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  • ATI Topic DescriptorsBasic Care and Comfort (13)Plan AHygiene Care: Evaluating Appropriate Use of Assistive DevicesCane instructions:Maintain two points of support on the ground at all timesKeep the cane on the stronger side of the bodySupport body wt on both legs, move cane forward 6-10 inches, then move the weakerleg forward toward the cane.Next, advance the stronger legDentures:Clients who have fragile oral mucosa require gentle brushing and flossing.Perform denture care for the client who is unable to do it himselfRemove dentures with a gloved hand, pulling down and out at the front of the upperdenture, and lifting up and out at the front of the lower denture.Place dentures in a denture cup or emesis basinBrush them with a soft brush and denture cleanerRinse them with waterStore the dentures, or assist the client with reinserting the denturesComplimentary and Alternative Therapies: Appropriate Use of Music Therapy forPain ManagementMusic decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15-30 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff highly effective in reducing postop pain if pain acute, increase volume of music
  • Prostate Surgeries: Calculating a Clientʼs Output When Receiving ContinuousBladder Irrigationspurpose: to maintain the patency of indwelling urinary catheters (bec blood, pus, orsediment can collect within tubing resulting in bladder sistention and buildup of stagnanturine)Med-Surg p. 1443after prostate surgery, irrigation is typically done to remove clotted blood from thebladder and ensure drainage of urine.if bladder manually irrigated, 50ml of irrigating soln should be instilled and thenwithdrawn with a syringe to remove clots that may be in bladder and catheter.with CBI, irrigating soln is continuously infused and drained from the bladder. The rateof infusion is based on the color of drainage. Ideally the urine drainage should be lightpink without clots. The inflow and outflow of irrigant must be continuously monitored. Ifoutflow is less than inflow, the catheter patency should be assessed for clots or kinks. Ifthe outflow is blocked and patency cannot be reestablished by manual irrigation, theCBI is stopped and the physician notified.Record amount of urine output andcharacter of urine every eight (8) hoursor as per physicianʼs orders.(To obtain urine output, subtract amountof fluid instilled into bladder from totaloutput.)intermittent irrigationdorsal recumbent or supine positionavoid cold solution bec may result in bladder spasmclamp cath just below soft injection portcleanse injection port with antiseptic swab (same port as specimen collection)insert needle through port at 30degree angleslowly inject fluid into cath and bladderwithdraw syringe remove clamp and allow solution to drain into drainage bagif ordered by MD, keep clamped to allow solution to remain in bladder for short time(20-30min)Closed continuous irrigationRecording and Reporting
  • Record type and amt of irrigation soln used, amt returned as drainage and the characterof drainageRecord and report any findings such as complaints of bladder spasms, inability to instillfluid into bladder and/or presence of blood clots.Urinary Elimination: Kegel Exercises for Urinary Incontinencesits on toilet with knees far apart and tightens muscle to stop the flow of urine ( tolearn the muscle)then practiced at nonvoiding timesinstruct client to contract muscle for a count of 3, hold and release for a count of 3, andrepeat this 10x.Client should repeat these cycles for 25-30x 3x/day for 6 months.Client should do this 5x.dayBowel Elimination Needs: Client Education Regarding Colostomy CareStoma s/b pink.Dusky blue stoma---ischemiaBrown-black stoma---necrosismild to moderate swelling for 1st 2-3 weeks after surgeryintact skin barriers with no evidence of leakage do not need to be changed daily andcan remain in place for 3-5 should be washed with mild soap, warm water and dried thoroughly beforebarrier appliedpouch must fit snugly to prevent leakage around stoma. The opening around theappliance should be no more than 1/16 inch larger than the stoma. Stoma shrinks anddoes not reach usual size for 6-8 weeksempty pouch before it is 1/3 full to prevent leakagecleanse skin and use skin barriers and deodorizers to prevent skin breakdown andmalodor View slide
  • apply skin barrier and pouch. if creases next to stoma occur, use barrier paste to fill in;let dry 1-2 minapply non-allergic paper tape around the pectin skin barrier in a picture frame method.Burns: Non-pharmacologic Comfort Interventions for Dressing ChangesMed/Surg p. 534-535DistractionsRelaxation tapesvisualizationguided imagerybiofeedbackmeditationused as adjuncts to traditional pharmacologic txs of painVisualization and guided imagery can be helpful to the nurse as well as the ptnurse ask the pt about a favorite hobby or recent vacationnurse can explore these areas further by asking questions that make the pt visualizeand describe a favorite hobby or recent vacationby using this method, both the nurse and the pt must focus on things besides the task athand. (ie dressing change) to keep the conversation flowingRelaxation tapes can be helpful when played at night to help the pt fall asleep.Application of Heat and Cold: Assess Need for Heat/Cold ApplicationsApplication of Cold: Ensure Safe Use of Cold ApplicationsPotter/Perry p. 1253-1254Cold and heat applications relieve pain and promote healing.selection varies with clientʼs conditions.moist heat can help relieve the pain from a tension HAcold heat can reduce the acute pain from inflamed jointsavoid injury to skin by checking the temp and avoiding direct application of the cold orhot surface to the skinesp at risk: spinal cord or other neuro injury, older adults, confused clients View slide
  • Ice massage or cold therapy are particularly effective for pain relief.Ice massage: apply the ice with firm pressure followed by slow steady, circular massageCold may be applied to pain site on the opposite side of the body corresponding to thepain site or on a site located between the brain and the pain site.takes 5-10 minutes to apply coldeach client responds differently to the site of the application that is the most effectiveapplication near the actual site of pain tends to work besta client feels cold, burning and aching sensations and numbness. When numbnessoccurs, the ice should be removed.cold is particularly effective for tooth or mouth pain when ice is place on the web of thehand between the thumb and index fingercold applications are also effective before invasive needle puncturesHeat applicationdonʼt lay on heating element bec burning could occurAssessment for Temperature Tolerance (P/P p. 1549)before applying either, the nurse should assess the clientʼs physical condition for signsof potential intolerance to heat and coldfirst observe the area to be txʼdalterations in skin integrity, such as abrasions, open wounds, edema, bruising, bleedingor localized areas of inflammation increase the clientʼs risk of injury.baseline skin assessment provides a guide for evaluating skin changes that might occurduring therapyassessment includes id of conditions that contraindicate heat or cold therapy:an active area of bleeding should not be covered by a warm application bec bleedingwill continuewarm applications are contraindicated when client has an acute, localized inflammationsuch as appendicitis bec the heat could cause the appendix to rupture.
  • if client has CV problems, it is unwise to apply heat to large portions of the body bec theresulting massive vasodilation may disrupt blood supply to vital organs.cold is contraindicated if the site of injury is already edematouscold furth retards circulation to the area and prevents absorption of the interstitial fluid.if client has impaired circulation (arteriosclerosis), cold further reduces blood supply toaffected areacold contraindicated in presence of neuropathy (client unable to perceive tempchanges)cold contraindicated in shivering (intensifies shivering and dangerously increase bodytemp)If MD orders cold therapy to lower extremity, assess for cap refill, observing skin colorand palpating skin temp, distal pulses and edematous areasif signs of circulatory inadequacy, question orderif confused or unresponsive, make freq observations of skin integrity after therapybeginsassess condition of equip usedbefore applying heat and cold, understand normal body responses to local tempvariations, assess the integrity of the body part, determine the clientʼs ability to sensetemp variations and ensure proper operation of equipment.Crohnʼs Disease: Selecting a Low-Fiber, Low-Residue DietNo raw vegetables, vegs not strained, dried beans, peas, and legumesNo raw fruits, fruits with skins, seedsNo nuts, raisins, rich dessertsno whole grain breads or cerealsno fried, smoked, pickled or cured meats,no alcohol, fruit juices with pulpDumping Syndrome: Client Education Regarding Dietary Interventionsmeal size must be reduced accordingly (6 small feedings)no drinking fluids with meals (30-45 min before or after meals) helps prevent distention or a feeling of fullnessdry foods with low-carb content and moderate protein and fat content
  • proteins and fats are increased promotes rebuilding of body tissues and to meet energy needs specifically meat, cheese, eggs and mild products no concentrated sweets (honey, sugar, jelly, jam) cause dizziness, diarrhea, a sense of fullnessshort rest period after each mealCholecystitis: Dietary RestrictionsLow in fat, and sometimes a wt reduction diet is also recommended (4-6 weekstake fat soluble vit supplementsPalliative Care: Client/ Family Teachingcaring interventions rather than curing interventionsfor any age, diagnosis, any time, and not just during the last few months of lifepreservation of dignity becomes the goal of palliative careallows clientʼs to make more informed choices, achieve better alleviation of sx and havemore opportunity to work on issues of life closureestablish a caring relationship with both client and familymanagement of sx of disease and therapiesPreparing the Dying Clientʼs Family (P/P 588)Objectives:family will be able to provide appropriate physical care for the dying client in homefamily will be able to provide appropriate psychological support to the dying client.Describe and demonstrate feeding techniques and selection of foods to facilitate easeof chewing and swallowingDemonstrate bathing, mouth care, and other hygiene measures and allow family toperform return demoshow video on simple transfer techniques to prevent injury to themselves and client,help family to practiceinstruct family on need to enforce rest periods
  • teach family to recognize s/s to expect as the clientʼs condition worsens and provide infoon who to call in an emergencydiscuss ways to support the dying person and listen to needs and fearssolicit questions from family and provide info as needed.Evaluation:Have the family members demo physical care techniquesask family members to describe how they vary approaches to care when the client hassx such as pain or fatigueask the family to discuss how they feel about their ability to support the client .Cognitive Disorders: Promoting Independence in Hygiene for A Client withAlzheimerʼs Disease Stage S/S Stage 1, Forgetfulness Short term memory loss Decreased Attn Span Subtle Personality Changes Mild cognitive deficits Difficulty with depth perception Stage 2, Confusion Obvious memory loss Confusion, impaired judgement, confabulation Wandering behavior Sundowning (more confusion in late afternoon/early evening) Irritability and agitation Poor spatial orientation, impaired motor skills Intensification of sx when the client is stressed, fatigued, or in an unfamiliar environment Depression r/t awareness of reduced capacities Stage 3, Ambulatory dementia loss of reasoning ability Increasing loss of expressive language Loss of ability to perform ADLs More Withdrawn
  • Stage S/S Stage 4, End Stage Impaired or absent cognitive, communication and/or motor skills Bowel and bladder incontinence Inability to recognize family members or self in mirrorAssess teaching needs for the client and especially for the family members when theclientʼs cognitive ability is progressively declining.Review the resources avail to the family as the clientʼs health declines. A wide variety ofhome care and community resources may be avail to the family in many areas of thecountry, and these resources may allow the client to remain at home rather than in aninstitutionPerform self assessment regarding possible feelings of frustration, anger, or fear whenperforming daily care for clients with progressive dementiaNCP Med/Surg 1592Monitor ptʼs ability for independent self-care to plan appropriate interventions specific topt unique problemsUse consistent repetition of daily health routines as a means of establishing them becmemory loss impairs ptʼs ability to plan and complete specific sequential activitiesassist pt in accepting dependency to ensure that all needs are met.teach family to encourage independence and to intervene only when the pt isunable to perform to promote independenceBathing/Hygieneprovide desired personal articles, such as bath soap and hairbrush, to enhance memoryand provide carefacilitate ptʼs bathing self as appropriate to facilitate independence and provideappropriate help in hygieneDressing/Groomingprovide ptʼs clothes in accessible area to facilitate dressingBe available for assistance in dressing as necessary to facilitate independence andprovide appropriate help in dressing
  • ToiletingAssist pt to toilet as specified intervals to promote regularityfacilitate toilet hygiene after completion of elimination to prevent discomfort and skinbreakdown.Rest and Sleep: Recognizing and Reporting Sleep Disorders (P/P 1203)If untreated lead to three problemsinsomniaabnormal movements or sensation during sleep or when awakening at night, orexcessive daytime sleepiness.Four categoriesDyssomnias (origins in body systems ) Intrinsic (initiating and maintaining sleep) psychophysiological insomnia narcolepsy periodic limb movement disorders sleep apnea syndromes Extrinsic (outside the body) inadequate sleep hygiene insufficient sleep syndrome hypnotic dependent sleep disorders alcohol dependent sleep disorders Circadian Rhythm Sleep Disorders (misalignment of timing and what is desired) Time Zone Change Shift work sleep disorder Delayed sleep phase syndromeParasomnias (undesirable behaviors that occur during sleep) Arousal Disorders Sleepwalking Sleep terrors Sleep-Wake Transition Disorders Sleeptalking Sleep starts
  • Nocturnal leg cramps REM Sleep disturbances nightmares REM Sleep behavior disorder sleep paralysis Other Parasomnias sleep bruxism (teeth grinding) sleep enuresis (bed-wetting) SIDSSleep Disorders associated with Med-Psych Disorders Psych Disorders Mood disorders Anxiety disorders Psychoses Alcoholism Neurologic Disorders Dementia Parkinsonism Central degenerative disorders Other Med Disorders Nocturnal cardiac ischemia COPD PUDProposed sleep Disorders Menstruation-associated sleep disorders Sleep choking syndrome Pregnancy associated sleep disordersQuestions to Ask to Assess for Sleep DisordersInsomniaHow easily do you fall asleepDo you fall asleep and have difficulty staying asleep? How many times do you awakenDo you awaken early from sleepWhat time do awaken for good? What causes you to awaken early?What do you do to prepare for sleep? To improve you sleep?What do you think about as you try to fall asleep
  • How often do you have trouble sleepingSleep ApneaDo you snore loudly?Has anyone ever told you that you often stop breathing for short periods during sleep?(Spouse or bed partner/roommate report this)Do you experience HAs after awakeningDo you have difficulty staying awake during the dayDoes anyone else in your family snore loudly or stop breathing during sleep?NarcolepsyAre you tired during the dayDo you fall asleep at inopportune times?Do you have episodes of losing muscle control or falling to the floorhave you ever had the feeling of being unable to move or talk just before falling asleepDo you have vivid lifelike dreams when going to sleep or waking up?Basic Care and Comfort (13)Plan BMobility and Immobility: Recognizing Proper Use of CrutchesCrutch instructionsDo not alter crutches after proper fit has been determinedFollow crutch gait prescribed by physical therapysupport body wt at hand grips with elbows flexed 30 degreesposition crutches on unaffected side when sitting or rising from chair. Elkin---pg 135Use of crutches may be a temporary aid for persons with strains, in a cast or followingsurgical treatmentscrutches may be routinely and continuously used for those with congenital or acquiredMS abnormalities, neuromuscular weakness, or paralysis or they may be used afteramputations.Crutch measurement includes three areas:
  • clientʼs height distance between crutch pad and axilla angle of elbow flexion [make sure shoes are on before measuring]Standing crutches 4-6 in in front of feet and side of feetCrutch pads two to three fingers between top of crutch and axillaElbow should be flexed (30 degrees ATI)***any tingling in torso means crutches are used incorrectly or wrong sizeif crutch too long---pressure on axilla causing paralysis of elbow and wrist (crutch palsy)if crutch too short---bent over and uncomfortablelow handgrips cause radial nerve damagehigh handgrips cause clientʼs elbow to be sharply flexed and strength and stability aredecreased4-point gait requires wt bearing on both legs often used when client has paralysis, as in spastic children with CP may also be used for arthritic clients improves balance by providing wider base of support R crutch, L foot, L crutch, R foot3 point gait requires wt bearing on 1 foot affected leg does not touch ground may be useful for client with broken leg or sprained ankle R/L crutches, unaffected foot, R/L crutches, unaffected foot2-point gait requires partial wt bearing on each foot faster than 4-point gait requires more balance crutch movements are similar to arm movements while walking L crutch and R foot together, R crutch and L foot together.Swing to gait freq used by clients whose lower extremities are paralyzed or who wear wt-supporting braces on their legs
  • easier of the two swing gaits requires ability to bear body wt partially on both legsSwing through gait requires client have ability to sustain partial wt bearing on both feetStairs ( up) unaffected leg on step, both crutches come to step, repeat (down) move crutches to stair below, move affected leg forward, then unaffected legPain Management: Nonpharmacological Pain Management P/P---ch 42 P/P---pg 1250Nonpharmacological interventions include cognitive-behavioral and physicalapproachesbest if taught when not experiencing painGoals of cognitive-behavioral interventions change clientʼs perceptions of pain alter pain behavior provide clients with greater sense of controlGoals of physical approaches providing comfort correcting physical dysfunction altering physiological responses reducing fears associated with pain-related immobilityRelaxation and Guided Imagery Relaxation mental and physical freedom from tension or stress provide self control when discomfort or pain occurs reverse physical and emotional stress of pain can be used at any phase of health or illness not taught when client is in acute discomfort bec inability to concentrate describe common sensations client may feel decrease in temp numbness of a body part use as feedback free of noise light sheet or blanket use with guided imagery or separate
  • progressive takes about 15 min pay attn to body noting areas of tension, tense areas replaced with warmth and relation some times better if eyes closed background music can help combination of controlled breathing exercises and a series of contractions and relaxation of muscle groups.Guided Imagery client creates an image in the mind, concentrate on that image and gradually becomes less aware of painDistraction RAS (reticular activating system) inhibits painful stimuli if a person receives sufficient or excessive sensory input directs attention to something else and reduces awareness of pain even increases tolerance 1 disadvantage if works, may question the existence of pain works best for short, intense pain lasting a few minutes ex: invasive procedure or while waiting for analgesic to work RN assesses activities enjoyed by client that may act as distractions singing praying describing photos or pictures aloud listening to music playing games may include ambulation, deep breathing, visitors, television, and musicMusic decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff
  • highly effective in reducing postop pain if pain acute, increase volume of musicBiofeedback behavioral therapy that involves giving individuals information about physiological responses (BP and tension) and ways to exercise voluntary control over those responses used to produce deep relaxation and is effective for muscle tension and migraine HACutaneous stimulation stimulation of the skin to relieve pain massage warm bath ice bag for inflammation transcutaneous electrical nerve stimulation (TENS) (also called counter stimulation) causes release of endorphins thus blocking transmission of painful stimulation advantage: measures can be used in the home reduce pain perception and help reduce muscle tension RN eliminates sources of environmental noise, helps client to assume a comfortable position, explains purpose of therapy Acupressure/Acupuncture vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points elevation of edematous extremities to promote venous return and decrease swellingUrinary Elimination Needs: Preventing IncontinenceUse timed voidings to increase intervals between voidings/decrease voiding frequencyperform pelvic floor (Kegel) exercisesperform relaxation techniquesoffer undergarments while client is retrainingteach client not to ignore urge to voidprovide positive reinforcement as client maintains continence
  • Urinary Elimination: Providing Catheter CarePrevent infectionMaintain unobstructed flow of urine through the cath drainage systemPerineal Hygieneperineal hygiene 2x/day or prn for client with retention cathsoap and water are effectivecan be delegated to APCatheter careassess urethral meatus and surrounding tissue for inflammation, swelling anddischarge. Note amt, color, odor, and consistency of discharge. Ask client if any burningor discharge is feltwith towel, soap and water, wipe in a circular motion along length of catheter for 4inchesapply an abx ointment at urethral meatus and along 1 inch of cath if ordered by MDMobility and Immobility: Evaluating for Complications of ImmobilityComplications of Immobility Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr Respiratory--maintain patent airway, teach the client to turn, cough and deep achieve optimal lung expansion and gas breath q 1-2 hr exchange and mobilize airway secretions yawn every hour use incentive spirometer CPT 2000ml fluid
  • Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr Cardiovascular---maintain CV fx, increase increase activity activity tolerance and prevent thrombus avoid valsalva maneuver formation stool softener ROM avoid pillows under knees use elastic stockings SCD give low dose heparin Metabolic---decrease injuries to skin and provide high calorie high protein diet with maintain metabolism within normal fxing additional vits B and C monitor oral intake Elimination--maintain or achieve normal maintain hydration (at least 2000 mL urinary and bowel elimination patterns stool softener bladder and bowel training insert cath if bladder distended Musculoskeletal--maintain or regain body change position in bed q 2 hrs alignment and stability decrease skin and ROM MS system changes, achieve full or nutritional intake optimal ROM and prevent contractures CPM Psychosocial--maintain normal sleep/wake coping skills patter, achieve socialization and achieve maintain orientation independent completion of self care develop scheduleGastroenteral Feedings: Monitoring Tube FeedingsMonitoring for tube placementinitial placement is confirmed with xraymonitor gastric contents for pH. A good indication of appropriate placement is obtaininggastric contents with a pH between 0-4Injecting air into the tube and listening over the abdomen is not an acceptable practice
  • Aspirate for residual volume---note: intestinal residual < 10 mL, gastric residual <100mLreturn aspirated contents or follow protocolFlush tubing with 30-60 mL of H20Acute Glomerulonephritis: Dietary ChoiceAcute Glomerulonephritis: insoluble immune complexes develop and become trapped inthe glomerular tissue producing swelling and capillary cell deathMaintain prescribed dietary restrictionsFluid restriction (24 hr output + 500 mL)Sodium restrictionProtein restriction (if azotemia is present)Edema is treated by restricting sodium and fluid intakeDietary protein intake may be restricted if there is evidence of nitrogenous wastes.Varies with degree of proteinuria.Low protein, low sodium, fluid restricted dietRest and Sleep: Interventions to Promote Sleep for Hospitalized ClientsAssist the client in establishing and following a bedtime routineAttempt to minimize the number of times the client is awakened during the night whilehospitalizedOffer to assist the client with personal hygiene needs and/or a back rub prior to sleep toincrease comfortInstruct the client to: Exercise regularly at least 2 hr before bed time Arrange the sleep environment to what is comfortable Limit alcohol, caffeine, and nicotine in the late afternoon and evening Engage in muscle relaxation before bedtimeApply CPAP devices as ordered by PCP for clients with sleep apnea
  • As a last resort, provide a pharmacological agent as prescribed.ATI Topic DescriptorsPlan AHealth Promotion and Maintenance (13)Uterine Atony: Performing Appropriate Assessment (Murray/Mckinney p. 734-736)Atony: lack of muscle tone that results in failure of the uterine muscle fibers to contractfirmly around the blood vessels when the placenta separatesrelaxed muscles allow rapid bleeding from the endometrial arterieries at the placentalsitebleeding continues until uterine muscle fibers contact to stop the flow of blood.retention of a large segment of the placenta does not allow the uterus to contract firmlyand therefore can cause uterine atonyMajor signs of uterine atony include:fundus that is difficult to locatea soft or boggy feel when the fundus is locateda uterus that becomes firm as it is massaged byt loses its tone when massage isstoppeda fundus that is located above the expected levels which is at or near the umbilicusexcessive lochia especially if it is bright redexcessive clots expelledif a peripad is saturated in an hour, a lg amt of blood is considered to have been lostsaturation in 15 min represents an excessive loss of blood in the early PP perioda constant steady trickle is just as dangeioursif uterus is not firmly contracted, the first intervention is to massage the fundus until it isfirm and to express clots that may have accumulated in the uterusone hand is placed just above the symphysis pubis o support the lower uterine segmentwhile the other hand getnly but firmly massages the fundus in a cirucular motionclots are expressed by applying firm but gently pressure on the fundus in the direction ofthe vagina
  • critical that uterus is contracted firmly before clots are expressedpushing on an uncontracted uterus could invert the uterus and cause massivehemorrhage and rapid shock.ATI book p.304uterine atony is hypotonic uterus that is not firm described as boggy.if untreated will result in postpartum hemorrhage and may result in uterine inversionNursing assessmentsmonitor for s/s of uterine atony which includea uterus that is larger than normal and boggy with possible lateral displacement onpelvic examprolonged lochia dischargeirregulaor or excessive bleedingAssessments for uterine atony include:fundal height, consistency and locationlochia quantity, color, and consistencyNormal Physiological Changes of Pregnancy: Calculating the clientʼs deliverydateATI p. 34Nageleʼs rule:take the first day of the last menstrual period, subtract 3 months and add 7 days and 1year.McDonaldʼs methodmeasure uterine fundal height in centimeteres from the symphysis pubis to the top ofthe uterine fundus (between 18 to 30 weeks gestation age). The calculation is as followsthe gestational age is estimated to be equal to fundal height.Cesarean Birth: Appropriate Client Positioning ATI p. 218
  • Positioning the client in a supine position with a wedge under one hip to laterally tilt herand keep her off her vena cava and descending aorta. This will help maintain optimalperfusion of oxygenated blood to the fetus during the procedure.Antepartum Diagnostic Interventions: Monitoring during a Nonstress Test ATI p.85Nonstress Testmonitor the response of the FHR to fetal movementclient pushes a button attached to the monitor whenever she feels a fetal movementthat is noted on the paper tracing.NST Reactive : FHR accelerates to 15 beats/min for at least 15 sec and occurs 2 ormore times during a 20 min period placenta is adequately perfused and the fetus is well-oxygenatedNST Nonreactive: FHR does not accelerate adequately with fetal movement or no fetalmovements occur in 40 min. if so, further assessment such as a contraction stress test or biophysical profile isindicatedDisadvantages: high rate of false nonreactive results with the fetal movement responseblunted by fetal sleep cycles, chronic tobacco smoking, meds, and fetal immaturityclient should be in a reclining chair or in a semi-fowlersʼ or left lateral positionif there are no fetal movements (fetal sleeping), vibroacoustic stimulation (sound source,usually laryngeal stimulator) may be activated for 3 sec on the maternal abdomen overthe fetal head to awaken a sleeping fetusIf still nonreactive, anticipate a CST or a BPPNewborn Hypoglycemia: Identify Appropriate Interventions ATI p. 424Hypoglycemia : serum glucose level of less than 40mg/dLdiffers from preterm and term newborn
  • Hypoglycemia occurring in the 1st 3 days of life in the term newborn is defined as ablood glucose level of <40 mg/dL. In the preterm newborn, hypoglycemia is defined as ablood glucose level of < 25 mg/dLUntreated hypoglycemia can result in mental retardationS/Spoor feedingjitteriness. tremorshypothermiadiaphoresisweak shrill crylethargyflaccid muscle toneseizures/comaassessments:monitoring BG level closelymonitoring IV if unable to orally feedmonitoring for signs of hypoglycemiamonitoring VS and tempNursing interventionsobtaining blood per heel stick for glucose monitoringfreq oral and/or gavage feeding or continuous parenteral nutrition is provided early afterbirth to treat hypoglycemia (untreated can lead to seizures, brain damage, and death)Labor and Birth Processes: Assess for True Labor vs. False Labor ATI p. 136True LaborContractions regular frequency stronger, last longer and are more freq felt in lower back, radiating to abdomen walking can increase contraction intensity continue despite comfort measuresCervix progressive change in dilation and effacement moves to anterior portion bloody show
  • Fetus presenting part engages in pelvisFalse LaborContractions painless, irregular freq, and intermittent decrease in freq, duration, and intensity with walking or position changes felt in lower back or abdomen above umbilicus often stop with comfort measures such as oral hydrationCervix (assessed by vaginal exam) no significant change in dilation or effacement often remains in posterior position no significant bloody showFetus presenting part is not engaged in fetusBonding: Promoting Maternal Psychosocial Adaptation During the Taking-InPhase ATI p. 290Taking In Phase--begins immediately following birth lasting a few hours to a couple ofdays. Characteristics include passive-dependent behavior and relying on others to meetneeds for comfort, rest, closeness, and nourishment. the client focuses on her ownneeds and is concerned about the overall health of her newborn. She is excited andtalkative, repeatedly reviewing the labor and birth experience.Facilitate the bonding process by placing the infant skin-to-skin wiht the mother soonafter birth in an en face positionEncourage the parents to bond with the infant through cuddling, feeding, diapering andinspecting the infantprovide a quiet and private environment that enhances the family bonding process.provide frequent praise, support and reassurance to the mother during the taking-holdphase as she moves toward independence in care of the newborn and adjusts to thematernal roleencourage the mother/parents to discuss their feelings, fears, and anxieties aboutcaring for their newborn
  • Toddler: Recognizing Expected Body-Image ChangesATIthe toddler appreciates the usefulness of various body partstoddlers develop gender identity by age 3Wongʼs Nursing Care of Children (p. 608)Growth slows considerably during toddlerhood.avg wt @ 2 years is 12 kg.head circumference slows and is usually equal to chest circumference by 1-2 years.Chest circumference continues to increase and exceeds head circumference during thetoddler years.After the 2nd year the the chest circumference exceeds the abdominal measurementwhich in addition to the growth of the lower extremities, gives the child, a taller leanerappearance.However, the toddler retains a squat, “pot-bellied” appearance bec of less well-developed abdominal musculature and short legs.Legs retain a slightly bowed or curved appearance during the second year form theweight of the relatively large trunk.Adolescent (12-20 years): Planning Age-Appropriate Health Promotion EducationSubstance abuse:Drug Abuse Resistance Education (DARE) and other similar programs provideassistance in preventing experimentationSexual Experimentation:
  • Abstinence is highly recommended. if sexually activity is occurring the use of birthcontrol is recommendedSexually Transmitted Diseases:Adolescents should undergo external genitalia exams, PAP smears, and cervical andurethral cultures (specific to gender).Rectal and oral cultures may also need to be takenThe adolescent should be counseled about risk taking behaviors and their exposure toSTDs as well as AIDS, hepatitis. The use of condoms will decrease the risk of STDsPregnancyidentification of pregnant adolescents should be done to ensure that nutrition andsupport is offered to promote the health of the adolescent and the fetus. Following infantdelivery, education should be given to prevent future pregnancies.Injury preventionencourage attendance at driverʼs ed courses. Emphasize the need for compliance withseat belt useteach the dangers of combining substance abuse with driving (MADD)Insist on helmet use with bicycles, motorcycles, skateboards, roller blades andsnowboardsscreen for substance abuseteach the adolescent not to swim aloneteach proper use of sporting equipmentAge-appropriate activities:nonviolent video gamesnonviolent musicsportscaring for a petcareer training programs
