nursing process: Evaluation

Mastitis

(inflammation of the breast) redness and pain in the left breast, a temperature of 100.8º F (38.2º C), chills, and malaise.

bougienage

A procedure involving the use of a bougie. A bougie is a thin cylinder of rubber, plastic, metal or another material that a physician inserts into or though a body passageway, such as the esophagus, to widen the passageway, guide another instrument into a passageway, or dislodge an object.

Levofloxacin

Absorption of the oral solution is enhanced when the stomach is empty, and it should be taken 1 hour before meals or 2 hours after meals. Food in the stomach will interfere with absorption. If the medication is taken just before a meal, food in the stomach shortly afterward will interfere with absorption. If the medication is taken 30 minutes after a meal, food remaining in the stomach will interfere with absorption.

side effect of haloperidol (Haldol)

Akathisia, a side effect of haloperidol (Haldol), develops early in therapy and is characterized by restlessness and agitation. Pseudoparkinsonism is characterized by motor retardation, rigidity, and tremors; the reaction resembles Parkinson's syndrome but usually responds to decreasing the dose, the administration of an antidyskinetic medication, or discontinuation of the haloperidol.

kidney transplant

As the transplanted organ functions, nitrogenous wastes are eliminated, lowering the serum creatinine. As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease. With end-stage kidney disease, fluid retention causes hypertension. There should be a correction of hypertension,. After the transplant, the serum potassium should correct to within expected limits for an adult.

Preconceptual thought

Attributing lifelike qualities to inanimate objects (animism) is associated with

school aged stage achievements

Concrete operational thought is achieved in school-age children. Concept of reversibility is a phase of concrete operations achieved by school-age children.

Dexamethasone

Corticosteroids, have a hyperglycemic effect, and blood glucose levels should be monitored routinely.

conduct disorder

Demonstrating respect for the rights of others is a specific outcome criterion for children with a risk for violence directed at others; children with the diagnosis of typically present with a repetitive and persistent pattern of behavior that violates the basic rights of others or major age-appropriate societal norms or rules.

Neuroleptic Malignant Syndrome

Diaphoresis, hyperrigidity, and hyperthermia occur with neuroleptic malignant syndrome as a result of dopamine blockade in the hypothalamus. Fatal reaction to antipsychotic meds.

Abdominal Hysterectomy Pt teaching

Discharge instructions after abdominal hysterectomy include avoiding jogging, aerobic exercise, participating in sports, and other any strenuous activity for 2 to 6 weeks after the surgery. The statement indicating that the client plans to start jogging again by next week means that the client requires more teaching. Stair climbing should be limited to fewer than five times per day. Nothing heavier than 5 to 10 lb should be lifted. The client should not cross her legs at the knees when sitting. Those three statements by the client are accurate and indicate understanding of the teaching.

signs of dumping syndrome

Faintness, feelings of fullness, diaphoresis, and cardiac palpitations

Disturbed Self Esteem goals

Identifying two positive personal attributes is a short-term goal for children who have

(RN) delegates a task to the licensed practical nurse (LPN). If the LPN fails to perform the task within acceptable standards

If the delegated task is not performed within acceptable standards, a potential for nursing malpractice emerges. Failure to delegate and supervise within acceptable standards may extend to direct corporate liability for the institution. Whenever care is provided by staff other than a registered nurse (RN), the accountability for care remains with the delegator who is an RN. The licensure of the licensed practical nurse (LPN) would not be cancelled because the LPN is not held accountable for the situation. When the work is assigned to the LPN, only responsibility of the task is transferred.

attention deficit hyperactivity disorder and oppositional defiant disorder goal

Increased impulse control is a short-term goal for children with a variety of mental disorders of childhood such as

Magnesium Sulfate

Monitoring deep tendon reflexes is required when administering

epidural anesthesia

Regional anesthesia lowers the blood pressure, which puts both mother and fetus in jeopardy. The client may not have the sensation to void, but the amount of urine manufactured does not decrease because a regional block does not affect the kidneys. It does not shorten the second stage of labor and does not cause uterine atony.

Healthcare Effectiveness Data and Information Set (HEDIS)

The Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS) is a survey that is conducted by randomly selecting samples of adults who were discharged from a hospital between 48 hours and six weeks ago. Healthcare Effectiveness Data and Information Set (HEDIS) is relied upon by health plans throughout the United States as a quality measure. HEDIS is the database of choice for the Centers for Medicare and Medicaid Services (CMS). HEDIS was created by the National Committee for Quality Assurance (NCQA) to collect data to measure the quality of care and services provided by different health plans.

stages of labor

The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.

impaired social interaction goal

Using age-appropriate play activities with at least one peer is a short-term goal for children who have

Rubeola (measles) virus

White spots (Koplik spots) and the rash with a mucous discharge from the nose (coryza) are clinical indicators of

Late decelerations

are indicative of uteroplacental insufficiency and, left uncorrected, lead to fetal hypoxia, fetal myocardial depression, or both.

fluid retention

causes hypertension

Paternalism

encompasses the practice of governing people in a fatherly manner, especially by providing for their needs without infringing on their rights or responsibilities.

