Incentive devices have many desired and positive effects. Incentive devices provide the stimulus for a spontaneous deep breath. Spontaneous deep breathing, using the sustained maximal inspiration concept, reduces atelectasis, opens airways, stimulates coughing, and actively encourages individual participation in recovery. Shallow breaths, wheezing, and unilateral chest expansion would indicate that the incentive spirometry was not effective. Wheezing indicates narrowing or obstruction of the airway and unilateral chest expansion could indicate atelectasis.
Prazosin (Minipress) is an alpha-adrenergic blocking agent. “First-dose hypotensive reaction” may occur during early therapy, which is characterized by dizziness, lightheadedness, and possible loss of consciousness. This can also occur when the dosage is increased. This effect usually disappears with continued use or when the dosage is decreased.
With an arterial ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps could not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway). Standard dressing technique includes the use of Kling rolls on circumferential dressings.
The stools of a child with celiac disease are characteristically malodorous, pale, large (bulky), and soft (loose). Excessive flatus is common, and bouts of diarrhea may occur.
Pregnancy-induced hypertension is the most common hypertensive disorder in pregnancy. It is characterized by the development of hypertension, proteinuria, and edema. Glycosuria and ketonuria occur in diabetes mellitus.
The major postoperative complication following craniotomy (supratentorial surgery) is increased intracranial pressure (ICP) from cerebral edema, hemorrhage, or obstruction of the normal flow of cerebrospinal fluid (CSF). Symptoms of increased ICP include severe headache, deteriorating level of consciousness, restlessness, irritability, and dilated or pinpoint pupils that are slow to react or nonreactive to light. Without prompt recognition and treatment, herniation syndromes develop and death can occur.
Buck’s extension traction is a form of skin traction and involves the use of a belt or boot that is attached to the skin and soft tissues. The purpose of this type of traction is to decrease painful muscle spasms that accompany fractures. The weight that is used as a pulling force is limited (usually 5 to 10 pounds) to prevent injury to the skin.
Cascara sagrada is a laxative that causes nausea and abdominal cramps as the most frequent side effects.
Biologic dressings are usually heterograft or homograft material. Heterograft is skin from another species. The most commonly used type of heterograft is pigskin because of its availability and its relative compatibility with human skin. Homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank. Autograft is skin from the client.
The client with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. The client is logrolled when turned to avoid extreme hip flexion. The head of the bed is elevated 30 to 45 degrees. All of these measures are used to enhance venous drainage, which helps prevent increased intracranial pressure (ICP).
Esophageal atresia prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia.
Indications for suctioning include moist, wet respirations, restlessness, rhonchi on auscultation of the lungs, visible mucus bubbling in the ET tube, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator. A low peak inspiratory pressure would indicate a leak in the mechanical ventilation system.
PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased blood pressure and increased pulse (compensatory). Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP.
Following thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax.
Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.
Fractured ribs are treated with good pulmonary therapy techniques such as coughing and deep breathing, rapid mobilization, and adequate pain control. Strapping of the ribs is not a treatment measure because it restricts deep breathing and can increase the incidence of atelectasis and pneumonia.
A pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), subcutaneous emphysema, tracheal deviation to the unaffected side, decreased fremitus, and worsening cyanosis. The client could have pain with respiration. The increased intrathoracic pressure would cause the blood pressure to fall, not rise.
Bronchial sounds are normally heard over the main bronchi. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation, because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Bronchovesicular sounds are normally heard over the main bronchi. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes.
Kaposi’s sarcoma generally starts with an area that is flat and pink that changes to a dark violet or black color. The lesions are usually present bilaterally. They may appear in many areas of the body and are treated with radiation, chemotherapy, and cryotherapy.
Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.
Pleural effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.
Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock. Clamping the tubing for 30 minutes allows for equilibration to prevent complications.
Amphotericin B (Fungizone) is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications.
Continuous bladder irrigation is done following TURP using sterile normal saline, which is isotonic.
The client with flail chest has painful, rapid, shallow respirations while experiencing severe dyspnea. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The client develops respiratory failure and requires intubation and mechanical ventilation, usually with positive end expiratory pressure (PEEP). Therefore, an intubation tray is necessary.
In a clietn with empyema whose going to have a thoracentesis performed at teh bedside. The nurse plans to have an chest tube and rainage system availabel in the event that the procedure is not effective. If the exudate is too thick for drainage via thoracentesis, the client may require placement of a chest tube to adequately drain the purulent effusion.
Aspiration of clear fluid of less than 1 mL is indicative of epidural catheter placement. More than 1 mL of clear fluid or bloody return means that the catheter may be in the subarachnoid space or in a vessel. Therefore, the nurse would not inject the medication and would notify the anesthesiologist.
If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first reestablish an underwater seal to prevent tension pneumothorax and mediastinal shift. This can be accomplished by reconnecting the chest tube, or in this case, immersing the end of the chest tube in a bottle of sterile normal saline or water. The physician should be notified after taking corrective action. If the physician is called first, tension pneumothorax has time to develop. Clamping the chest tube could also cause tension pneumothorax. A petrolatum gauze would be applied to the skin over the chest tube insertion site if the entire chest tube was accidentally removed from the chest.
In the client with Cushing’s syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus.
If the client experiences air embolus, the nurse should clamp the catheter immediately and notify the physician. The client is placed in the lateral Trendelenburg position on the left side to trap the air in the right atrium.
Aldosteronism can lead to hypokalemia, which in turn can cause life-threatening dysrhythmias.
Oxygen may be removed safely from the client with carbon monoxide poisoning once carboxyhemoglobin levels are less than 5%.
Poor nutrition during pregnancy can negatively influence fetal growth and development. Although pregnancy poses some nutritional risk for the mother, not all clients are at high risk. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is insufficient for the majority of pregnant women, and iron supplements are routinely prescribed.
When Cushing’s syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mental status changes, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention, producing edema and hypertension.
Indirect laryngoscopy is done to assess the function of the vocal cords or to obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. The tongue cannot be moved back because it would occlude the airway. Swallowing cannot be done with the mirror in place.
The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldosteronoma. Surgery is the treatment of choice. Clients undergoing a bilateral adrenalectomy will need permanent replacement of adrenal hormones.
A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison’s crisis) that occurs as a result of the adrenalectomy. Aldactone is a potassium-sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid.
Following treatment with radioactive iodine therapy, a decrease in thyroid hormone level should be noted, which would help alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse needs to reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates. Occasionally, a client may require a second or third dose, but treatments are not lifelong.
The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum.
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