  • readingsocial eventsContraception: Recognizing Correct Use of Condoms ATI p. 6Condoms: a thin flexible sheath worn on the penis during intercourse to prevent semenfrom entering the uterusClient Instructionman places condom on his erect penis, leaving an empty space at the tip for a spermreservoirfollowing ejaculation, the man withdraws his penis from the womanʼs vagina whileholding condom rim to prevent any semen spillage to vulva or vaginal areamay be used in conjunction with spermicidal gel or cream to increase effectiveness.only water soluble lubricants should be used with latex condoms to avoid condombreakage.Immunizations: Recognizing Complications to Report ATI p. 279anaphylaxis review sx with parents prodromal sx--uneasiness, impending doom, restlessness, irritability, severe anxiety, HA, dizziness, parethesia, disorientation cutaneous signs are the most common initial sign,child may complain of feeling warm. angioedema is most noticeable in the eyelids, lips, tongue, hands, feet and genitalia cutaneous manifestations are often followed by bronchiolar constriction--narrowing of the airway, dilated pulmonary circulation causes pulmonary edema and hemorrhages and there is often life- threatening laryngeal edema instruct parents to call 991 or other emergency number and to keep the child quiet until help arrivesEncephalitis, seizures, and.or neuritis review sx with parents. instruct parents when to seek medical care teach parents to prevent injury during a seizureThrombocytopenia usually associated with measles vaccination teach parents to observe for bleeding
  • instruct the parents to call the primary care provider if bleeding, bruising, or re dot-like rash occurs.Older Adult (0ver 65 years): Assessing Risk for Social IsolationTwo forms of isolationmay be a choice, the result of a desire not to interact with othersmay be a response to conditions that inhibit the ability or the opportunity to interact wihtothers.vulnerable to its consequencesvulnerability increased in the absence of the support of other adults as may occur withloss of the work role or relocation to unfamiliar surroundings.impaired hearing, diminished vision, and reduced mobility all contribute to reducedinteraction with others and isolationthe loss of the ability to drive may limit older adultsʼ ability to live independently as wellas contributing to isolationsome withdraw bec of feelings of rejectionolder adults see themselves as unattractive and rejected bec of changes in theirpersonal appearance due to normal agingnurse can assist lonely older adults to rebuild social networks and reverse patterns ofisolationoutreach programsmeals on wheelssocialization needsdaily telephone call by volunteersneed for activities such as outingsSpinal Cord Injury: Promoting Independence In Self-CareSpinal cord injuries involve losses of motor fx, sensory, fx, reflexes, and control ofeliminationThe level of cord involved dictates the consequences of spinal cord injury. For example,injury at C3 to C5 poses a great risk for impaired spontaneous ventilation bec ofproximity of the phrenic nerve.Tetraplegia/paresis = 4 extremities. Paraplegia/paresis= 2 lower extremitiesTetraplegiaC1-C8ParaplegiaT1-L4
  • Level of Injury Movement Remaining Rehab PotentialC1-C3 movement in neck and ability to drive electricOften fatal injury, vagus above, loss of innervation to wheelchair equipped withnerve domination of heart, diaphragm, absence of portable ventilator by usingrespiration, blood vessels, independent respiratory fx chin control or mouth stick,and all organs below injury headrest to stabilize head; computer use with mouth stick, head wand, or noise control; 24 hr attendant care, able to instruct othersC4 sensation and movement in Same as C1-C3vagus nerve domination of neck and above; may beheart, respirations and all able to breathe without avessels and organs below ventilatorinjuryC5 full neck, partial shoulder, Ability to drive electricvagus nerve domination of back, biceps; gross elbow, wheelchair with mobile handheart, respirations, and all inability to roll over or use supports; indoor mobility invessels and organs below hands; decreased manual wheelchair; able tothe injury respiratory reserve feed self with setup and adaptive equipment; attendant care 10 hrs per dayC6 shoulder and upper back ability to assist with transfervagus nerve domination of abduction and rotation at and perform some self-care;heart, respirations, and all shoulder, full biceps to feed self with hand devices;vessels and organs below elbow flexion, wrist push wheelchair on smooth,the injury extension, weak grasp of flat surface; drive adapted thumb, decreased van from wheelchair; respiratory reserve independent computer use with adaptive equipment; attendant care 6 hrs per day
  • Level of Injury Movement Remaining Rehab Potential C7-C8 All triceps to elbow ability to transfer self to vagus nerve domination of extension, finger extensors wheelchair; roll over and sit heart, respirations, and all and flexors, good grasp with up in bed; push self on most vessels and organs below some decreased strength, surfaces; perform most self- the injury decreased respiratory care; independent use of reserve wheelchair; ability to drive care with powered hand controls (in some pts); attendant care 0-6 hrs per day T1-T6 full innervation of upper full independence in self- Sympathetic innervation to extremities, back essential care and in wheelchair heart, vagus nerve intrinsic muscles of hand; ability to drive car with hand domination of all vessels full strength and dexterity of controls (in most patients); and organs below injury grasp; decreased trunk independent standing in stability, decreased standing frame respiratory reserve T6-T12 Full stable thoracic muscle Full independent us of Vagus nerve domination and upper back; functional wheelchair; ability to stand only of leg vessels, GI and intercostals, resulting in erect with full leg brace, genitourinary organs increased respiratory ambulate on crutches with reserve swing (although gait difficult); inability to climb stairs L1- L2 Varying control of legs and Good sitting balance; full Vagus nerve domination of pelvis, instability of lower use of wheelchair; leg vessels back ambulation with long leg braces Level of Injury Movement Remaining Rehabilitation Potential L3-L4 Quadriceps and hip flexors, Completely independent Partial vagus nerve absence of hamstring ambulation with short leg domination of leg vessels, function, flail ankles braces and canes; inability GI and genitourinary organs to stand for long periodsThe success of rehabilitation depends on many variables, including the following:
  • • level and severity of the SCI • type and degree of resulting impairments and disabilities • overall health of the patient • family supportIt is important to focus on maximizing the patients capabilities at home and in thecommunity. Positive reinforcement helps recovery by improving self-esteem andpromoting independence.The goal of SCI rehabilitation is to help the patient return to the highest level of functionand independence possible, while improving the overall quality of life - physically,emotionally, and socially.Health Promotion and MaintenancePlan BAntepartum Diagnostic Interventions: Prenatal Fetal Heart Rate MonitoringNonstress Test (see below)Contraction Stress test (CST) an assessment performed to stimulate contractions(which decrease placental blood flow) and analyze the FHR in conjunction with thecontractions to determine how the fetus will tolerate the stress of labor.A pattern of at least 3 contractions within a 10 min time period with duratio of 40-60 seceach must be obtained to use for assessment dataNipple stimulated CST consists of the woman lightly brushing her palm across thenipple for 2 or 3 min, which causes the pituitary gland to release endogenous oxytocin,and then stopping the nipple stimulation when a contraction begins The same processis repeated after a 5 min rest period Hyperstimulation of the uterus (uterine contraction longer than 90 sec or morefreq than q 2 min) should be avoided by stimulating the nipple intermittently with restperiods in between and avoiding bimanual stimulation of both nipples unless stimulationof one nipple is uncuccessfulOxytocin admin CST is used if nipple stimulation fails and consists of IV admin ofoxytocin to induce uterine contractions Contractions started with oxytocin may be difficult to stop and can lead topreterm labor
  • A negative CST (normal finding) is indicated if within a 10 min period, with 3 uterinecontractions, there are no late decels of the FHRA positive CST (abnormal finding) is indicated with persistent and consistent late decelson more than half of the contractions. This is suggestive of uteroplacental insufficiency.Variable decels may indicate cord compression and early decls may indicate fetal headcompression.Nursing ManagementFor a CST, the nurse should Obtain a baseline of the FHR, fetal movement and contractions for 10-20 min and document Complete an assessment without artificial stimulation if contractions are occurring spontaneously Initiate nipple stimulation if there are no contractions. Instruct the client to roll a nipple between her thumb and fingers or brush her palm across her nipple. the client should stop when a uterine contraction occurs. Monitor and provide adequate rest periods for the client to avoid hyperstimulation of the uterus. Initiate IV oxytocin admin if nipple stimulation fails to elicit a sufficient uterine contraction patternComplications Hyperstimulation of the uterus Preterm labor Monitor for contractions lasting longer than 90 sec and/or occurring more freq than q 2 minBiophysical Profile (BPP)uses a real time ultrasound to visualize physical and physiological characteristics of thefetus and observe for fetal biophysical responses to stimuli.Five variablesReactive FHR: reactive nonstress test = 2, nonreactive = 0
  • Fetal breathing movements: at least 1 episode of 30 sec in 30 min = 2, absent or lessthan 30 sec duration = 0Gross body movements: at least 3 body or limb extensions with return to flexion in 30min = 2, less than 3 episodes = 0Fetal tone: at least 1 episode of extension with return to flexion = 2; slow extension andflexion, lack of flexion, or absent of movement = 0Amniotic fluid volume: at least 1 pocket of fluid that measures at least 1 cm in 2perpendicular planes = 2; pockets absent or less than 1 cm = 0For BPP the nurse should follow the same management as ultrasoundComplications of Pregnancy: Recognizing Abnormal FindingsBleeding during Pregnancy vaginal bleeding during pregnancy is always abnormal and must be carefully investigated in order to determine the causeSpontaneous Abortion when a pregnancy is terminated before 20 weeks gestation (the point of fetalviability) or fetal wt less than 500 g.Assessments vaginal spotting or moderate to heavy bleeding with or without pain in early pregnancy passage of tissue (products of conception) mild to severe uterine atony backache rupture of membranes dilation of the cervix fever abdominal tenderness s/s of hemorrhage such as hypotensionEctopic Pregnancy
  • abnormal implantation of the fertilized ovum outside of the uterine cavity. The implantation is usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage.Assessments one or two missed menses unilateral stabbing pain and tenderness in the lower abdominal quadrant scant, dark red or brown vaginal spotting if tube ruptures (bleeding may be into intraperitoneal area). referred shoulder pain from blood irritation of the diaphragm or phrenic nerve (common sx) N/V freq after tube rupture sx of hemorrhage and shockGestational Trophoblastic Disease proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluid-filled and takes on the appearance of grape-like clusters. the embryo fails to develop beyond a primitive start and these structures are associated with choriocarcinoma which is a rapidly metastasizing malignancy. Two types of molar growths are identifies by chromosomal analysisAssessments rapid uterine growth larger than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells vaginal bleeding at approximately 16 wks gestation. Bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks bleeding accompanied by discharge from the clear fluid-filled vesciles excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels sx of pregnancy-induced HTN (PIH), including HTN, edema, and proteinuria that occur prior to 20 weeks gestation (PIH usually does not occur until after 20 wks gestation)
  • Incompetent Cervix painless, passive dilation of the cervix in the absence of uterine contractions. The cervix is incapable of supporting the wt and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy. This usually occurs around week 20 of gestation.Assessments pink stained vaginal discharge or bleeding increase in pelvic pressure possible gush of fluid (rupture of membranes) uterine contractions with the expulsion of the fetus postop (cerclage) monitoring for uterine contractions, rupture of membranes and signs of infectionPlacenta Previa when the placenta abnormally implants in the lower segment of the uterus nearor over the cervical os instead of attaching to the fundus. The abnormal implantationresults in bleeding during the third trimester of pregnancy as the cervix begins to dilateand effaceAssessments painless, bright red vaginal bleeding that increases as the cervix dilates a soft relaxed, nontender uterus with normal tone a fundal ht greater than usually expected for gestational age a fetus in a breech, oblique or transverse position a palpable placenta VS that are usual and within normal limitsAbruptio Placenta
  • the premature separation of the placenta from the uterus, which can be a partial or complete detachment. This separation occurs after 20 wks gestation, which is usually in the third trimester. It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal deathAssessments sudden onset of intense localized uterine pain vaginal bleeding that is bright red or dark A board like abdomen that is tender a firm rigid uterus with contractions (uterine hypertonicity) fetal distress sx of hypovolemic shockHyperemesis Gravidarum excess N/V (r/t elevated HcG levels) that is prolonged past 12 weeks gestation and results in a 5% wt loss form prepregnancy wt, dehydration, electrolyte imbalance, ketosis, and acetonuria.Assessments excessive vomiting for prolonged periods dehydration with possible electrolyte imbalance wt loss decreased blood pressure increased pulse rate poor skin turgorGestational Hypertension/Pregnancy Induced Hypertension begins after the 20th wk of pregnancy,
  • woman has an elevated BP at 140/90 mmHg or greater, or a systolic increase of 30 mmHg or diastolic increase of 15 mmHg from the prepregnancy state Mild preeclampsia is GH with the addition of proteinuria of 1 - 2+ and a wt gain of more than 2 kg per wk in the 2nd and 3rd trimesters. Severe preeclampsia consists of BP that is 160-100 mmHg or greater, proteinuria 3-4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (HA and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and RUQ pain. Eclampsia is severe preeclampsia sx along with the onset of seizure activity or coma.Assessments progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening HtN, cerebral involvement, and developing coagulopathies rapid wt gain 2 kg per wk in the second and third trimester fetal distressGestational Diabetes an impaired toleratnce to glucose with the first onset or recognition duringpregnancy. The ideal blood glucose level should fall between 60-120 mg/dLAssessments hunger and thirst freq urination blurred vision excess wt gain during pregnancyTORCH infections group of infections that can negatively affect a woman who is pregnant. Theseinfections can cross the placenta and have teratogenic affects on the fetus. TORCHdoes not include all the major infections that present risks to the mother and fetus
  • infection sign/symptom T-toxoplasmosis influenza sx or lymphadenopathy O-other infection dependent on infection R-rubella (german measles) rash, muscle aches, joint pain, mild lymphedema, fetal consequences including miscarriage, congenital anomalies and death C-cytomegalovirus (member of Herpes asymptomatic or mononucleosis-like sx virus family) H-Herpes simples virus (HSV) lesions initial outbreakCircumcision: Evaluating Effectiveness of Discharge TeachingPostop parent teaching:Teach the parents to keep the area clean. Change the infantʼs diaper at least every 4 hrand clean the penis with warm water with each diaper change.With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hrafter the circumcision to keep the diaper from adhering to the penis. The diaper shouldbe fan folded to prevent pressure on the circumcised areaAvoid wrapping the penis in tight gauze, which can impair circulation to the glans.A tub bath should not be given until the circumcision is completely healed. Until then,warm water should be gently trickled over the penisNotify the PCP if there is any redness, discharge, swelling, strong odor, tenderness,decrease in urination, or excessive crying from the infant.Tell the parents a film of yellowish mucus may form over the glans by day 2 and it isimportant not to wash this offTeach the parents to avoid using premoistened towelettes to clean the penis bec theycontain alcohol.Inform the parents that the newborn may be fussy or may sleep for several hrs after thecircumcision
  • Inform the parents that the circumcision will heal completely within a couple of weeks.Discharge Teaching: Evaluating Clientʼs Understanding of Bulb Syringe UseOral and Nasal Suctioningteach the parents to use a bulb syringe to suction any excess mucus from the nose andmouthparents should suction the mouth first and then the nose, one nostril at a timethe bulb should be compressed before inserting it into the infantʼs mouth or nosewhen suctioning the infantʼs mouth, always insert the bulb on the sides of the infantʼsmouth not in the middle and do not touch the back of the throat to avoid the gag reflexPostpartum Physiological Changes and Nursing Care: Performing FundalAssessmentDocument the fundal height, location and uterine consistencyDetermine the fundal ht by placing fingers on the abdomen and measuring how manyfingerbreadths (cm) fit between the fundus and the umbilicus above, below, or at theumbilical levelDetermine if the fundus is midline in the pelvis or displaced laterally (caused by a fullbladder)Determine if the fundus is firm or boggy. If the fundus is boggy (not firm), lightlymassage the fundus in a circular motion.Toddler: Provide Education on Age-Specific Growth and DevelopmentStages of Development Theorist Type of Development Stage Erickson Psychosocial Autonomy vs Shame Freud Psychosocial Anal
  • Theorist Type of Development Stage Piaget Cognitive Sensorimotor Transitions to preoperationalPhysical Developmentanterior fontanel close by 18 months of ageWt: At 30 months the toddler should weigh 4x his birth wt.Ht: the toddler grows by 7.5 cm (3 in) per yearDevelopmental Skillsdevelopment of steady gaitclimbing stairsjumping and standing on one foot for short periodsstacking blocks in increasingly higher numbersdrawing stick figuresundressing and feeding selftoilet trainingCognitive Developmentconcept of object permanence is fully developedToddlers demonstrate memory of events that relate to themlanguage increase to about 400 words with the toddler speaking in 2-3 word phrasespre-operational thought does not allow for the toddler to understand other viewpoints,but it does allow toddlers to symbolize objects and people in order to imitate activitiesthey have seen previouslyPsychosocial Development
  • independence is paramount for the toddler who is attempting to do everything forhimselfseparation anxiety continues to occur when a parent leaves the childMoral DevelopmentMoral development is closely associated with cognitive developmentEgocentric--toddlers are unable to see anotherʼs perspective; they can only view thingfrom their point of view.the toddlerʼs punishment and obedience orientation begins with a sense of goodbehavior is rewarded and bad behavior is punished.Self Concept Developmenttoddlers progressively see themselves as separate from their parents and increase theirexplorations away from themAge Appropriate ActivitiesSolitary play evolves into parallel play where the toddler observes other children andthen may engage in activities nearby filling and emptying containers playing with blocks reading books playing with toys that can be pushed and pulled tossing a ballInfant (Birth to 1 yr): Identifying Normal Physical Assessment FindingsPhysical DevelopmentThe infantʼs posterior fontanel closes at 2-3 months of ageThe infantʼs size is tracked by wt, ht, and head circumference
  • Wt: the infant gains 0.7 kg (1.5 lb) per month the first 6 months and 0.3 kg (0.75 lb) permonth the last 6 months. The infant triples birth wt by the end of the first yearHt: The infant grows 2.5 cm (1 in) per month the first 6 month and then 1.25 cm (0.5 in)per month the last 6 months.Head Circumference: The circumference of the infantʼs head increases 1.25 cm (0.5 in)per month the first 6 monthsFollowing size, the infant develops gross motor skillsHolds head up at 3 monthsRolls over at 5-6 monthsHolds head steady when sitting at 6 monthsGets to sitting position alone and can pull up to a standing position at 9 monthsStand hold on at 12 monthsStands alone at 12 monthsFine motor development follows next in the sequenceBrings hans togethergrasps rattlelooks for items that are dropped from viewtransfers an object from one hand to the other (6 months)rakes finger food with hand ( 6 months)uses thumb-finger to grasp items (9 months)Bangs two toys together (9 months)Can nest one object inside another (12 months)Scoliosis: Recognizing Signs During Routine ScreeningSchool age children should be screened for scoliosis by examining for a lateralcurvature of the spine before and during growth spurts.
  • Marked curvatures in posture are abnormal.A slight limp, a crooked hemline, or ℅ a sore back are other s/s of scoliosisinspect the back for any tufts of hair, dimples, or discoloration. Mobility of vertebralcolumn is easily assessed in children bec of their propensity for constant motion durinexamATI Topic DescriptorsManagement of Care (24)Plan AAdvance Directives: Recognize Purpose(ATI)Advance directive are written instructions that allow a client to convey his wishesregarding medical tx for situations when those wishes can no longer be personallycommunicated.All clients admitted to a health care facility be asked if they have an advance directive.The client without an advance directive must be given written information that outlineshis rights r/t health care decisions and how to formulate an advance directive.A health care representative should be available to help with this processLiving wills allows the client to specify end of life decisions she does or does not sanctionwhen unable to speak for herself. For example, the client can specify use or refusal of:CPR, if cardiac or respiratory arrest occursArtificial nutrition through IV or tube feedingsProlonged maintenance on a respirator if unable to breathe adequately aloneLiving wills must be specific and be signed by two witnesses.They can minimize conflict and confusion regarding health care decisions that need tobe madevary from state to state
  • A durable power of attorney for health care (health proxy) is an indiv designated tomake health care decisions for a client who is unable based upon the clientʼs living willBased upon the clientʼs advance directives, the physician writes orders for life-sustaining tx. Examples include:DNRMedical interventions (eg comfort measures only, IV fluids but no intubation, full tx)Use of ABXArtificially administered nutrition through a tube.Nursing responsibilities regarding advance directives include:provide written information regarding advance directivesdocument the clients advance directive statusensure that the advance directive is current and reflective of the clientʼs currentdecisions.inform all members of the health care team of the clients advance directive. (P/P)Two basic advance directivesliving will written documents that direct tx in accordance with a clientʼs wishes in the event of a terminal illness or condition. may be difficult to interpret two witnesses, neither of whom can be a relative or physician, are needed when the client signs the document if health care workers follow the directions of the living will, they are immune from liabilitydurable power of attorney for health care
  • designates an agent, surrogate, or proxy to make health care decisions if and when the client is no longer able to make decisions on his or her own behalf.In order for living wills or durable powers of attorney for health care to be enforceable,the client must be legally incompetent or lack decisional capacity to make decisionsregarding health care treatmentThe determination of legal competency is made by a judge, and the determination ofdecisional capacity is usually made by the physician and family.The implementation of the advance directive is done within the context of the healthcare team and the health care institution.When clients are legally incompetent and are unable to make health care decisions, thecourts balance the stateʼs interest with what the client would have wanted.Client Advocacy: Intervening on behalf of the ClientAs an advocate, nurses must ensure that clients are informed of their rights and haveadequate information on which to base health care decisionsNurses must be careful to “assist” clients with health care decisions and not “direct” or“control” their decisionsSituations in which the nurse may advocate for the client or assist the client to advocatefor herself include:End of life decisionsAccess to health careProtection of client privacyInformed consentSubstandard practiceEssential Components of Advocacy
  • Skills risk taking vision self-confidence Articulate communication assertivenessValues caring autonomy respect empowermentThe nurse protects the clientʼs human and legal rights and provides assistance inasserting those rights if the need ariseskeep in mind the clientʼs religion and cultureDischarge Planning: Interventions to Promote Timely Client DischargesThe process begins at time of admissionPlans are developed with client and family input, focusing on active participation by theclient to facilitate a timely dischargeServes as a starting point for continuity of care for the client by the caregiver, homehealth nurse, or receiving facility.The need for additional client or family support is included with recommendations forsupport services such as home health, outpatient therapy and respite care.Discharge Summary includes:Step by step instructions for procedures to be done at homePrecautions to take when performing procedures or administering medsS/s of complications that should be reportedNames and numbers of health care providers and community services the client/familycan contact.Plans for follow up care and therapies
  • Time of discharge, mode of transportation, and who accompanied the client.This should begin when the client is admitted to the facility unless the facility is to be theclientʼs permanent residenceassess whether or not the client will be able to return to his previous residencedetermine whether or not the client will nee and/or have someone to assist him at homeassess the residence to see if adaptations are required to accommodate the client priorto dischargemake a referral to the social worker to arrange for community services required by theclient at dischargecommunicate client health status and needs to community service providers.Clients Rights: Recognizing Client Rights Regarding Review of RecordsOnly health care team members directly responsible for the clientʼs care should beallowed access to the clientʼs records. The client has the right to review his medicalrecord and request information as necessary for understanding.Clientʼs rightsTo inspect and copy PHITo ask the health care agency to amend the PHI that is contained in a record if the PHIis inaccurateTo request a list of disclosures made regarding the PHI as specified by HIPAATo request to restrict the way the health care agency uses or discloses PHI regarding tx,payment or health care operations unless info is needed to provide emergency txTo request that the healthcare agency communicates with the client in a certain way orat a certain location ; the request must specify how or where the clientʼs wishes to becontacted.Collaboration with Interdisciplinary Team: Methods for CollaborationAn interdisciplinary team is a group of health care professionals from differentdisciplinesCollaboration is used by interdisciplinary teams to make health care decisions aboutclients with multiple problems. Collaboration, which may take place at team meetings,allows the achievement of results that the participants would be incapable ofaccomplishing if working alone.Key elements of collaboration include:
  • Effective communication skills Mutual respect and trust Shared decision makingThe nurse contributes Knowledge of nursing care and its management A holistic understanding of the client, her health care needs,and health caresystemsNurse-primary care provider collaboration should be fostered to create a climate ofmutual respect and collaborative practiceCollaboration can occur among different levels of nurses and nurses with different areasof expertise.Nursing Interventions:Use effective communication skillsParticipate in client rounds and interdisciplinary team meetingsPresent info relevant to the clientʼs health status and tx regimenAttend interdisciplinary clinical conferences/case presentations.COPD: Planning Strategies for FatigueATI---determine the clientʼs physical limitations and structure activity to includeperiods of restpromote adequate nutrition increased work of breathing increases caloric demandsMed-SurgEnergy Conservation Techniquespacing and pursing (pacing activity and using pursed lip breathing with activities
  • assuming the tripod position and a mirror placed on the table during use of an electricrazor or hair dryer conserves more energy than when the pt stands in front of a mirror toshave or blow dry hair.use 02 during activities of hygiene bec these are energy consumingpt should be encouraged to make a schedule and plan daily and weekly activities so asto leave plenty of time for rest periodspt should also try to sit as much as possible when performing activitiesexhale when pushing, pulling or exerting effort during and activity and inhale during rest.walking is the best exercise for COPDcoordinated walking with slow, pursed-lip breathing without breath holding.breathe in and out through now while taking one step then to breathe out throughpursed lips while taking 2-4 stepswalk 15-20 minutes a day with gradual increasesuse MDI 10 minutes before exercisesConflict Resolution: Identify StrategiesConflict is the result of opposing thoughts, ideas, feeling, perceptions, behaviors,values, opinions, or actions between individuals.Conflict is an inevitable part of professional, social, and personal life and can result inconstructive or destructive consequences Constructive Consequences Destructive Consequences stimulates growth and open and honest can produce divisiveness communication may foster rivalry and compeitition increases group cohesion and commitment misperceptions, distrust, and frustration to common goals can be created facilitates understanding and problem group dissatisfaction with the outcome may solving occur motivates group to changeLack of conflict can create organizational stasis, while too much conflict can bedemoralizing, produce anxiety, and contribute to burnout
  • The desired goal in resolving conflict in both parties is to reach a satisfactory resolution.This is a win-win situationConflict Resolution Strategies Strategy Characteristics Compromising Each party gives up something To consider this a win-win solution, both parties must give up something equally valuable. If one party gives up more than the other it can become a win-lose situation Competing One party pursues a desired solution at the expense of others This is a win-lose solution Managers may use this when a quick or unpopular decision must be made The party who loses something may experience anger, frustration, and a desire for retribution Cooperating/Accommodating One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing. this is a lose-win solution. The original problem may not actually be resolved. The solution may contribute to future conflict
  • Strategy CharacteristicsSmoothing One party attempts to “smooth” other party, decreasing the emotional component of the conflict Often used to preserve or maintain a peaceful work environment The focus may be on what is agreed upon, leaving conflict largely unresolved This is usually a lose-lose solutionAvoiding Both parties know there is a conflict, but they refuse to face it or attempt to resolve it. May be appropriate for minor conflicts or when one party holds more power than the other party or if the issue may work itself out over time Since the conflict remains, it may surface again at a later date and escalate over time this is usually a lose-lose solution Conflict Resolution Advantages Disadvantages TechniqueAvoiding--ignoring the does not make a big deal conflict can become biggerconflict out of nothing; conflict may than anticipated be minor in comparison to other prioritiesAccommodating--- one side is more concerned one side holds more powersmoothing or cooperating. with the issue than the other and can force the other sideOne side gives in to the side to give inother sideCompeting---forcing; the two produces a winner; good Produces a loser; leavesor three sides are forced to when time is short and anger and resentment oncompete for the goal stakes are high losing sides
  • Conflict Resolution Advantages Disadvantages Technique Compromising---each side no one should win or lose may cause a return to the gives up something and but both should gain conflict if what is given up gains something something; good for becomes more important disagreements between than the original goal indiv Negotiating---high level stakes are high and solution agreements are permanent, discussion that seeks is rather permanent; often even though each side has agreement but not involves powerful groups gains and losses necessarily consensus Collaborating--both sides best solution for the conflict takes a lot of time; requires work together to develop and encompasses all the commitment to success optimal outcome goals to each side Confronting--immediate and does not allow conflict o may leave impression that obvious movement to stop take root; very powerful conflict is not tolerated conflict at the very startGenitalia and Rectum: Providing PrivacyPreparation of the client (for Female pelvic exam)Client is asked to empty her bladder so that urine is not accidently expelled during theexam.Client is assisted in assuming the lithotomy position in bed or on an exam table for anexternal genitalia assessment and is assisted in stirrups if a speculum exam is to beperformed.The nurse places a hand to the edge of the table and then instructs the client to moveuntil touching the hand. The clientʼs arms should be at her side or folded across thechest to prevent tightening of abdominal musclesA square drape or sheet is given to the client. She holds one corner over the sternum,the adjacent corners fall over each knee, and the fourth corner covers the perineum.Close the door, or pull room curtains around the bathing area. While bathing the client,expose only the areas being bathed.During bowel elimination, the nurse should maintain the clientʼs privacy.
