1340 final powerpoint

preop orthopedic surgery

Before surgery, the nurse obtains a complete medical, drug, and allergy history from the client or a family member. The nurse also assesses the client's physical condition and mental status at the time of the initial interview. Review of the client's chart includes noting the diagnosis, type of surgery to be performed, and any previous treatments, such as traction or drug use. If the client's disorder was treated previously, the nurse needs to determine whether any complications or problems occurred because of or during treatment. Client goals in the preoperative period focus on helping the client to experience reduced pain; continue to be active, mobile, and injury free; practice measures to reduce the potential for postoperative wound infection; control anxiety at manageable levels; understand instructions; and comprehend the procedures and rationale of postoperative management Ensuring Complete Care for Clients Before Orthopedic Surgery Review the operation and the reason for it. Administer prescribed analgesics. Relieve the client's discomfort through positioning and joint immobilization. Support painful joints and be gentle when moving the client. Allow ample time for physical activities, because the client with a musculoskeletal disorder needs more time to carry out preoperative routines. Allow the client to use any ambulatory aid that was brought from home. Demonstrate use of the overbed trapeze and encourage its use. Demonstrate and have the client perform necessary postoperative activities, such as coughing and deep-breathing exercises. Provide preoperative skin care as indicated by agency policy and procedure. If the client has initiated skin preparation at home, check to be sure the procedures were performed. Obtain adequate help when transferring a sedated client who is not in traction from the bed to the surgical stretcher. However, keep a client who is in traction in the hospital bed. Then, without lifting or removing the traction weights, transport the bed to the operating room. Administer the intravenous (IV) prophylactic antibiotic if ordered before surgery. (Although laminar airflow in the operating suite has reduced the incidence of postoperative infection, a great risk for infection remains for every client having orthopedic surgery. The number of personnel in the operating room may need to be limited to reduce a potential reservoir of infecting microorganisms.) Avoiding Hip Dislocation After Conventional Replacement Surgery Until the hip prosthesis stabilizes after hip replacement surgery, the client needs to learn about proper positioning so that the prosthesis remains in place. Dislocation of the hip is a serious complication of surgery that causes pain and necessitates reoperation to correct the dislocation. Desirable positions include abduction, neutral rotation, and flexion of less than 90°. When the client is seated, the knees should be lower than the hip. Guidelines for avoiding displacement are as follows: Keep the knees apart at all times. Put a pillow between the legs when sleeping. Never cross the legs when seated. Avoid bending forward when seated in a chair. Avoid bending forward to pick up an object on the floor. Use a raised toilet seat. Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes.

treatment of gastric ulcers

Most clients with PUD have H. pylori. Thus, the goals of treatment are to (1) eradicate the bacteria and (2) reduce the acid levels in the digestive system to relieve pain and promote healing. Use of only one antibiotic is inadequate to kill the bacterium; eradication therapy includes a combination of antibiotics for at least 2 weeks. Drugs are also prescribed to reduce acid, relieve pain, and promote healing, including H2-receptor antagonists, antacids, proton pump inhibitors, and cytoprotective agents. These drugs may be prescribed for longer than 2 weeks. The following list provides examples of drugs used to treat PUD: Antibiotics: Commonly prescribed antibiotics are amoxicillin (Amoxil), clarithromycin (Biaxin), and tetracycline, which exert bactericidal effects to eradicate H. pylori. Amebicides: Metronidazole (Flagyl) assists in the eradication of H. pylori. H2-receptor antagonists: Cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac) block H2 receptors and decrease hydrochloric acid secretion in the stomach, relieving pain and promoting healing. Antacids: These drugs initially are used to neutralize existing stomach acid and provide quick pain relief. They are not absorbed from the GI tract and therefore do not produce alkalosis, even when given in large doses. Proton pump inhibitors: Omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), rabeprazole (AcipHex), and pantoprazole (Protonix) block the final step in acid production at the surface of parietal cells. These medications also promote healing and appear to inhibit the growth of H. pylori. Cytoprotective agents: Sucralfate (Carafate) forms a seal over the ulcer, protecting it from irritation. Misoprostol (Cytotec), a synthetic prostaglandin, is used to sustain the mucosal layer especially among clients who require large doses or long-term treatment with aspirin or NSAIDs. Bismuth salts such as bismuth subsalicylate (Pepto-Bismol) suppress H. pylori, assist in healing mucosal lesions, and protect the lining of the stomach and intestines. Combination drugs: Some drug companies provide medication combinations for the treatment of PUD, which include two antibiotics with an H2-receptor antagonist or cytoprotective agent. Examples include Prevpac and Helidac. Clients with PUD may experience obstruction resulting from edema and inflammation. Gastric intubation is necessary, along with treatment for the ulcer. Treatment of hemorrhage includes complete rest for the GI tract, blood transfusions, and gastric lavage with saline solution. IV fluids are administered until the bleeding has stopped. If more conservative measures are unsuccessful, endoscopic laser therapy or endoscopic injections of epinephrine or anhydrous alcohol into the ulcer bed may be used to control bleeding. Ulcers that persist (referred to as refractory ulcers) despite medical interventions, repeatedly recur, cause severe hemorrhage, create unrelieved obstruction, cause perforation, or are predisposed to malignant changes justify surgical interventions as described in Table 45-3. If a total gastrectomy (removal of the stomach) is performed, the client receives vitamin B12 injections or intranasal vitamin B12 for life because, without the stomach, the intrinsic factor necessary for absorption of vitamin B12 no longer is produced. Vitamin B12 therapy usually is not necessary for 1 or 2 years after surgery because the body uses very small amounts of this vitamin and body reserves usually are sufficient for several years. In addition, the nurse notes the client's bowel patterns and stool characteristics. He or she also evaluates the client's emotional status and response to activity. The nurse monitors the nonsurgical client closely for medical complications, which includes assessing vital signs and fluid status. Nursing Guidelines 45-3 describes assessment of gastric pH. For a discussion of appropriate nursing management of a surgical client, refer to the Nursing Management section that accompanies the discussion of cancer of the stomach.

