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD.
Clients with HIV often show some evidence of immune dysfunction and may have increased vulnerability to common infections. HIV infection impairs cellular and humoral immune function; therefore, individuals with HIV are vulnerable to common bacterial infections.
One of the most common early signs of lithium toxicity is gastrointestinal (GI) disturbances such as nausea, vomiting, or diarrhea.
When checking the perineum, the lochia is monitored for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is a dark red color.
The first maneuver determines the contents of the fundus (either the fetal head or breech) and thereby the fetal lie. Leopold maneuvers are not performed during a contraction.
Areflexia characterizes spinal shock. Therefore, reflexes would provide the best information about recovery.
Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain on the brain stem is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain stem than those that control consciousness, pulse pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.
The nurse should return the unit of blood to the blood bank. The presence of gas bubbles in the bag indicates possible bacterial growth, and the unit is considered contaminated.
An intravenous line used to infuse blood should be at least 19-gauge or larger. This allows infusion of the blood elements without clogging the line or the IV access site. A 22- or 24-gauge is too small to infuse blood.
Just before removing the tube, the client is asked to take a deep breath and hold it. This action is important because the airway is partially occluded during tube removal. Also, breath-holding minimizes the risk of aspirating gastric contents if spilled from the tube during removal. The nurse pulls the tube out steadily and smoothly while the client holds the breath.
Intralipid solutions should not be refrigerated. No additives should be placed in the bottle because this could affect the stability of the solution. The solution should be checked for separation or an oily appearance. If found, it should not be used. An in-line filter is not used because it could disturb the flow of solution or become clogged.
The nasogastric feeding tube is checked at least every 4 hours for residual when administering continuous tube feedings. The residual is also checked before each bolus with intermittent feedings or before administering medications. If the residual exceeds an amount of 100 mL (or as defined by agency policy), the feeding is held. The bag and tubing are completely changed every 24 hours. The bag should be rinsed before adding new formula to the bag that is hanging.
The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape.
Clients who undergo pneumonectomy may experience numbness, altered sensation, or tenderness in the area that surrounds the incision. These sensations may last for months. It is not considered to be a severe problem and is not indicative of a wound infection.
Pneumonectomy involves removal of the entire lung, usually caused by extensive disease such as bronchogenic carcinoma, unilateral tuberculosis, or lung abscess. Chest tubes are not inserted because the cavity is left to fill with serosanguineous fluid, which later solidifies. The phrenic nerve is severed or crushed to elevate the diaphragm, further decreasing the size of the chest cavity on the operative side.
The nurse avoids deep palpation in the client in which a dissecting abdominal aortic aneurysm is known or suspected. Doing so could place the client at risk for rupture. The nurse looks for ecchymoses on the lower back to determine if the aneurysm is leaking and tells the client to report back, neck, shoulder, or extremity pain. The nurse may auscultate the arteries for bruits.
Bleeding after iliac artery angioplasty causes blood to accumulate in the retroperitoneal area. This can most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determines patency. Assessment of pain is routinely done, and mild regional discomfort is expected.
When a high BP reading is noted, the nurse takes the pressure in the opposite arm to see if the blood pressure is elevated in one extremity only. The nurse would also recheck the blood pressure in the same arm, but would wait at least 2 minutes between readings. The nurse would inquire about the presence of kidney disorders that could contribute to the elevated blood pressure. The nurse would notify the physician because immediate treatment may be required, but this would not be done without obtaining verification of the elevation.
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