  • this is especially important for a client using a bedpan. The call light and a supply oftoilet paper should be within easy reach. Respond immediately.Consultation: Referral in Response to a Client ConcernA consultant is a professional who provides expert advice in a particular area. Aconsultation is requested to determine what tx/services the client requires.Consultations provide expertise to clients who require a particular type of knowledge orservice (eg, a cardiologist for a client who had a myocardial infarction, a psychiatrist fora client whose risk for suicide needs to be assessed)Coordination of the consultantʼs recommendations with other health care providersʼrecommendations is necessary to protect the client form conflicting and potentiallydangerous orders.Consultation is a process in which a specialist is sought to identify methods of care or txplans to meet the needs of a client.Consultation is needed when the nurse encounters a problem that cannot be solvedusing nursing knowledge, skills, and available resourcesConsultation also is needed when the exact problem remains unclear; a consultant canobjectively and more clearly assess and identify the exact nature of the problemReferrals are made so that the client can access the care identified by the PCP orconsultantThe care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eg,hospice care, home health aide)Discharge referrals are based on client needs in r/t actual and potential problems andmay enlist the aid of:social servicesspecialized therapists (eg PT,OT, speech)care providers (home health nurses, hospice nurse)Knowledge of community resources i necessary to appropriately link the client withneeded servicesConsultation (interventions)Initiate the necessary consults or notify the PCP of the clientʼs needs so the consult canbe initiated.Provide the consultant with all pertinent info about the problem
  • Incorporate the consultantʼs recommendations into the clientʼs plan of careFacilitate coordination of the consultantʼs recommendations with other health careproviders; recommendations to protect the client from conflicting and potentiallydangerous orders.Referrals (Interventions)To ensure continuity of care by the use of referrals, the nurse should:Initiate the discharge plan upon the clientʼs admission.Evaluate client/family competencies in r/t home care prior to discharge.Involve the client and family in care planningCollaborate with other health care professionals to ensure all health care needs are metComplete referral forms to ensure proper reimbursement for services ordered.Client Education: Document Client TeachingClient teaching documentationInformation presented, method of instruction (eg discussion, demonstration, videotape,booklet), client response, including questions and evidence of understanding such asreturn demo or change in behavior.Nursing documentation must be accurate to correctly record information regarding theclientʼs care.The purpose of reporting is to provide continuity of care for client when several nursesprovide care. Reporting should be conducted in a confidential manner.Evaluation of Client TeachingObserve the client demonstrating the learned activity (best for eval of psychomotorlearning)Ask questions.Listen to the client explain the info learneduse written tools to measure accuracy of information
  • Request the clientʼs self-eval of progressObserve verbal and nonverbal communicationRevise the care plan as needed.Delegation: Use of the Five Rights of DelegationRight TaskThe right task is one that is delegable for a specific client, such as tasks that arerepetitive, require little supervision and are relatively noninvasive.Identify what tasks are appropriate to delegate for each specific client.Delegate activities to appropriate levels of team members (eg LPN, AP) based onprofessional standards of practice, legal and facility guidelines, and available resources.Ex: Right Task Wrong Task Delegate LPN to perform a dressing Delegate LPN to develop the care plan for change on a client with cellulitis. a client with cellulitis. Delegate AP to assist a client with Delegate AP to administer a neb tx to a pneumonia to use a bedpan client with pneumonia.Right CircumstancesThe appropriate client, available resources, and other relevant factors are considered.In an acute care setting, clientʼs conditions can change quickly. good clinical decisionmaking is needed to determine what to delegate. If the circumstances have beenassessed or are deemed too complicated, the nurse takes the responsibility and doesnot delegate to the AP.Ex:
  • Right Circumstance Wrong Circumstance Delegate AP to take and record check-in Delegate AP to take VS on a client VS of office clients. receiving IV therapy for hypovolemic shock. Delegate AP to assist in obtaining VS from a stable postop client. Delegate AP to assist in obtain VS from a postop client who required naloxone (Narcan) for depressed respirations.Right personthe right person is delegating the right tasks to the right person to be performed on theright person.Assess and verify the competency of the health care team member. the task must be within the team memberʼs scope of practice the team member must have the necessary competence/trainingContinually review the performance of the team member and determine carecompetency.Assess team member performance based on standards, and when necessary, takesteps to remediate failure to meet standards.Ex: Right person Wrong Person Delegate an LPN to administer enteral Delegate an AP to administer enteral feedings to a client with a head injury. feedings to a client with a head injury. Delegate LPN to perform trach care on a Delegate an AP to perform trach care on a client client.Right Direction/ Communication
  • A clear, concise, description of the task, including its objective, limits, and expectationsis given. Communication must be ongoing between RN and AP during a shift of care.Communicate either in writing or orally:Data that need to be collectedMethod and timeline for reporting, including when to report concerns/assessmentfindingsSpecific task(s) to be performed; client specific instructionsExpected results, timelines, and expectations for follow-up communication.Ex: Right direction/communication Wrong direction/communication Delegate AP the task of assisting the client Delegate AP the task of assisting the client in room 312 with a shower, to be in room 312 with morning hygiene. completed by 0900. Delegate AP the task of obtaining a urine Delegate AP the task of obtaining a clean- specimen on a client in room 423, but not catch urine specimen from the client in informing her of what type of urine room 423, bed 2 specimen, or which specific client in the room needs the specimen.Right SupervisionAppropriate monitoring, evaluation, intervention as needed and feedback are provided.AP should feel comfortable to ask questions and seek assistance.Ex:
  • Right Supervision Wrong Supervision An RN delegates to an LPN the task of An RN delegates to an LPN the task of administering enteral feedings to a client providing client teaching to a client without (after the RN performs a physical a written care plan in place. assessment to evaluate the clientʼs tolerance to feedings thus far). An RN delegates an AP to ambulate a client prior to performing an admission An RN delegates to an AP the task of assessment. ambulating a client after completing the admission assessmentCare that cannot be delegated:Nursing process. Assessment Diagnosis Planning EvaluationNursing judgment.Delegation: Monitoring Outcomes of Delegated TasksAnother important step in delegation is evaluation of clientʼs outcomes. The RN mustgive constructive and appropriate feedback. The RN should always give specificfeedback in regard to any mistakes that were made, explaining how the mistakes couldhave been avoiding. Giving feedback in private is the professional way and preservesthe APs dignity. The RN may discover the need to review a procedure with staff andoffer demonstration or even recommend that additional training by scheduled with theeducation dept.Delegation: Assigning Tasks To AP Based On Role parameters and Skill RequiredAssess the knowledge and skills of the delegate open ended questionsMatch tasks to the delegateʼs skills know what skills are included in the training program of the facilityCommunicate clearly
  • alway provide unambiguous and clear directions by describing a task, the desiredoutcome, time period within which the task should be completed. never give task through another staff memberListen attentivelyProvide feedback.Roles/Tasks for AP/LPN Task AP LPN RN Developing a teaching plan for a client newly dxʼd with diabetes x mellitus Assessing a client admitted for surgery x Collecting VS q 30 min for a client who is 1 hr post cardiac cath x x x Calculating a clientʼs I/O x x x Administering blood to a client x Monitoring a clientʼs condition during blood transfusions and IV admin x x Providing oral and bathing hygiene to an immobilized client x x x Initiating client referrals x Dressing change of an uncomplicated wound x x Routine nasotracheal suctioning x x Receiving report from surgery nurse regarding a client to be admitted x to a unit from the PACU Initiating a continuous IV infusion of dopamine with dosage titration x based on hemodynamic measurements Administering subcutaneous insulin x x Assessing and documenting a clientʼs decubitus ulcer x x Evaluating a clientʼs advance directive status x
  • Task AP LPN RN Providing written information regarding advance directives x x Initial feeding of a client who had a stroke and is at risk for aspiration x Assisting a client with toileting x x x Developing a plan of care for a client x Administering an oral med x x Assisting a client with ambulation x x x Administering an IM pain med x x Checking a clientʼs feeding tube placement and patency x x Turning a client q 2 hr x x x Calculating and monitoring TPN flow rate xDisaster Planning and Emergency Management: Prioritizing Delivery of ClientCareTriage is the process of separating casualties and allocating tx on the basis of thevictimsʼ potentials for survival.Highest priority is always given to victims who have life-threatening injuries but whohave a high probability of survival once stabilized.Second priority is given to victims with injuries that have systemic complications that arenot yet life threatening and could wait 45-60 min for txLast priority is given to those victims with local injuries without immediate complicationsand who can wait several hours for medical attention, or those who have minimalprobability of surviving.Ethics and Values: Appropriate Response to Experiencing Negative Feelingsabout a Client
  • Countertransference refers to the feelings and thoughts that service providers havetoward the client. The provider may harbor certain images of the client that result in“blind spots” which can be destructive or disruptive to the therapeutic process.This nontherapeutic event can be resolved with consultation, supervision, or both.Nurses must be aware of possible countertransference responses.Beneficence---the care give is in the best interest of the client.Client Education: Assisting Clients to Access current Health Information UsingInformation TechnologyClient education assists individuals, families, and communities in achieving optimalhealth.Teaching in interactive, promotes learning, and leads to a change in a behavior.Information technology can be used to enhance access to and delivery of knowledgeClient Education: Selecting Appropriate Information Technology for AdolescentClient EducationAdolescents are in transition between childhood and adulthood.Transition between concrete operations to formal operations in reasoning.Use logic and reasoning to grasp simultaneous influence of several variables to invent asystematic procedure for keeping track of results of experiments.Peer teaching is very effective. Teens benefit from visiting others who are copingsuccessfully with similar problems.Group instruction/discussion is a very powerful way to help teens belong to a group
  • Informed Consent: Ensure Informed ConsentInformed Consent Once surgery has been discussed with the client or surrogate as tx, it is theresponsibility of the PcP to obtain consent after discussing the risks and benefits of theprocedure. The nurse is not to obtain consent for the PcP in any circumstance the nurse can clarify any information that remains unclear after the PCPʼsexplanation of the procedureThe nurseʼs role is to witness the clientʼs signing of the consent forma after the clientacknowledges understanding of the procedure.Informed Consent Consent is required for all tx that is given to the client in a healthcare facility State laws prescribe who is able to give informed consent. Laws will varyregarding age limitations and emergencies. the nurse is responsible for knowing thelaws in the state of practicePeople authorized to grant consent for another person include:parent of a minorlegal guardiancourt specified representative by a court orderspouse or closest avail relative who has durable power of attorney for health careThe Provider: obtains informed consentThe Client: gives informed consentThe Nurse: witnesses informed consent ensuring that the provide gave the client the necessary information ensuring that the client understood the information and is competent to give informed consentLegal Responsibilities: Reporting Client AbuseAbuse and Neglect of Vulnerable Older AdultsDescription older adults may be the victims of emotional, physical and sexual abuse
  • the nurse must be alert to the signs of abuse and neglect possible from caregiversSigns of abuse include unexplained bruises or welts, multiple bruises; unexplainedfractures, abrasions, and lacerations; multiple injuries; withdrawal or passivity or fear;depression and hopelessnessSigns of neglect include dehydration; malnourishment; overmedication orundermedication; desertion or abandonment; inappropriate or soiled clothes; lack ofglasses; dentures, or other aids if usually worn; and being left unattendedExploitation of the vulnerable older adult includes disappearance of possessions, forcedto sell possessions or change a will, overcharged for home repairs, inadequate livingenvironment, inability to afford social activities, being forced to sign over control offinances and no money for food or clothesThe nurse must report abuse, neglect and exploitation to the proper authoritiesIntentional TortsAssault: any intentional threat to bring about harmful or offensive contactno contact is madethe law protects clients who are afraid of harmful contactIt is an assault for a nurse to threaten to give a client an injection or to threaten torestrain a client for an xray procedure when the client has refused consentBattery is any intentional touching without consent. Contact can be harmfulPerformance Improvement: Utilize References to Improve Performance andMaintain Safe PracticePerformance Improvement:includes measuring performance against a set of predetermined standards. In healthcare these standards may be set by the specific facility and take into considerationaccrediting and professional standards.The Joint Commission (formerly JCAHO):sets standards in relation to policies, procedures, and the competency of health careteam membersAnnually publishes the National Patient Safety Goals which specify the standard of carethat clients should receive.
  • Requirements include:policies, procedures, and standards describe and guide how the nursing staff providesnursing care, tx, and servicesAll nursing policies, procedures, and standards are defined, documented, andaccessible in written or electronic format.Step 1 Standard is developed and approved by facility committeeStep 2 Provide and document care according to the developed standard. An audit is performed to determine if the standard is being met.Retrospective audit: happens after the client receives careConcurrent audit: occurs while the client is receiving careProspective audit: predicts how future client care will be affected by current level ofservices.Step 3Educational or corrective action is provided when results indicate that a standard is notbeing met.The Nurseʼs Role in Performance Improvement:Step 1Serve as unit representative on committees developing policies and proceduresUse reliable resources for information (CDC, professional journals, evidenced basedresearch)Step 2Enhance knowledge and understanding of the facilityʼs policies and procedures.Provide client care consistent with these policies and proceduresDocument client care thoroughly and according to facility guidelinesParticipate in the collection of info/data r/t staffʼs adherence to selected policy orprocedureAssist with analysis of the info/data
  • Compare results with the established standardMake a judgment about performance in regard tot eh findingsStep 3Assist with the provision of education of training necessary to improve the performanceof staffAct as a role model by practicing in accordance with the established standardAssist with re-evaluation of staff performance by collection of info/data at a specifiedtime.Referrals: Assessing Need to Refer Clients for AssistanceA referral is made so that the client can access the care identified by the primary careprovider or the consultantThe care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eghospice care, home health aide)Clients being released from health care facilities and discharged to their home stillrequire nursing care.Discharge referrals are based on client needs in relation to actual and potentialproblems and may enlist the aid of : social services specialized therapists (eg: PT, OT, speech) care providers (eg home health nurses, hospice nurseKnowledge of community resources is necessary to appropriately link the client withneeded servicesTo ensure continuity of care by the use of referrals, the nurse should: Initiate the discharge upon the clientʼs admission Evaluate client/family competencies in relation to home care prior to discharge Involve the client and family in care planning Collaborate with other health care professionals to ensure all health care needsare met
  • Complete referral forms to ensure proper reimbursement for services offered.Staff Development: Selecting Staff Education Activities Based on Staff LearningStylesDomains of LearningCognitive learning, which includes all intellectual activities.Ex: person is taught and then can list what is learned.Affective learning, which includes feelings, opinions, and values.Ex: person is attentive and willing to listen to instructorPsychomotor learning, which is learning to complete a physical activity.Ex: client practices a skill.Auditory learners---learn by listeningVisual learners---learn by seeingKinesthetic learners---learn by doingStaff Development and Performance Improvement: Selecting EducationalActivities to Ensure Staff CompetenciesCompetence the ability to meet the requirement of a particular role Strategies to maintain competence include
  • use of checklists to provide a record of opportunities and the level of proficiency in relation to skills peer observation/evaluation, planned or incidental, to assess competence complete of electronic learning modules attendance at in-services to update skills attendance at training sessions to learn specialized skills (ACLS, PLSSupervising Client Care: Information Sources for Making Client AssignmentsAssignment Factors Client Factors complexity of care needed specific care needs (eg cardiac monitoring, mechanical ventilation) need for special precautions (eg private room with negative air pressure and anteroom, fall precautions, seizure precautions) Health care team factors Skills Experience Nurse to client ratioManagement of Care (24)Plan BCulturally Competent Care: Recognize Need for Use of Translator for Non-EnglishSpeaking ClientCommunication Improve the nurse/client relationship when the communication barrier is great enough to impact the exchange of info between the nurse and client
  • use interpreters when the communication barrier is great enough to impact the exchange of info between the nurse and the client cautiously use nonverbal communication as it may have very different meanings for the client and the nursePeripheral Venous Disease: Modification of Care Plan in Response to DVTDevelopmentInterventionsDeep Vein Thrombosis and ThrombophlebitisEncourage REST facilitate bedrest and elevation of extremity above the level of the heart (avoidusing a knee gatch or pillow under knees) admin intermittent or continuous warm moist compresses (to prevent thrombusfrom dislodging and becoming an embolus, DO NOT massage the affected limb) provide thigh-high compression or antiembolism stockings to reduce venousstasis and to assist in venous return of blood to the heart.Admin meds as prescribed anticoags unfractionated heparin IV based on body wt is given to prevent formation ofother clots and to prevent enlargement of existing clot, followed by oral anticoag with warfarin. hospital admin is required for lab value monitoring and dose adjustment monitor aPTT to allow for adjustments of heparin dosage monitor platelet counts for heparin-induced thrombocytopenia ensure that protamine sulfate, the antidote for heparin is available if needed for excessive bleeding monitor the hazards and SE associated with anticoag therapy Low molecular wt Heparin (LMWH) is given subq.
  • Enoxaparin (Lovenox), dalteparin (Fragmin) and ardeparin (Normiflo) have consistent action and are approved for the prevent and tx of DVT may be managed at home by home care nurse must have stable DVT or PE, low risk for bleedign, adequate renal function and normal VS client must be willing to learn self injection the aPTT is not checked on an ongoing basis bec the doses of LMWH are not adjusted Warfarin works in the liver to inhibit synthesis of the four vit K dependent clotting factors takes 3-4 days before it has therapeutic anticoagulation heparin is continued until the warfarin effect is achieved then IV heparin may be d/cʼd if client is on LMWH, warfarin is added after the first dose of LMWH. Therapeutic levels are measured by INR monitor for bleeding ensure that Vit K (the antidote for warfarin) is available in case of excessive bleedingThrombolytic Therapy effective in dissolving thrombi quickly and completely must be initiated within 5 days after onset of sx to be most effective advantage is the prevention of valvular damage and consequential venousinsufficiency or postphlebitis syndrome contraindicated during pregnancy and following surgery, childbirth, trauma, aCVA, or spinal injury tissue plasminogen activator (t-PA), a thrombolytic agent, and platelet inhibitorssuch as abciximab (REoPRo), tirofiban (Aggrastat) and sptifibatide (Integrilin) may beeffective in dissolving a clot or preventing new clots during the first 24 hr.
  • primary complication of therapy is serious bleedingAnalgesics: Admin as ordered to reduce painVenous Insufficiency Instruct client to elevate legs for at least 20 min four to five times/day above the level of the heart avoid prolonged sitting or standing, constrictive clothing or crossing legs when seated wear elastic or compression stockings during the day and evening put elastic stockings on before getting out of bed after sleep clean the elastic stockings each day, keep the seams to the outside, and do not wear bunched up or rolled down replace worn out compression stockings as needed on using an intermittent sequential pneumatic compression system instruct the client to apply the system twice daily for 1 hour in am and evening advise the client with an open ulcer that the compression system is applied over a dressingVaricose Veins emphasize the importance of antiembolism stockings as prescribed instruct the client to elevate the legs as much as possible instruct the client to avoid constrictive clothing and pressure on the legs.Consultation: Contacting Wound Care Consultant when Outcomes are Not BeingMetA consultant is a professional who provides expert advice in a particular area. Aconsultation is requested to help determine what tx/services the client requires.
  • Consultants provide expertise to clients who require a particular type of knowledge orservice (eg. a cardiologist for a client who had a myocardial infarction, a psychiatrist fora client whose risk for suicide needs to be assessed.Coordination of the consultantʼs recommendations with other health care providersʼrecommendations is necessary to protect the client form conflicting and potentiallydangerous orders.Interventions:Initiate the necessary consults or notify the PCP of the clientʼs needs so the consult canbe initiated.Provide the consultant with all pertinent info about the problem (eg,, info from the client/family, the clientʼs medical records).Incorporate the consultantʼs recommendations into the clientʼs plan of care.Facilitate coordination of the consultantʼs recommendations with other health careprovidersʼ recommendations to protect the client from conflicting and potentiallydangerous orders.Question:A nurse is assigned to care for an older adult client who has been in the health carefacility for 3 weeks due to a total hip replacement and subsequent pulmonarycomplications. During morning assessment, the nurse notes that the client is beginningto develop a decubitus ulcer on his coccyx. Which of the following actions by the nursewould be most appropriate in an effort to obtain a plan of care for this problem?a. Notify the unit manager that staff may not be consistently or effectively carrying out the skin care protocol for high-risk clients.b. Call for a consult with the wound care nurse.c. Bring the problem to the attention of the surgeon during roundsd. Develop a nursing care plan for “impaired skin integrity: decubitus ulcer.”The nurse should call the wound care nurse for a consult with this client. since thewound care nurse is an expert in this area, she would be the most knowledgeableperson to enlist in the development of a plan of care. While the surgeon should benotified of the decubitus ulcer, she may not be as knowledgeable about tx options. It isappropriate to notify the unit manager that a client on the unit has developed adecubitus ulcer and that this may indicate a staff education need. However, this actionwould not facilitate the development of a plan of care for this client. Development of anursing care plan for “impaired skin integrity: decubitus ulcer: is indicated but should bedone with the wound care nurse to enhance the quality of care prescribed.
  • Delegation: Making Appropriate Client Assignment for a Float NurseAssignment Factors:Complexity of care neededSpecific care needs (eg cardiac monitoring, mechanical ventilation)Need for special precautions (eg private room with negative air pressure and anteroom,fall precautions, seizure precautions)Health care team factors:SkillsExperienceNurse-to-Client ratioFloating is an acceptable, legal practice used by hospitals to solve their understaffingproblemsLegally a nurse cannot refuse to float unless a union contract guarantess that nursescan work only in a specified area or the nurse can prove lack of knowledge for theperformance of assigned tasks.Nurses in a floating situation must not assume responsibility beyond their level ofexperience or qualificationNurses who float should inform the supervisor of any lack of experience in caring for thetype of clients on the new nursing unitThe nurse should request and be given orientation to the new unitDelegation: Identification of Client Concerns to be Reported to Nurse by AP forDelegated TasksQuestion:Toward the end of the shift, an LPN reports to an RN that a recently hired AP has nottotaled clientʼs I&O for the past 8 hr. Which of the following should the RN take?A. Confront the AP and instruct him to complete the I&O measurementsB. Delegate this task to the LPN since the AP may not have been educated on this taskC. Ask the AP if he needs assistance completing the I&O records.D. Notify the nurse manager to include this on the APʼs evaluation.
  • I&O measurements are routine AP tasks; however the AP is new and my need someassistance. Making assumptions and negative evaluation without direct evidence shouldbe avoided.Prioritizing Client Care: Recognizing Assessment Priorities Among MultipleClientsPrioritizing is deciding which needs or problems require immediate action and whichones could be delayed until a later time bec they are not urgent.Guidelines for PrioritizingThe nurse and client mutually rank the clientʼs needs in order of importance based onthe clientʼs physical and psychological needs, safety, and the clientʼs own needs andexpectations; what the client sees as his or her priority needs may be different fromwhat the nurse sees as the priorityPriorities are classified as high, intermediate, or low.Client needs that are life threatening or that could result in harm to the client if they areleft untreated are high prioritiesNonemergency and non-life-threatening client needs are intermediate prioritiesClient needs that are not related directly to the clientʼs illness or prognosis are lowprioritiesWhen providing care, the nurse needs to decide which ones could be delayed until alater time bec they are not urgentThe nurse considers client problems that involve actual or life-threatening concernsbefore potential health-threatening concernsWhen prioritizing care, the nurse must consider time constraints and availbalberesourcesProblems identified as important by the client must be given high priorityThe nurse can use the ABCs---as a guide when determining priorities; client needs r/tmaintaining a patent airway are always the priority
  • The nurse can use Maslowʼs hierarchy of needs theory as a guide to determinepriorities and identify the levels of physiological needs; safety, love and belonging, self-esteem; and self-actualization (basic needs are met before moving to other needs in thehierarchy)The nurse can use the steps of the nursing process as a guide to determine priorities;remember that assessment is the first step of the nursing processEthical Practice: Recognizing Clientʼs RightsThe clientʼs rights document also called the patientʼs bill of rights reflectsacknowledgement of clientʼs right to participate in their health care with an emphasis onclient autonomyThe document provides a list of rights of the client and responsibilities that the hospitalcannot violate.Right to considerate and respectful careRight to be informed about illness, possible txs, likely outcome, and to discuss this infowith the MDRight to know the names and roles of the persons who are involved in careRight to consent or refuse a txRight to have an advance directiveRight to privacyRight to expect that medical records are confidentialRight to review the medical record and to have info explainedRight to expect that the hospital will provide necessary health servicesRight to know if the hospital has relationships with outside parties that may influence txor careRight to consent or refuse to take part in researchRight to be told or realistic car alternatives when hospital care is no longer appropriateRight to know about hospital rules that affect tx and about charges and paymentmethods
  • Legal Responsibilities: Reporting Suspected Staff Substance AbuseNurses are required to report certain communicable diseases or criminal activities suchas abuse, gunshot or stab wounds, assaults, homicides and suicides to the appropriateauthoritiesThe impaired nurse If a nurse suspects that a co-worker is abusing chemicals, the nurse must report the individual to nursing admin in a confidential manner. Nursing admin then notifies the board of nursing regarding the nurseʼs behaviorResource Management: Identifying and Reporting Client Care NeedsResources (eg., supplies, equipment, personnel) are critical to accomplishing the goalsand objectives in a health care facilityResource management includes budgeting and resource allocationBudgeting is usually the responsibility of the unit manager, but the staff nurse may beasked to provide input.Resource allocation is responsibility of the the unit manager as well as every practicingnurse. Providing cost-effective client care should be balanced with quality of care.Cost-effective resource allocation includes:providing necessary equipment and properly charging client.Returning uncontaminated unused equipment to the appropriate dept for credit.Using equipment properly to prevent wastage.Providing training to staff unfamiliar with equipment.Returning equipment (eg., IV, kangaroo pumps) to the proper dept (eg central service,central distribution) as soon as it is no longer needed. This action will prevent furthercost to the client.Performance Improvement: Recognizing Priority Data Needed to Plan Staffing
  • Referrals: Recognizing Client Need for Rehabilitation ServicesResource Management: Safe Cost-Effectiveness Nursing InterventionsCost-Effective resource allocation includes:Providing necessary equipment and properly charging the clientReturning uncontaminated, unused equipment to the appropriate dept for credit.using equipment properly to prevent wastageProviding training to staff unfamiliar with equipmentReturning equipment (eg IV, kangaroo pumps) to the proper dept (eg central service,central distribution) as soon as it is no longer needed. This action will prevent furthercost to the client.Staff Development: Evaluate Outcomes of Staff Education ActivitiesStaff Development: Orientation to the WorkplaceOrientation helps new graduates translate knowledge, principles, skills, and theories learned in nursing school into practice
  • is necessary for nurses new to health care facility or unit to learn the procedures and protocolsTopic DescriptorsPHARMACOLOGICAL AND PARENTERAL THERAPIES (24)Form AMedications to Treat Depression: Recognizing Side Effects of TricyclicAntidepressantsMohr---predominant SE of tricyclic antidepressants are:sedationdry mouthblurred visionurinary retentiondelayed micturitiondizzinessfaintingOther SEconfusiondisturbed concentrationweight gainconstipationATI----Select Prototype Med: amytriptyline (Elavil)
  • Side/Adverse Effect Nursing Intervention/Client Education Orthostatic Hypotension Instruct clients about the signs of postural hypotension (lightheadedness, dizziness). If these occur, advise the client to sit or lie down. Orthostatic hypotension can be minimized by getting up slowly Anticholinergic effects (eg., dry mouth, Instruct the client on ways to minimize blurred vision, photophobia, acute urinary anticholinergic effects. retention, constipation, tachycardia) Advise the client to chew sugarless gum, eat foods high in fiber, and increase water intake to at lease 8-10 glasses/day Teach the client to monitor HR and report noteworthy increases. Advise the client to notify the primary care provider if sx are intolerable. Cardiac toxicity usually only at excessive Obtain the clientʼs baseline ECG and dosing monitor during tx Sedation Usually diminishes over time Advise clients to avoid hazardous activities such as driving if sedation is excessive. Advise the client to take med at bedtime to minimize daytime sleepiness and to promote sleep Toxicity evidenced by dysrhythmias, Give Clients who are acutely ill only a 1- mental confusion, and agitation, followed week supply of med by seizures, and coma Monitor the client for signs of toxicity Notify the PCP if signs of toxicity occur.Immunosuppressants: Recognizing Risk Factors for InfectionCalcineurin inhibitors: cyclosporine(Sandimmune, Gengraf, Neoral)Glucocorticoids: PrednisoneCytotoxics: azathioprine (Imuran)tacrolimus (Prograf), methotrexate (Rheumatrex, trexall)
  • increases risk of infection such as fever an/or sore throughadvise the client if sx occur to notify the primary care provider immediatelyGlucocorticoids are contraindicated in recurring live virus vaccines (increases risk ofinfection) and systemic fungal infections.Cyclosporine is contraindicated in recent contact or active infection of chicken pox orherpes zosterEstrogens: Recognizing Side Effectsendometrial and ovarian CA--occur when prolonged estrogen is the onlypostmenopausal therapy give client progestins along with estrogen instruct client to report persistent vaginal bleeding advise client to have endometrial biopsy q 2 yearspotential risk for estrogen-dependent breast CA-- rule out prior to starting therapy encourage regular self-breast exams and mammogramsembolic events (ie: MI, pulmonary embolism, DVT, CVA) discourage client from smoking monitor the client for pain, swelling, warmth or erythema in lower legsfeminization (gynecomastia, testicular and penile atrophy),, impotence, and decreasedlibido in males avoid use of estrogen vaginal creams prior to sexual intercourse sx disappear when med is discontinuedMagnesium Sulfate Therapy: Appropriate Interventions to Counteract Toxicity fora client with Gestational HypertensionGestational Hypertension begins after the 20th week of pregnancy
  • BP at 140/90 or greatersystolic increase of 30 mmHgdiastolic increase of 15 mmHgthere is no proteinuria or edemaclientʼs BP returns to baseline by 6 weeks postpartumMagnesium Sulfate Toxicity includeabsence of patellar DTRsUOP < 30 cc/hrResp < 12/mindecreased LOCIf Mag toxicity is suspected immediately discontinue infusion administer calcium gluconate, (IV admin of 1 g (10ml of 10% soln) at 1 ml/min)Discontinue mag if RR < 12, a low pulse ox (<95%) persists or DTRs are absentNotify MDIf UOP falls below 20ml/hr the MD is notified so that the drugʼs admin can be adjusted tomaintain a therapeutic rangeCalcium opposes the effects of mag at the neuromuscular junctionAlways have an injectable form of calcium gluconate avail when administeringmagnesium sulfate by IVSuccinylcholine: Recognizing and Responding to Malignant HyperthermiaMalignant hyperthermia is a rare metabolic disease characterized by hyperthermia withrigidity of skeletal muscles that can result in deathoccurs in affected people exposed to certain anesthetic agentsSuccinylcholine (Anectine) especially in conjunction with volatile inhalation agents,appears to be the primary trigger of the disorderusually during general anesthesia but it may manifest in the recovery period as well.