prostatectomy nursing interventions

Prostatectomy nursing interventions: Assessment Determine the following after surgery: •Level of consciousness •Vital signs •Level of discomfort •Location of urinary catheter(s) •Volume and color of urine RC of Hemorrhage related to inadequate hemostasis Expected Outcome. The nurse will monitor to detect, manage, and minimize excessive bleeding. InterventionsRationalesMonitor vital signs every 15 minutes until stable and then every 4 hours. Hypotension and tachycardia suggest a loss of blood volume. Assess color of urine and status of dressing, if there is one, at least every 4 hours. A change from burgundy to bright red, like catsup, suggests fresh bleeding. Maintain traction on the urinary catheter for at least 6 hours after surgery. Traction provides pressure on blood vessels, which facilitates hemostasis. Discourage straining to have a bowel movement, attempts to void with the catheter in place, and lifting heavy objects. Bearing down increases blood pressure, which can trigger fresh bleeding. Report signs of hypovolemic shock to the physician. The physician determines the medical measures such as administering blood transfusions and medications for stabilizing the client's condition. Evaluation of Expected OutcomeClient's urine is light pink, clear, or amber. RC of Anemia related to postoperative bleeding Expected Outcome. The nurse will monitor to detect, manage, and minimize anemia. InterventionsRationalesMonitor laboratory test results when a complete blood count is performed. Assist with administering whole blood or packed cells as prescribed by the physician. Low erythrocyte, hemoglobin, and hematocrit results indicate that the client may require the replacement of blood. Transfusions of whole blood or packed cells replace depleted cells and intravascular fluid volume faster than the bone marrow can reproduce erythrocytes. Evaluation of Expected OutcomeClient's hemoglobin is at least 10 g/dL. Nursing Diagnosis. Risk for Urinary Retention related to obstruction of urinary catheter with tissue debris and blood clots or urethral stricture Expected Outcome. Catheter will remain patent. InterventionsRationalesInstill bladder irrigation solution at a rate to maintain light pink or clear urine (Fig. 55-11). Irrigating solution dilutes blood cells and tissue debris and facilitates removal from the bladder by gravity drainage. Encourage client to drink about one glass of water every hour while awake. A generous fluid intake keeps the urine dilute and the catheter patent. Palpate bladder and assess true urine volume every 4 hours whenever client complains of pain or if urine leaks around catheter. The bladder is not palpable unless distended. True urine volume is assessed by subtracting the volume of irrigating solution from the total urinary output. Pain and leaking fluid suggest accumulated urine with no appropriate outlet. Interference with gravity drainage results in urine accumulation in the bladder. Avoid dependent loops and kinks in urinary catheter, never clamp urinary catheter, and do not allow client to lie on the drainage tubing. Keep drainage bag below the level of the bladder. Fluid (urine in this case) flows by gravity from higher to lower locations. If the urinary drainage bag is above the bladder, urine flows backward into the bladder. Evaluation and Expected OutcomeUrine drains freely from the catheter or with spontaneous voiding. RC of Hyponatremia related to absorption of bladder irrigation solution Expected Outcome. The nurse will monitor to detect, manage, and minimize hyponatremia. InterventionsRationalesAnalyze if there is a realistic relationship between the amount of instilled irrigation solution and the drainage volume. A deficit in irrigation volume suggests systemic absorption of a portion of the full amount. Monitor and report if client develops weakness, muscle cramps, nausea, vomiting, confusion, seizures, or elevated blood pressure. Hyponatremia is manifested in physical signs and symptoms, and serum sodium < 135 mEq/dL. Slow or interrupt the bladder irrigation if you suspect hyponatremia or fluid excess; report assessment data to the physician. The nurse collaborates with the physician when the management of the client's problems involves medical interventions. Evaluation of Expected OutcomeClient's serum sodium level is 135-145 mEq/L. Nursing Diagnosis. Acute Pain related to tissue injury or bladder spasms Expected Outcome. Pain will be controlled within the client's level of tolerance. InterventionsRationalesCheck that catheter is patent and draining before administering medication. Obstruction in the flow of urine contributes to pain. Administer a prescribed antispasmodic, such as a belladonna and opium suppository, or prescribed medications such as oxybutynin (Ditropan) or propantheline (Pro-Banthine), or an analgesic for incisional pain. Anticholinergics relieve bladder spasms. Analgesics interfere with the perception of pain. Explain that the large balloon holding the catheter in place, traction on the catheter, and the volume of instilling irrigant tend to produce the urge to void, but an effort to do so contributes to discomfort. Offering the client an explanation helps alleviate the anxiety concerning the cause of discomfort. Use nursing measures such as placing a rolled towel beneath the scrotum, assisting with the application of an athletic support, suggesting the use of a recliner rather than sitting on a hard surface, changing position, and diversional activities. Alternative measures enhance the response to drug therapy. Evaluation of Expected OutcomePain and discomfort are tolerable. Nursing Diagnosis. Risk for Infection related to impaired tissue and potential contamination of catheters and incisional drains Expected Outcome. Client will be free of infection as evidenced by progressive wound healing, no fever, no purulent drainage, expected white blood cell count, and urine free of bacteria. InterventionsRationalesPractice conscientious hand hygiene before providing nursing care. Hand hygiene is the single most important method to reduce the potential for spreading microorganisms. Keep ports used for emptying drainage clean. Reinforce or change moist dressings using surgical asepsis. A contaminated port provides a portal for microorganisms that can ascend to other structures in the urinary tract. Moisture on a dressing wicks microorganisms into the wound. Keep perineum clean after a bowel movement for clients with a perineal prostatectomy. Stool contains many bacteria that can easily enter a perineal wound because of its close proximity to the anus. Report tenderness, unusual drainage, foul odor, and fever. An infection produces a cluster of common signs and symptoms. Evaluation of Expected OutcomeThere is no evidence of infection; vital signs are normal. Nursing Diagnosis. Risk for Impaired Skin Integrity related to leaking urine from suprapubic catheter Expected Outcome. Skin will remain free of redness and excoriation around the catheter site. InterventionsRationalesClean skin around suprapubic catheter with mild soap and water; dry skin thoroughly (Nursing Guidelines 55-1). Wet skin causes maceration of tissue. Strong soaps can irritate the skin. Apply and change drain gauze around suprapubic catheter because it becomes moist. A drain gauze absorbs moisture. Enclose the suprapubic catheter in an ostomy appliance. Ostomy equipment can be used as a means to collect urine and prevent contact between the skin and the urine. Consult an enterostomal therapist on substances such as karaya that can be applied to the skin. Karaya provides a moisture-resistant barrier and protects the skin.

