The most effective means of preventing foot drop is the use of posterior splints or high-top sneakers. A foot board prevents plantar flexion, but also places the client more at risk for developing pressure ulcers of the feet. Pneumatic boots prevent deep vein thrombosis, but not foot drop. Heel protectors protect the skin, but do not prevent foot drop.
The client with a halo vest should avoid bending at the waist because the halo vest is heavy, and the client’s trunk is limited in flexibility. It is helpful for the client to scan the environment visually because the client’s peripheral vision is diminished from keeping the neck in a stationary position. Use of a walker and rubber-soled shoes may help prevent falls and injury, and are therefore also helpful.
A common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from a deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client’s urine output to determine whether this complication is occurring.
The fetal heart rate can first be heard with a fetoscope at 18 to 20 weeks’ gestation. If a Doppler ultrasound device is used, the fetal heart rate can be detected as early as 10 weeks’ gestation.
A client who had a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until they are discontinued. Also, because of the antiinflammatory properties of corticosteroids produced by the adrenals, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present. The client does not need to maintain a diabetic diet, and the client will not have an ostomy following this surgery.
The client should report frequent swallowing or postnasal drip after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The surgeon removes the nasal packing, usually after 24 hours. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure. The client should also report severe headache because it could indicate increased intracranial pressure.
Common side effects of amitriptyline (a tricyclic antidepressant) include the central nervous system effects of drowsiness, fatigue, lethargy, and sedation. Other common side effects include dry mouth or eyes, blurred vision, hypotension, and constipation. The nurse monitors the client for these side effects.
In an emergency, lifesaving facts are obtained first. The name of and the amount of medication ingested is of utmost importance in treating this potentially life-threatening situation. The relatives and the reason for the suicide attempt are not the most important initial assessment. The length of time on the medication is also not the priority in this situation.
The absence of normal flora needed to synthesize vitamin K in the normal newborn gut results in low levels of vitamin K and creates a transient blood coagulation deficiency between the second and fifth day of life. From a low point at about 2 to 3 days after birth, these coagulation factors rise slowly, but do not approach normal adult levels until 9 months of age or later. Increasing levels of these vitamin K–dependent factors indicate a response to dietary intake and bacterial colonization of the intestines. An injection of vitamin K (Aqua-MEPHYTON) is administered prophylactically on the day of birth to combat the deficiency. Options 1, 2, and 3 are incorrect.
Dehydration causes interstitial fluid to shift to the vascular compartment in an attempt to maintain fluid volume. When the body is unable to compensate for fluid lost, circulatory failure occurs. The blood pressure will decrease and the pulse rate will increase. This will be followed by peripheral symptoms.
Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure
Headache occurs as a side effect of nitrates in many clients. Tylenol may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.
Obstruction of the urinary tract is the primary problem associated with urolithiasis. Stones recovered from straining urine can be analyzed and can provide direction for prevention of further stone formation. Activities should not be restricted.
To help prevent jaundice, the mother should feed the infant frequently in the immediate birth period because colostrum is a natural laxative and helps promote the passage of meconium. Offering the infant a formula supplement will cause nipple confusion and decrease the amount of milk produced by the mother. Breastfeeding should begin as soon as possible after birth while the infant is in the first period of reactivity. Delaying breastfeeding decreases the production of prolactin, which decreases the mother’s milk production. Phototherapy requires a physician’s order and is not implemented until bilirubin levels are 12 mg/dL or higher in the healthy term infant.
Secretions will become orange in color as a result of the rifampin. The client should be instructed that this side effect will likely occur and should be told that soft contact lenses, if used by the client, will become permanently discolored.
Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue is the only method of confirming the diagnosis.
Dysrhythmias are the major complication and cause of death after an MI. Cardiogenic shock, congestive heart failure, and recurrent MI are also complications, but occur less frequently.