  • fundamental defect: hypermetabolism resulting in altered control of intracellular calciumleading to muscle contracture, hyperthermia, hypoxemia, lactic acidosis andhemodynamic and cardiac alterations.hyperthermia not an early signdefinitive treatment is Dantrolene (Dantrium) which slows metabolism along withsymptomatic support to correct hemodynamic instabilityBlood and Blood Products: Evaluating Client Response to Blood TransfusionsNS okNo dexrose solnʼs or lactated other additives s/b given via the same tubingDuring 1st 15 min or 50ml the nurse should remain with the ptrate s/b no more than 2ml per minusual rate after the 1st 15 min...1 unit over 2 hrsshould not take more than 4 hrs to administer.Steps if acute blood reaction occurs.e. Stop the transfusionf. Maintain a patent IV line with saline solng. notify the blood bank and HCP immediatelyh. recheck ID tags and numbersi. monitor VS and UOPj. tx sx per MD orderk. save the blood bag and tubing and send them to blood bank for examl. complete tranfusion reaction reportsm.collect required blood and urine specimens at intervals stipulated by hospital policy to evaluate for hemolysisn. document on transfusion reaction.Acute reactions: 15 minDelayed reactions: 2-14 days after administration
  • Acute hemolytictreat shock if presentdraw blood samplesmaintain BP with IV colloid solngive diuretics to maintain urine flowinsert indwelling cath or measure amts of hourly UOPdo not transfuse additional RBCFebrilegive antipyretics as prescribeddo not restart transfusionMild allergicgive antihistamine as directedif sx are mild and transient, transfusion may be restartedAnaphylactic and severe allergicinitiate CPR if indicatedhave epi ready for injection 0.4 ml of 1:1000 soln SQ or 0.1 ml 1:1000 soln diluted to10ml with saline for IV useDo not restart transfusionCirculatory overloadplace pt upright with feet in dependent positionadmin prescribed diuretics, 02, morphinephlebotomy may be indicatedSepsisobtain culture of ptʼs blood and send bag with remaining blood and tubing to blood bankfor further studytreat septicemia as directed---abx, IV, fluidsVascular Access: Recognizing and Documenting Expected Finding for a Clientwith a central venous access device.PICC line
  • Insertion: basilic or cephalic vein at least 1 fingerʼs breadth below or above theanticubital fossa. tip is positioned in the lower 1/3 of the superior vena cavaIndications:admin of bloodlong term admin of chemoabxtpncare:assess q 8 hr. note redness, swelling, drainage, tenderness and condition of dressingchange tube and positive pressure cap per protocol (usually q 3 days)us 10ML or larger syringe to flush the lineclean insertion port with alcohol for 3 sec, let dryperform flush for intermittent med admin usually 10 Ml of NS before, between and aftermeds.use transparent dressing usually change q 7 days and when indicatedadvise client to avoid excessive physical exercise on affected extremityTunneled Caths (Hickman)Insertion: subq tunnel separating point where the cath enters the vein from where itenters the skin with a cuffindication:need for vascular access is long term (1 year or more)commonly for chemocare:to access:apply local anesthetic, palpate to locate the portclean with alcohol for 3 secaccess with noncoring needleflush after q use and at least once a monthBasic Pharmacological Principles: Expected Dosage Adjustments Based on Ageof ClientPediatric dosages are based on body wt, body surface area and maturation of bodyorgans.meds are based on age bec of greater risk for decreased skeletal growth, acute CVfailure or hepatic toxicity.
  • Hematopoietic Growth Factors: Evaluating Client OutcomesHematopoietic growth factors act on the bone marrow to increase production of redblood cellsEpoetinused for anemia of CRF HIV infected clients taking Retrovir anemia induced by chemo anemia in clients scheduled for elective surgerySE: hypertension secondary to elevations in HCT increased risk for CV eventNursing Interventions:Monitor clientʼs iron levelsRBC growth dependent on adequate quantities of iron, folic acid, and vit B12monitor the clientʼs Hgb and Hct twice a week until target range is reachedobtain baseline BPin CRF, control HTN before txdo not combine with other medEvaluation of med effectiveness : Hgb level of 10-12 and HCT of 40% increased reticulocyte countfilgrastin (Neupogen), pegfilgrastin (Neulasta)stimulate the bone marrow to increase production of neutrophilsdecreases the risk of infection in clients with neutropeniaSE: bone painleukocytosis---decrease dose or stop tx if WBC > 50000 or platelets > 500000contraindicated in clients sensitive to E. Colishould not be combined with other med
  • Evaluation of Medication Effectivenessabsence of infectionin chemo for CA tx, an absolute neutrophil count increase to greater than 10,000 afterchemo induced nadir.sargramostim (leukine)acts on the bone marrow to increase production of WBC (neutrophils, monocytes,macrophages, eosinophilsfacilitates recovery of bone marrow after bone marrow transplantused in the tx of failed bone marrow transplantSE: diarrhea, weakness, rash, bone painleukocytosis, thrombocytosisreduce tx if WBC> 50000, neutrophil > 20000 or platelets > 500000contraindicated in clients allergic to yeast productsuse cautiously in clients with heart disease, hypoxia, peripheral edema, pleural andpericardial effusionEvaluation of Medication Effectivenessabsence of infectionWBC and differential within normal rangesProton Pump Inhibitors: Client Educationomeprazole (Prilosec)reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastricacidprescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions(Zollinger-Ellison syndrome)Allow at least a 2 hr interval between this med and:AmpicillinDigoxin
  • Ironketoconazoledelayed absorption of these meds may occur if taken concurrently with omeprazole.Therapeutic Interventions and Client EducationDo not crush, chew, or break sustained release capsulesmay sprinkle contents of the capsule over food to facilitate swallowingtake once a day prior to eatingavoid irritating meds (ibuprofen, ETOH)active ulcers should be txʼd for 4-6 weeksProtonix (pantoprazole) can be admin to client IV. Monitor IV site. may be low incidenceof HA and diarrheatnotify PCP for any sign of obvious or occult GI bleedingMigraine Medications: Evaluating Appropriate Use of Sumatriptan (Imitrex)sumatriptan (Imitrex)serotonin receptor agonistprevent the inflammation and dilation of the incranial blood vessels thereby relievingmigraine paintherapeutic usesto abort acute migraine attackprevent migraine attackContraindicated in clients with ischemic heart disease, hx of MI, uncontrolled HTN andother heart diseasesdo not give with ergotamine (ergostat)---leads to spastic reaction of blood vessels.don not give triptans within 2 weeks of stopping MAOIs---can lead to MAO toxicity.
  • Cephalosporins: Evaluating Tx Effectivenessbeta-lactam abx similar to PCNs that destroy bacterial cell walls causing destruction ofmicroorganismseffective against gram neg organisms and anaerobesmore able to reach CSFbroad spectrum bactericidal meds with a high therapeutic index that treat UTIs, post opinfections, pelvic infections, and meningitis.Evaluation of Medication Effectivenessimprovement of infection sx: reduction of fever, pain, and inflammation, clear breathsounds, reduced UTI sx, negative urine CXBasic Principles of Med Admin: Client Education Regarding Age RelatedinterventionsPromoting Compliance in the older adultsgive clear and concise instructions, verbally and in writingensure dosage form is appropriate. liquids should be admin to clients who have difficultyswallowingprovide clearly marked containers that are easy to openassist the client to set up a daily calendar with the use of pill containerssuggest that the client obtain assistance from a friend, neighbor, or relative.Medication Admin and Error Prevention: Disposing of Unused ControlledSchedule MedicationsIf only one part of a premeasured dose of a controlled substance is given, a secondnurse witnesses disposal of the unused portion and documents such on the record formDosage Calculation: Calculating Hourly Infusion Rate for a Large Volume of FluidA RN is to admin 500 mL of D5W over 4 hr. The IV pump should be set to deliver howmany mL per hour125 mL/ hr
  • An IV med is to run over 20 min on the pump. The med is mixed in 50 ML of NS. The IVpump should be set to deliver how many mL/hr.150mL/hrAn IV med is to run over 45 min on the pump. The med is mixed in 100mL of NS. The IVpump should be set to deliver how many mL/ hr?133 mL/hr.Intravenous Therapy: Priority Interventions with Initiation of TherapyUnexpected Outcomes and Related InterventionsFluid volume deficit AMB decreased UOP, dry mucous membranes, hypotension,tachycardia notify MD, may require adjustment of infusion rateFluid Volume excess AMB crackles in lungs, shortness of breath, edema reduce IV flow rate if sx appear and notify MDElectrolyte imbalances AMB abnormal serum electrolyte levels, changes in mentalstatus and alterations in neuromuscular function, changes in VS and othermanifestations notify MD. additives in IV or type of IV fluid may be adjusted.Infiltration as indicated by swelling and possible pitting edema, pallor, coolness, pain atinsertion site and possible decrease in flow rate stop infusion and d/c IV. elevate affected extremity. restart new IV if continuedtherapy is necessaryphlebitis as indicated by pain, increased skin temp, erythema along path of vein. stop infusion and d/c IV. restart new IV if continued therapy is necessary. place moist warm compress over area of phlebitisBleeding occurs at venipuncture site bleeding from vein is usually slow, continuous seepage. common in clients whohave received heparin or have a bleeding disorder or if the IV site is over bend in arm/handif bleeding occurs around venipuncture site and catheter is within vein, gauze dressingmay be applied over site. eventually IV may need to be discontinuedblood on the dressing can result when the administration set becomes disconnectedfrom the catheterʼs hub. When blood appears on the dressing, verify that the system isintact and change the dressing
  • Intravenous Therapy: Documenting Discontinuation of IV Following Signs ofPhlebitisSigns of PhlebitisEdemaThrobbing, burning or pain at the siteWarmthErythemaMay be a red line up the arm with a palpable band at the vein siteSlowed infusionPrevention:rotation of sitesavoiding the lower extremitiesproper handwashing and surgical aseptic technique.Promptly d/c infusion.Notify PCPelevationwarm/moist compressesrestarting with new tubing and fluidTED hose and/or anticoagulantsculturing the site if drainage is present(P/P)Unexpected Outcomes and Related InterventionsPhlebitis is present, as evidenced by erythema and tenderness along vein pathway. Stop IV infusion and d/c IV. Restart new IV in other extremity if continued therapyis necessary.Record appearance of IV site, type of dressing, and status of IV fluid infusion.A special parenteral fluid flow sheet may be used for recording.Medications Affecting the Respiratory System: Recognizing Ineffectiveness ofBeta2-Adrenergic Agonists.albuterol (Proventil, ventolin)act by selectively activating the beta2 receptors in the bronchial smooth muscleresulting in bronchodilation. As a result:
  • bronchodilation is relievedhistamine release is inhibitedciliary motility is increasedprevention of asthmatx for ongoing asthma attacklong term control of asthmaEffectiveness may be evidenced bylong term control of asthma attacksprevention of exercise induced asthma attackresolution of asthma attack as evidenced by absence of SOB, clear breath sounds,absence of wheezing, return of RR to baseline.Oral Hypoglycemics: Client Teaching Regarding Use in PregnancyAvoid use in pregnancy and lactation (risk for fetal/infant hypoglycemia)Oral hypoglycemic medication contraindicated (causes birth defects).Medications Used to Treat TB: Recognizing Risk for Phenytoin Toxicity due toMed interactions.INH (isoniazid)highly specific for mycobacteria. Isoniazid inhibits growth of mycobacteria by preventingsynthesis of mycolic acid in the cell wallindicated for active and latent TB Latent INH only ---daily for 6 months Active: multiple med therapy including INH, rifampin, pyrazinamide, and/orpyridoxine daily for 6 monthsMed reaction:Phenytoin--INH interferes with the metabolism of phenytoin with accumulation ofphenytoin, resulting in ataxia, and incoordinationmonitor levels of phenytoin. dosage of phenytoin may need to be adjusted based onphenytoin levels.Opioids: Monitoring Client for Interactions with Anesthesia
  • Opioids are used preoperatively for sedation and analgesia, intraoperatively forinduction and maintenance of anesthesia and postop for pain management. Opioidsalter the perception of pain and the response to painful stimuli. When admin before theend of a surgical procedure the residual analgesia often carries over into the PACUallowing the pt to awaken relatively pain free.All opioids produce dose-related respiratory depression. Respiratory depression maybe difficult to detect in the OR and therefore requires close observation and pulseoximetry monitoring. Respiratory depression is reversed with naloxone (Narcan).However its use is often associated with a reversal of the analgesic effects of thenarcotics as well.Pain Management: Evaluating Effectiveness of TreatmentPain Management:The goals of teaching r/t pain management include that the pt and family memberunderstand the followingneed to maintain a record of pain level and effectiveness of txno need to wait until becomes severe to take drugs or use nondrug therapies for painreliefmed will stop working after it is taken for a period of time, and dosages may need to beadjustedpotential SE and complications associated with therapy. SE: N/V, constipation, itching,sedation and drowsiness, urinary retention, sweatingneed to report when pain is not relieved to tolerable levels.client attained her pain relief goal most of the timeclient is performing ADLs, walking and ability to sleepif nurse assess that a client continues to have discomfort after an intervention, it may benecessary to try a different approach. If an analgesic provides only partial relief, thenurse may add relaxation exercises or guided imagery exercises. The nurse may alsoconsult with the physician about increasing the dosage, decreasing the interval betweendoses, or trying different analgesics.nurse evaluates the clientʼs perceptions of the effectiveness of the interventions. Theclient may help decide the best times to attempt a tx. in essence, the client is the bestjudge of whether an intervention works. The nurse also evaluates tolerance to therapyand the overall relief obtained. a nurse admin an analgesic, SE from the med and theclientʼs reported pain relief must be assessed.client is the best resource for evaluating the effectiveness of pain relief measures.TPN: Recognizing Appropriate TPN Interventions
  • TPN: a nutritionally adequate hypertonic soln consisting of glucose and other nutrientsand electrolytes given through an indwelling or central IV catheter which may beinserted peripherally or percutaneously, implanted or tunneled.PN: is a form of specialized nutrition support in which nutrients are providedintravenously. Safe admin of the form of nutrition depends on appropriate assessmentof nutrition needs, meticulous management of the CVC and careful monitoring toprevent or tx metabolic complications. Parenteral nutrition is admin in a variety of settingincluding the clientʼs home. Regardless of the setting, the nurse adheres to the sameprinciple of asepsis and infusion management to ensure safe nutrition support.clients who are unable to digest or absorb enteral nutrition benefit from PN.goal to move toward the use of the GI tract is constant.lipid emulsions provide supplemental kilocalories and prevent essential fatty aciddeficiencies. These emulsions can be admin through a separate peripheral line, throughthe central line by Y-connector tubing or as an admixture to the PN soln.The addition of lipid emulsion to the PN solution is called a 3-in-1 mixture and is givenover a 24 hr period. The mixture should not be used if oil droplets are observed or i anoil or creamy layer is observed on the surface of mixture. indicates that the emulsionhas broken into large lipid droplets that can cause fat emboli if admin.Initiating PN:Clients with short-term nutritional needs often receive IV solnʼs of less than 10%dextrose via a peripheral vein in combination with amino acids and lipids. Peripheralsolns are not as caloricly dense as TPN solutions and therefore are usually temporary.Parenteral nutrition with greater than 10% dextrose requires a CVC that is placed into ahigh-flow central vein such as the superior vena cava by a MD under sterile conditions.After placement, the cath is flushed with saline or heparin until the position isradiographically confirmedBefore beginning any parenteral nutrition infusion, verify MDʼs order and inspect thesoln for particulate matter or a break in the lipid emulsion. An infusion pump is alwaysused. An initial rate of 40-60 ml/hr is recommended. The rate is gradually increased untilthe clientʼs complete nutrition needs are supplied.Preventing Complicationsinclude:mechanical complication from insertion of the CVCinfectionmetabolic alterations
  • pneumothorax results from a puncture insult to the pulmonary system and results in theaccumulation of air in the pleural cavity with subsequent collapse of the lung andimpaired breathing. sudden sharp chest pain dyspnea coughingair embolus can occur during insertion of the catheter or when changing the tubing orcap have pt perform valsalva maneuver (hold breath and bear down) while assuminga left lateral decubitus position can prevent air embolus the increased venous pressure created by the maneuver prevents air fromentering the bloodstream during cath insertioninfection tubing should be changed q 24 hrs with lipids and q 48 hrs with no lipids. during dressing changes, sterile mask and gloves are always used and insertionsites should be assessed for s/s of infectionVit K must be given as ordered throughout therapy. Vit K can be synthesized bymicroflora found in the jejunum and ileum with normal use of the GI tract however becPN circumvents GI use, exogenous vit K must be administered.Admin of concentrated glucose is accompanied by increases in endogenous insulinproduction, which causes cations (K+, Mg+ and Ph+) to move intracellularly.In malnourished or cachetic clients, the resulting low serum extracellular levels ofelectrolytes and edema may cause cardiac dysrhythmias, CHF, respiratory distress,convulsions, coma, death. (Refeeding syndrome)Too rapid admin of hypertonic dextrose can result in an osmotic diuresis anddehydration. If an infusion falls behind scheule, the nurse should not increase the rate inan attempt to catch up.Sudden discontinuation of the soln can cause hypoglycemia.usually 5-10% dextrose is infused when PN soln is suddenly d/cʼd.catheter occlusion
  • temporarily stop infusion and flush with NS or heparin. if effort to flush isunsuccessful, attempt to aspirate a clot, is still unsuccessful, follow protocol for use ofthrombolytic agent (urokinase)hypoglycemia to prevent: do not abruptly discontinue TPN but taper rate down to within 10% ofinfusion rate 1-2 hours before stopping.hyperglycemia monitor BG level daily until stable then as ordered or prn. TPN is initiated slowlyand tapered up to maximal infusion rate. additional insulin may be required duringtherapy if problem persists.Form BAminoglycosides: Assessing for NephrotoxicityNephrotoxicity r/t high total cumulative dose resulting in acute tubular necrosis(proteinuria, casts in the urine, dilute urine, elevated BUN, creatinine levelsMonitor I/O, BUN, creatinine levelsNormal values:BUN 5-20 mg/dLCreatinine 0.5-1.3 mg/dLInstruct pt to report a significant decrease in UOPGlucocorticoids: Recognizing SE of Long Term TherapyHypokalemia may developPredisposition to peptic ulcer diseaseskeletal muscle atrophy and weaknessmood and behavior changesfat from extremities is redistributed to trunk and facehypocalcemia r/t anti-vit D effecthealing is delayed. at increased risk for wound dehiscencesusceptibility to infection is increased. Infection develops more rapidly and spreadsmore widelysuppression of pituitary ACTH synthesis occursincreased BP occurs
  • Protein depletion decreases bone formation, density and strengthCeftriaxone (Rocephin): Clostridium Difficile Complication During AntimicrobialTherapyantibiotic associated pseudomembranous colitis observe the pt for diarrhea and notify the PCP d/c abxAbx can cause diarrhea by altering the normal bowel flora. Pts receiving abx aresusceptible to Clostridium difficile infection. Health care workers who do not adhere toinfection control precautions can transmit C. difficile from pt to pt.Some strains of C. difficile release a toxin that causes mucosal damage resulting incramping, pain and diarrhea that may be bloody. C. Difficile infection can also result inpseudomembranous enterocolitis and intestinal perforation.Sx: watery diarrhea to severe abdominal pain; fever; leukocytosis; leukocytes in thestoolMedications Affecting Blood: Appropriate Procedure for Transfusing PackedRBCsAdmin of packed red blood cells increases the number of RBCBefore starting a packed RBC transfusion, verify the PCPʼs order, clientʼs blood typing,obtain consent for transfusion, and check clientʼs transfusion hxA second person is necessary to check id of donor blood and recipient, bloodcompatibility, and expiration orderassess the client before, during and after adminUpon initiation of the transfusion, obtain baseline VS and assessment of UOP,document on clientʼs MR, record start and completion times of transfusion, total volumeof transfusion and clientʼs response to transfusion,Assess infusion site for infection or infiltrationassess patency of IV linedo not admin blood along with any IV solution other than NS. IV solutions containingdextrose cause hemolysis of RBC
  • Admin blood using a gauge 19 or larger IV needle (to avoid breakage of cells andblockage of needle lumen), a blood filter (to remove particles and possible contaminantswithin old blood), and use a Y tubing connection (so that NS can be infused bypiggyback)Observe universal precautions during handling and admin of blood productsDo no admin blood products with any other medsComplete transfusion within 2-4 hrIn the event of a blood transfusion reaction Stop transfusion immediately and notify the PcP do not turn on IV fluids that are connected to the Y tubing bec the remainingblood in the Y tubing will be infused and aggravate the clientʼs reaction. Admin a new IVsoln of NSStay with the client and monitor VS and UOPNotify the blood bank, recheck ID tag and numbers on the blood tag and send bloodbag and IV tubing to blood bank for analysisObtain urine specimen and send to lab to determine for RBC hemolysisComplete transfusion log sheet, which includes complete record of baseline VS,ongoing monitoring, and clientʼs response to transfusion.Basic Dosage Calculation: Monitoring IV Heparin InfusionMonitor VS.In the case of heparin overdose, stop heparin, admin protamine sulfate and avoid ASAMonitor activated partial thromboplastin time (aPTT). Keep value at , 2 times thebaseline.Dosages must be checked by another nurse before admin.For continuous IV admin, use an infusion pump. Rate of infusion must be monitored q30-60 min.Monitor aPPT q 4-6 hr until appropriate dose is determined and then monitor dailyMedication effectiveness:
  • aPTT levels of 60-80 secNo development or no further development of venous thrombiGlucocorticoids for Rheumatoid Arthritis: Evaluating Client Education RegardingLong Term EffectsClient Teaching for Corticosteroid TherapyE. Plan a diet high in protein, calcium (at least 1500 mg per day) and potassium but low in fat and concentrated simple carbs such as sugar, honey, syrups and candy.F. Identify measures to ensure adequate rest and sleep such as daily naps and avoidance of caffeine lat in the dayG.develop and maintain an exercise program to help maintain bone integrityH.recognize edema and ways to restrict sodium intake to less than 2000mg per day if edema occursI. monitor glucose levels and recognize sx and signs of hyperglycemia (eg polydipsia, polyuria, blurred vision) and glycosuria (glucose in the urine). The pt should be instructed to report hyperglycemic sx or capillary glucose levels greater than 180 mg/ dL or urine positive for glucoseJ. notify HCP if experiencing postprandial heartburn or epigastric pain that is not relieved by antacids.K. See an eye specialist yearly to assess development of possible cataractsL. use safety measures such as getting up slowly from bed or a chair and use good lighting to avoid accidental injuryM.maintain good hygiene practices and avoid contact with persons with colds or other contagious illnesses to avoid infection.Osteoporosis Advise the client to take Ca supplements, vit D, and/or biphosphonateAdrenal suppression advise client to observe for sxInsulin: Monitoring Adequate Blood Glucose ControlMedication effectiveness:Glucose levels of 90-130 mg/dL preprandial and < 180 mg/dL postprandialHgA1c < 7 %Normotensive (< 130/80 mmHg)
  • Cholesterol levels within normal range Insulin Duration For meal time Onset Peak dose, admin Lispro insulin Short, rapid 15 min ac Rapid 15-30 min 1/2 - 2 1/2 hr (Humalog) acting (3-6.5 hr) Aspart insulin Short, rapid 5-10 min ac Rapid 10-20 min 1-3 hr (Novolog) acting (3-5 hr) Reg Insulin Short, slower 30 min ac 30 -60 min 1-5 hr (Humulin R, acting (6-10 hr) Bolus 30 min ac Novolin R) NPH insulin Intermediate Admin 2x/day 1-2 hr 6-14 hr (Humulin-N, (16-24 hr) (same time) Novolin-N) Glargine insulin Long (24 hr) Admin 1x/day 70 min None (Lantus) (same time)Cardiac Glycosides: Client Education to Reduce RiskTherapeutic Nursing Interventions and Client EducationAdvise clients to take med as prescribed and not to double the dose when a dose is nottaken at the prescribed timeCheck pulse rate and rhythm before admin of digoxin and record, notify the PcP if HR is< 60 beats/min in an adult, <70 beats/min in children and < 90 beats/min in infants.Admin dig at same time daily.Monitor dig levels periodically while on tx and maintain therapeutic levels between0.5-2.0 ng/mL to prevent dig toxicityAvoid taking OTC meds to prevent adverse SE and med interactionsInstruct clients to observe symptoms of hypokalemia such as muscle weakness, and tonotify the PCP if sx occur.
  • Instruct clients to observe sx of dig toxicity (eg anorexia, fatigue, weakness) and tonotify PcP if sx occurManagement of dig toxicityDig and potassium sparing med should be stopped immediatelyMonitor K levels. For levels, < 3.5 mEq/L, potassium should be administered IV or bymouth. Do not give any further K+ level > 5.0 mEq/LTreat dysrhythmias with phenytoin or lidocainetreat bradycardia with atropineFor excessive overdose, activated charcoal, cholestyramine, or Digibind can be used tobind Digoxin and prevent absorptionPharmacological Pain Management: Knowledge of Pudendal BlocksPudendal blocks anesthetizes the lower vagina and part of the perineum to provideanesthesia for an episiotomy and vaginal birth using low forceps if neededA pudendal block does not block pain from uterine contractions and the mother feelspressure.The pudendal block is a highly localized type of regional block similar to a dentalanesthetic that provides numbness for dental proceduresThe MD injects the pudendal nerves near each ischial spine with a local anesthetic.Perineum is infiltrated with local anesthetic bec the pudendal block does not fullyanesthetize this area.As in local infiltration, a delay occurs between injection and onset of numbness.Possible maternal complications include a toxic reaction to the anesthetic, rectalpuncture, hematoma, and sciatic nerve block.If maternal toxicity is avoided, the fetus is usually not affectedMedications to Treat Psychoses: Recognizing Adverse EffectsAntipsychotics: Conventional Thorazine, HaldolExtrapyramidal Symptoms
  • Early dystonia (severe spasms of tongue, neck, face and back) Parkinsonism (bradykinesia, rigidity, shuffling gait, drooling) tremors Akathisia (inability to stand or sit , pacing)Late tardive dyskinesia (twisting or worm-like movement of the tongue and face, lip smacking)Neuroleptic Malignant Syndrome sudden high grade fever, BP flucuations, dysrhythmias, muscle rigidity, change in LOC developing into comaAnticholinergic Effects dry mouth, visual disturbance, acute urinary retention, constipation, tachycardiaOrthostatic HypotensionSedationNeuroendocrine effects gynecomastia, galactorrhea, menstrual irregularitiesSexual dysfunctionSkin effects photosensitivity resulting in severe sunburn, contact dermatitis from handlingmedsAgranulocytosisSevere dysrhythmiasAntipsychotics-Atypical Clozapine Risperidone olanzapine quetiapine aripiprazoleAdverse Effects Agranulocytosis Seizures New onset of DM or loss of glucose control in clients with DM Wt gain Inflammation of hear muscle AEB dyspnea, increased RR, CP, palpitations.