Meniere's disease

The nurse obtains a history of symptoms; their duration; and complete medical, drug, and allergy histories. He or she assesses gross hearing and performs the Rinne and Weber tests. It is also important to determine the extent and effect of the client's disability. The client with Ménière's disease requires a great deal of emotional support because of the unpredictability of the attacks and the resulting impairments. During an attack, the nurse administers prescribed drugs, limits movement, and promotes the client's safety. He or she assists the client with activities of daily living because the least amount of motion can produce severe vertigo. The nurse is available, empathic, and responsive to the client. Trust and confidence develop when the client does not feel abandoned or required to convince caregivers of the necessity for attention. Clients are comforted when the nurse acknowledges that dealing with temporary or permanent hearing loss is a challenge. Meniere's disease: Onset of Ménière's disease may be sudden, and symptoms may occur daily or infrequently. Vertigo is the most incapacitating symptom; clients report whirling dizziness and the need to lie down. Severe vertigo causes nausea and vomiting. Typically, clients also experience tinnitus and hearing loss that lasts for several hours as well as headaches and abdominal discomfort. Nystagmus of the eyes may result from an imbalance in vestibular control of eye movements. Generally, hearing returns between attacks but gradually becomes worse with repeated attacks. An attack lasts from a few minutes to weeks. Because episodes can be unexpected, some clients are reluctant to leave their homes for fear they will have an attack in public. Continued employment becomes impossible for some clients. In addition to a thorough medical history and physical examination, clients should have hearing and balance tests. Tests that measure inner ear function (Mayo Clinic Staff, 2015) include the following: Videonystagmography (VNG)—evaluates balance and eye movement by introducing warm and cool water and/or air into the auditory canal. Involuntary eye movements are measured in response to this stimulation through specialized video goggles. Sensors for balance in the inner ear send signals to the oculomotor muscles. For clients with Ménière's disease, they cannot maintain focus on an object while having this stimuli. The eye movement demonstrates this phenomenon. Rotary chair testing—measures inner ear function. The client sits in a computer-controlled rotating chair and eye movement is measured. Vestibular-evoked myogenic potentials testing (VEMP)—determines if specific inner ear structures (the saccule, inferior vestibular nerve, and their central brain connections) are working normally. The saccule has slight sound sensitivity, which can be measured and recorded when sounds are presented to the ear. Posturography—determines issues of balance related to vision, inner ear function, or sensation from skin, muscles, tendons, or joints. The client, wearing a safety harness, stands barefoot on a platform and maintains (or tries to) balance while being exposed to various conditions. Video head impulse test (vHIT)—measures eye reactions to abrupt movements by having the client focus on a specific point while his or her head is turned abruptly. If the client cannot maintain focus, it is considered an abnormal response. CT scan or magnetic resonance imaging (MRI)—rules out other possible causes of the symptoms, such as a tumor that involves the vestibulocochlear nerve. Audiometry—identifies the type and magnitude of the hearing deficit. Electrocochleography (ECoG)—records the electrical activity of the inner ear in response to sound and helps to confirm the diagnosis.

