The client with fractured ribs typically has pain over the fracture site with inspiration and to palpation. Respirations are shallow, and guarding of the area is often noted. Bruising may or may not be present.
The client with flail chest is in obvious respiratory distress. The client has severe dyspnea and cyanosis accompanied by paradoxical chest movement. Respirations are shallow, rapid, and grunting in nature.
Gastroschisis is an abdominal wall defect in which the viscera are outside the abdominal cavity and not covered with a sac. Embryonal weakness in the abdominal wall causes herniation of the gut on one side of the umbilical cord during early development.
A patient is prescribed zolpidem (Ambien) for insomia and the client should be instructed to take the medication at bedtime and to swallow the medication whole with a full glass of water. For faster onset of sleep, the client should be instructed not to administer the medication with milk or food, or immediately after a meal. Antacids should be avoided with the administration of the medication because of interactive effects.
Manifestations of acute SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, convulsions, psychosis, and coma.
Severely anemic persons (those with a hemoglobin below 8 g/dL) appear pale and always feel exhausted. They may have palpitations, sensitivity to cold, loss of appetite, profound weakness, dizziness, and headaches.
Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of congestive heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.
When the neutrophil count is less than 500/mm3, visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client’s room. All live plants, flowers, and stuffed animals are removed from the client’s room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables. Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection.
Toxic shock syndrome is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the physician promptly if signs and symptoms are noted
The level of consciousness is the most sensitive indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurologic signs or vital signs. Vital sign changes occur late.
The client with adrenocorticosteroid excess experiences hyperkalemia, hyperglycemia, elevated WBC count, and elevated plasma cortisol and adrenocorticotropic hormone (ACTH) levels. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.
The safe wall suction range for an adult is 80 to 120 mm Hg (120 to 150 mm Hg with the tubing occluded)
Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever.
The water seal chamber should be filled to the 2 cm mark to provide an adequate water seal between the external environment and the client’s pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding water until the level is again at the 2 cm mark.
The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes. It is not necessary that the client remain in the hospital for this treatment.
The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are complete proteins with the highest biologic value. Foods such as meat, fish, milk, and eggs are complete proteins, which are optimal for the client with chronic renal failure.
Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum
The stomach capacity of a newborn infant is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-week-old infant.
Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant’s stomach against the mother’s. Additional measures include rotating breastfeeding positions; breaking suction with the little finger; nursing frequently; beginning feeding on the less sore nipple; not allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth; and applying tea bags soaked in warm water to the nipple.
Bleeding is a major side effect of t-PA therapy. The bleeding can be superficial or internal and can be spontaneous.
Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus need to be expelled by fundal massage. A fundus that is not located in the midline may indicate a full bladder.
Vital signs return to normal within the first hour postpartum if no complications arise. If the temperature is greater than 2° F above normal, this may indicate infection, and the physician should be notified.
Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Because the client received anesthesia, she would not feel pain or pressure. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma.
The most common metabolic complication in the SGA newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action because the post-term SGA newborn is typically dehydrated from placental dysfunction. Hemoglobin and hematocrit levels are monitored because the post-term SGA newborn exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.
Methylergonovine (Methergine), an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The first dose is usually administered intramuscularly, and then if it needs to be continued, it is given by mouth. It increases the strength and frequency of contractions and may elevate blood pressure.
The priority action for a newborn infant with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment
Butorphanol tartrate (Stadol) is an opioid analgesic that provides systemic pain relief during labor. The nurse would ensure that naloxone and resuscitation equipment are readily available to treat respiratory depression, should it occur. Although an antiemetic may be prescribed for vomiting, antiemetics may enhance the respiratory depressant effects of the butorphanol tartrate.
Clients taking allopurinol (Zyloprim) are encouraged to drink 3000 mL of fluid a day. Allopurinol is to be given with or immediately following meals or milk. If the client develops a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the physician because this may indicate hypersensitivity.
Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward.
Testicular self-examination is a self-screening examination for testicular cancer, which predominantly affects men in their late teens and twenties. The self-examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. The self-examination should not be painful. It is easiest to do either during or after a warm shower (or bath) when the scrotum is relaxed.
The client with fibrocystic breast disorder experiences worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Clients should understand that this is part of the clinical picture of this disorder.
Dimenhydrinate (Dramamine) is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness.
Bright red bleeding should be reported, because it could indicate complications related to active bleeding. If the bladder irrigation is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Tea-colored urine is not seen after TURP, but may be noted in the client with renal failure or other renal disorders.
The manifestations of hypertensive crisis include hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia and bradycardia and constricting chest pain may also be present. The antidote for hypertensive crisis is phentolamine (Regitine) and a dosage by intravenous injection is administered. Protamine sulfate is the antidote for heparin, and vitamin K is the antidote for warfarin (Coumadin) overdose. Calcium gluconate is used for magnesium overdose.
orchidectomy (or-kih-DEK-toh-mee). Surgery to remove one or both testicles.
Signs of prostatism that may be reported to the nurse are reduced force and size of urinary stream, intermittent stream, hesitancy in beginning the flow of urine, inability to stop urinating quickly, a sensation of incomplete bladder emptying after voiding, and an increase in episodes of nocturia. These symptoms are the result of pressure of the enlarging prostate on the client’s urethra.
The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal. Scabies is characterized by erythematous, papular eruptions. Genital warts are characterized by cauliflower-like growths, or growths that are soft and fleshy.
A limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
Following total knee replacement, the neurovascular status of the affected leg is assessed, and findings should be within normal limits. The client should have intact capillary refill and adequate color, temperature, sensation, and motion to the limb. Incisional pain should be relieved by narcotic analgesic administration. The knee incision may have a wound suction drain in place, which is expected to drain up to 200 mL in the first 8 hours after surgery. Drainage of 175 mL per hour is excessive and should be reported.
Upon removal of a chest tube, a dressing is placed over the chest tube site. This is maintained in place until the physician says it may be removed. The client is taught to monitor and report any respiratory difficulty or increased temperature. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing.
The client taking epoetin alfa (Epogen) is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia.
Article copyright NurseReview.org - #1 source of information to update nurses all over the world. All rights reserved. No part of an article may be reproduced without the prior permission.