  • ACE Inhibitors: Intervening for Client ResponseACE inhibitors produce their effects by blocking the production of angiotensin II Thisresults in: vasodilation (mostly arteriole) excretion of Na and H20, and retention of K+ (through effects on kidney) possible prevention of angiotensin II and aldosterone-induced pathological changes in blood vessels and heart. Side/Adverse Effects Interventions/Client Education First dose orthostatic hypotension if pt taking diuretic, stop med temporarily for 2-3 days prior to the start of an ACE inhibitor Start tx with a low dosage monitor the BP for 2 hr after initiation of tx instruct the client to change positions slowly and to lie down if feeling dizzy, lightheaded, or faint Cough inform client of dry cough notify PCP as med will most likely be d/cʼd HYPERKALEMIA monitor K+ levels to maintain normal range of 3.0-5.0 mEq/L Only take K+ substitutes if instructed by PCP Rash and dysgeusia (altered taste) client should inform PCP Angioedema (manifested as treat severe effects with swelling of the tongue and oral subcutaneous injection of pharynx epinephrine Neutropenia--rare complication of monitor the clientʼs WBC counts Captopril every 2 wks for 3 months, then periodically. inform the client to notify PCP at first signs of infection
  • Furosemide: Recognizing Interactions with Other MedicationsFurosemide (Lasix), a high ceiling loop diuretics work in the ascending limb of Loop ofHenle to Block reabsorption of Na+ and Cl-, and prevent the reabsorption of H20 Cause extensive diuresisSE: dehydration hypotension ototoxicity hypokalemiaInteractions with other Meds Medication Nursing Intervention Digoxin toxicity (can occur in the monitor ptʼs cardiac status and K+ and presence of hypokalemia dig levels K+ sparing diuretics are often used in conjunction with loop diuretics to reduce the risk of hypokalemia Antihypertensives--concurrent use can monitor BP have additive hypotensive effect Lithium--levels can rise due to diuresis monitor Lithium levels NSAIDS blunt diuretic effect Watch for a decrease in effectiveness of diuretic such as a decrease in UOPMedications to Treat Pain: Identifying Need for Additional Analgesia
  • Pain is whatever the person experiencing it says it is, and existing whenever the personsays it does. The clientʼs report of pain is the most reliable diagnostic measure of pain.Self report using standardized pain scales are useful in clients over the age of &Pain assessment should be done and recorded freq, and may be considered the fifthVSSubjective:LocationQualityIntensityTimingSettingAssociated sxBehaviors complement self-report and assist in pain assessment of nonverbal clients facial expressions body movements moaning, crying decreased attention spanPhysiological measures of BP, pulse, RR will be temporarily increased by acute pain.Follow a clinical approach ABCDE to pain assessment and managementA---ask about pain regularly, ASSESS pain systematicallyB---believe the client and familyC---choose appropriate pain control optionsD---deliver interventions in a timely fashionE--empower the client and familyRaking a proactive approach by giving analgesics before pain is severe (for PRN ordersof pain med)Educating the client regarding misconceptions about painAssisting the client to reduce fear and anxietyCreating a tx plan that includes both nonpharmacological and pharmacological painrelief measures.Total Parenteral Nutrition: Recognizing Desired Client Outcomes Based onPathophysiology
  • TPN: a nutritionally adequate hypertonic soln consisting of glucose and other nutrientsand electrolytes given through an indwelling or central IV catheter which may beinserted peripherally or percutaneously, implanted or tunneled.PN: is a form of specialized nutrition support in which nutrients are providedintravenously. Safe admin of the form of nutrition depends on appropriate assessmentof nutrition needs, meticulous management of the CVC and careful monitoring toprevent or tx metabolic complications. Parenteral nutrition is admin in a variety of settingincluding the clientʼs home. Regardless of the setting, the nurse adheres to the sameprinciple of asepsis and infusion management to ensure safe nutrition support.clients who are unable to digest or absorb enteral nutrition benefit from PN.goal to move toward the use of the GI tract is constant.lipid emulsions provide supplemental kilocalories and prevent essential fatty aciddeficiencies. These emulsions can be admin through a separate peripheral line, throughthe central line by Y-connector tubing or as an admixture to the PN soln.The addition of lipid emulsion to the PN solution is called a 3-in-1 mixture and is givenover a 24 hr period. The mixture should not be used if oil droplets are observed or i anoil or creamy layer is observed on the surface of mixture. indicates that the emulsionhas broken into large lipid droplets that can cause fat emboli if admin.Initiating PN:Clients with short-term nutritional needs often receive IV solnʼs of less than 10%dextrose via a peripheral vein in combination with amino acids and lipids. Peripheralsolns are not as caloricly dense as TPN solutions and therefore are usually temporary.Parenteral nutrition with greater than 10% dextrose requires a CVC that is placed into ahigh-flow central vein such as the superior vena cava by a MD under sterile conditions.After placement, the cath is flushed with saline or heparin until the position isradiographically confirmedBefore beginning any parenteral nutrition infusion, verify MDʼs order and inspect thesoln for particulate matter or a break in the lipid emulsion. An infusion pump is alwaysused. An initial rate of 40-60 ml/hr is recommended. The rate is gradually increased untilthe clientʼs complete nutrition needs are supplied.Preventing Complicationsinclude:mechanical complication from insertion of the CVCinfectionmetabolic alterations
  • pneumothorax results from a puncture insult to the pulmonary system and results in theaccumulation of air in the pleural cavity with subsequent collapse of the lung andimpaired breathing. sudden sharp chest pain dyspnea coughingair embolus can occur during insertion of the catheter or when changing the tubing orcap have pt perform valsalva maneuver (hold breath and bear down) while assuminga left lateral decubitus position can prevent air embolus the increased venous pressure created by the maneuver prevents air fromentering the bloodstream during cath insertioninfection tubing should be changed q 24 hrs with lipids and q 48 hrs with no lipids. during dressing changes, sterile mask and gloves are always used and insertionsites should be assessed for s/s of infectionVit K must be given as ordered throughout therapy. Vit K can be synthesized bymicroflora found in the jejunum and ileum with normal use of the GI tract however becPN circumvents GI use, exogenous vit K must be administered.Admin of concentrated glucose is accompanied by increases in endogenous insulinproduction, which causes cations (K+, Mg+ and Ph+) to move intracellularly.In malnourished or cachetic clients, the resulting low serum extracellular levels ofelectrolytes and edema may cause cardiac dysrhythmias, CHF, respiratory distress,convulsions, coma, death. (Refeeding syndrome)Too rapid admin of hypertonic dextrose can result in an osmotic diuresis anddehydration. If an infusion falls behind schedule, the nurse should not increase the ratein an attempt to catch up.Sudden discontinuation of the soln can cause hypoglycemia.usually 5-10% dextrose is infused when PN soln is suddenly d/cʼd.catheter occlusion
  • temporarily stop infusion and flush with NS or heparin. if effort to flush isunsuccessful, attempt to aspirate a clot, is still unsuccessful, follow protocol for use ofthrombolytic agent (urokinase)hypoglycemia to prevent: do not abruptly discontinue TPN but taper rate down to within 10% ofinfusion rate 1-2 hours before stopping.hyperglycemia monitor BG level daily until stable then as ordered or prn. TPN is initiated slowlyand tapered up to maximal infusion rate. additional insulin may be required duringtherapy if problem persists.Topic DescriptorsPhysiological Adaption (21)Form AProlapsed Umbilical Cord: Emergency Nursing ResponseProlapsed Umbilical Cord occurs when the umbilical cord is displaced preceding thepresenting part of the fetus or protruding through the cervixresults in cord compression and compromised fetal circulationAssessment:client states she can feel something coming through the vaginavisualization or palpation of the umbilical cord protruding from the introitusassessment that show FHR to have variable decelerationsextreme increase in fetal activity that occurs and then ceases. This may be suggestiveof severe fetal hypoxia.Nursing interventionsinclude relieving the cord compression immediately and increasing fetal oxygenationcall for assistance immediatelynotify the primary care provider of the prolapsed cordposition the clientʼs hips higher than her head
  • reposition the client in a knee chest position. Trendelenberg or a side-lying position witha rolled towel under the clientʼs right or left hip to relieve pressure on the cordusing a sterile gloved hand, insert two fingers into the vagina and apply finger pressureon either side of the cord to the fetal presenting part to elevate it off the cordapply a sterile saline soaked towel to the cord to prevent drying and to maintain bloodflow if it is protruding from the vaginal introitus.closely monitor the FHR with an electronic fetal monitor for variable decelerationsindicative of fetal asphyxia and hypoxia from cord compressionadminister oxygen at 8-10 L via a face mask. This will improve fetal oxygenationAmnioinfusion of NS or LR solution as prescribed should be instilled into the amnioticcavity through a transcervical catheter introduced into the uterus to alleviate cordcompression if it is caused by oligohydramniosprepare the client for a C-section if other measures fail.Myocardial Infarction: Evaluating Effectiveness of Medication InterventionsNursing InterventionsAdminister 02 4-6 L as prescribedObtain and maintain IV accessAdminister meds as prescribedVasodilators oppose coronary artery vasospasm and reduce preload and afterload,decreasing myocardial oxygen demand NITROGlYCERINAnalgesics reduce pain, which decrease sympathetic stress leading to preloadreduction MORPHINEBeta blockers have antidysrhythmic and antihypertensive properties and decrease theimbalance between myocardial oxygen supply and demand by reducing afterloadin an acute MI, beta-blockers decrease infarct size and improve short and long termsurvival ratesThrombolytic agents can be effective in dissolving thrombi if admin within the first 6 hrsfollowing an MI. Contraindications include recent surgery, recent head trauma, and anyother situation that poses an additive risk for bleeding internally.
  • Antiplatelet agents inhibit cyclooxygenase, which produces thromboxane A2, a potentplatelet activator ASPIRINAnticoags (heparin, low molecular wt heparins) are used to prevent the recurrence of aclot after fibrinolysisClient education regarding response to chest painstop activity and restplace nitro under tongue to dissolve (quick absorption)repeat every 5 min if the pain is not 911 if pain is not relieved in 15 min.Fractures: Discharge Teaching Regarding Cast CarePatient and Family Teaching GuideDo NotGet plaster cast wetRemove any paddingInsert any foreign object inside castBear wt on new cast for 48 hr (not all casts are made for wt bearing; check with HCPwhen unsureCover cast with plastic for prolonged periodsDoApply ice directly over fracture site for first 24 hr (avoid getting cast wet by keeping icein plastic bag and protecting cast with clothCheck with HcP before getting fiberglass cast wetDry cast thoroughly after exposure to water blot dry with towel use hair dryer on low setting until cast is thoroughly dryElevate extremity above level of heart for 1st 48 hrMove joints above and below cast regularlyReport signs of possible problems to HCP increasing pain
  • swelling associated with pain and discoloration of toes or fingers pain during movement burning or tingling under the cast sores or foul odor under the castKeep appointment to have fracture and cast checked.Electrolyte Imbalances: Evaluating Effectiveness of Hypokalemia InterventionsPotassium normal levels (3.5-5.0 mEq/L)most common causes: abnormal losses via the kidneys or GI tract, metabolic alkalosis,sometimes associated with tx of diabetic ketoacidosis bec of increased urinary K lossand shift of K into cells with admin of Insulin and correction of acidosisS/SExpected Findingsserum K+ < 3.5 mEq/Lmetabolic alkalosis: pH> 7.45EKG: PVCs, bradycardia, blocks, VTach, inverted T waves, ST depressionalters resting membrane potentialpotentially lethal ventricular arrhythmiasflattening of T wave and eventual emergence of a U wave, increased P waveskeletal muscle weakness and paralysis (most observed in legs)respiratory muscles and those innervated by cranial nerves not involvedmuscle cramps and muscle cell breakdown (rhabdomyolysis)leads to myoglobin in the plasma and urine which can in tern, lead to renal failure.Nursing Implementationtxʼd by giving potassium chloride supplements (PO or IV) and increasing dietary intakeof potassium
  • Except in severe deficiencies, KCl is never given unless there is UOP of at lease 0.5 ml/kg of body wt per hour.KCl supplements added to IV should never exceed 60mEq/L. Preferred level is 40 mEq/LRate should not exceed 10 to 20 mEq per hour to prevent hyperkalemia and cardiacarrest.ATIEncourage foods high in potassium (avocados, broccoli, dairy products, dried fruit,cantaloupe, bananasIV potassium never IV push (risk of cardiac arrest maximum recommended rate is 5-10 mEq/hr monitor for phlebitis monitor and maintain UOPmonitor for shallow ineffective respirations and diminished breath soundsmonitor the clientʼs cardiac rhythm and intervene promptly as neededmonitor LOC and maintain client safetymonitor bowel sounds and abdominal distention and intervene as needed.Fluid Imbalances: Appropriate Intervention in Response to Signs of Fluid VolumeExcesshypervolemia: both water and sodium are retained abnormally high proportionsoverhydration: more water is gained than electrolytesExpected FindingsHGB and HCT: Overhydration: decreased (hemodilution)Serum Osmolarity: Overhydration: decreased (hemodilution) osmolarity (<270mOsm/L) decreased protein and electrolytesSerum Sodium Overhydration: decreased (hemodilution)Electrolytes, BUN, creatinine
  • Hypervolemia: Increased electrolytes, BUN, and creatinineNursing Interventions: Report abnormal findings to PCPClient Findings:VS: tachycardia, bounding pule, HTN, tachypnea, increased ICPNeuro: confusionMS: muscle weaknessGI: wt gain, ascitesResp: dyspnea, orthopnea, cracklesOther: edema, distended neck veinsNursing Interventions:Assess breath soundsMonitor ABGs for hypoxemia and respiratory alkalosisposition the client in semi-Fowlerʼs positionadminister 02 as neededreduce IV flow ratesAdminister diuretics (osmotic, loop) as ordered.monitor daily I/O and WtLimit fluid and sodium as orderedMonitor and document presence of edema (pretibial, sacral, periorbital) monitor and document circulation to the extremities Turn and position the client at least q 2 hr support arms and legs to decrease dependent edema as appropriate monitor for/treat skin breakdownComplications:Pulmonary Edemas/s include ascending crackles, dyspnea at rest, and confusionposition in high Fowlerʼsadmin IV morphineAdmin IV diureticprepare for possible intubation and mechanical ventilationElectrolyte Imbalances: Recognizing Priority Interventions in Response toHyponatremia
  • Na+ serum level 135-145 mEq/Lhyponatremia is a net gain of water or loss of sodium rich fluidsdelays and slow the depolarization of membranesExpected FindingsSerum sodium decreased <135 mEq/LSerum osmolarity decreased < 270 mOsm/LExpected Client findingsdepends on whether it is associated with a normal decreased or increased ECF volumeVS: hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotensionNeur: HA, confusion, lethargyMS: muscle weakness to the point of possible respiratory compromise, fatigue,decreased DTRsGI: Increased motility, hyperactive bowel sounds, abdominal crampingNursing interventionsReport abnormal findings to PCPFluid Overload: restrict water intake as orderedacute hyponatremia admin hypertonic oral and IV fluids as ordered encourage foods and fluids high in sodium (cheese, milk, condiments)restoration of normal ECF: administer isotonic IV therapy (0.9% NS, LR)monitor I/O and daily wtmonitor VS and LOC--report abnormal findings.Complications: SeizuresCongenital Heart Disease: Interventions for Decreased Cardiac OutputCardiac output (CO) depends on preload, afterload, and myocardial contractility, HR,and metabolic state of the individ.
  • overloaded heart resorts to compensatory mechanisms to try to maintain adequate CO.The main compensatory mechanisms include ventricular dilation, ventricularhypertrophy, increased SNS stimulation and neurohormonal responses.As CO falls, blood flow to kidneys decreases,Low CO causes a decrease in cerebral perfusion pressure.Interventions for CHF:If client is experiencing respiratory distress, place the client in high Fowlerʼs position andadmin 02 as prescribedencourage bedrest until the client is stableencourage energy conservation by assisting with care and ADLsmaintain dietary restrictions as prescribed (restricted fluid intake, restricted sodiumintake)administer meds as prescribed diuretics: todecrease preload loop diuretics (furosemide (Lasix), bumetanine (Bumex) ) thiazide diuretics: HCTZ tech client taking loop or or thiazide diuretics to ingest foods and drinks that arehigh in K+ to counter hypokalemia effect. Potassium supplement may be required. Administer IV furosemide no fast than 20mg/min Afterload reducing agents ACE inhibitors (enalapril, captopril, monitor for initial dose hypotension beta blockers (Coreg, metoprolol) Angiotensin II blockers such as losartan Inotropic agents digoxin dopamine dobutamine milrinone to increase contractility and thereby improve CO Vasodilators nitrates to decrease preload and afterload
  • hBNP nesiritide (Natrecor) to tx acute HF by causing natriuresis (loss of sodium and vasodilation) Anticoagulants warfarin (Coumadin), heparin, clopidrogrel to prevent thrombus formation associated with congestion/stasis and associated afib.Shock: Recognizing S/S of HypovolemiaHypovolemic shock occurs when there is a loss of intravascular fluid volumeOne of the first clinical signs of shock may be a fall in BPDecreased LOCRestlessnessAnxietyWeaknessRapid, weak, thready pulsesArrhythmiasHypotensionNarrowed pulse pressurecool clammy skintachypnea, dyspnea, shallow irregular respirationsdecreased 02 saturationextreme thirstN/Vchillsfeeling of impending doompallorcyanosisobvious hemorrhage or injurytemp dysregulationAcute GI Disorders: Recognizing S/S to reportAppendicitismild or cramping, epigastric or periumbilical pain (initial)constant, intense RLQ pain (later)N/V
  • anorexiaRebound tenderness (pain after deep pressure is applied and released overMcBurneyʼs point (located halfway between the umbilicus and anterior iliac spine)Pain that decrease with a decrease in right hip flexion or increases with coughing andmovement may indicate perforation with peritonitismuscle rigidity, tense positioning, guarding may indicate perforation with peritonitisnormal to low grade temp (higher suggests peritonitis)Acute Abdominal/GI Findings (Med-Surg)Diffuse, localized, dull, burning or sharp abdominal pain or tendernessrebound tendernessabdominal distentionabdominal rigidityN/V/DhematemesismelenaAbdominal TraumaSurface Findingsabrasions or ecchymosis on abdominal wall, flank, or peritoneumopen wounds, lacerations,eviscerationspuncture wounds, gunshot woundsimpaled objecthealed incisions or old scarsAbdominal/GI FindingsN/VBloody urineabdominal distentionabdominal rigidityabdominal pain with palpationrebound tendernesspain radiation to shoulder and backHerpes Zoster: Evaluating Client TeachingInterventionsUse an air mattress or bed cradle for pain prevention/controlisolate the client until the vesicles are crusted
  • maintain strict wound care precautionsHerpes zoster is potentially transmissible and caution should be exercised aroundinfants, pregnant women who have not had chickenpox, and immunocompromisedclients.Administer meds as prescribed Analgesics (NSAIDS, narcotics) Antiviral agens such as acyclovir, valacyclovir, favicilovir (shorten the clinicalcourse)moisten dressings with cool tap water or 5% aluminum acetate (Burowʼs solution) andapply to the affected skin for 30-60 min 4-6x/day as prescribedLotions (for example, Calamine) may help relieve discomfort.Cystic Fibrosis: Managing Illness at HomeCare in the Home (ATI)Ensure parents/caregivers have information regarding access to medical equipmentProvide teaching about equipment prior to dischargeInstruct parents/caregivers in ways to provide CPT and breathing exercises. Forexample, a child can “stand on her head” by using a large cushioned chair place againsta wall.administer abx through a venous access port. Parents/caregivers need instruction inadmin techniques, SE to observe for, and how to manage difficulties with the venousaccess portPromote regular PCP visitsEnsure up-to-date immunizations with the addition of initial influenza vaccine at 6months of age and then a yearly booster.Encourage regular physical activityEncourage participation in a support group and involvement in community resources.Question:
  • A child with cystic fibrosis and his parent are receiving discharge teaching by a nurse.Which of the following statements made by the parent indicates a need for furtherinstructiono. My child should not get an annual influenza vaccine bec of increased riskp. I will have my child stand on his head for chest physiotherapyq. We will encourage our child to use the Flutter mucus clearance devicer. Our child will use a metered dose inhaler to administer a bronchodilatorCystic fibrosis is hereditary and is transmitted as an autosomal recessive trait, bothparents must be carriers.Cystic fibrosis is a dysfunction of the exocrine glands, causing the glands to producethick, tenacious mucus.Major organs affected are the lungs, pancreas and liverInitial sx may occur at varying ages during infancy, childhood, or adolescenceThick mucus obstructs the respiratory passages causing trapped air and overinflation ofthe lungs.Abnormally thick mucus leads to obstruction of the secretory ducts of the pancreas, liverand reproductive organs which alters the fx of those organsSweat and salivary glands excrete excessive electrolytes specifically sodium andchlorideThe multisystem disease results in increased viscosity of secretions, causingobstruction of small pathways in various organs (eg bronchioles, pancreas, smallintestine, bile ductsChronic, recurrent respiratory infections are a classic sign of the disease process.Atelectasis and small lung abscess are common early complications. Bronchiectasisand emphysema may develop with pulmonary fibrosisInterventionsResp interventionsPromptly tx resp infx with abx therapyprovide pulmonary hygiene with CPT (eg breathing exercises to strengthen thoracicmuscles) a minimum of twice a day (in the am and at bedtime)Have the child use the Flutter mucus clearing device to assist with mucus removal
  • Administer bronchodilators through MDIs or hand held neb to promote expectoration ofexcretionsAdminister dornase alfa (Pulmozyme) through a nebulizer to decrease viscosity ofmucus.Promote physical activity that the child enjoys to improve mental well being, self-esteem, and mucus secretion.GI interventionsAdminister pancreatic enzymes with meals and snacks The amt of enzyme replacement will vary between children based on each childʼsdeficiency and response to the replacement instruct the child/family that the capsules can be swallowed whole or opened tosprinkle the contents on a small amt of food encourage the child to select meals and snacks if appropriate facilitate high caloric, high protein intake through meals and snacks multiple vits and water soluble forms of A, D, E, K are often prescribed.HIV/AIDS: Interventions to Prevent Spread of HIVHIV is transmitted through blood and body fluids (semen, vaginal secretions)HIV is found in breast milk, amniotic fluid, urine, feces, saliva, tears, CSF, lymph nodes,cervical cells, corneal tissue and brain tissue, but epidemiologic studies indicate thatthese are unlikely sources of infections.Risk Factorsunprotected sex (vaginal, anal, oral)multiple sex partnersoccupational exposure (healthcare worker)perinatal exposureblood transfusions (not a significant source of infection in the U.S.)IV drug use with contaminated needle
  • Med/Surg---Prevention techniques divided into safe activities (those that eliminate risk) and risk-reducing activities (those that decrease risk but do not eliminate it).Decreasing risks r/t sexual intercoursesafe sex eliminates the risk of exposure to HIV in semen and vaginal secretionsabstaining is the most effective way to accomplish this but there are safe options forthose who cannot or do not wish to abstainoutercourse (limiting sexual behavior to activities in which the mouth, penis, vagina orrectum does not come into contact with a partnerʼs mouth, penis, vagina, or rectum) issafe bec there is not contact includes massage, masturbation, mutual masturbation, telephone sexinsertive sex between partners who are not infected with HIV or not at risk of becominginfected with HIV is considered to be safeRisk reducing sexual activities decrease the risk of contact through the use of barriers. should be used when engaging in insertive sexual activity with a partner who isknown to be HIV infected or with a partner whose HIV status is not known most common barrier device is male condom female condoms squares of latex plastic food wrapDecreasing risks r/t drug usemajor risk for HIV infection is r/t sharing injecting equipment and/or having unsafe sexexperiences while under the influence of drugs.basic rulesdo not use drugsif you do, donʼt share equipment
  • do not have sex when under the influence of any drug (including alcohol) that impairsdecision making abilityuse alternatives to injecting such as smoking, snorting, or ingesting the durginjecting equipment includes needles, syringes, cookers (spoons or bottle caps used tomix the drug) cotton, and rinse wateranother safe tactic is for the user to have access to sterile equipment (needle exchangeprograms)cleaning equipment before use is a risk-reducing activityDecreasing risks for perinatal transmissionbest way to prevent HIV in infants is to prevent HIV infection in womenIf HIV-infected pregnant women are txʼd with AZT, REtrovir, the rate of perinataltransmission is decreased.tx has minimal SE for the babyCombination ART as appropriate for the motherʼs HIV infection can further decrease therisk of perinatal transmission to less than 2%Decreasing risks at workemployers must protect workers from exposure to blood and other potentially infectiousmaterials.precautions and safety devices decrease the risk of direct contact with blood and bodyfluids.should exposure to HIV infected fluids occur, postexposure prophylaxis withcombination ART based on the type of exposure the volume of exposure and the statusof the source pt decreases the risk of infections.Glomerular Disease: Recognizing Risk factorsRisk Factors (ATI)Immunological Reactions Primary infection with group A beta-hemolytic streptococcal infection (mostcommon) Systemic Lupus Erythematosus
  • Vascular injury (HTN)Metabolic disease (DM)Nephrotoxic drugsExcessively high protein and high sodium dietsBurns: Priority InterventionsChemical BurnsEmergency InterventionsEnsure patent airwayassess airway, breathing, circulation before decontamination proceduresBrush dry chemical from skin before irrigationflush chemical from wound and surrounding area with saline or waterremove clothing, including shoes, watches, jewelry and contact lenses if face exposedestablish IV access with large-bore catheter needle if greater than 15% TBSA burnbegin fluid replacementblot skin dry with clean towels. Do not rub drycover burned areas with dry, sterile dressing or clean, dry sheetanticipate intubation if significant inhalation injury presentcontact poison control center for assistancecaregiver should protect self from potential exposureOngoing monitoringmonitor airway if airway exposed to chemicalsInhalation injuryEmergency ManagementEnsure patent airwayadminister high flow 02 by non rebreather maskremove ptʼs clothingestablish IV access with large bore catheter needlebegin fluid replacementplace in high fowlerʼs position unless spinal cord injury suspectedassess for facial/neck burns or other traumaobtain arterial blood gas carboxyhemoglobin levels and chest xrayanticipate need for fiberoptic bronchoscopy or intubation
  • Ongoing MonitoringMonitor VS, LOC, 02 sat, respiratory status, cardiac rhythmElectrical BurnsEmergency ManagementRemoval of current source must be done by trained personnel with special equipment toprevent injury to rescuerAssess and tx pt after removal from source of currentensure patent airwaystabilize cervical spineadminister hi flow 02 by non rebreather maskestablish IV access with large-bore catheter needlebegin fluid replacementremove ptʼs clothingcheck pulses distal to burnscover burn sites with dry dressing assess for any other injuries (fractures, head injury)Ongoing Monitoringmonitor cardiac rhythm, VS, LOC, 02 sat, neurovascular status in injured limbsmonitor UOP to ensure adequate volume replacementmonitor urine for development of myoglobinuria secondary to muscle breakdownanticipate admin of mannitol and NaHCO3 for myoglobinuria and hemoglobinuria.Thermal BurnsEmergency ManagementEnsure patent airwayStop the burning processinspect face and neck for singed nasal hair, hoarseness of voice, stridor, soot in thesputumadminister high flow 02 by non rebreather maskanticipate intubation with significant inhalation injuryestablish IV access with large bore catheterbegin fluid replacementremove clothing and jewelryidentify and tx associated injuries (fractured ribs, pneumothorax)determine depth, extent, and severity of burnadminister IV analgesiacover large burns with dry dressingapply cool compresses or immerse in cool water for minor injuries only (less than 10%TBSA burn)
  • insert urinary catheter for severe burnsprevent loss of body heattransport asap to burn centerdo not debride burns or apply topical agents before transfer to a burn centeradminister tetanus prophylaxis as appropriateOngoing monitoringmonitor VS, LOC, 02 sat, cardiac rhythm, UOPmonitor tempmonitor pain and medicate as needed based on pt response.Mechanical Ventilation: Response to Ventilator Alarms and Respiratory DistressATIVentilators have alarms to signal that the client is not receiving correct ventilation If the nurse cannot determine the cause of a ventilator dysfx, the client isdisconnected from the ventilator and manually ventilated with an Ambu bagVentilator alarms should never be turned offThere are three types of ventilator alarms: volume, pressure, and apnea alarmsvolume(low pressure) alarms indicate low exhaled volume due to disconnection, cuffleak and tube displacementpressure (high pressure) alarms indicate excess secretions, client biting the tubing,kinks in the tubing, client coughing, pulmonary edema, bronchospasm, andpneumothrorax.apnea alarms indicate that the ventilator does not detect spontaneous respiration in apresent time period.QuestionsThe high pressure alarm sounds on the ventilator. What should the nurse assess for?client biting of the tubebreath sounds---indicating the need for suctioningkinks in the tubeThe low pressure alarm sounds on the ventilator. What should the nurse assess for?Tubing disconnections
  • air leak around the cuff.Pulmonary Embolism: Evaluation of Tx EffectivenessObjectives:prevent further growth or multiplication of thrombi in the lower extremitiesprevent embolization from the upper or lower extremities to the pulmonary vascularsystemprovide cardiopulmonary support if indicatedEvaluationThe expected outcomes are that the pt who has pulmonary embolism will have adequate tissue perfusion and respiratory fx adequate CO increased level of comfort no recurrence of PETreatment includesConservative Therapy02 by mask or cannula may be adequate02 is given in a concentration determined ABG analysisendotrach intubation and mechanical vent may be needed to maintain adequate 02turning, coughing and deep breathing to prevent or tx atelectasisfor shock, vasopressor agents to support systemic circulationfor heart failure, digitalis, diureticspain with narcotics, usually morphineDrug TherapyanticoagsHeparin and warfarin drugs of choiceheparin should be started immediately and is continued while oral anticoags areinitiated.
  • dosage adjusted according to PTT and warfarin dose is determined by INRmay be indicated if the pt has blood dyscrasias, hepatic dysfunction, overt bleeding, ahx of hemorrhagic stroke or neurologic conditionsThrombolytic agents, such as tPA dissolve PE and the source of the thrombus in thepelvis or deep leg veins thereby decreasing the likelihood of recurrent pulmonary emboliSurgical Therapyif degree of pulmonary arterial obstruction is severe (greater than 50%) and the pt doesnot respond to conservative therapy, an immediate embolectomy may be indicated.COPD: Evaluating ABGsABGsserial ABGs are monitored to evaluate respiratory statusIncreased paCO2 and decreased PaO2Respiratory acidosis, metabolic alkalosis (compensation)Med-SurgABGsEmphysemanear normal ABGs, decreased PaO2, normal or decreased PaCO2Chronic Bronchitisdecreased Pa02, increased Pa02Cancer: Preventing Complications of Radiation TreatmentsStomatitis:Encourage pt to use artificial salivateach pt to assess oral mucosa dailydiscourage use of irritant such as tobacco and alcoholapply topical anesthetics such as viscous LidocaineN/V
  • teach to eat and drink when not nauseatedadmin antiemetics as neededuse diversional activitiesAnorexiamonitor wtprovide small freq meals of high protein, high calorie foodsgently encourage pt to eat but avoid naggingserve food in pleasant environmentDiarrheagive antidiarrheal agents as neededConstipationprovide stool softener as neededencourage to eat high fiber foodsHepatotoxicitymonitor liver function testsAnemiaMonitor Hgb and Hct levelsEncourage intake of foods that promote RBC productionLeukopeniamonitor WBC count, especially neutrophilsteach to report temp elevation and any other manifestations of infectionteach to avoid large crowds and people with infectionsteach to use good hand washing techniquesThrombocytopeniaobserve for signs of bleedingmonitor hgb and hct and platelet countsteach to use soft bristle toothbrush and use electric razorAlopeciadiscuss impact of hair loss on self image
  • suggest way t to cope with hair loss (hair pieces, wigs, scarves)cut long hair before therapyavoid excessive shampooing, brushing, and combing of hairavoid use of electric hair dryers curler and curling ironsSkin reactionsprotect skin from traumalubricate dry skin with nonirritating creamsavoid the use of harsh soapsCystitis monitor manifestations such as urgency, freq, and hematuriaReproductive dysfunction discuss these changes with patientsNephrotoxicity monitor BUN and serum creatinine levelsIncreased ICP may be controlled with steroids and pain medsPeripheral neuropathy monitor for these manifestations in pts on these drugsPneumonitis monitor for dry, hacking cough, fever and exertional dyspneaPericarditis and myocarditis monitor for clinical manifestations of these disorderscardiotoxicity monitor heart with ECG and cardiac ejection factions drug therapy may need to be modifiedHyperuricemia
  • monitor uric acid levels allopurinol (zyloprim) may be given as a prophylactic measure encourage high fluid intakeFatigue tell pt that fatigue is an expected SE of therapy encourage pt to rest when fatigued to maintain usual lifestyle patterns as closelyas possible and to pace activities in accordance with energy levelPain use an analgesic ladder to provide basis for pain med admin teach use of imagery, relaxation therapyPain Management: Recognizing and Responding to Complications of Opioid UseATIOverdosing of opioid analgesics can lead to respiratory depression and even deathsedation always precedes respiratory depressionOversedation and respiratory depression can be prevented byIdentifying risks, titrating doses carefully and monitoring the clientstopping the opioid and giving the antagonist naloxone if the clientʼs respirations areless than 8/min and shallow and the client is difficult to arouse. Naloxone must bediluted in NS (0.4mg/10mL) and given by IV slowly. After admin of naloxone, the clientshould be reassessed.Assessing the cause of sedation and monitoring the clientʼs level of arousal andrespiratory rate and depth for one full minuteusing a sedation scale in addition to a pain rating scale to assess a clientʼs painespecially when administering opioids.Blood Transfusions: Interventions for ComplicationsTransfusion ReactionsAcute Hemolytic
  • Onset: Immediatechills, fever, low back pain, tachycardia, flushing, hypotension, chest tightening or pain,tachypnea, nausea, anxiety, and hemoglobinuriaFebrileOnset: 30min to 6 hrchills, fever, flushing, HA, anxietyadmin: antipyreticsMild allergicOnset: During or up to 24 hr after transfusionitching, urticaria, flushingAdmin antihistamines such as BenadrylAnaphylacticImmediatewheezing, dyspnea, chest tightness, cyanosis, hypotensionMaintain airway, administer 02, IV fluids, antihistamines, corticosteroids, vasopressorsStop the transfusion immediately if a reaction is suspectedInitiate a saline infusion. The saline infusion should be initiated with a separate line soas not to give more blood from the transfusion tubingSave the blood ag with the remaining blood and the blood tubing for testingCirculatory overloadSx include: dyspnea, chest tightness, tachycardia, tachypnea, HA, HTN, JVD,peripheral edema, orthopnea, sudden anxiety and crackles in the base of the lungsAdmin 02, monitor VS, slow the infusion rate and admin diuretics as orderedNotify PCP immediatelySepsis and Septic Shock
  • sx include: fever, N/V, abdominal pain, chills, hypotensionmaintain patent airway and admin 02admin abx therapy as orderedobtain samples for blood culturesadmin vasopressors such as dopamine, to combat vasodilation in the late phaseelevate the clientʼs feetIf DIC occursadmin anticoags such as heparin in early phaseadmin clotting factors and blood products during the late phase (clotting factors areused up in the early stageadminister activated protein C (xigris) to control inflammatory response.Oxygen Therapy: Assessing for S/S of ToxicityS/S includenonproductive coughsubsternal painnasal stiffnessN/VfatigueHASThypoventilationuse the lowest level of 02 to maintain adequate Sa02Monitor ABGs and notify PCP if Sa02 levels rise above expected parametersuse of 02 mask with CPAP continuous positive airway pressure, bilevel positive airwaypressure, or positive end-expiratory pressure while a client is on a mechanical ventilatormay decrease the amt of need 02the oxygen amt should be decreased as soon as the client conditions permits.