surgical medical management prostate cancer

The tumor size, microscopic characteristics (sometimes referred to as the Gleason score), and any metastases are used to establish the stage, which in turn determines treatment (Table 55-4). The client's age, general health status, potential life expectancy, and the possible negative effects of treatments, such as incontinence and impotence, are also considered when planning treatment. Common treatment regimens include active surveillance to monitor the cancer closely as often as every 6 months; observation, which is sometimes called "watchful waiting," using fewer tests in lieu of relying on changes in symptoms; surgery; cryotherapy; which freezes and kills prostate cancer cells; external or internal radiation (brachytherapy); hormone therapy; immunotherapy; or a combination of these. Surgical: If the nodule is localized, an open suprapubic prostatectomy is the treatment of choice. A radical prostatectomy, performed through a perineal or retropubic approach, is the surgical preference if the tumor is large enough to be palpated or if it has spread to adjacent tissue. When a radical prostatectomy is performed, the entire prostate, its capsule, and the seminal vesicles are removed. The bladder neck is sutured to the membranous urethra over an indwelling urethral catheter, which is left in place for 10 to 14 days. Potential complications of this surgery include a 25% to 50% chance of impotence, difficulty with urinary control, and genital and lower extremity edema. A TURP may be performed if the client has urethral obstruction and his physical status is not amenable to treatment. Occasionally, permanent suprapubic urinary drainage may need to be established. The removal of a cancerous prostate can also be performed laparoscopically. Although this procedure is technically more difficult, it has the same advantages as other similar, minimally invasive procedures: less pain, less blood loss, shorter recovery period, and quicker resumption of previous lifestyle. The American Cancer Society (2016) indicates that laparoscopic and robotic-assisted laparoscopic radical prostatectomies are as effective as open radical prostatectomy, the long-term results have not been determined at this time. A bilateral orchiectomy (surgical removal of the testes) may be performed to eliminate the production of testosterone in men with advanced prostatic carcinoma (stage IV). Permanent side effects are impotence, loss of libido, hot flashes, and possible psychological disturbances. Many men do not accept surgical castration, and lower levels of testosterone can be achieved with hormone therapy. Cryotherapy: Cryotherapy is an outpatient treatment modality that destroys the prostate gland using a gas cooled to -40 °F passing through as many as 30 hollow probes inserted through the perineum. The tubes, which are observed with transrectal ultrasound, freeze and decimate the prostate gland within 3 minutes. The procedure is more effective if used before any type of radiation treatment. Clients can be discharged with a retention catheter on the same day as the treatment or after a brief stay in the hospital. Hematuria may be observed for a few days during the few weeks that the catheter is in place. There may be temporary discomfort in the location, where the probes were placed. ED is common as well as short-term swelling of the penis or scrotum. The PSA levels are monitored regularly to detect a recurrence of the cancer Radiation therapy: Radiation therapy (see Chap. 18) may be used alone or in conjunction with other treatment modalities, especially when there is local metastasis. Possible side effects include impotence, diarrhea, and urinary frequency and urgency. Hormone therapy: Men with stages III or IV carcinoma of the prostate are candidates for hormone therapy (Drug Therapy Table 55-2). With the use of luteinizing hormone-releasing hormone (LHRH) agonists and antagonists; a CYP17 inhibitor that blocks an enzyme that fuels cancer growth; and antiandrogenic (male) hormones or estrogenic hormones, the progression of the malignancy may be retarded and there may be a prolonged period of palliation (comfort). Estramustine (Emcyt) is a combination of estrogen and an antineoplastic drug that is also used for palliative treatment. Immuno therapy: The FDA has approved sipuleucel-T (Provenge), a therapeutic vaccine for prostate cancer. A therapeutic vaccine is one that treats an existing disease as opposed to a vaccine that prevents disease. The Provenge vaccine is made from the client's harvested white cells that are stimulated in a laboratory with a prostatic acid phosphatase antigen present in about 95% of prostate cancer cells. The stimulated cells are returned to the client intravenously every 2 weeks for three treatments. The vaccine is palliative rather than curative; it extends the client's life by approximately 4 months. Vaccine side effects seem to be minor and short-lived, and include chills, fever, headache, fatigue, shortness of breath, vomiting, and mild tremor (Cancer Research Institute, 2016; Prostate Cancer Foundation, 2016). Additional clinical trials of yet approved therapeutic vaccines are being developed.