After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother is diabetic. At delivery, when the umbilical cord is clamped and cut, maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant’s blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia is not performed, the newborn may suffer central nervous system damage caused by inadequate circulation of glucose to the brain. Indirect and direct bilirubin levels are usually ordered after the first 24 hours, because jaundice is usually seen at 48 to 72 hours after birth.
Respiratory distress syndrome (RDS) is the most common cause of morbidity and mortality in preterm infants. Betamethasone (Celestone), a corticosteroid, is administered to enhance fetal lung maturity. The medication’s optimal benefits begin 24 hours after initial therapy.
Symptoms of air embolism include chest pain, decreased level of consciousness, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension.
Signs of excess fluid volume include bounding pulse, elevated blood pressure, crackles or other adventitious breath sounds, edema of the sacrum or lower extremities, and neck vein distention with the head of the bed positioned at a 45-degree angle. Another sign may include changes in level of consciousness if fluids shifts are occurring.
The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgement. The drainage bag is kept below the level of the bladder.
Following nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and to detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could impact on the client’s ability to reposition, cough, and deep breathe. Therefore, the next most important measurements are vital signs (including temperature), pain level, and bed mobility. Clear liquids are not given until the client has bowel sounds.
The most serious complication of polycystic kidney disease is ESRD, which would be managed with dialysis or transplant. There is no reliable way to predict who will ultimately progress to ESRD. Chronic UTIs are the most common complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria.
Activity Intolerance is characterized by exertional dyspnea, adverse changes in blood pressure or heart rate with activity, and fatigue. Ineffective Breathing Pattern occurs when the rate, timing, depth, or rhythm of breathing is insufficient to maintain optimal ventilation. Ineffective Airway Clearance occurs when the client is unable to clear his or her own secretions from the airway. Impaired Physical Mobility occurs when the client is limited in physical movement and has limited muscle strength, range of motion, or coordination.
Slowed walking and talking is a characteristic behavior of a psychomotor retarded depression. The physical symptoms may be explained by the person’s pessimistic view of the future, leading to the psychomotor inhibition or vegetative signs typically seen with depressed clients.
The term “involution” is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its nonpregnant state. Immediately following the delivery of the placenta, the uterus contracts to the size of a large grapefruit. The fundus is situated in the midline between the symphysis pubis and the umbilicus. Within 6 to12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one finger breadth on each succeeding day.
In the Billroth II procedure, the lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum.
Humulin regular insulin is a short-acting insulin. Its onset of action occurs in one-half hour and peaks in 2 to 4 hours. Its duration of action is 4 to 6 hours.
Toothbrushing, sneezing, coughing, nose blowing, and bending are activities that should be avoided postoperatively in the client who underwent a hypophysectomy. These activities interfere with the healing of the incision and can disrupt the graft.
Hypophysectomy is the surgical removal of the pituitary gland, also called hypophysis. It is most commonly performed to treat tumors, especially craniopharyngioma tumors. Sometimes it is used to treat Cushing's syndrome due to pituitary adenoma.
The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek’s and Trousseau’s signs. Hoarseness and neck pain are expected findings postoperatively.
Raynaud’s disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted. Peripheral pulses may be normal, absent, or diminished.
A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can cause changes in the stimuli responses in the extremities on the opposite side of the body, especially if the infant is actively bleeding.
Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urinary retention. The nurse monitors the client for any of these effects in the immediate postoperative period.
Ketorolac (Toradol) is a nonopioid analgesic and nonsteroidal antiinflammatory drug (NSAID). It acts by inhibiting prostaglandin synthesis and produces analgesia that is peripherally mediated. The nurse evaluates the effectiveness of this medication by using the pain rating scale with the client.
Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain, and pathological fractures.
Raynaud’s disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.
The client with increased ICP may exhibit Cheyne-Stokes respirations. These types of respirations have a variable rate. The cycle of respirations begin shallow and then increase in depth to hyperventilation, followed by a decrease in depth to apnea. The cycle then repeats itself.
Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough resulting from nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse upon arising after sleep.
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