  • Form BBurns: Sequencing of Wound Care InterventionsWound care should be delayed until a patent airway, adequate circulation and adequatefluid replacement have been established.Full thickness wounds will be dry and waxy white to dark brown/black and will have littleto no sensation bec nerve endings have been destroyed.Partial thickness burns are pink to cherry red and wet and shiny with serous exudate.These wounds may or may not have intact blisters and are painful when touched orexposed air.Cleansing and debridement can be done in a hydrotherapy tub, cart shower, shower, orbed.Debridement may need to be done in the operating room.During these procedures, loose, necrotic skin is removed. Care should be taken toaccomplish this procedure as quickly and effectively as possible.Immersion in a tank for longer than 20-30 min can cause electrolyte loss from openburned areasProlonged immersion can lead to chilling after the bath and cross-contamination ofwounds from one area of the body to anotherBec of these factors, some institutions do not submerge the pt.Instead the pt can be showeredThe water does not need to be sterile and tap water not exceeding 104 degrees isacceptable.Bec pathogenic organisms are present on the burn wound, a surgical detergent,disinfectant, or cleansing agent may be used.The pt may be bathed two time daily to limit the amt of bacterial growth. Degree of freqmay be too painful for pt.A once daily bath or shower followed by a dressing change in the ptʼs room is a popularalternative
  • Infection is the most serious threat to further tissue injury and further sepsis. Survival isdirectly r/t prevention of wound contamination. The source of infection in burn woundsis the ptʼs own flora, predominantly form the skin, respiratory tract and TI tract.Prevention of cross-contamination from one pt to another is a priorityTwo type of wound tx are used to control infectionopen methoduse of multiple dressing changesOpen methodburn is covered with a topical abx and has no dressing over the woundMultiple dressing changessterile gauze dressings are impregnated with or laid over a topical abx. These dressingsmay be changed two to three times q 24 hr to once q 3 days.When ptʼs wounds are exposed, the staff must wear disposable hats, masks, gownsand gloves.When removing dressing and washing the wound, the nurse should use nonsteriledisposable gloves. Sterile gloves are used when applying ointments and striledressings.Room must be kept warm (85%)All attire is changed before nurse treats another pt.Careful hand washing is also required to prevent cross-contamination.After the pt has bee txʼd in the tub, car shower, or shower, the equipment is disinfectedwith a chemical prep.Coverage is the primary goal for burn wounds. Bec there is rarely enough unburnedskin in the major burn pt for immediate skin grafting, other temp wound closure methodsare used. Allograft or homograft skin (usually from cadavers) is commonly used.rejection eventually occurs bec the ptʼs immune system reacts against foreignsubstance.Monitoring Intracranial Pressure: Preventing ComplicationsCaring for a Client undergoing ICP monitoring
  • Before the insertion procedure, medication may be given to help the client relax. Thehead is shaved around the insertion site. The site is then scrubbed with an antibacterialsoln. Local anesthetic is applied to numb the area.After the insertion procedure, the nurse observes ICP waveforms, noting the pattern ofwaveforms and monitoring for increased ICP (a sustained elevation of pressure above15 mmHg). Normal ICP is 10-15 mmHg.Assess the clientʼs clinical status and monitor routine and neurologic VS q hour asneeded.Calculate cerebral perfusion pressure (CPP) hourly. To calculate CPP, subtract ICP frommean arterial pressure (MAP)Keep the system closed at all times. There is a serious risk of infection.Inspect the insertion site at least q 24 hours for redness, swelling and drainage. Changethe sterile dressing covering the access site per facility protocol.ICP monitoring equipment must be balanced and recalibrated as per facility protocols.Caring for clients with or at risk for increased ICPMonitoring and maintaining airway patency is the PRIORITY intervention for clients withincreased IcP and deteriorating neurological status.When suctioning a client with increased ICP, hyperoxygenate with 100% prior to eachsuctioning attempt.Keep the PaCO2 around 35 mmHg and maintain a normal oxygen level by adjusting therate of mechanical ventilation (for ex, hyperventilating to blow off CO2). Hypercarbialeads to cerebral vasodilation which increases ICPMaintain head at midline neutral position and keep the HOB at greater than 30 degreesto promote venous drainage. Prevent neck flexion or extension. Log roll client whenturning.Avoid clustering nursing activitiesAvoid overstimulation of the client keep the clientʼs room dark and quiet discuss visiting limitations
  • speak softly and limit conversations to light and pleasant discussions.ComplicationsInfection and Bleeding Follow strict surgical aseptic technique Perform sterile dressing changes Keep drainage systems closed Limit monitoring to 3-5 days Irrigate the system only as needed to maintain patencyOcclusion of the Catheter--brain herniationOverdrainage and Collapse of the VentriclesElectrolyte Imbalances: Priority Interventions for HyperkalemiaExpected Client FindingsVS: Slow, irregular pulse, hypotensionNeuro: Restless, irritability, parethesiasMS: weakness to the point of ascending flaccid paralysisGI: N/V/D, increased motility, hyperactive bowel soundsOther signs: oliguriaNursing InterventionsDecrease potassium intake Stop infusion of IV potassium Withhold oral potassium Provide potassium restricted diet (avoid foods high in potassium such asavocados, broccoli, dairy products, dried fruits, cantaloupe, bananas).Increase potassium excretion Administer loop diuretics, such as furosemide (Lasix), if renal fx is adequate Administer cation exchange resins such as sodium polystyrene sulfonate(Kayexalate)
  • Promote movement of potassium from ECF to ICF Admin IV fluids with dextrose (glucose) and Reg Insulin Administer sodium bicarbonate (reverse acidosis)Monitor the clientʼs cardiac rhythm and intervene promptly as needed.Tonsillitis/Tonsillectomy: Assessing for Postoperative ComplicationsHemorrhage use a good light source and possibly a tongue depressor to directly observe thechildʼs throat assess the child for signs of bleeding (eg tachycardia, repeated swallowing, andclearing of throat, hemoptysis). Hypotension is a late sign of shock contact PCP immediately if there is any indication of bleedingBleeding can occur either immediately or several days after the procedure. Dischargeinstructions must be carefully followed.Chronically infected tonsils may pose a potential threat to other parts of the body.some children who have freq bouts with severe tonsillitis may develop other diseasessuch as rheumatic fever and kidney diseaseCleft Lip and Palate: Client Eduction Regarding Feeding TechniquesSupport motherʼs decision to continue breastfeeding her infant. Assist her to be open toalternatives such as using breast milk placed in special feeding devices if necessaryprovide instruction to promote feeding. Teach the parents to use an enlarged nipple,which will stimulate the infantʼs suck reflex and ensure that the infant swallowappropriately. After feeding, infant should be allowed to rest.Identify alternate feeding devices such as special nipple for a bottleTeach parents to feed the infant in an upright positionTeach parent to burp the infant more freq due to the amt of air swallowed. This will helpprevent aspiration and abdominal distention.
  • Glaucoma: Planning Appropriate Postoperative InterventionsIOP is checked 1-2 hr postoperatively by the surgeonpostop eye is covered with a patch or protective shieldclient is instructed not to lie on the operative side and to report severe pain or nausea(possible hemorrhage)GERD: Recognizing Signs and SymptomsThe chief sx of GERD is frequent and prolonged retrosternal heartburn (dyspepsia) andregurgitation (acid reflux) in relationship to eating or activities.Other sx include chronic cough, dysphagia, belching (eructation), flatulence (gas),atypical chest pain and asthma exacerbationsInfection Control: Preventing TransmissionCommunicable Diseases: Interventions to Prevent TransmissionTransmission Precautions (Tier Two)Airborne precautions are to protect against droplet infections smaller than 5micrometers (eg measles, varicella, pulmonary or laryngeal tuberculosis). Airborneprecautions require a:private roommask/respiratory protection device for caregivers and visitorsnegative pressure airflow exchange in the room of at least six exchanges an hour.Droplet precautions protect against droplets larger than 5 micrometers (streptococcalpharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasmapneumonia, meningococcal pneumonia/sepsis or pneumonic plague) Dropletprecautions require a: Private room or a room with other clients with the same infectious disease Mask for providers and visitors
  • Contact precautions protect the visitors and caregivers against direct client/environmental contact infections (eg respiratory synctial virus, shigella, enteric diseasescaused by micor-organisms, wound infections, herpes simplex, scabies, varicella zoster,and multidrug-resistant organisms). Contact precautions require private room or a room with other clients with the same infection gloves and gowns worn by the caregivers and visitors disposal of infectious dressing material in to a single nonporous bag without touching the outside of bagEmergency Nursing Principles: Establish Patent AirwayThis is the most important step in performing the primary survey.If a patent airway is not established, subsequent steps of the primary survey are futileIf the client is awake and responsive, the airway is openIf the clientʼs ability to maintain an airway is lost, it is important to inspect for blood,broken teeth, vomitus, or other foreign materials in the airway that may cause anobstructionUnresponsive without suspicion of trauma the airway should be opened with a head tilt chin lift maneuver this is the most effective manual technique for opening a clientʼs airway It must NOT be performed on clients who have a potential cervical spine injuryTechnique: The nurse should assume a position at the head of the client, place onehand on the forehead, and the other on the chin. The head should be tilted while thechin is lifted superiorly. This lifts the tongue out of the laryngopharynx and provides for apatent airway.Unresponsive with suspicion of trauma The airway should be opened with modified jaw thrust maneuverTechnique: The nurse should assume a position at the head of the client and place bothhands on the side of the clientʼs head. Locate the connection between the maxilla andthe mandible. Lift the jaw superiorly while maintaining alignment of the cervical spine.
  • Once the airway is opened, it should be inspected for blood, broken teeth, vomitus andsecretions. If present obstruction should be cleared with suction or a finger sweepmethod.The open airway can be maintained with airway adjustments, such as an oropharygealor nasopharyngeal airway.Bag-Valve-mask with a 100% 02 source is indicated for clients who need additionalsupport during resuscitationEsophageal Varices: Response to HemorrhageHemorrhage and hypovolemic shock are serious complications of esophageal varices.observe the client carefully for sings of hemorrhage and shockMonitor VS, Hgb, and hematocritReplace losses and employ therapeutic procedures such as gastric lavage, shunts andsclerotherapy to stop/control bleedingHIV/AIDS: Evaluating Antiretroviral TreatmentThe use of potent combination ART to suppress HIV replication limits the potential forselection of antiretroviral resistant HIV variants, the major factor limiting the ability ofantiretroviral drugs to inhibit virus replication and delay disease progression. Maximumachievable suppression of HIV replication should be the goal of therapythe most effective means to accomplish durable suppression of HIV replication is thesimultaneous initiation of combinations of effective anti HIV drugs with which the pt hasnot been previously treated and that are not cross resistant with antiretroviral agentswith which the pt has been previously treated.Antiretroviral drugs used in combo therapy regimens should always be used accordingto optimum schedules dosages.The available effective antiretroviral drugs are limited to number and mechanism ofaction and cross resistance between specific drugs has been documented. Thereforeany change in ART can decrease future therapeutic optionsWomen should receive optimal ART regardless of pregnancy statusAcute primary HIV infections should be txʼd with combination ART to suppress virusreplication to levels below the limit of detection
  • HIV infected persons even those with viral loads below detectable limits and those oneffective ART should be considered infectious and should be counseled to avoid sexualand drug use behavior that are associated with transmission or acquisition of HIV andother infections pathogensOncological Emergencies: Recognizing Sx of Radiation Therapy ComplicationsMetabolic Emergencies are caused by the production of ectopic hormones directly fromthe tumor secondary to cancer tx. They include:Syndrome of inappropriate antidiuretic hormone (SIADH)from vincristine and cyclophosphamide (Cytoxan) which stimulate the release of ADHfrom the pituitary or tumor cells.Sx include:wt gainweaknessanorexiaN/Vpersonality changesseizurescomaTx:fluid restrictionin severe cases: IV admin of 3% sodium chloride solutionTumor Lysis syndrome (TLS)freq triggered by chemotherapyResults from rapid destruction of a large number of tumor cells which can cause fatalbiochemical changes.often associated with tumors that have a high growth rates and are sensitive to theeffects of chemo.TLS can result in acute renal failureThe four hallmark signs of TLS are:hyperuricemiahyperphosphatemiahyperkalemiahypocalcemia
  • Usually occurs within the first 24-48 hrs after the initiation of chemo and may persist forapprox 5-7 days.Primary goal of management is preventing renal failure and severe electrolyteimbalancesPrimary tx includes increasing urine production using hydration therapy and decreasinguric acid concentrations using allopurinolSpinal Cord Compressionr/t metastases. Assess the clientʼs neurological status, including motor and/or sensorydeficits. Administer corticosteroids as prescribed. Support the client during radiationtherapy.HypercalcemiaA common complication of leukemia; breast lung, head and neck CA; lymphomas,multiple myelomas; and bony metastases of any cancer. Sx include:AnorexiaN/VShortened QT intervalKidney stonesBone painChanges in mental statusAdminister isotonic saline, fusosemide (Lasix), pamidronate, and phosphates asprescribedSuper vena cava syndromeResults from obstruction (for example, metastases from breast or lung CA) of venousreturn and engorgement of the vessels from the head and upper body. Sx includeperiorbital and facial edema, erythema of the upper body, dyspnea, and epistaxis. Initiallung expansion. High dose radiation therapy may be used for emergency temporaryrelief.Disseminated intravascular coagulation (DIC)A coagulation complication secondary to leukemia or adenocarcinomas. Observe theclient for bleeding and apply pressure as needed. Avoid ASA and NSAIDS.Pneumonia: Recognizing and Responding to Hypoxia
  • Hypoxia occurs when the PaO2 has fallen sufficiently to cause s/s of inadequateoxygenationHypoxia is adequate tissue oxygenation at the cellular levelS/S:apprehensionrestlessnessinability to concentratedeclining LOCdizzinessbehavioral changesClient is unable to lie down and appears fatigued and agitated.VS changes include an increased pulse rate and increased rate and depth of respirationDuring early stages, BP is elevated unless the condition is caused by shockAs hypoxia worsens, the RR may decline as a result of respiratory muscle fatigueHypoxemia can lead to hypoxia if not corrected.If hypoxia or hypoxemia is severe, the cells shift from aerobic to anaerobicmetabolism . Anaerobic metabolism uses more fuel adn produces less energy and isless efficient.Waste produce is lactic acid.monitor oxygenation levels and acid-base balanceprepare for intubation and mechanical ventilation as indicatedmaintain adequate oxygenation and ventilationdone by collaboration among the nursing, medical and respiratory care teamsprimary goal: correct hypoxemiaIneffective Breathing Pattern r/t inflammation and pain (amb rapid respirations, dyspnea,tachypnea, nasal flaring, altered chest excursion.Interventions
  • monitor respiratory and oxygenation status to provide baseline assessmentauscultate breath sounds, noting areas of decreased or absent ventilation, andpresence of adventitious soundsPosition to minimize respiratory efforts to reduce oxygen needsmonitor effects of position change on oxygenation (SpO2) to assess appropriatepositioninitiate and maintain supplemental oxygen as prescribed to improve respiratory statusadmin drugs (eg bronchodilators) that promote airway patency and gas exchangeTopic DescriptorsPsychosocial Integrity (14)Form AFamily and Community Violence: Evaluating Client Outcomes for the Client WhoHas been AbusedNon-substance Related Dependencies: Providing Care and Support for Clientwith Gambling DependencyATIprovide emotional support and reassurance to the client and familyBegin to educate the client about addition and the initial treatment goal of abstinence
  • Begin to develop motivation and commitment for abstinence and recovery(abstinence plus working a program of personal growth and self-discovery)Encourage self-responsibilityhelp the client develop an emergency plan---a list of things the client would do andpeople he would contact if he felt like using or actually used.Individual psychotherapies CBT psychodynamic therapies relapse prevention therapy teaches the client to recognize s/s of relapse andfactors that contribute to relapse and helps the client develop strategies such asmeditating, exercising to create feelings of pleasure form activities other than usingsubstances or from process addictionsGroup Therapy groups of clients with similar dx may meet in an outpt setting and within mentalhealth residential facilitiesFamily Therapy teaches families about abuse of substances educates the family regarding such issues as family coping, problem solving,relapse signs, and availability of support groupsSelf-help groups 12-step programs including AA, NA, Gamblerʼs anonymous teach that abstinenceis necessary for recovery and use the belief in a higher power to assist in recovery.Crisis Management: Identifying InterventionsProvide for client safety ensure that external controls such as hospitalization are applied for protection ofthe person in crisis if the indiv has suicidal or homicidal thoughts organize interventions so tangible threats are addressed firstUse strategies to decrease anxiety develop a therapeutic nurse-client relationship
  • listen, observe and ask questions make eye contact ask questions r/t the clientʼs feelings ask questions r/t the event demonstrate genuineness and caring communicate clearly and, if needed, with clear directives avoid false reassurance and other nontherapeutic responses teach relaxation techniques such as medication use problem solving to anticipate the clientʼs needs (anticipatory guidance)identify and teach coping skills (eg assertiveness training, parenting skills, occupationaltraining)assist the client with the development of an action plan short term no longer than 24-72 hrs focused on the crisis realistic and manageableidentify and coordinate with support agencies and other resourcesplan and provide for follow up careCare of Those Who Are Dying: Providing Support to the Family RegardingDecision makingEnd of life issues include decision making in a highly stressful time during which thenurse must consider the desires of the client and the family. Any decisions must beshared with other HCP for smooth transition during this time of stress, grief, andbereavement.Advance directives are legal documents for medical treatment per the clientʼs wishesDurable power of attorney for health care---an agent appointed by the client or thecourts to make medical decisions when the client is no longer able to do so.Mood disorders: Recognizing S/S of Relapse for Bipolar DisorderUse of substances (eg alcohol, drugs of abuse, caffeine) can lead to an episode ofmania.
  • sleep disturbances may come before, be associated with, or brought on by an episodeof mania.Cognitive Disorders: Recognizing S/S of Impaired CognitionImpairments in memory, judgment, ability to focus, and ability to calculate; impairmentsmay fluctuate throughout the day (delirium) or not change throughout the day(dementia). LOC can be altered (delirium) or unchanged (dementia). Restless, agitationare common, sundowning (confusion during the night) may occur, behaviors mayincrease or decrease daily (delirium) or remain stable (dementia).Amnestic disorderdecreased awareness of surroundingsinability to learn new info despite normal attentioninability to recall previously learned infopossible disorientation to place and timetypically there is no personality change or impairment in abstract thinking.Psychopharmacological Therapies: Evaluating Client Teaching RegardingLithium, Methlyphenidate, Disulfiram, and FluoxetineLithiumClients must maintain adequate sodium and fluid intake while taking lithium lithium takes the place of sodium in bodyadvise the clients that effects of lithium begin within 5-7 days and that it may take 2-3weeks to achieve full benefitsadvise the client to report signs of toxicity and to take the med as prescribedencourage the client to comply with lab appts needed to monitor lithium effectivenessand adverse effectsencourage the client to comply with follow up appts to monitor thyroid and renal functionMethylphenidate (Ritalin)Advising the client to swallow sustained release tablets whole and to avoid chewing orcrushing tablets
  • Teaching the client the importance of administering the med on a regular schedule andtaking the med exactly as prescribedInstructing the client to be alert for signs of mild overdose such as restlessness,insomnia and nervousness. Signs of severe overdose include panic, hallucinations,circulatory collapse and seizures.Suggesting to parents to initiate a periodic pill count if they doubt the clientʼs medcomplianceadvising the client to avoid other CNS stimulants such as coffee, cola, tea, andchocolateinstructing the client to avoid alcohol or OTC meds unless approved by the PcP. ManyOTC meds contain CNS stimulant propertiesEducating the client about the SE of abruptly stopping the med (potential for abstinencesyndrome)Instructing the client to take the morning (or daily) dose after breakfast and the last dosein the early afternoon to minimize wt loss and insomnia. the med should be taken atleast 6 hr before bedtimeadvising the client that sucking hard candy, chewing gum and taking sips of water mayhelp minimize dry mouth.Disulfiram (Antabuse)Inform the client of the potentials dangers of drinking any alcoholadvise the client to avoid any products that contain alcohol (eg cough syrups,aftershave lotion)encourage the client to wear medic alert braceletFluoxetine (Prozac)Advise the client to take med with meals/food and to take the med on a daily basis toestablish therapeutic plasma levelsassist the client with med regimen compliance by informing hte client that therapeuticeffects may not be experienced for 1-3 weeks and that it might take 2-3 months for fullbenefits to be achieved.instruct the client tot continue therapy after improvement in sx. sudden d/c of med canresult in relapse
  • advise the client that therapy usually continues for 6 months after resolution of sx andmay continue for 1 yr or longerolder adults clients taking diuretics should be monitored for sodium levels. Obtainbaseline sodium levels and monitor periodically.Spiritual Care: Evaluating If Needs Have Been MetInterventionsIdentify the clientʼs perceptions for the existence of a higher powerfacilitate growth in the clientʼs abilities to connect with a higher powerassist the client to feel connected or reconnected to a higher power by allowing time and/or resources fro the practice of religious rituals providing privacy for prayer, meditation, or the reading of religious materialsfacilitate development of a positive outcome in a particular situationprovide stability for the person experiencing a dysfunctional spiritual mood.establish a caring presence in “being with” the client and family rather than merelyperforming tasks for themsupport all healing relationships holistic approach to care--seeing the large picture for the client using client-identified spiritual resources and needsidentify and provide for the clientʼs support system family community pastoral religious artifacts and ritualsbe aware of diet therapies included in spiritual beliefssupport religious rituals icons statues prayer rugs devotional reads musicsupport restorative care
  • prayer meditation grief workEvaluation of care is ongoing and continuous with a need for flexibility as the client andfamily process the current crisis through their spiritual identity.Potter/PerryEvaluationReview the clientʼs self-perceptions regarding spiritual healthReview the clientʼs view of his or her purpose in lifeDiscuss with family and close associates the clientʼs connectednessask if the clientʼs needs are being metExample: if the nurseʼs assessment finds the client losing hope, the follow-up evaluationwill involve a discussion with the client to determine if the client has regained an attitudeof something to live forfamily and friends with whom the client seeks to have fellowship can be a useful sourceof evaluative informationsuccessful outcomes should reveal the client developing an increased or restored senseof connectedness with family; maintaining, renewing, or reforming a sense of purpose inlife and for some, a confidence and trust in a supreme being or poweruse established expected outcomes to evaluate the clientʼs response to careThe nurse evaluates whether the client expectations were met.evaluating if the clientʼs spiritual practices were respected and if the nurse-clientrelationship was one of caring and supportboth client and family should be able to relate if opportunities were offered for religiousritualsSensoriperceptual Alterations: Planning Interventions for the Hearing ImpairedClientCommunication get the clientʼs attention before speaking Stand/sit facing the client in a well-lit, quiet room without distractions speak clearly and slowly to the client without shouting and without hands or otherobjects covering the mouth arrange for communication assistance (sign language interpreter, closed caption,phone amplifiers, TTY capabilities) as needed
  • Planning (P/P)select strategies to assist the client in remaining functional in the homeadapt therapies depending on whether sensory deficit is hort or long terminvolve the family in helping the client adjust to limitationsrefer to appropriate HCP and/or community agencyClients who enter the health care setting and who have sensory alterations at the timeare usually more informed about how to adapt interventions to their lifestyle.Stress Management: Evaluate Effectiveness of Teaching Regarding StressManagement TechniquesInterventionsRelaxation Techniques meditation includes formal meditation techniques as well as prayer for those whobelieve in a higher power guided imagery---a leader guides the client through a series of images topromote relaxation. Images vary depending on the indiv. for example, one client mightimagine walking on a beach, while another might imagine himself in a position ofsuccess breathing exercises are used to slow rapid breathing and promote relaxation progressive muscle relation (PMR)--a person trained in this method can help aclient attain complete relaxation within a few minutes of time physical exercise (eg yoga, walking, biking) causes release of endorphins thatlower anxiety, promote relaxation, and have antidepressant effectsJournal Writing journaling has been shown to allow for therapeutic release of stress this activity can help the client identify stressors and plan for the future with morehopeCognitive reframing the client is helped to look at irrational cognitions (thoughts) in a more realisticlight and to restructure the thoughts in a more positive way
  • Priority restructuring the client learns to prioritize differently to reduce the number of stressorsimpacting herBiofeedback a nurse or other HCP trained in this method can assist the client to gain voluntarycontrol of such autonomic functions a heart rate and blood pressureAssertiveness training the client learns to communicate in a more assertive manner in order to decreasepsychological stressors(P/P) Goals and OutcomesDesirable outcomes for persons experiencing stresss. effective copingt. family copingu. caregiver emotional healthv. psychosocial adjustment: life changeBy evaluating goals expected outcomes, the nurse knows if the nursing interentionswere effective and if the client is coping with stress.Family Dynamics: Interventions Involving Client Support SystemsATI FundamentalsInterventionsIdentify and adapt family strengths to perceived stressors Communication Adaptability Nurturing Crisis as a growth element parenting skills resiliencySet goals with the family that are realisticProvide information on support networks Child and adult day care caregiver support groups
  • Promote family unityEncourage conflict resolution when it existsminimize family process disruption effectsremove barriers to health promotionincrease family members abilities to participateperform interventions that the family cannot performevaluate goals within the context of the family by checking back to ensure that the goalswere realistic and achievableEffective Communication in Mental Health Nursing: Giving Broad Openings(Mohr)Giving broad openingsPurpose:communicates a desire to begin a meaningful interaction Ex: What would like to discuss today?allows the client to define the problem or issue Ex: Tell me about how you have been doing?Creating and Maintaining a Therapeutic and Safe Environment: Promote aTherapeutic Milieu for Group of ClientsManagement of the milieu means manipulating the total environment of the mentalhealth unit in order to provide the least amount of stress while promoting the greatestbenefit for all the clientsWithin this therapeutic milieu of the mental health facility the client is expected to learnadaptive coping, interaction, and relationship skills that can be generalized to otheraspects of lifeThe nurse, as manager of care, is responsible for structuring and/or implementing manyaspects of the therapeutic milieu within the unitThe structure of the therapeutic milieu often includes regular community meetings,which include both nursing staff and clients.Characteristicsclean and orderly unitcolor scheme should be appropriate for the clientʼs agesetting should include comfortable furniture for lounging and interacting with otherssolitary spaces for reading and thinking alone, comfortable places conducive to meals,and quiet areas for sleepingfloors should be attractive, easy to clean, safe for walking
  • traffic flow considerations should be conducive to client and staffpromote independence for self care and individual growth in clientsallow choices for clients within the daily routine and within indiv tx planstx client as indivapply rules of fair tx for all clientsmodel good social behavior for clients, such as respect for the rights of otherswork cooperatively as a team to provide caremaintain boundaries with clientsmaintain professional appearance and demeanorpromote safe and satisfying peer interactions among clientspractice open communication techniques with HCP and clientspromote feelings of self-worth and hope for the futureclients should feel safe from harm (self-harm, as well as harm from disruptive behaviorsof other clients)clients should feel cared about and accepted by the staff and othersThe therapeutic milieu includes safety for both the clients and the staff within theenvironmentPhysical Safety the nurseʼs station and other areas should be set up for easy observation ofclients by staff and access to staff by clientsSet up the following provisions to prevent client self-harm or harm by others: no access to sharp or otherwise harmful objects restriction of client access to out of bounds or locked areas monitoring of visitors restriction of alcohol and illegal drug access or use restriction of sexual activity among clients deterrence for elopement from facility rapid de-escalation of disruptive and potentially violent behaviors throughplanned interventions by trained staffSeclusion rooms and restraints should be set up for safety and used only after all lessrestrictive measures have been tried. When used, there should be procedures andpolicies to prevent any client harmPlan for safe access to recreational areas, occupational therapy and meeting rooms
  • Teach fire, evacuation, and other safety rules to all staff Have clear plans for keeping clients and staff safe in emergencies Maintain staff skills, such as CPR with in service trainingConsiderations of room assignments on a 24 hr inpatient unit should include personalities of each roommate the likelihood of nighttime disruptions for a roommate if one client has difficultysleeping medical diagnoses, such as how two clients with severe paranoia might interactwith each otherNurses within a mental health unit must allow time for both structured and unstructuredactivity for clients and staff Structured activity may include time for Community meetings Group activities and indiv therapy sessions recreational activities psychoeducational classes such as learning about medication side effects Unstructured flexible time in which the nurse and other staff are able to observeclients and interact spontaneously within the milieuBody Image: Interventions to Assist Client AdaptationATI FundamentalsInterventionsEstablish a therapeutic relationship with the client. A caring and nonjudgmental mannerputs the client at ease and fosters meaningful communicationensure privacy and confidentiality. many sensitive issues may be discussed, and hteclient needs to know that these issues are safe to discuss.identify indiv who may be at risk for body image disturbancesacknowledge anger, depression, and denial as normal feelings when adjusting to bodychanges
  • encourage the client to participate in the plan of carearrange for a visit form a volunteer who has experienced a similar body image change.Form BCognitive Disorders: Identifying Appropriate InterventionsEnvironmentAssign the client to a room close to the nurseʼs station for close observationprovide a room with a low level of visual and auditory stimuliprovide compensatory memory aids such as clocks, calendars, photos, memorabilia,seasonal decorations and familiar objectswindows may help time orientation and help decrease the “sundowning” effectPharm TxAdmin meds as prescribedMeds that have been approved by the FDA that demonstrate positive effects oncognitive, behavioral and daily activity function includeTacrine (Cognex)Donepezil (Aricept)Rivastigmine (Exelon)Galantamine (Reminyl)Memantine (Namenda)CommunicationReinforce orientation to time, place and personEstablish eye contact and use short, simple sentences when speaking to the clientEncourage reminiscence about happy times, talk about familiar thingsBreak instructions and activities into short timeframes when instructing the clientSafetyHave the client wear an id bracelet; use monitors and bed alarm devices as needed
  • Ensure safety in the physical environment, such as lowered bed and removal of scatterrugs to prevent falls. Many aspects of the physical environment may need to bechanged for the home bound client with dementiaProvide eyeglasses and hearing assistive devices as neededNursing care and Caregiver EducationMonitor food and fluid intake, bowel and bladder fx, and sleep patternsEducate family/caregivers about illness, methods of care, and adaptation of the homeenvironmentprovide support for caregivers; recommend local support groups for caregivers as wellas respite careEstablish a routine. Make sure all caregivers know/apply the routine. Attempt to haveconsistency in all caregivers.Group Therapy: Appropriate Group Leader Communication TechniquesLeadership StylesDemocratic: this style supports group interaction and decision making to solve problemsLaissez-faire: the group process progresses without any attempt by the leader to controlthe direction of the groupAutocratic: The leader completely controls the direction and structure of the groupwithout allowing group interaction or decision making to solve problemsAll therapy sessions should provide open and clear communication, guidelines for thetherapy session and cohesivenessBe goal directedCoping: Assessing Support SystemsIdentify the strengths and abilities of the client and familyDiscuss the client and familyʼs ability to deal with the current situationIdentify available community resources and refer for counseling if neededCulturally Competent Care: Incorporate Religious BeliefsRespect the religious/spiritual practices of the client
  • Death rituals vary among cultures and the nurse must be prepared to facilitate suchpractices whenever possibleEnd of Life: Assessing Client CopingSymptoms of Normal Grief feelings range from sadness to anxiety to yearning thoughts may be confused, hopeless and preoccupied with the decreased person difficulties sleeping, eating and crying are common behaviors fatigue, muscle tension or weakness and oversensitivity to stimuli are commonphysical sxDetermine the state of grief the client and family are experiencingUnderstand the factors influencing the grieving process type of loss significance of loss past coping mechanisms that have been effective availability of support systems prior experiences with lossUnderstand the desires and expectations of the family for end of life careFamily Dynamics: Interventions to promote Integration of Older Adults into familyStructureDeath and Dying: Recognizing Preschool Responses to DeathEgocentric thinkingthink magically, which causes them to feel guiltily, shameful and to sense punishment
  • interpret separation from parents as punishment for bad behaviorview dying as temporary, since they have no concept of time and the dead person maystill have attribute of the living (sleeping, eating and breathing)Schizophrenia: Identifying Signs and Symptoms characteristics symptoms positive sx hallucinations delusions disorganized speech bizarre behavior, such as walking backward constantly negative sx blunted affect alogia (poverty of though or speech) avolition (lack of motivation in activities and hygiene) anhedonia anergia cognitive sx disordered thinking inability to make decisions poor problem solving ablilty difficulty concentrating to perform task memory deficits (long term) depressive sx hopelessness suicidal ideation type symptoms paranoid hallucinations and delusions
  • type symptoms disorganized loose associations bizarre mannerisms incoherent speech hallucinations and delusions catatonic withdrawn stage (psychomotor retardation, waxy flexibility, self care needs) excited stage (constant movement, unusual posturing, incoherent speech, elf care needs, danger to self or others residual anergia, anhedonia, avolition withdrawal from social activities impaired role fx speech probs undifferentiated any positive or negative sx may be presentDeveloping and Maintaining a Therapeutic Nurse-Client Relationship: Intervene toPromote TrustIn the orientation phase of relationship, build trust by establishing expectations andboundariesTopic DescriptorsReduction of Risk Potential (24)Form ASeizures: Client Education Regarding EEGEEG records electrical activity and identifies the origin of seizure activity. Clientinstruction includes:
  • No caffeineWash hair before the procedure (no oils, sprays) and after the procedure (removeelectrode glue)May be asked to take deep breaths and/or be exposed to flashes of a strobe light duringthe testSleep may be withheld prior to test and possible induced during testRheumatic Fever: Recognizing Expected Lab FindingsAntistreptolysin O titer > 250 IU/mlErythrocyte sedimentation rate > 15 mm/hr in men, > 20 mm/hr in womenC-reactive protein PositiveThroat culture Positive for streptococci (usually negative)WBC count ElevatedRed blood cell parameters Mild to mod degress of normocytic, normo-(HCT, Hgb, RBC) chromic anemiaDiabetes Mellitus: Client Teaching Regarding Purpose of Self-Blood GlucoseMonitoringAttempt to maintain normal blood glucose levels to prevent development ofcomplicationsHypoglycemiaHyperglycemiaDiabetic KetoacidosisAcid-Base Imbalances: Identify Expected lab Data pH PaCO2 HCO3 Diagnosis 7.35-7.45 35-45 22-26 homeostasis < 7.35 > 45 22-26 respiratory acidosis
  • pH PaCO2 HCO3 Diagnosis < 7.35 35-45 < 22 metabolic acidosis > 7.45 < 35 22-26 respiratory alkalosis > 7.45 35-45 > 26 metabolic alkalosisUncompensated: The pH will be abnormal and either the HCO3 or the PaCO2 will beabnormalPartially compensated: The pH, HCO3, and PaCO2 will be abnormalFully Compensated: The pH will be normal, but the PaCO2 and HCO3 will both beabnormalDiabetic Ketoacidosis: Recognize Clinical ManifestationsDKA is an acute, life-threatening condition characterized by hyperglycemia (> 300mg/dL) resulting in breakdown of body fat for energy and an accumulation of ketones int ehblood and urine. The onset is rapid.Results in severe hyperglycemia from lack of sufficient insulin increased need for insulinDKA is more common in indiv with type 1 DMSigns/Symptomspolyuria, polydipsia, polyphagia (early signs)change in mental statussigns of dehydration (dry mucous membranes, wt loss, sunken eyeballs, resulting fromfluid loss such as polyuriaKussmaul respiration pattern, rapid and deep respirations, “fruity” breathN/V, abdominal pain
  • Fluid Imbalances: Interpret Lab Values for DehydrationExpected FindingsHgb and HCT = increased Normal Hgb = 13.5-18 g/dL (males) 12-16 g/dL (females) Normal HCT = 40-54% (males) 38-47% (femalesSerum osmolarity = increased (hemoconcentration) osmolarity (> 300mOsm/L) -increased protein, BUN, electrolytes and glucose Normal BUN = 10-30 mg/dL Potassium = 3.5-5.5 mEq/L Urine Specific Gravity and osmolarity = increased (concentration) Normal Specific Gravity = 1.005-1.030Serum Sodium = Increased (hemoconcentration) Normal 135-145 mEq/LDiabetes Insipidus: Recognizing Expected Lab FindingsUrine chemistry: think DILUTEdecreased urine specific gravity ( < 1.005)decreased urine osmolality (50-200 mOsm/kg)decreased urine pHdecreased urine Nadecreased urine KAs urine volume increases, urine osmolality decreasesSerum chemistry
  • increased serum osmolality ( > 295 mOsm/kgincreased serum Naincreased serum K+As serum volume decreases, the serum osmolality increasesHeart Failure: Recognizing Expected Lab FindingsBNP (Human B type Natriuretic Peptide) used to differentiate dyspnea r/t CHF vs respiratory problem and to monitor theneed for and effectiveness of aggressive CHF interventionBNP levels < 100 pg/mL = no CHFBNP levels 100-300 pg/mL suggest CHF is presentBNP levels >300 pg/mL = mild CHFBNP levels > 600 pg.mL = moderate CHFBNP levels > 900 pg/mL = severe CHFHemodynamic Monitoringincreased CVP (central venous pressure)increased right arterial pressureincreased PCWP (pulmonary capillary wedge pressure)increased pulmonary artery pressure (PAP)decreased COConscious Sedation: Monitoring Client Physiologic Response FollowingConscious SedationConscious Sedation is the admin of sedatives and/or hypnotics to the point where theclient is relaxed enough that minor procedures can be performed without comfort, yetthe client can respond to verbal stimuli, retains protective reflexes (gag reflex), is easilyarousable and (most important) independently maintains a patent airway.Nursing Responsibilities After the ProcedureThe monitoring nurse continues to record VS and LOC until the client is fully awake andall assessment criteria return to pre-sedation levels.Typical discharge criteria: LOC as on admission VS stable for 30-90 min
  • Ability to cough and deep breathe ability to take oral fluids No N/V, SOB, or dizzinessPeripheral Venous Disease: Prevent ComplicationsComplicationsUlcer Formation: typically over malleolus, more often medially than laterally . May leadto amputation and/or deathPulmonary Embolism: occurs when thrombus is dislodge, becomes emboli and lodgesin the pulmonary vesselsInterventionsDeep Vein Thrombosis and ThrombophlebitisEncourage REST facilitate bedrest and elevation of extremity above the level of the heart (avoidusing a knee gatch or pillow under knees) admin intermittent or continuous warm moist compresses (to prevent thrombusfrom dislodging and becoming an embolus, DO NOT massage the affected limb) provide thigh-high compression or antiembolism stockings to reduce venousstasis and to assist in venous return of blood to the heart.Admin meds as prescribed anticoags unfractionated heparin IV based on body wt is given to prevent formation ofother clots and to prevent enlargement of existing clot, followed by oral anticoag with warfarin. hospital admin is required for lab value monitoring and dose adjustment monitor aPTT to allow for adjustments of heparin dosage monitor platelet counts for heparin-induced thrombocytopenia
  • ensure that protamine sulfate, the antidote for heparin is available if needed for excessive bleeding monitor the hazards and SE associated with anticoag therapy Low molecular wt Heparin (LMWH) is given subq. Enoxaparin (Lovenox), dalteparin (Fragmin) and ardeparin (Normiflo) have consistent action and are approved for the prevent and tx of DVT may be managed at home by home care nurse must have stable DVT or PE, low risk for bleedign, adequate renal function and normal VS client must be willing to learn self injection the aPTT is not checked on an ongoing basis bec the doses of LMWH are not adjusted Warfarin works in the liver to inhibit synthesis of the four vit K dependent clotting factors takes 3-4 days before it has therapeutic anticoagulation heparin is continued until the warfarin effect is achieved then IV heparin may be d/cʼd if client is on LMWH, warfarin is added after the first dose of LMWH. Therapeutic levels are measured by INR monitor for bleeding ensure that Vit K (the antidote for warfarin) is available in case of excessive bleedingThrombolytic Therapy effective in dissolving thrombi quickly and completely must be initiated within 5 days after onset of sx to be most effective advantage is the prevention of valvular damage and consequential venousinsufficiency or postphlebitis syndrome
  • contraindicated during pregnancy and following surgery, childbirth, trauma, aCVA, or spinal injury tissue plasminogen activator (t-PA), a thrombolytic agent, and platelet inhibitorssuch as abciximab (REoPRo), tirofiban (Aggrastat) and sptifibatide (Integrilin) may beeffective in dissolving a clot or preventing new clots during the first 24 hr. primary complication of therapy is serious bleedingAnalgesics: Admin as ordered to reduce painVenous Insufficiency Instruct client to elevate legs for at least 20 min four to five times/day above the level of the heart avoid prolonged sitting or standing, constrictive clothing or crossing legs when seated wear elastic or compression stockings during the day and evening put elastic stockings on before getting out of bed after sleep clean the elastic stockings each day, keep the seams to the outside, and do not wear bunched up or rolled down replace worn out compression stockings as needed on using an intermittent sequential pneumatic compression system instruct the client to apply the system twice daily for 1 hour in am and evening advise the client with an open ulcer that the compression system is applied over a dressingVaricose Veins emphasize the importance of antiembolism stockings as prescribed instruct the client to elevate the legs as much as possible instruct the client to avoid constrictive clothing and pressure on the legs.
  • Sickle Cell Anemia: Preventing Sickle Cell CrisisManifestationsVaso-occlusive (painful episode) usually lasting 4-6 daysAcute severe pain, usually in bones, joints, and abdomen swollen joints, hands and feet anorexia, vomiting and fever hematuria obstructive jaundice visual disturbancesChronic increased risk of respiratory infections and/or osteomyelitis retinal detachment and blindness systolic murmurs renal failure and enuresis liver failure seizures deformities of the skeletonSequestration excessive pooling of blood in the liver (hepatomegaly) and spleen(splenomegaly) tachycardia, dyspnea, weakness, pallor, and shockAplastic extreme anemia as a result of decreased RBC productionHyperhemolytic increased rate of RBC destruction leading to anemia, jaundice, and/orreticulocytosisAvoiding Complicationsavoid high altitudesmaintain adequate fluid intaketreat infections promptly
  • pneumovax, influenza, and hepatitis immunizations should be admintreat chronic leg ulcers with bed rest, abx, warm saline soaks.take freq rest breaks during physical activities (minimize tissue deoxygenation)avoid contact sports if spleen is enlargedadequate nutrition, freq medical supervision, proper hand washing and isolation fromknown sources of infectionThyroidectomy: Assess for ComplicationsComplicationsHemorrhage the surgical dressing and incision need to be assessed for excessive drainage or bleeding during the postop period. inspect the surgical dressing for bleeding especially at the back of the neck and change the dressing as directed avoid pressure on the suture line, encourage the client to avoid neck flexion or extension support the head and neck with pillows or sandbags. If client needs to be transferred from stretcher to bed, support the head and neck in good body alignmentThyroid Storm monitor for signs of thyrotoxicosis (tachycardia, diaphoresis, increased BPs, anxiety)Airway Obstruction a trach tray should be kept near the client at all times during the immediate recovery period maintain the bed in high-fowlerʼs position to decrease edema and swelling of the neck
  • if the client reports the dressing feels tight, the surgeon needs to be alerted immediatelyHypocalcemia and Tetany (due to damage to the parathyroid glands) monitor for s/s of hypocalcemia (tingling of the fingers and toes, carpopedal spasms and convulsions) have calcium gluconate available maintain seizure precautionsNerve damage nerve damage can lead to vocal cord paralysis and vocal disturbances teach the client that he/she will be able to speak only rarely and will need to rest the voice for several days and should expect to be hoarse after the procedure, monitor the clientʼs ability to speak with each measurement of VS assess the clientʼs voice tone and quality and compare it to the preop voice.CVA: Interventions to Prevent AspirationNursing InterventionsMaintain a patent airwaymonitor for changes in clientʼs LOC (increased ICP sign)Elevate clientʼs head to reduce ICP and to promote venous drainage. Avoid extremeflexion or extension, maintain head in midline neutral position and elevate to 30 degreesinstitute seizure precautionsmaintain a non-stimulating environmentassist with communication skills if clientʼs speech is impaired.assist with safe feeding assess swallowing reflexes: swallowing, gag, and cough before feeding
  • the clientʼs liquids may need to be thickened to avoid aspiration have client eat in an upright position and swallow with the head and neck flexed slightly forward place food in the back of the mouth on the unaffected side suction on standby maintain a distraction free environment during mealsAspiration Complication---suction as needed. preassess the clientʼs swallowing abilities.Postoperative Nursing: Preventing Circulatory ComplicationsPrevent and Monitor for thromboembolism (esp following abdominal and pelvicsurgeries) apply pneumatic compression stockings and/or elastic stockings reposition the client every 2 hr and ambulate early and regularly administer low-level anticoag as prescribed monitor extremities for calf pain, warmth, erythema, and edemaClient positioning position the client supine with head flat (prevent hypotension) do not elevate the legs higher than placement on a pillow if the client has received spinal anesthesia do not put pillows under knees or use a knee gatch (decreases venous return)Angiography: Recognizing ComplicationsComplicationsCardiac Tamponade results from fluid accumulation in the pericardial sac signs include hypotension JVD muffled heart sound
  • paradoxical pulse (variation of 10 mmHg or more in systolic blood pressure between expiration and inspiration) hemodynamic monitoring will reveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressures) notify the PCP immediately admin IV fluids to combat hypotension as ordered obtain a chest xray or echocardiogram to confirm dx prepare the client for pericardiocentesis (informed consent, gather materials, admin meds as appropriate) monitor hemodynamic pressures as they normalize monitor heart rhythm; changes indicate improper positioning of the needle monitor for reoccurrence of signs after the procedureHematoma Formation assess the groin at prescribed intervals and as needed hold pressure for uncontrolled oozing/bleeding monitor peripheral circulation notify PCPRestenosis (of treated vessel) assess ECG patterns and for occurrence of CP notify PCP immediately prepare the client for return to the cardiac cath labRetroperitoneal Bleeding assess for flank pain and hypotension notify the PCP admin IV fluids and blood products as ordered.
  • Gastroenteral Feedings: Measures to prevent AspirationAssess for gag reflex. Place tongue blade in clientʼs mouth, touching uvula to induce agag response. identifies ability to swallow and determines if there is a risk for aspiration. Clients with impaired LOC may also have impaired gag reflex and their risk of aspiration is increased.Assist client to High Fowlerʼs position unless contraindicated reduces risk of aspiration and promotes effective swallowingComplicationAspiration of stomach contents into the respiratory tract (immediate response)evidenced by coughing, dyspnea, cyanosis, auscultation of crackles and wheezes position client on side suction nasotracheally and oral tracheally consult PCP to order chest x-ray examAspiration of stomach contents into respiratory tract (delayed response) evidenced bydyspnea, fever, auscultation of crackles and wheezes consult PCP to obtain order for chest xray prepare for possible initiation of abxHead Injury: Assessing Neurological StatusAssess/MonitorRespiratory Status---the priority assessmentChanges in LOC--the EARLIEST indication of neurological deteriorationLOC and lengthCushing reflex (severe HTN with a widened pulse pressure and bradycardia)--late signof ICPPosturing (decorticate, decerebrate, flaccid)Cranial Nerve function
  • Pupillary changes (PERRLA, pinpoint, fixed/nonresponsive, dilated)Signs of infection (nuchal rigidity with meningitis)CSF leakage from nose and ears (halo sign yellow stain surrounded by by blood, testpositive for glucose)GCS rating (15 normal; 3=deep coma) Eye opening Verbal Response Motor Response Response (E) (V) (M) 4 = spontaneous 5 = normal 6 = normal conversation 3 = to voice 4 = disoriented 5 = localizes to pain conversation 2 = to pain 3 = words; but not 4 = withdraws to pain coherent 1 = none 2 = no words, only 3 = decorticate sounds posture 1 = none 2 = decerebrate posture 1 = none E Score V Score M Score E+ V+ M = total scoreUrinary Tract Infection: Recognizing Risk FactorsRisk Factors/Causes of UTI
  • Female Gender short urethra close proximity of the urethra to the rectum decreased estrogen in aging women promotes atrophy of the urethral openingtoward the rectum. sexual intercourse freq use of feminine hygiene sprays, tampons, sanitary napkins, spermicidaljellies pregnancy women who are fitted poorly for diaphragms hormonal influences within the vaginal flora synthetic underwear and pantyhose wet bathing suits freq submersion into baths or hottubsIndwelling urinary cathetersstool incontinencebladder distentionurinary conditions (anomalies, stasis, calculi, and residual urinepossible genetic linksdisease (DM)Joint Replacement: Client Teaching Regarding Postop Activity LimitsHip Replacement SurgeryEarly AmbulationTransfer out of bed from unaffected sideWt bearing status is determined by the orthopedic surgeon and by the choice ofcemented (partial/full wt bearing as tolerated) vs non cemented prostheses (only partialwt bearing until after a few weeks of bone growth)use of assistive devices (for example, walker) Do Donʼt use elevated seating/raised avoid flexion of hip > 90 toilet seat degrees use straight chairs with arms avoid low chairs
  • Do Donʼt use and abduction between do not cross legs legs while in bed (and with turning) externally rotate toes don not internally rotate toesClient position: supine with head slightly elevated with affected leg n neutral positionand a pillow or abduction device between legs to prevent abduction (movement towardmidline) which could cause hip dislocationarrange for raised toilet seats, extended handle items (shoehorn, dressing sticks)Knee Replacement SurgeryPositions of flexion of the knee are limited to avoid flexion contracturesAvoid knee gatch and pillows placed behind the kneeknee immobilizer may be used while in bedgoal is to be able to straight leg raisekneeling and deep knee bends are limited indefinitelyCPM is used to promote motion in the knee and prevent scar tissue formation .Preoperative Nursing: Recognizing Client Finding Indicative of Readiness forSurgical InterventionPreoperative Assessment Detailed hx (including med problems, allergies, med use, substance abuse, psychosocial probs, cultural considerations) anxiety level regarding the procedure lab results H-T assessment VS
  • Informed Consent Once surgery has been discussed with the client or surrogate as tx, it is theresponsibility of the PcP to obtain consent after discussing the risks and benefits of theprocedure. The nurse is not to obtain consent for the PcP in any circumstance the nurse can clarify any information that remains unclear after the PCPʼsexplanation of the procedureThe nurseʼs role is to witness the clientʼs signing of the consent forma after the clientacknowledges understanding of the procedure.Postoperative Nursing: Maintain Function of Jackson-Pratt DrainMonitor incisions and drain sites for bleeding and/or infection monitor drainage (should progress from sanguineous to serosanguineous toserous) monitor the incision site (expected findings include pink wound edges, slightswelling, under sutures/staples, slight crusting of drainage). Report signs of infection,including redness, excessive tenderness and purulent drainage. monitor wound drains (with each VS assessment). Empty as often as needed tomaintain compression. Report increases in drainage (possible hemorrhage) Change wound dressing as required using surgical aseptic technique use an abdominal binder for obese or debilitated clients encourage splinting with position changes administer prophylactic abx as prescribedThe nurse looks for drainage flow through the tubing as well as around the tubing. Asudden decrease in drainage may indicate a blocked drain, and the PcP should benotified. When a drain is connected to suction, the nurse asses the system to be surethe pressure ordered is being exerted. Evacuator units such as Hemovac or Jackson-Pratt exert a constant low pressure as long as the suction device (bladder or bag) isfully compressed. These types of drainage devices are referred to as self-suction.When the evacuator device is unable to maintain a vacuum on its own, the nursenotifies the surgeon who can then order a secondary vacuum system (such as a wallsuction) If fluid is allowed to accumulate in the tissues, wound healing will not progressat an optimum rate, and the risk of infection is increased.
  • Pain Management: Management of an Epidural CatheterEpidural analgesia is the infusion of pain-relieving medication through a catheter placedinto the epidural space surrounding the spinal cord. the goal is delivery of med directlyto opiate receptors in the spinal cord. The admin may be intermittent or constant and ismonitored by the nurse. The overall effectiveness and the technique of admin result inconstant circulating level and a total reduced dose of med.Intrathecal morphine can produce the same SE of nausea, mental clouding, andsedation bec it is absorbed via the CSF into the circulation of the epidural vascularplexusNursing Implicationscatheter is connected to an epidural infusion pump, a port or reservoir or is capped offfor bolus reduce the risk of accidental epidural injections of drugs intended for IV use, thecatheter should be clearly labeled “epidural catheter”continuous infusions must be administered through electronic infusion devices forproper control.bec of catheter location, strict surgical asepsis is needed to prevent a serious andpotentially fatal infectionPcP notified immediately of any s/s of infections or pain at the insertion sitethorough nursing care is needed during hygiene procedures to keep the cathetersystem clean and drayPrevent catheter displacement secure catheter (if not connected to implanted reservoir) carefully to outside skinMaintain catheter function check external dressing around catheter site for dampness or discharge (leak ofCSF may develop) use transparent dressing to secure catheter and to aid inspection inspect catheter for breaksPrevent infection
  • use strict aseptic technique when caring for catheter do not routing change dressing over site change infusion tubing q 24 hrsMonitor for respiratory depression monitor VS esp respirations, per policy pulse oximetry and apnea monitoring may be usedPrevent undesirable complications assess for pruritus (itching) and N/V administer antiemetics as orderedMaintain urinary and bowel function monitor I/O assess for bladder and bowel distention assess for discomfort, freq, and urgencyIntraoperative Nursing: Circulating Nurse Role PrioritiesCirculating nurse must be an RNResponsibilities include:review of the preop assessmentestablishing and implementing the intraoperative plan of careevaluating the careproviding for continuity of care postoperativelyassists with procedures as needed such as endotrach intubation and blood adminmonitors sterile technique and a safe operating room environmentassists the surgeon and surgical team by operating nonsterile equipment, providesadditional supplies verifies sponge and instrument counts and maintains accurate andcomplete written records.Blood Pressure: Recognizing and Responding to Factors Affecting BloodPressureKey FactorsPulse pressure
  • the difference between the systolic and the diastolic pressure reading sPostural (orthostatic) hypotension a BP that falls when a client changes position from lying to sitting or standing andit may result from various causes (eg peripheral vasodilation, med SE, fluid depletion) Orthostatic changes are assessed by taking the clientʼs BP and HR in the supineposition. next, have the client change to the sitting or standing position, wait 1-5 min,and reassess the BP and HR. the client is experiencing orthostatic hypotension if theSBP decreases more than 20 mmHg and/or the DBP decreases more than 10 mmHgwith a 10-20% increase in the HR.Age infants have a low BP that gradually increases with age older children and adolescents will have varying BP based on body size. Largechildren will have higher BP older adult clients may have a slightly elevated SBP due to decreased elasticityof blood vesselsCircadian Rhythms affect BP with BP usually being the lowest in the early morning hours andpeaking during the later part of the afternoon or eveningStress associated with fear, emotional strain, and acute pain can increase BPEthnicity African Americans have a higher incidence of HTN in general and at earlier agesGender Adolescent to middle-age men have higher BPs than their female counterparts.Postmenopausal women have higher BPs than their male counterpartsMedications opiates, antihypertensives, and cardiac meds can lower BP. Some illicit drugs(cocaine), cold meds, oral contraceptives and antidepressants can increase BPExercise can decrease BP for several hours afterwards.
