In a client with Lyme disease, Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage II. A rash occurs in stage I.
Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep.
If the child is obtunded, the child sleeps unless aroused and once aroused has limited interaction with the environment.
The inadequate production of aldosterone in Addison’s disease causes inadequate excretion of potassium and results in hyperkalemia. The clinical manifestations of hyperkalemia are the result of altered nerve transmission. The most harmful consequence of hyperkalemia is its effect on cardiac function.
Before radial puncture for obtaining an arterial specimen for ABGs, an Allen test is performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand, if damage to the radial artery occurs with arterial puncture. The Allen test does not determine adequacy of femoral, brachial, or carotid circulation.
The nurse assesses the pregnant client with diabetes mellitus for glucose and ketones in the urine at each prenatal visit because the physiological changes of pregnancy can drastically alter insulin requirements.
Fever, exertional dyspnea, and a nonproductive cough are signs of Pneumocystis pneumonia, a common, life-threatening opportunistic infection afflicting those with AIDS.
Otitis media in the adult is typically one-sided and presents as an acute process with earache, nausea and possible vomiting, fever, and fullness in the ear. The client may complain of diminished hearing in that ear. The nurse takes a client history first, assessing whether the client has had a recent URI.
The client with heart failure may present different symptoms depending on whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all signs of right-sided heart function. Assessment of breath sounds provides information about left-sided heart function.
Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic CVA, the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Other signs and symptoms of thrombotic CVA vary, but may include dizziness, cognitive changes, or seizures. Headache is rare, and loss of consciousness is not likely to occur.
Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client is most often NPO before and during the testing period. Because the studies may be done over a period exceeding 24 hours, the client may become dehydrated and/or malnourished.
The vegetative signs of depression are changes in physiological functioning during depression. These include appetite, weight, sleep patterns, and psychomotor activity.
Spironolactone (Aldactone) is a potassium-sparing diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium-sparing, which means that the concern with the administration of this medication is hyperkalemia. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.
Fetal well-being must be confirmed before and after amniotomy. Fetal heart rate should be checked by Doppler or by the application of the external fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority.
During an oxytocin infusion, the woman is monitored closely for water intoxication. Signs of water intoxication include tachycardia, cardiac dysrhythmias, shortness of breath, nausea, and vomiting.
At age 15 months, the nurse would expect that the child could build a tower of two blocks. A 24-month-old would be able to open a doorknob and unzip a large zipper. At age 30 months, the child would be able to put on simple clothes independently.
Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted.
Koplik spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off.
Clinical manifestations associated with nephrotic syndrome include edema, anorexia, fatigue, and abdominal pain from the presence of extra fluid in the peritoneal cavity. Diarrhea caused by edema of the bowel occurs and may cause decreased absorption of nutrients. Increased weight and a normal blood pressure are noted.
The primary clinical manifestations of von Willebrand’s disease are bruising and mucous membrane bleeding from the nose, mouth, and gastrointestinal tract. Prolonged bleeding after trauma and surgery, including tooth extraction, may be the first evidence of abnormal hemostasis in those with mild disease. In females, menorrhagia and profuse postpartum bleeding may occur. Bleeding associated with von Willebrand’s disease may be severe and lead to anemia and shock, but unlike the situation in hemophilia, deep bleeding into joints and muscles is rare.
The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle sign and raccoon eyes. Battle sign is the presence of bruising or ecchymosis behind the ear caused by leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and cause an edematous and bruised periorbital area.
Kernig’s sign is the inability of the child to extend the legs fully when lying supine. Brudzinski’s sign is flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest. Homans' sign is elicited when pain occurs in the calf region when the foot is dorsiflexed. Homans' sign is present in thrombophlebitis.
Activities of daily living refer to the client’s ability to bath, toilet, ambulate, dress, and feed oneself. These functional abilities are always assessed by the home care nurse. The normal routine in the home is not a component of functional assessment. The ability to do housework and drive a car relates to instrumental activities of daily living.
A reactive nonstress test (normal/negative) indicates a healthy fetus. It is described as two or more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end in association with fetal movement, during a 20-minute period. A nonreactive nonstress test (abnormal) is described as no accelerations or accelerations of less than 15 beats per minute or lasting less than 15 seconds in duration throughout any fetal movement during the testing period. An unsatisfactory test cannot be interpreted because of the poor quality of the FHR.