Cause of DKA

DKA, a type of potentially life-threatening metabolic acidosis, occurs when there is an accumulation of ketones, a product of fat metabolism when cells cannot utilize glucose for energy. It occurs as a consequence of an acute insulin deficiency or an inability to use whatever insulin the pancreas secretes. DKA is sometimes the event that leads to an initial diagnosis of diabetes.

preparation for a pelvic exam

A physician, clinical nurse specialist, physician's assistant, or nurse practitioner performs the gynecologic examination, an inspection and palpation of pelvic reproductive structures. In preparation for the test, the nurse obtains examination gloves, lubricant, several sizes of bivalve speculums, a light source, and materials for obtaining a Papanicolaou test (discussed next). The nurse is sensitive to the fact that many women dislike having gynecologic examinations because they anticipate discomfort, are embarrassed, and have anxiety over possible diagnoses. Nursing Guidelines 52-1 provides suggestions on assisting the client undergoing a gynecologic examination. Inspection of the external genitalia and adjacent structures occurs first, followed by the inspection of the vaginal wall and cervix using a bivalve speculum (Fig. 52-6). Next, one or two fingers of a lubricated, gloved hand are placed into the vagina. By vaginal-abdominal palpation, the structures beyond the vaginal orifice are examined, and the position, size, and contour of the uterus, ovaries, and other pelvic structures are assessed (Fig. 52-7). At the end of the examination, a gloved finger may be inserted into the rectum to palpate the posterior surface of the uterus.

bronchitis teaching

Acute bronchitis usually is self-limiting, lasting for several days. Suggested treatment is bed rest, antipyretics, expectorants, antitussives (drugs used to alleviate coughing), and increased fluids. Humidifiers assist in keeping mucous membranes moist because dry air aggravates the cough. If secondary bacterial invasion occurs, the previously mild infection becomes more serious and usually is accompanied by a persistent cough and thick, purulent sputum. Secondary infections usually subside as the bronchitis subsides, but they may persist for several weeks. When a secondary infection is evident, the physician orders a broad-spectrum antibiotic when sputum culture results are available.

nursing interventions for pericarditis

Assess pain status as often as vital signs. Assist client to a position of comfort such as sitting upright and leaning forward. Only the outer layer of the lower parietal pericardium is sensitive to pain (Porth, 2014); some of the pain of pericarditis results from inflammation of surrounding structures. Sitting up and leaning forward positions the stretched pericardium away from the pleura, which relieves discomfort.Administer anti-inflammatory drugs and analgesics as prescribed.

nursing assessment anticoagulants

Assess patient taking anticoagulants for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; tarry, black stools; hematuria; fall in hematocrit or BP; guaiac-positive stools; urine; or NG aspirate). Assess patient for evidence of additional or increased thrombosis. Symptoms will depend on area of involvement. Lab Test Considerations: Monitor prothrombin time (PT) or international normalized ratio (INR) with warfarin therapy, activated partial thromboplastin time (aPTT) with full-dose heparin therapy and hematocrit, and other clotting factors frequently during therapy. Toxicity and Overdose: If overdose occurs or anticoagulation needs to be immediately reversed, the antidote for heparins is protamine sulfate; for warfarin, the antidote is vitamin K (phytonadione); for dabigatran, the antidote is idarucizumab; for rivaroxaban and apixaban, the antidote is andexanet alfa. Administration of fresh frozen plasma or prothrombin complex concentrate may also be required in severe bleeding due to warfarin, the oral direct thrombin inhibitors, or the oral factor Xa inhibitors.

Atrial fibrillation definition and treatment

Atrial Fib-In atrial fibrillation, several areas in the right atrium initiate impulses resulting in disorganized, rapid activity. The atria quiver rather than contract (Fig. 26-5, Evidence-Based Practice 26-1). The ventricles respond to the atrial stimulus randomly, causing an irregular ventricular heart rate, which may be too infrequent to maintain adequate cardiac output. One of the chief complications of atrial fibrillation is the formation of blood clots within the atria that may become stroke-causing emboli if they enter the circulation. Ibutilide (Corvert) is an antiarrhythmic drug used to convert new-onset atrial fibrillation into sinus rhythm; flecainide (Tambocor) and propafenone (Rythmol) also are used to treat and prevent atrial fibrillation. Use of drugs to eliminate an arrhythmia is referred to as chemical cardioversion. Atrial fibrillation also is treated with elective cardioversion (discussed later) or digitalis if the ventricular rate is not too slow. Some individuals with atrial fibrillation continue to experience chronic atrial fibrillation or episodic events.