  • Form BAngina: Recognize Appropriate Diagnostic Test Based on Client FindingsElectrocardiograms (ECG): check for changes on serial ECGs Angina: ST depression and/or T wave inversion (ischemia) MI: T-wave inversion (ischemia), ST segment elevation (injury) and an abnormal Q wave (necrosis)Clients with non-ST elevation MIs have other indicators ST segment depression that resolves with relief of chest pain New Development of left BBB T-wave inversion in all chest leadSerial Cardiac Enzymes: Typical pattern of elevation and decrease back to baselineoccurs with MI Cardiac Enzyme Normal Levels Elevated Levels 1st Expected Duration Detectable of Elevated Levels Following Myocardial Injury Creatinine kinase MB 0% of total CK 4-6 hr 3 days isoenzyme (CK-MB)- (30-170 units/L) more sensitive to myocardium Troponin T < 0.2 ng/L 3-5 hr 14-21 days Troponin I < 0.03 ng/L 3 hr 7-10 days Myoglobin < 90 mcg/L 2 hr 24 hrMyocardial Infarction: Recognizing Diagnostic findings and Planning Care inResponseSee above
  • Cervical CA: Recognizing Indications for Colposcopy and BiopsiesEarly cervical CA is generally asymptomatic. Sx do not develop until the cA has becomeinvasivePap tests are an effective screening tool for detecting the earliest changes associatedwith cervical CA.Cervical biopsy (definitive) is performed for cytologic studies when a cervical lesion isidentified. Biopsy is usually performed during colposcopy as a follow up to an abnormalPap smear.Unsatisfactory colposcopy findings or a positive biopsy necessitates removal of thelesion by conization, cryotherapy, laser ablation or loop electrosurgical excisionprocedure (LEEP)Clients with more extensive CA may require a total abdominal hysterectomy or a moreextensive pelvic surgery called exenterationS/Spainless vaginal bleedingwatery blood tinged vaginal dischargeleg pain (sciatic) or leg swellingFlank pain (hydronephrosis)unexplained wt losspelvic painIron Deficiency Anemia: Identifying Expected lab FindingsHb/Hct---decreasedMcV---decreasedMCH---decreasedMCHC----decreasedReticulocytes------normal or decreasedSerum iron-----decreasedTIBC------increasedBilirubin------normal or decreasedPlatelets------normal or increasedConscious Sedation: Intervene for ComplicationsComplications that may arise airway obstruction: insert airway, suction
  • respiratory depression: admin 02 and reversal agents, such as naloxone(Narcan) and flumazenil (Romazicon) cardiac arrhythmias: set up 12 lead ECG, provide antidysrhythmics and fluids hypotension: provide fluids, vasopressors Anaphylaxis: Administer epinephrineOsteoporosis: Measures to Prevent InjuryAssess the home environment for safety (remove throw rugs, adequate lighting, clearwalkways)Reinforce the use of safety equipment and assistive devicesInstruct the client to avoid inclement weather (ice or slippery surfaces)Clearly mark thresholds, doorways and stepsPrevention Teach the importance of regular, wt bearing exerciseLeukemia: Interventions to Reduce Infection Risks of ChemotherapyPrevent Infections freq thorough handwashing is a priority intervention place the client in a private room screen visitors carefully encourage good nutrition (low-bacteria diet, avoid salads, raw fruits, and vegs) and fluid intake Monitor WBC counts Encourage good personal hygiene Avoid crowds if possible
  • Immobilizing Interventions: Assessing for Altered Tissue PerfusionNeurovascular assessment is essential throughout immobilization. Assessments aredone frequently following initial trauma to prevent neurovascular compromise r/t edemaand/or immobilization device. Neurovascular assessment includes assessment of thefollowingPainParesthesiaPallorPolarParalysisPulses Neurovascular Early or Late Sign Assessment Client Teaching/Sx Components Parameters to Report Pain Early Assess area involved increasign pain not using 0-10 rating relieved with scale; 0= no pain, 10 elevation or pain = worst pain med Paresthesia Early assess for numbness or tingling, numbness/tingling; pins or needles pins or needles sensation sensation: should be absent Pallor Early assess cap refill increased cap refill Brisk is < 3 sec time > 3 sec , blue fingers or toes Polar Late assess skin temp by cool/cold fingers or touch: warm or cool toes Paralysis Late assess mobility; unable to move moves fingers or fingers or toes toes able to plantar dorsiflex the ankle area not involved or restricted by cast
  • Neurovascular Early or Late Sign Assessment Client Teaching/Sx Components Parameters to Report Pulses Late assess pulses distal weak palpable to injury; pulse is pulses, unable to palpable and strong palpate pulses, pulse detected only with DopplerAngina: Assessing Risk FactorsRisk factors:male genderhypertensionsmoking hxincreased agehyperlipidemiametabolic disorders: DM, hyperthyroidismMethamphetamine or cocaine useStress: Occupational, physical exercise, sexual activityPostoperative Nursing: Evaluating Postop Interventions to Prevent ComplicationsComplicationsAirway ObstructionMonitor for choking, noisy irregular respirations, decreased 02 sat scores, and cyanosisand intervene accordingly. Keep emergency equipment at the bedside in the PACUHypoxiaMonitor oxygenation status and admin 02 as prescribed. Encourage the client to coughand deep breathe. Position the client to facilitate respiratory expansionHypovolemic ShockMonitor for decreased BP and UOP, increased HR and slow cap refill. Admin fluids andvasopressors as indicatedParalytic ileus: Monitor bowel sounds, encourage ambulation, advance the diet astolerated, and admin prokinetic agents, such as metoclopramide (Reglan) as prescribedWound Dehiscence or Evisceration:
  • Monitor risk factors (obesity, coughing, moving without splinting, DM, day 5-10). Ifwound dehiscence or evisceration occurs, call for help, stay with the client, cover withsterile towel or dressing moistened with sterile saline, do not attempt to reinsert organs,monitor the client for shock and notify PCP immediately.Retinal Detachment: Evaluating Client Education Regarding Postop CareRestrict activity to prevent additional detachmentcover the affected eye with an eye patchmonitor for drainageAdmin meds as prescribed mydriatics (dilating)--prevent pupil constriction and reduce accommodation antiemetics analgesicsInstruct client to avoid activities that increase IOP bending over at the waist sneezing coughing straining vomiting head hyperflexion wearing restrictive clothing (for example tight shirt collars)DM: S/S of HypoglycemiaBS: < 50 mg/dLcool, clammy skindiaphoresisanxiety, irritability, confusion, blurred visionhungergeneral weakness, seizures, (severe hypoglycemia)Suctioning: Evaluation of Endotrach Suctioning Effectiveness
  • Endotrach Suctioning (ETS) is performed through a trach or endotrach tubeSterility must be maintained during endotracheal suctioningThe outer diameter of the suction catheter should be less than 1/2 the internal diameterof the endotrach tubeHyperoxygenate the client utilizing a bag-valve-mask (BVM) or specialized ventilatorfunction with 100% Fi02immediately after the BVM ventilator is removed from the trach or endotrach tube, insertthe catheter into the lumen of the airway. Advance until resistance is met. The cathetershould reach the level of the carina (location of bifurcation into the main stem bronchi).Intermittent suction is only applied during catheter withdrawal, lasting no longer than10-15 sec at a time. Suction is performed by covering and releasing the suction portwith the thumb while concurrently withdrawing the catheter, rotating it between thethumb and forefinger.Reattach the BVM or ventilator and supply the client with 100% inspired 02.Clear the catheter and tubingAllow time for client recovery between sessions.Repeat as necessaryMany mechanical ventilators have in-line suction devices. This may eliminate the needfor an assistant. Follow institution protocols for these systems. Always maintain surgicalaseptic techniqueCOPD: Interventions for Abnormal 02 Saturation FindingsPulse Oximetrymonitor oxygen saturation levelsLess than normal (normal = 94-98%) oxygen saturation levelsPosition the client to maximize ventilation (high Fowlerʼs)Encourage effective coughing, or suction to remove secretionsEncourage deep breathing and use of incentive spirometerAdminister breathing txs and meds as prescribed
  • Bronchodilators Short acting beta agonists, such as albuterol (Proventil, Ventolin) provide rapid relief Cholinergic antagonists (anticholinergic drugs, such as ipratropium (Atrovent), block the parasympathetic nervous system. This allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions Methylxanthines, such as theophylline (Theo-Dur), require close monitoring of serum med levels due to narrow therapeutic range. Anti-inflammatories decrease inflammation Corticosteroids such as fluticasone (Flovent) and prednisone. If given systemically, monitor for serious SE (immunosuppression, fluid retention, hyperglycemia, hypokalemia, poor wound healing) Leukotriene antagonists, such as montelukast (Singulair) Mast cell stabilizers, such as cromolyn sodium (Intal) Combination agents (bronchodilator and anti-inflammatory) Ipratropium and albuterol (Combivent) Fluticasone and salmeterol (Advair) If prescribed separately for inhalation admin at the same time, administer the bronchodilator first in order to increase the absorption of the anti-inflammatory agent.Admin heated and humidified oxygen therapy as prescribed. Monitor for skin breakdownfrom the 02 device.Instruct clients to practice breathing techniques to control dyspneic episodes Diaphragmatic or abdominal breathing Pursed lip breathingProvide oxygen therapy as prescribed to relieve hypoxemia
  • client with COPD may need 2-4 L/min per nasal cannula or up to 40% Venturi mask Clients with chronic hypercarbia usually require 1-2 L/min via nasal cannula. It is important to recognize that low arterial levels of oxygen serve as their primary drive for breathingDetermine the clientʼs physical limitations and structure activity to include periods of restPromote adequate nutrition increased work of breathing increases caloric demands proper nutrition aids in the prevention of secondary respiratory infectionsProvide support to the client and familyEncourage verbalization of feelingsEncourage smoking cessation if applicable. Smoking and other flame sources must beavoided by clients on supplemental oxygen (enhances (combustion) in the homeTopic DescriptorsSafety and Infection Control (17)Form ANewborn Discharge Teaching: Infant Safety PrioritiesProvide community resources to clients who may need additional and ongoingassessment and instruction on infant care (eg adolescent parents)Never leave the infant unattended with pets or other small childrenKeep small objects (coins) out of reach of infants (choking hazard)Never leave the infant alone on a bed, couch, or table. Infants move enough to reachthe edge and fall offNever provide an infant a soft surface to sleep (eg pillows and waterbed). The infantʼsmattress should be firm. Never put pillows, large floppy toys or loose plastic sheeting ina crib. The infant can suffocate.
  • Never place the infant on its stomach to sleep during the first few months of life. Theback lying position is the position of choicewhen using an infant carrier, always be within armʼs reach when the carrier is on a highplace such as a table. If possible, place the carrier on the floor near you.Do not tie anything around the infantʼs neck. Check the infantʼs crib for safety. Slatsshould be no more than 2.5 inches apart. The space between the mattress and sidesshould be less than 2 finger widthsKeep a crib or playpen away form window blinds and drapery cords. Infants canbecome strangled in them.The bassinet or crib should be placed on an inner wall, not next to a window to preventcold stress by radiation.Eliminate potential fire hazards. Keep a crib and playpen away from heaters, radiators,and heat vents. Linens could catch fire if in contact with heat sourcesSmoke detectors should be on every floor of a home and should be checked monthly toassure they are working. Batteries should be changed yearly. (Change batteries whendaylight saving occurs)Provide adequate ventilation. Control the temp and humidity of the infantʼs environment.Avoid exposure to cigarette or cigar smoke in a home or elsewhere. Passive exposureincreases the infantʼs risk of developing respiratory sx and illnesses.Be gentle with the infant. Do not swing the infant by his arms or throw the infant up inthe airAll visitors should wash their hands before touching the newbornAny individual with an infection should be kept away from the newborn.Always use an approved car seat when traveling. Parent should be instructed about theproper installation of an approved car safety seat.The infant should always be in a rear-facing car seat from birth to 9.1 kg (20 lb) or 1year of age, after which, a toddler seat should be used.The infant car seat should be secured in the rear seat of the car.The shoulder straps should be snug enough so they do not fall off the infantʼsshoulders.
  • Disaster Planning: Identify Disaster Preparedness ActivitiesDevelop a disaster response plan based on the most probable disaster threatsidentifying community disaster warning system and communication center and learninghow to use itidentify the first responders in the community disaster planmaking a list of agencies that are available for the varying levels of disaster both locallyand nationallydefining the nursing roles in first priority, second priority and third priority triageidentifying specific roles of personnel involved in disaster response and the chain ofcommand.locating all equipment and supplies needed for disaster management, including LevelIII suits, infectious control items, medical supplies, food, and potable water. Replenishthese regularly.Checking equipment (including evacuation vehicles) regularly to ensure properoperation.evaluating the efficiency, response time, and safety of disaster drills, mass casualtydrills and disaster plans.Emergency Management: Decontamination Following Exposure to BioterrorismAnthrax: instruct clients to remove contaminated clothing and store in labeled plasticbags. Handle clothing minimally to avoid agitation. Instruct clients to shower throroughlywith soap and water. Use standard precautions and wear appropriate protective barrierswhen handling contaminated clothing or other items. Recommended postexposureprophylaxis includes the admin of oral fluorquinolones (cipro, levofloxacin, andofloxacin)Botulism: decontamination is not requiredPlague: Risk for reaerosolization form contaminated clothing of exposed persons is low.In the case of gross exposure, instruct clients to remove contaminated clothing andstore in labeled plastic bags. Handle clothing minimally to avoid agitation. Instructclients to shower thoroughly with soap and water. Use standard precautions and wearappropriate protective barriers when handling contaminated clothing or other items.Postexposure prophylaxis is recommended for clients and HCP. The antimicrobial agentof choice is doxycycline or cipro.
  • Smallpox: Client decontamination after exposure is not indicated.Ergonomic Principles: Prevention of Carpal Tunnel SyndromeAvoid repetitive movements of the hands, wrists, and shoulders. Take a break q 15-20min to flex and stretch joints and muscles.Adaptive devices such as wrist splints may be worn to hold the wrist in slightdorsiflexion to relieve pressure on the median nerve.Special keyboard pads that help prevent repetitive pressure on the median nerveSafe Medication Administration and Error Prevention: Selecting AppropriateResources for Checking Prescription AccuracyNursing drug handbooksPharmacology textbooksProfessional journalsPDRProfessional Websites.Error Prevention: Ensuring Client Safety When Transcribing OrdersComponents of a medication orderName of clientDate and time of orderName of medDosageRoute of AdminTime and Freq --exact times or number of times per day (dictated by facility/agencypolicy or specific qualities of the med)Signature of prescribing doctor
  • When the nurse receives a verbal or telephone order, he or she writes the completeorder or enters it into a computer and then reads it back and receives confirmation fromthe prescriber to confirm accuracy. The nurse indicates the time and the name of theprescriber who gave the order and then signs the order.Common abbreviations may be used when writing orders. However, JCAHO nowrequires healthcare organizations to develop a “dangerous” abbreviation acronyms andsymbols list.Handling Infectious Materials: Appropriate DisposalThe CDC recommends a single bag for discarding items if the bag is impervious andsturdy and if the article can be placed in the bag without contaminating the outside ofthe bag. Soiled linen should be place in an impervious laundry bag in the clientʼs roomthe CDC recommends double bagging if it is impossible to prevent contamination of thebagʼs outer surface. Double bagging is not otherwise recommended.Client Safety: Removing Fire HazardsFaulty equipment (eg frayed cords, disrepair) can start a fire or cause a shock andshould be removed and reported immediately per the health care agencyʼs policy.Seizures: Appropriate Use of Seizure Precautions to Maintain Client SafetyTo develop a plan of care, assess the client with a hx of seizures for: freq type and date of last seizure meds triggers or trends of the seizuresEnsure rescue equipment is at the bedside to include oxygen, an oral airway, andsuction equipment. A saline lock may be put in for IV access if the client is at high riskfor experiencing a generalized seizureInspect the clientʼs environment for items that may cause injury in the event of a seizureand remove items that are not necessary for current txAssist the client at risk for a seizure in ambulation and transfer to reduce the risk ofinjuryAdvise all caregivers and family not top put anything in the clientʼs mouth (except instatus epilepticus, where an airway is needed) in the event of a seizureAdvise all caregivers and family not to restrain the client in the event of a seizure,ensure the clientʼs safety by lowering him to the floor or bed, protect his head, remove
  • nearby furniture, provide privacy, put the client on his side, if possible and loosenclothing to prevent injury and promote dignity of the clientAfter a seizure, explain what happened to the client, provide comfort and understandingand a quiet environment for the client to recover.Document the seizure in the clientʼs record with any precipitating behaviors and adescription of the event (eg movements, any injuries, length of seizure, aura, postictalstate) and report it to the PCP.Surgical Asepsis: Performing Aseptic TechniqueProcedure:Wash handsOpen plastic covering of package per manufacturerʼs directions, slipping the packageonto the center of the workspace with the top flap of wrapper opening away from thebody.Reach around the package to open the top flap of the package, grasp the outside flapbetween the thumb and index finger and unfold the top flap away from body.Next open the side flaps, using the right hand for the right flap and the left hand for theleft flapThe last flap should be grasped and turned down toward bodyAdditional sterile packages Open next to the sterile field by holding the bottom edge with one hand andpulling back on the top flap with the other hand. Place the packages that are to be usedlast furthest from the sterile field, and open these first. Add them directly to the sterile field. Lift the package from the dry surface holdingit 15 cm (6 in) above the sterile field, pulling the two surfaces apart, and dropping it ontothe sterile field.Pour sterile solutions by Removing the bottle cap Placing the bottle cap face up on the surface Holding the bottle with the label in the palm of the hand so that the solution does not run down the label
  • First pouring a small amt (1 -2 ml) of the solution into an available receptacle. pouring the solution onto the dressing or site without touching the bottle to the site.Once the sterile field is set up, it is necessary to don sterile gloves.Sterile gloving includes opening the wrapper and handling only the outside of thewrapper. Don gloves by using the following steps. With the cuff side pointing toward the body, use the left hand and pick up the righ hand glove by grasping the folded bottom edge of the cuff and lifting it up and away from the wrapper. While picking up the edge of the cuff, pull the right glove on the hand. With the sterile right gloved hand, place the fingers of the right hand inside the cuff of the left glove, lifting it off the wrapper and put the left hand into it. When both hands are gloved, adjustments of the fingers in the gloves may be made if necessary. During that time, only the sterile gloved hand can touch the other sterile glvoed hand. At the close of the sterile procedure, or if the gloves tear, the gloves must be removed. Take off the gloves by grasping the outer part at the wrist, pulling the glove down over the fingers and into the hand that is still gloved. Then, place the ungloved hand inside the soiled glove and pull the glove off so that it is inside out and only the clean inside part is exposed. Discard into an appropriate receptacle.Infection Control: Identifying and Reporting Errors in Surgical Skin PreparationSurgical handwashingTurn on water using knee or foot controls and adjust to comfortable tempWet hands and arms under running lukewarm water and lather with detergent to 5 cm (2in) above the elbows. (Hands need to be above the elbows at all timesRinse hands and arms thoroughly under running water. Remember to keep handsabove elbows.Under running water, clean under nails of both hands with nail pick. Discard after use
  • Wet clean sponge and apply antimicrobial detergent. Scrub nails of one hand with 15strokes. Holding sponge perpendicular, scrub palm, each side of thumb and fingers andposterior side of hand with 10 strokes each. The arm is mentally divided into thirds andeach third is scrubbed 10 times. Entire scrub should last 5-10 min. Rinse sponge andrepeat sequence for other arm. A two-sponge method may be substituted.Discard sponge and rinse hands and arm thoroughly. Turn water off with foot and kneecontrol and back into room entrance with hands elevated in front of and away from thebody.Artificial Airway: Instructing Family on Safe Use of EquipmentProvide trach care q 8 hrs to decrease the risk of infection and skin breakdown suction the trach tube, if necessary using sterile suctioning supplies remove old dressing and excess secretions apply the oxygen source loosely if the client desaturates during the procedure use cotton-tipped applicators and gauze pads to clean exposed outer cannulasurfaces. Begin with H202 followed by normal saline. Clean in circular motion fromstoma site outward. using surgical aseptic technique, remove and clean the inner cannula (use H202to clean the cannula and sterile saline to rinse it. Use new inner cannula if it isdisposable)Clean the stoma site and the trach plate with H202 followed by sterile saline.Place split 4x4 dressing around trach.Change trach ties if they are soiled. Secure new ties in place before removing soiledones to prevent accidental decannulation.If a know is needed, tie a square know that is visible on the side of the neck. One or twofinger should be able to be placed between the tie tape and the neck.document the type and amt of secretions, the general condition of the stoma andsurrounding skin, the clientʼs response to the procedure, and any teaching thatoccurred.Provide adequate humidification and hydration to thin secretions and decrease risk ofmucus plugging
  • Do not suction routinely as this causes mucosal damage, bleeding and bronchospasm.Suction PRN when assessment findings indicate (eg audible/noisy secretions, crackles,restlessness, tachypnea, tachycardia, presence of mucus in the airway.Emergency Management: Order of Client Evacuation in Response to a FireClients who are close to the fire, regardless of its size, are at risk of injury and should bemoved to another area.If a client is receiving oxygen but not life support, the nurse discontinues the oxygen,which is combustible and can fuel an existing fire.If the client is on life support, the nurse may need to maintain the clientʼs respiratorystatus manually with an Ambu-bag until the client is moved away from the fire. Abulatoryclients can be directed to walk by themselves to a safe area and in some cases may beable to assist in moving clients in wheelchairs.Bedridden clients are generally moved form the scene of a fire by a stretcher, their bedor a wheelchair.If none of these methods, the client must be carried from the area.HIV/AIDS: Appropriate Environmental PrecautionsDirect contact (skin to skin or contact with mucous membrane discharges)HIV is transmitted through blood and body fluids (semen, vaginal secretions)HIV is found in breast milk, amniotic fluid, urine, feces, saliva, tears, CSF, lymph nodes,cervical cells, corneal tissue and brain tissue, but epidemiologic studies indicate thatthese are unlikely sources of infections.Decreasing risks r/t sexual intercoursesafe sex eliminates the risk of exposure to HIV in semen and vaginal secretionsabstaining is the most effective way to accomplish this but there are safe options forthose who cannot or do not wish to abstainoutercourse (limiting sexual behavior to activities in which the mouth, penis, vagina orrectum does not come into contact with a partnerʼs mouth, penis, vagina, or rectum) issafe bec there is not contact
  • includes massage, masturbation, mutual masturbation, telephone sexinsertive sex between partners who are not infected with HIV or not at risk of becominginfected with HIV is considered to be safeRisk reducing sexual activities decrease the risk of contact through the use of barriers. should be used when engaging in insertive sexual activity with a partner who isknown to be HIV infected or with a partner whose HIV status is not known most common barrier device is male condom female condoms squares of latex plastic food wrapDecreasing risks r/t drug usemajor risk for HIV infection is r/t sharing injecting equipment and/or having unsafe sexexperiences while under the influence of drugs.basic rulesdo not use drugsif you do, donʼt share equipmentdo not have sex when under the influence of any drug (including alcohol) that impairsdecision making abilityuse alternatives to injecting such as smoking, snorting, or ingesting the druginjecting equipment includes needles, syringes, cookers (spoons or bottle caps used tomix the drug) cotton, and rinse wateranother safe tactic is for the user to have access to sterile equipment (needle exchangeprograms)cleaning equipment before use is a risk-reducing activityDecreasing risks for perinatal transmissionbest way to prevent HIV in infants is to prevent HIV infection in women
  • If HIV-infected pregnant women are txʼd with AZT, REtrovir, the rate of perinataltransmission is decreased.tx has minimal SE for the babyCombination ART as appropriate for the motherʼs HIV infection can further decrease therisk of perinatal transmission to less than 2%Decreasing risks at workemployers must protect workers from exposure to blood and other potentially infectiousmaterials.precautions and safety devices decrease the risk of direct contact with blood and bodyfluids.should exposure to HIV infected fluids occur, postexposure prophylaxis withcombination ART based on the type of exposure the volume of exposure and the statusof the source pt decreases the risk of infections.Meningitis: Client Education Regarding Prophylactic PrecautionsRisk FactorsBacterial Infections (Neisseria meningitidis, Streptococcus pneumoniae, Haemophilusinfluenzae) such as upper respiratory infections (otitis media, pneumonia, sinusitis)ImmunosuppressionInvasive Procedures, skull fracture, or penetrating head wound (direct access to CSF)Overcrowded Living conditionsprevention of respiratory infection through vaccination program for pneumococcalpneumonia and influenza should be supportedIn addition, early and vigorous tx of respiratory and ear infections is important.persons who have close contact with anyone who has bacterial meningitis should begiven prophylactic antibiotics.Client Safety: Evaluating Appropriate Selection of Restraints Based on ClientSituation
  • Client Safety: Appropriate Use of RestraintsReasons for use of a physical restraint are to be clearly statedthe use of restraints must be part of clientʼs medical tx all less restrictive interventionsmust be tried first, other disciplines must be consulted, and supporting documentationmust be provided.if a nurse uses restraints in an emergent situation, such as when a client is a danger toself or others, a face-to-face assessment is to be done within 1 hr by a PCPa physicianʼs order is required based on a face-to-face assessment of the client.the order must state the type of restraint, location, and specific client behaviors forwhich restraints are to be used and must have a limited time frame.these orders should be renewed within a specific time frame according to the agencyʼspolicy.Assessment must ongoing.Proper documentation including behaviors that necessitated the application ofrestraints, the procedure used in restraining and the condition of the body partrestrained and the evaluation of the client response is essential.Use of restraints must meet the following objectives:reduce the risk of client injury from fallsprevent interruption of therapy such as traction, IV infusions, NG tube feeding or Foleycathprevent the confuse or combative client from removing life support equipmentreduce the risk of injury to others by the clientClient Safety: Maintain Prescribed RestraintsRemove or replace restraints frequently to ensure good ciruclation to the area and allowfor full ROM to the limb that has been restricted.Pad bony prominences and do neurosensory checks (to include loosening or removingthe restraint and testing temperature, mobility, and capillary refill) q 2 hr to identify anyneurological or circulatory deficits.
  • Always tie the restraint to the bed frame (loose knots that are easily removed) where itwill not tighten when the bed is raised or lowered.Leave the restraint loose enough for ROM and with enough room to fit two fingersbetween the device and the client to prevent injury.always explain the need for the restraint to the client and family so as to help themunderstand that these actions are for the safety of the client.Regularly assess the need for continued use of the restraints to allow for discontinuationof the restraint or limiting the restraint at the earliest possible time while ensuring theclientʼs safety.Never leave the client unattended without the restraint.Restraints should:Never interfere with txRestrict movement as little as is necessary to ensure safetyFit properlyBe easily changed to decrease the chance of injury and to provide for the greatest levelof dignityDocumentation for the use of restraints is very specific and must include:the behavior that makes the restraint necessarynursing interventions used prior to the placement of restraints.clientʼs LOCtype of restraint used and locationeducation/explanations to the client and familyexact time of application of removalclientʼs behavior while restrained.
  • Form BEmergency Management: Appropriate Response to FireThe RACE mnemonic is a basic guideline for reacting to a fire within the health carefacility. Rescue Rescue everyone from the area Alarm Pull the fire alarm which will activate the EMS response Systems that could increase fire spread are automatically shut down with activation of alarm Contain Once the room or area has been cleared, the fire doors should be kept closed in order to contain the fire. Keep fire doors closed as much as possible when moving from section to section within the facility
  • Rescue Rescue everyone from the area Extinguish Make an attempt to extinguish small fires using a single fire extinguisher, smothering, or water (except with an electrical or grease fire). Evacuation should occur if the nurse cannot put the fire out with these methods. Attempts at extinguishing the fire should only be made when the employee has been properly trained in the safe and proper use of a fire extinguisher and when only one extinguisher is needed.Clients who are close to the fire, regardless of its size, are at risk of injury and should bemoved to another area.If a client is receiving oxygen but not life support, the nurse discontinues the oxygen,which is combustible and can fuel an existing fire.If the client is on life support, the nurse may need to maintain the clientʼs respiratorystatus manually with an Ambu-bag until the client is moved away from the fire. Abulatoryclients can be directed to walk by themselves to a safe area and in some cases may beable to assist in moving clients in wheelchairs.Bedridden clients are generally moved form the scene of a fire by a stretcher, their bedor a wheelchair.If none of these methods, the client must be carried from the area.Ergonomic Principles: using Body Mechanics to Prevent Injuries to the NurseThe center of gravity is the center of a mass. In the body, the center of gravity is thepelvis. When an individual moves, the center of gravity also shifts. The closer the line ofgravity is to the center of the base of support, the more stable the individual is. To lowerthe center of gravity, bend the hips and knees. Avoid twisting the spine or bending at thewaist (flexion) to minimize the risk for injuryWhen lifting, use the major muscle groups to prevent back strain and tighten theabdominal muscles to increase support to the back muscles. Distribute the wt betweenthe large muscles of the arms and legs to decrease the strain on any one muscle group
  • and avoid strain to smaller muscles. When lifting from the floor, flex the hips, knees andback. Get the object to thigh level keeping the knees bent and straightening the back.Hold the object as close as possible, bringing the load to the center of gravity toincrease stability and decrease strain. Use assistive devices whenever possible, andfind assistance whenever it is needed.When pushing or pulling a load, widen the base of support. if pushing, move the frontfoot forward and if pulling, move the rear leg back and promote stability. Face thedirection of movement if moving a client. It is easier and safer to pull toward than topush away from the center of gravity. use body wt when pushing or pulling to decreasethe strain on muscles which makes the movement easier. Sliding, rolling and pushingrequire less energy than lifting and have less risk for injuryGuidelines to Prevent InjuryPlan ahead for activities that require lifting, transfer or ambulation of a cliet and askothers to be ready to assist at the time planned.Rest between these heavy activities to decrease muscle fatigueMaintain good posture and exercise regularly to increase the strength of arm, leg, backand abdominal muscles so these activities require less energyGet help from others, use assistive devices and offer to help others in lifting clients toreduce the load for any one indiv.Use smooth movements when lifting and moving clients to prevent injury throughsudden or jerky muscle movementsWhen standing for long periods of time, flex the hip and knee through use of a foot rest.When sitting for long periods of time, keep the knees slightly higher than the hipsThe client who is debilitated does not move easily and has difficulty changing positionsfreq. it is the responsibility of the caregiver to reposition the client regularly whilemaintaining good body alignment for the client, and using good body mechanics for theproviderʼs safety.Avoid repetitive movements of the hand, wrists and shoulders. Take a break every15-20 min to flex and stretch joints and muscles.Maintain good posture (head and neck in straight line with the pelvic) to avoid neckflexion and hunched shoulders which can cause impingement of nerves in the neck.Error prevention: Questioning Prescriptions
  • A nurse is obligated to carry out a physicianʼs order except when the nurse believes anorder to be inappropriate or inaccurateA nurse carrying out an inaccurate order may be legally responsible for any harmsuffered by the clientThe nurse should clarify with the physician an unclear or inappropriate order or an orderin questionIf no resolution occurs regarding he order in questions, the nurse should contact thenurse manager or supervisorHazardous Materials: Appropriate Handling of ChemotherapyDisposal of Cytoxic Drug1. All material contaminated with cytotoxic drugs must be placed in yellowplastic sharps/chemotherapy disposal containers.2. All needles and syringes must be placed as a single unit into the yellow sharps/chemotherapy disposal containers.Client Safety: Interventions to Prevent FallsAssess the clientʼs risk for fallingAssign the client at risk for falling to a room near the nurseʼs stationAlert all personnel to the clientʼs risk for fallingOrient the client to physical surrounding sInstruct the client to seek assistance when getting upExplain use of the call bell systemKeep the bed in the low position with side rails up if requiredLock all beds, wheelchairs, and stretcherKeep personal items within reachEliminate clutter and obstacles in the clientʼs roomProvide adequate lightingReduce bathroom hazardsmaintain the clientʼs toileting schedule throughout the dayIncidents: Priority Responses
  • Incident reports are used as a means of identifying risk situations and improving clientcare.Follow specific documentation guidelinesfill out the report completely, accurately and factuallyThe report form should not be copied or placed in the clientʼs recordMake no reference to the incident report form in the clientʼs record.The report is not a substitute for a complete entry in the clientʼs record regarding theincident.Examples of incidents:Accidental omission of ordered therapiesCircumstances that led to injury or a risk for client injuryClient fallsMedication admin errorNeedlestick injuriesProcedure related or equipment related accidentsA visitor having symptoms of an illnessSecurity Plans: Appropriate Interventions to Maintain Security on Obstetrical UnitTeach parents how to recognize picture identification badges worn by birth facilitypersonnelParents should also be aware of other identifying measures such as color codedbadges or uniforms for maternity staffWritten and verbal information, including a picture of special identification badges wornby staff should be given to parentsParents must be cautioned never to give their infant to anyone who does not haveproper identificationQuestion anyone carrying a newborn near an exit or in an unusual part of the facility
  • Be suspicious of anyone who does not seem to be visiting a specific mother, asksdetailed questions about the nursery or discharge routines, asks to hold infants orbehaves in an unusual mannerBe suspicious of unknown people carrying large bags or packages that could contain aninfantrespond immediately when an alarm signals that a remote exit has been opened or aninfant has been taken into an unauthorized areaNever leave infants unattended. Teach parents that infant must be observed at all times.Suggest that mothers have the nursing staff take over care of the infant if the motherfeels unwell or is napping and no family members are available to watch the infantTake infants to mothers one at at time. never leave an infant in a crib in the hall whilethe nurse is in a room with another mother. Never leave an infant unsupervised.When infants are left in motherʼs room, position the crib away from the doorways,preferably on the side of the motherʼs bed opposite the doorIf entrances to the maternity unit or nurseries are equipped with locks that open tocodes or card keys, protect them from othersWhen a parent or family member comes to the nursery to take an infant, always matchthe infant and adult identification bracelet numbers. never give an infant to anyone whodoes not have the correct identification bracelet or other proper idAlert hospital security immediately when any suspicious activity occursSuggest that parents do no place announcements in the paper or signs in their yard thatmight alert an abductor that a new baby is in the home