Meconium staining alone is not a sign of fetal distress. Meconium passage is a normal physiological function, frequently noted with a fetus over 38 weeks’ gestation. Old meconium staining may be the result of a prenatal trauma that is resolved. It is not unusual for the fetal heart rate to drop below the 140 to 160 beats per minute range in late labor during contractions, and in a healthy fetus the feta lheart rate will recover between contractions. Fresh meconium in combination with late decelerations and a variable descending baseline is an ominous signal of fetal distress caused by fetal hypoxia.
When carbamazepine is administered, plasma levels of the medication need to be monitored periodically to check for the child’s absorption of the medication. The amount of the medication prescribed is based on the results of this laboratory test. The therapeutic plasma level of carbamazepine is 3 to 14 mcg/mL.
Bumetanide (Bumex) is a loop diuretic. The client on this medication would be at risk for hypokalemia. Spironolactone (Aldactone), triamterene (Dyrenium), and amiloride HCL (Midamor) are potassium-sparing diuretics.
Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid is sometimes prescribed for clients with Ménière’s disease.
Adverse reactions or toxic effects of rifampin include hepatotoxicity, hepatitis, blood dyscrasias, Stevens-Johnson syndrome, and antibiotic-related colitis. The nurse monitors for increased liver function, bilirubin, blood urea nitrogen, and uric acid levels because elevations indicate an adverse reaction. A normal white blood cell count is 4500 to 11,000/ul. The normal sedimentation rate is 0 to 30 mm/hour. The normal total bilirubin level is less than 1.5 mg/dL. The normal alkaline phosphatase is 4.5 to 13 King-Armstrong units/dL.
Oral antacids commonly contain bicarbonate or other alkaline components. These bind onto the hydrochloric acid in the stomach to neutralize the acid. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis over time.
Hypertension, cigarette smoking, and hyperlipidemia are major risk factors of CHD. Glucose intolerance, obesity, and response to stress are also contributing factors. Age greater than 40 is a nonmodifiable risk factor. A cholesterol level of 190 mg/dL and a blood glucose level of 110 mg/dL are within the normal range. The nurse places priority on major risk factors that need modification.
Following IVP, the client should take in increased fluids to aid in clearance of the dye used for the procedure
Metabolic acidosis occurs when the pH falls below 7.35 and the bicarbonate level falls below 22 mEq/L. With respiratory acidosis, the pH drops below 7.35 and the carbon dioxide level rises above 45 mm Hg. With respiratory alkalosis, the pH rises above 7.45 and the carbon dioxide level falls below 35 mm Hg. With metabolic alkalosis, the pH rises above 7.45 and the bicarbonate level rises above 27 mEq/L.
The client with cirrhosis has impaired ability to metabolize protein because of liver dysfunction. Administration of lactulose aids in the clearance of ammonia via the gastrointestinal (GI) tract. Ethacrynic acid is a diuretic. Folic acid and thiamine are vitamins, which may be used in clients with liver disease as supplemental therapy.
Hypernatremia occurs when the sodium level is greater that 145 mEq/L. Clinical manifestations include intense thirst, oliguria, agitation and restlessness, flushed skin, peripheral and pulmonary edema, dry sticky mucous membranes, and nausea and vomiting.
The two primary pathophysiologic alterations associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased because the red blood cell production cannot keep pace with red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction accompanying this disorder as well as from the normally decreased ability of the neonate’s liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of insulin.
Live measles vaccine is produced by chick embryo cell culture, so the possibility of an anaphylactic hypersensitivity in children with egg allergies should be considered. If there is a question of sensitivity, children should be tested before the administration of MMR vaccine. If a child tests positive for sensitivity, the killed measles vaccine may be given as an alternative.
IVIG is usually effective in rapidly increasing the platelet count. It is thought to act by interfering with the attachment of antibody-coded platelets to receptors on the macrophage cells of the reticuloendothelial system. Corticosteroids may be prescribed to enhance vascular stability and decrease the production of antiplatelet antibodies.
In post-streptococcal glomerulonephritis, a urinalysis will reveal hematuria with red cell casts. Proteinuria is also present. If renal insufficiency is severe, the BUN and creatinine levels will be elevated. The WBC is usually within normal limits, and mild anemia is common.
Thrombocytopenia is the term for a reduced platelet (thrombocyte) count.
In pyloric stenosis, the vomitus contains sour, undigested food, but no bile, the child is constipated, and visible peristaltic waves move from left to right across the abdomen. A movable, palpable, firm olive-shaped mass in the right upper quadrant may be noted. Crying during the evening hours, appearing to be in pain, but eating well and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Ribbon-like stool, bile-stained emesis, absence of peristalsis, and abdominal distension are symptoms of congenital megacolon (Hirschsprung’s disease).
A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy CSF, high protein, and low glucose.
Shock may be classified as compensated or decompensated. In compensated shock, the child becomes tachycardic in an effort to increase the cardiac output. The blood pressure remains normal. Capillary refill time may be prolonged and greater than 2 seconds, and the child may become irritable because of increasing hypoxia. The most prevalent cause of hypovolemic shock is fluid and electrolyte losses associated with gastroenteritis. Diarrhea is not a sign of shock, but rather it is a cause of the fluid and electrolyte imbalance.
Absence seizures are a type of generalized seizure. They consist of a sudden, brief (no longer than 30 seconds) arrest of the child’s motor activities accompanied by a blank stare and loss of awareness. The child’s posture is maintained at the end of the seizure. The child returns to activity that was in process as though nothing has happened. A child with attention deficit hyperactivity syndrome becomes easily distracted, is fidgety, and has difficulty following directions. School phobia includes physical symptoms that usually occur at home and may prevent the child from attending school. Behavior problems would be noted by more overt symptoms than described in this question.
The normal PKU level is less the 2 mg/dL. With early postpartum discharge, screening is often performed at less than 2 days of age because of the concern that the infant will be lost to follow-up. Infants should be rescreened by 14 days of age if the initial screen was done at 24 to 48 hours of age.
The diagnosis of bacterial endocarditis is primarily established on the basis of a positive blood culture of the organisms and visualization of vegetation on echocardiographic studies. Other laboratory tests that may help confirm the diagnosis are an elevated sedimentation rate and C-reactive protein level. An ECG is not usually helpful in the diagnosis of bacterial endocarditis.
Ptosis of the eyelid is caused by pressure on and dysfunction of cranial nerve III.
Following CVA, the client often experiences periods of emotional lability, which is characterized by sudden bouts of laughing or crying, or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture for the client with this health problem, although it may be difficult for health care personnel and family members to deal with.
Signs and symptoms of cholinergic crisis include nausea, vomiting, abdominal cramping, diarrhea, blurred vision, pallor, facial muscle twitching, pupillary myosis, and hypotension. It is caused by overmedication with cholinergic (anticholinesterase) medications and is treated by withholding medications. Myasthenic crisis is an exacerbation of myasthenic symptoms caused by undermedication with anticholinesterase medications.
A fracture pan is designed for use in clients with body or leg casts. A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. Therefore, a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care.
Five perecent dextrose in water is an isotonic solution. Another example of an isotonic solution is 0.9% normal saline. 0.45% normal saline is a hypotonic solution. 10% dextrose in water and 5% dextrose in 0.9% normal saline are hypertonic solutions.
Adrenalectomy can lead to adrenal insufficiency. Adrenal hormones are essential in maintaining homeostasis in response to stressors.
Constipation can cause the client to use the Valsalva maneuver. This maneuver can cause blood to rush to the heart and overload the cardiac system. A low-calorie diet is not recommended during pregnancy. Diets low in fluid and fiber can cause a decrease in blood volume that can deprive the fetus of nutrients. Therefore, adequate fluid intake and high-fiber foods are important. Sodium should be restricted to some degree as prescribed by the physician because this will cause an overload to the circulating blood volume and contribute to cardiac complications.
For a newborn infant diagnosed with bilateral club feet, Casting should begin at birth and continue for at least 12 weeks or until maximum correction is achieved. At this time, corrective shoes may provide support to maintain alignment, or surgery can be performed. Surgery is usually delayed until 4 to 12 months of age.
The arterial blood gas sample is obtained using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory immediately. A preservative is not used.
The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or release of antidiuretic hormone (ADH) in conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin (Pitressin). Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.
The most important problem relates to adequate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical.
Carditis is the inflammation of all parts of the heart, primarily the mitral valve, and is a complication of rheumatic fever.