care post hysterectomy

Care post hysterectomy: Assessment •Assess vital signs and level of consciousness. •Evaluate pain intensity. •Monitor condition of the dressing, location of drains (nasogastric, wound), and patency of urinary catheter. •Check the type, volume, and rate of IV fluid and the location and appearance of the IV site regularly. •Note the presence of antiembolic stockings. Nursing Diagnosis. Acute Pain related to tissue trauma Expected Outcome. Pain will be reduced to a tolerable level within 30 minutes of a nursing intervention. InterventionsRationaleAssess type of pain, intensity, and location each time vital signs are assessed and as needed. Administer analgesics as ordered. Implement nonpharmacologic interventions, such as distraction, imagery, and repositioning, to augment analgesia. Pain assessment is the fifth vital sign. They reduce pain perception. Substituting alternative stimuli to the brain decreases pain perception. Evaluation of Expected OutcomeClient reports decreased discomfort; pain is adequately controlled. RC of Vaginal Hemorrhage Expected Outcome. The nurse will monitor to detect, manage, and minimize hemorrhage. InterventionsRationaleRecord the number of perineal pads used. Assess blood pressure and pulse every 15 minutes if bleeding seems severe. Record the color of bloody drainage. Report excessive bleeding or passage of blood clots to the physician. Counting perineal pads facilitates the assessment of blood loss. Blood pressure falls and pulse rate increases in relation to loss of circulating blood volume. Bright red bleeding correlates with arterial bleeding; dark red blood is more likely venous. A blood transfusion or an increased rate of IV fluid may be necessary to maintain blood volume to prevent shock. Evaluation of Expected OutcomeClient has normal postoperative vaginal drainage; vital signs are within normal range. RC of Abdominal Distention, Paralytic Ileus Expected Outcome. The nurse will monitor to detect, manage, and minimize abdominal distention. InterventionsRationale Palpate the abdomen every 4 hours for signs of rigidity. Encourage ambulation. Report abdominal discomfort, nausea, abdominal distention, or diminished or faint bowel sounds to the physician. The abdomen loses its soft quality as it distends with gas. Movement promotes intestinal peristalsis, which moves gas toward the rectum. Elimination of intestinal gas may be facilitated by using a rectal tube, which must be medically ordered. Evaluation of Expected OutcomeAbdomen is soft; bowel sounds are active; client passes flatus rectally. RC of Thrombophlebitis Expected Outcome. The nurse will monitor to detect, manage, and minimize thrombophlebitis. InterventionsRationaleRemove and reapply antiembolic stockings every 8 hours. Encourage active leg exercises every 2-4 hours. Assess for calf swelling and tenderness bilaterally every shift. Do not place pillows beneath the knees or raise the knees with the electric bed. Ambulate as much as possible. Antiembolic stockings support valves in veins and reduce venous stasis. Skeletal muscle contraction propels venous blood toward the heart. Calf tenderness and swelling are suggestive of a thrombus in the lower extremities. Bending the knees interferes with venous circulation and promotes venous stasis and clot formation. Walking requires skeletal muscle contraction, which promotes venous circulation. Evaluation of Expected OutcomeNo evidence of thrombus formation. RC of Urinary Retention Expected Outcome. The nurse will monitor to detect, manage, and minimize urinary retention after indwelling catheter is removed. InterventionsRationaleMeasure intake and output every shift. Palpate the lower abdomen for distention. Measure the volume of each voiding. Encourage liberal fluid intake. Report bladder distention in the absence of voiding to the physician. Intake and output facilitate assessment of fluid status. The bladder is palpable when distended with urine. Voiding small amounts can indicate urinary retention with overflow. Urinary elimination is related to fluid intake. Medically prescribed interventions such as inserting a straight or indwelling catheter require an order from the physician. Evaluation of Expected OutcomeClient voids in sufficient quantity. Nursing Diagnosis. Risk for Disturbed Body Image related to misconceptions about physical and sexual consequences of hysterectomy Expected Outcome. Client will maintain an accurate body image after surgery. InterventionsRationaleGive client an opportunity to verbalize perceptions and fears. Clarify that a hysterectomy does not physically compromise libido or ability to achieve orgasm or cause premature aging, depression, or masculinization. Clients are less apt to discuss personal problems or fears if they sense that the nurse does not have time to engage in a discussion. Many women accept common myths and misperceptions as fact. Evaluation of Expected OutcomeClient has a realistic understanding of the physical outcomes of surgery.

Cataracts signs and symptoms

Cataracts: One of the earliest symptoms is seeing a halo around lights. Other symptoms include difficulty reading, changes in color vision (colors that look faded or yellow), glaring of objects in bright light, distortion of objects, blurred vision, poor night vision, and double vision in one eye. As the cataract worsens, visual acuity is so severely reduced that the client can only read the largest letter on a Snellen chart, count fingers, and distinguish movement. On inspection, a white or gray spot is visible behind the pupil (Fig. 42-8). Under ophthalmoscopic and slit-lamp examination, the lens appears in varying stages of opacity. Some lenses are so cloudy that the examiner cannot see through the cataract to the posterior of the eye. Tonometry determines whether the cataract is increasing the IOP. BLURRY

diet for patient with gastric ulcer disease

Clients with a gastrojejunostomy are at risk for developing dumping syndrome when they begin to take solid food. Dumping syndrome, which produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, results from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure (BP) can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which, in turn, causes hypoglycemia. The nurse must explore each symptom of PUD in depth. For example, if pain occurs, the nurse determines its type, onset in relation to eating food, location, and duration. A dietary history must include relevant questions pertaining to foods that cause distress, the amount of food eaten at each meal, and whether eating food relieves pain. For a client to continue eating, it may be necessary to modify ingredients, temperature, or consistency of foods as well as to use smaller portions on smaller plates. Clients need nutritional supplements. If the client is receiving tube feedings, reinstilling the gastric residual is necessary because it contains partially digested nutrients and essential electrolytes. bland diet avoid spicy hard to digest foods, avoid fatty foods, avoid stimulants such as alcohol. Upper GI bleed gives tarry black stool, pain

glaucoma signs and symptoms

Clients with open-angle glaucoma may be asymptomatic, and the condition may not be discovered until the client has a routine ophthalmologic examination. When symptoms do occur, they are often ignored because they are not dramatic. Clients may complain of eye discomfort, occasional and temporary blurred vision, the appearance of halos around lights, reduced peripheral vision, and the feeling that their eyeglass prescription needs to be changed (Fig. 42-7). In contrast, clients with acute angle-closure glaucoma become symptomatic quite suddenly. They experience severe headache and eye pain. The eyes become rock hard and sightless. Nausea and vomiting may occur. The conjunctiva is red; the cornea becomes cloudy and is commonly described as appearing "steamy." The attack is self-limiting, but with each subsequent attack, vision becomes more impaired. LOSS OF VISION PERIPHERALLY INWARDS

nursing management for all arrhythmias

Clients with symptomatic arrhythmias require careful monitoring and documentation of symptoms. Clients with serious arrhythmias are potentially unstable, making frequent rhythm analyses important. Administering and monitoring the effects of antiarrhythmic drugs are key nursing responsibilities. Drugs given to restore or control cardiac rhythm are powerful, and their therapeutic levels often are close to toxic levels. Many of these drugs cause unwanted side effects and are contraindicated in certain conditions. The nurse assists with medical procedures that help to restore normal sinus rhythm and manages postprocedural care. The nurse also provides health teaching that promotes the client's ability to maintain safe self-management after discharge. Clients with cardiac risk factors should avoid drinking more than 6 oz of beer or wine per day; during alcohol withdrawal, catecholamines are released and may cause dangerous arrhythmias. Defibrillation is instituted as soon as possible after a dangerous arrhythmia is detected. Until such time, the nurse administers CPR to maintain oxygenation and circulation of blood. Defibrillation is performed by a nurse or other healthcare team member who is trained in the use of the defibrillator

mechanism of diuretic therapy for heart failure

Diuretic therapy helps reduce the heart's workload by decreasing the exertion required to overcome afterload. Thiazide diuretics such as hydrochlorothiazide (HydroDIURIL) can manage many cases of mild heart failure. Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium excretion and therefore water excretion, but they also increase potassium excretion

osteomyelitis signs and symptoms

Evidence of an acute infection appears suddenly: high fever, chills, rapid pulse, tenderness or pain over the affected area, redness, and swelling. Chronic infection may be characterized by a persistent draining sinus. With acute osteomyelitis, laboratory tests usually show an elevated leukocyte count, an elevated ESR, and possibly a blood culture positive for infective organisms. Identification of the causative organism may require a bone biopsy and/or aspiration of subperiosteal pus for culture and sensitivity. Radiographic findings may be inconclusive in the early stages of infection, but later studies demonstrate irregular bone decalcification, bone necrosis, elevation of the periosteum, and new bone formation. Bone scans and MRI are useful in definitive diagnoses. Radiographic studies for chronic osteomyelitis show large cavities, sequestra or dense bone formations, and raised periosteum. Areas of infection are delineated by bone scan. Blood studies reveal a normal leukocyte count and ESR and possible anemia.

discharge instructions for prostate cancer

Expected outcomes for the client who is treated for cancer of the prostate are urinary continence and no evidence of infection. The client finds acceptable techniques for sexual expression, when impotence is permanent. He identifies techniques that assist in monitoring for a recurrence of the primary cancer or its metastatic spread. As the client recovers, promote increased self-care and provide instructions for home management. The discharge plan of care includes, but is not limited to, the following: Maintain medical follow-up., Take medications as prescribed., Decrease dietary fat and increase fiber.l Exercise regularly to increase lean body mass and decrease insulin levels, which is a catabolic hormone that promotes weight gain., Join a support group to learn more about the disease process and clinical research trials., Consult with the family physician or oncologist before self-treating with herbal supplements.

pyelophephritis signs and symptoms

Flank pain or tenderness, chills, fever, and malaise occur in clients with acute pyelonephritis. Frequency and burning on urination are present if there is accompanying cystitis (bladder infection). Some clients with chronic pyelonephritis are asymptomatic; others have a low-grade fever and vague gastrointestinal complaints. Polyuria and nocturia develop when the tubules of the nephrons fail to reabsorb water efficiently. There may be hematuria and/or pyuria. Clients may report that their urine has a foul odor and is cloudy and/or bloody.

hypovolemia treatment

Fluid deficit is restored by treating its etiology, increasing the volume of oral intake, administering IV fluids (see Chap. 13), and controlling fluid losses.

treatment for PID

Hospitalization with complete bed rest often is necessary. Parenteral or oral antibiotics are administered as soon as culture and sensitivity tests are obtained. Intravenous (IV) fluids are ordered if the client is dehydrated, and antipyretics are used if the temperature is elevated. A ruptured pelvic abscess requires emergency surgery.

nursing interventions for knee and hip fractures

Ideally, postoperative nursing management begins before surgery with demonstrations of deep-breathing and coughing exercises and descriptions and demonstrations of the incentive spirometer (if that is likely to be used after surgery). Even if the client will have postoperative physical therapy, the nurse explains and helps the client practice active and isometric leg exercises. He or she also describes other devices that may be used after surgery, such as IV infusions of fluid and blood, oxygen, a wound drain, elastic stockings, or roller bandages. It also is necessary to include a discussion of the possible use of traction or the CPM machine. If a client is scheduled for joint replacement or other surgery, the nurse withholds aspirin before surgery to reduce the risk for excessive bleeding. It is essential to monitor the complete blood count, prothrombin time, and bleeding and clotting times to ensure that the client's ability to control bleeding is not compromised. If the client will use a CPM machine after surgery, it is useful for the client to be fitted for this before surgery. When the client returns from surgery, the nurse reviews the physician's orders concerning movement, turning, or positioning of the extremities. Usually, the head of the bed remains at 45° or less. The client with a total hip replacement needs to have legs abducted with pillows or abductor cushion and extended because the opposite positions of adduction and flexion beyond 90° can dislocate the prosthetic femoral head from the acetabulum. Clients with a total hip replacement need to sit in an elevated chair or on a seat raised by pillows, so that the flexion remains less than 90°. Ice packs help reduce pain and inflammation to the incisional site (particularly after knee surgery). Box 61-5 provides information about avoiding hip dislocation after total hip replacement.

nursing assessment for cirrhosis

If the client has active alcoholism, the nurse monitors vital signs closely. A rise in blood pressure (BP), pulse, and temperature correlates with alcohol withdrawal; the nurse must recognize and treat these appropriately along with the other presenting symptoms (see Chap. 71). The nurse weighs the client daily and keeps an accurate record of intake and output. If the abdomen appears enlarged, the nurse measures it according to a set routine (Fig. 47-4). Because of the anorexia that accompanies severe cirrhosis, the client may better tolerate frequent, small, semisolid, or liquid meals rather than three full meals a day. Careful evaluation of the client's response to drug therapy is important because the liver cannot metabolize many substances. The nurse reports any change in mental status or signs of GI bleeding immediately because they indicate secondary complications. The nurse provides educational information specific to the liver disorder. He or she can refer the client to the American Liver Foundation (or a similar organization) for information about available support groups. The nurse emphasizes the need for abstinence from alcohol and all nonprescription drugs unless approved by the physician. In addition, he or she contacts social services about referrals to alcohol or drug cessation programs. Additional teaching depends on the type and cause of the disorder and the physician's prescribed or recommended home care (Client and Family Teaching 47-1). See Nursing Care Plan 47-1 later in this chapter for a description of additional nursing management. The following topics are appropriate for a teaching plan: Follow the diet recommended by the physician. Consult a dietitian if you require a special diet (e.g., a low-sodium diet to prevent edema and ascites). Many metabolic liver disorders require highly specialized diets and necessitate extensive teaching from nursing and nutritional staff. Some diets require routine monitoring and home care. Avoid situations that could further damage the liver, such as drinking alcohol, taking tranquilizers, or inhaling chemicals such as benzene or vinyl chloride, which are toxic. Rest frequently, especially if activity causes fatigue. Avoid exposure to people with known infections. Continue skin care. Avoid nonprescription drugs (especially aspirin and products that contain it because they contribute to bleeding problems) unless approved by the physician. Be prepared for rejection as a blood donor because of liver disease. Contact the physician immediately about vomiting of blood, tarry stools, extreme fatigue, yellow skin, light-colored stools, or dark urine. Signs and symptoms of cirrhosis increase in severity as the disease progresses and are categorized as compensated or decompensated (Box 47-2). Compensated cirrhosis is less severe, and signs and symptoms are more vague. As the disease progresses, it is referred to as decompensated cirrhosis. Signs and symptoms of decompensated cirrhosis are very pronounced and indicate liver failure. The client's history often correlates with factors that predispose to cirrhosis, such as chronic alcohol use, hepatitis, or exposure to toxins. The client typically experiences chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation, with accompanying weight loss. Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal (GI) tract. They may also report dark or "tea-colored" urine from increased concentrations of urobilin. