To perform percussion, the nurse places the middle finger of the nondominant hand against the body’s surface. The tip of the middle finger of the dominant hand strikes the top of the middle finger of the nondominant hand. Auscultation is listening to sounds produced by the body. Palpation is performed through the sense of touch. Inspection is the process of observation.
The caregiver of a confused client is taught measures and techniques that will keep the client oriented and calm. Sensory overload or tasks and activities that are overwhelming for the client will cause disorientation and additional confusion. Therefore, any measures or activities that will increase sensory overload are avoided. Some helpful techniques include displaying a calendar and a clock around the house and in the client’s room; maintaining a predictable routine; limiting the number of visitors who come to see the client; limiting the number of choices given to the client; using simple, clear communication; and turning the lights on at dusk to avoid the sundown syndrome of increased confusion and combative behavior.
A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus.
Prednisone is irritating to the gastrointestinal (GI) tract, which could be worsened by the use of other products that have the same side effect. Therefore, products such as aspirin and nonsteroidal antiinflammatory drugs are not used during corticosteroid therapy.
The use of condoms and avoiding casual sex with multiple partners should be the focus of discussion because these measures prevent STDs. The use of condoms does provide some protection against STDs. Birth control pills and the use of a diaphragm help prevent pregnancy but do not provide protection from STDs.
A pacemaker is shielded from interference from most electrical devices. Radios, TVs, electric blankets, toasters, microwave ovens, heating pads, and hair dryers are considered to be safe. Devices to be forewarned about include those with a strong electric current or magnetic field, such as antitheft devices in stores, metal detectors used in airports, and radiation therapy (if applicable and which might require relocation of the pacemaker)
Walking and swimming are very beneficial in strengthening back muscles for the client with low back pain.
Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology
Dietary sources of iron that are easy for the body to absorb include meat, poultry, and fish. Vegetables, fruits, cereals, and breads are also dietary sources of iron, but they are harder for the body to absorb.
Patent ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. It allows abnormal blood flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt.
The purpose of autotransplantation of some parathyroid tissue is to regain function of the parathyroid gland. Autotransplantation of parathyroid tissue takes some time to mature. Oral calcium and vitamin D supplements must be taken to prevent hypoparathyroidism until the transplant matures and becomes an active endocrine gland.
Von Willebrand's disease - his may be an inerited disorder or blood coagulation or an acquired disease, secondary to a number of conditions, including certain drugs. Typically patients do not know they have the disease but may notice Frequent or prolonged nosebleeds, easy brusing, prolonged or heavy menstrual periods, and prolonged or unusual bleeding following a minor injury, surgery, or dental work.
The child should be positioned erect, sitting with head tilted forward to avoid blood dripping posteriorly to the pharynx. The soft part of the nose should be tightly pinched against the center wall for 10 minutes, and the mother should be instructed that this pinch should be timed by a clock, not estimated. The mother should be told not to release pressure for 10 minutes. The child is encouraged to remain calm and quiet and to breathe through the mouth.
Rheumatic fever characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta hemolytic streptococcal infection of the respiratory tract. Initially, the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks.
Orchitis can be related to epididymitis infection that has spread to the testicles.
Unilateral orchitis occurs more frequently than bilateral orchitis. About one week after the appearance of parotitis, there is an abrupt onset of testicular pain, tenderness, fever, chills, headache, and vomiting. The affected testicle becomes red, swollen, and tender. Atrophy, resulting in sterility, occurs only in a small number of cases. Difficulty urinating is not a sign of this complication. Swollen glands and facial swelling normally occurs in mumps.
Parotitis is an inflammation of one or both parotid glands, the major salivary glands located on either side of the face, in humans. The parotid gland is the salivary gland most commonly affected by inflammation.
Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.
Laser therapy is performed in an outpatient setting and is used when all boundaries of the lesion are visible.
School-aged children have the cognitive and motor skills to independently administer insulin with adult supervision. Developmentally, they do not yet have the maturity to make situational decisions without adult validation.
Kegel exercises will assist to strengthen the pelvic floor (pubococcygeal muscle). Pelvic tilt exercises will help reduce backaches. Instructing a client to drink 8 ounces of fluids six times a day will help prevent urinary tract infections. Leg elevation will assist in preventing ankle edema.
Management of the severe pain that occurs with vaso-occlusive crisis includes the use of strong narcotic analgesics, such as morphine sulfate and hydromorphone hydrochloride (Dilaudid). Meperidine hydrochloride is contraindicated because of its side effects and increased risk of seizures. Oxygen is administered to increase tissue perfusion. Fluids are necessary to promote hydration.
The vaccination schedule for an infant whose mother tests negative for hepatitis B consists of a series of three immunizations given at 0 months (birth), 1 to 2 months of age, and then 4 months after the initial dose. An infant whose mother tests positive receives hepatitis B immune globulin along with the first dose of the hepatitis vaccine within 12 hours of birth.
The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the classic signs and symptoms of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client’s health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status.
Acetylcysteine restores sulfhydryl groups that are depleted by acetaminophen metabolism. Vitamin K is the antidote for warfarin sodium (Coumadin). Naloxone hydrochloride (Narcan) reverses respiratory depression. Protamine sulfate is the antidote for heparin.
Olanzapine (Zyprexa) is an antipsychotic medication used in the management of manifestations associated with psychotic disorders. It is the first-line treatment for schizophrenia targeting both the positive and the negative symptoms.
Before administering any medication, the nurse must assess for allergy or hypersensitivity to substances used in producing the medication. Fat emulsions such as intralipids contain an emulsifying agent obtained from egg yolks. Clients sensitive to eggs are at risk for developing hypersensitivity reactions.
The P-R interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The P-R interval range is 0.12 to 0.2 seconds.
NPH is an intermediate-acting insulin with an onset of action in 60 to 120 minutes, a peak time in 6 to 14 hours, and a duration time of 16 to 24 hours.
Adverse effects of haloperidol (Haldol) include extrapyramidal symptoms such as marked drowsiness and lethargy, excessive salivation, a fixed stare, akathisia, acute dystonias, and tardive dyskinesia. Hypotension, nausea, and blurred vision are occasional side effects.
Indomethacin (Indocin) may be prescribed to treat gouty arthritis. It may alleviate pain but is administered on a scheduled timeframe, not a prn schedule. When pain occurs, the client will usually limit movement and rest. A rash should be reported because it could indicate hypersensitivity to the medication. The client should be instructed to monitor for swelling and gastric distress, which can be caused by the medication.
Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers will often use fear and intimidation to the point where their victims will do anything just to avoid further abuse.
An IV cholangiogram is for diagnostic purposes. It outlines both the gallbladder and the ducts, so gallstones that have moved into the ductal system can be detected. X-rays are used to visualize the biliary duct system after IV injection of a radiopaque dye.
Most people who do commit suicide have given definite clues or warnings about their intentions. Suicide is not an inherited condition. A suicide attempt is not an attention-seeking behavior, and each act should be taken very seriously. The individual who is suicidal is not necessarily psychotic.
The use of a defense mechanism allows a person to avoid the painful experience of anxiety or to transform it into a more tolerable symptom, such as regression. Regression allows the threatened client to move backward developmentally to a stage in which more security is felt. The recognition of regression is a signal that the client feels anxious.
Health care professionals must use caution during the intrapartal period to reduce the risk of the transmission of HIV to the fetus. Any procedure that exposes blood or body fluids from the mother to the fetus should be avoided. Direct (internal) fetal monitoring is a procedure that may expose the fetus to maternal blood or body fluids and therefore should be avoided.
Sodium nitroprusside decreases the blood pressure by vasodilation.
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