A padded tongue blade should never be used; in fact, nothing should be placed in the mouth during a seizure. During a seizure, the infant should be placed in a side-lying position, but should not be restrained. Suctioning may be required during a seizure to remove secretions that obstruct the airway. It is not necessary to place a code cart at the bedside, but a cart should be readily available on the nursing unit.
Cerebral edema is a progressive part of the disease process in Reye’s syndrome. A major component of care for a child with Reye’s syndrome is to maintain effective cerebral perfusion and control intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue and neuron responses. Hearing loss does not occur in this disorder. Although monitoring I&O may be a component of the plan, it is not the critical nursing action. Changing the body position every 2 hours would not affect the cerebral edema and intracranial pressure directly. The child should be in a head-elevated position to decrease the progression of cerebral edema and promote drainage of cerebrospinal fluid.
Cerebral palsy is a chronic disability characterized by a difficulty in controlling muscles because of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infections. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.
Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary characteristic is lack of social interaction and awareness. Social behaviors in autism include lack of or abnormal imitations of others’ actions and the lack of or abnormal social play. Additional characteristics include lack of or impaired verbal communication and marked abnormal nonverbal communication.
Following tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, causing the child to clear the throat, thus increasing the risk of bleeding.
Measures that will decrease the workload on the heart for a patient with CHF includes limiting the time the child is allowed to bottle-feed or breastfeed, elevating the head of the bed, allowing for uninterrupted rest periods, and providing oxygen during stressful periods.
When the child is receiving chemotherapy, the nurse should avoid taking rectal temperatures. Oral temperatures are also avoided if mouth ulcers are present. Axillary temperatures should be taken to prevent alterations in skin integrity. Meticulous mouth care should be performed, but the nurse should avoid alcohol-based mouthwash and should use a soft-bristled toothbrush. The nurse should assess the mouth and anus each shift for ulcers, erythema, or breakdown. Bland, nonirritating foods and liquids should be provided to the child. Fresh fruits and vegetables need to be avoided because they can harbor organisms. Chemotherapy can cause neutropenia, and the child should be maintained on a low-bacteria diet if the white blood cell count is low.
The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as for the client undergoing craniotomy. This client requires hourly neurological assessment, as well as monitoring of cardiovascular and respiratory status.
The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for emergency use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the need for cardiac monitoring.
The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. To further prevent vertigo attacks, the client should change positions slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture. The client should maintain the home in a state that is free of clutter and has throw rugs removed, because the effort of trying to regain balance after slipping could trigger the onset of vertigo.
Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism.
The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist in some of his or her own rehabilitative care. In addition, the goal in home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant.
The reddened heel results from pressure of the foot against the mattress. The nurse obtains a sheepskin, heel protectors, or an alternating pressure mattress. The bed cradle will keep the linens off the client’s lower extremities but not assist in managing a reddened heel. A draw sheet and trapeze are of general use for this client but are not specific in dealing with the reddened heel.
Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce the risk of aspiration.
Mumps generally affect the salivary glands but can also affect multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the physician.
Meperidine hydrochloride is contraindicated for ongoing pain management of sickle cell crisis because of the increased risk of seizures associated with the use of the medication. Management for severe pain generally includes the use of strong narcotic analgesics such as morphine sulfate or hydromorphone (Dilaudid). These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock.
Intracranial pressure is a complication associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of skin integrity at the site.
The primary legal responsibility of the nurse when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case.
The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half donut may be useful in positioning to prevent this pressure. A sheepskin, feather pillow, or sandbag will not protect the encephalocele from pressure.
Decorticate posturing refers to flexion of the upper extremities and extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate posturing involves extension of the upper extremities with internal rotation of the upper arm and wrist. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification.
The suctioning procedure for pediatric clients varies from that which is used in adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings than in the adult. Suction settings for a neonate is 60 to 80 mm Hg, for an infant is 80 to 100 mm Hg, and for larger children is 100 to 120 mm Hg.
Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates drainage of secretions, which could help prevent aspiration. The nurse would also remove restrictive clothing and the pillow, and raise the padded side rails if present, but these actions would not decrease the risk of aspiration. Rather, they are general safety measures to use during seizure activity. The nurse would not raise the client’s head of bed.
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