Justice

fairness; rightfulness

Signs of rehydration

include increased urine output and a dilution of the urine, which results in a decrease in specific gravity. A classic sign of dehydration is oliguria and a concomitant increase in the urine specific gravity as the body attempts to compensate for the fluid loss by releasing antidiuretic hormone. With rehydration the heart rate and capillary refill time should decrease and return to their expected ranges, and blood pressure should increase to the normal range.

tardive dyskinesia

is characterized by gross involuntary movements of the extremities, tongue, and facial muscles that develop after prolonged therapy.

Pseudoparkinsonism

is characterized by motor retardation, rigidity, and tremors;

evidence

is data presented in proof of the facts, which may include witness testimony, records, documents, or objects.

Common Cause

means to unite one's interest with another's.

Asian cultures

tend to make little eye contact, particularly with people perceived as authority figures.

sensimotor stage

infant

Beneficence

relates to the state or act of doing good, being kind and charitable.It also includes promotion of well-being and abstaining from the injuring of others.

A client with achalasia is scheduled to have a bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for what complications related to esophageal perforation? Correct1 Tachycardia and abdominal pain 2 Faintness and feelings of fullness 3 Diaphoresis and cardiac palpitations 4 Increased blood pressure and urinary output

An increased heart rate is related to an autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux. Faintness, feelings of fullness, diaphoresis, and cardiac palpitations are signs of dumping syndrome. Blood pressure may increase, but increased urinary output has no relationship to esophageal perforation.

CF have altered glucose tolerance

Pancreatic scarring affects the ability of the islets of Langerhans to produce insulin; about half of all children with this condition have altered glucose tolerance. The endocrine glands, which produce insulin, are ductless and are not affected by the thickened mucus in the ducts. However, the general scarring throughout the pancreas does affect the insulin-producing glands. The glucose tolerance test is a measure of the body's ability to produce and metabolize carbohydrates, not a measure of the child's adherence to the diet. The dosage of pancreatic enzymes is based on food consumption, not the blood glucose level.

postterm newborn

Profuse scalp hair is associated with a them. As the fetus matures, usually the hair on the scalp becomes more profuse. Parchmentlike skin is associated with a newborn. Skin desquamation occurs as a result of prolonged exposure to amniotic fluid, causing cracking, peeling, and drying of skin and resulting in a parchmentlike appearance. Creases will cover the entire sole of each foot if the newborn is full term or ; newborns exhibit little vernix caseosa. As the fetus reaches full term and beyond, both testes usually descend and rugae cover the scrotal sac.

Child correct crutches use

The child should maintain an erect walking posture, without looking down, to ensure equilibrium and avoid losing balance. Taking short steps is the correct technique for safe ambulation while crutch-walking. Looking forward is the correct technique for safe ambulation while crutch-walking; it keeps the body's center of gravity over the hips. Maintaining an erect posture is the correct technique for safe ambulation during crutch-walking; it keeps the body's center of gravity over the hips.

newborns respirations

The expected breathing pattern is abdominal and irregular in rhythm and depth (alternating between shallow and deep); the expected rate ranges from 30 to 60 breaths/min.They are irregular and abdominal.

complication after removal of parathyroid tissue during a thyroidectomy

These symptoms may indicate impending hypocalcemic tetany, a complication after removal of parathyroid tissue during a thyroidectomy. Physical assessment and notification of the health care provider are the priorities. These symptoms may be related to postoperative anxiety, but the priority is to assess for impending tetany. Taking the vital signs and placing the client in a high-Fowler position is not helpful for the complaint made by the client; further assessment for tetany is indicated.

Achalasia

is a rare disorder of the esophagus, the tube that carries food from the throat to the stomach. It is characterized by impaired ability to push food down toward the stomach (peristalsis), failure of the ring-shaped muscle at the bottom of the esophagus, the lower esophageal sphincter (LES), to relax.

tort

is a wrongful act, not including a breach of contract or trust that results in injury to another person.

Torticollis

is characterized by a stiff neck (wry neck).

proximate cause

is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury .

preterm newborn

newborns have an absence of or few skin creases on the soles of the feet. Abundant vernix caseosa is associated with a newborn. Immature genitals (e.g., undescended testes, small scrotum, few rugae over the scrotum) are associated with a newborn.

Ketoacidosis (DKA)

occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there is not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.

Hypersensitivity reactions

results from the production of antibodies in response to exposure to certain foreign substances (allergens). Earlier exposure is necessary for the development of these antibodies. This is not a sensitivity reaction to penicillin; hay fever and asthma are atopic conditions. It is an active, not passive, immune response. Antibodies developed when there was a previous, not current, exposure to penicillin.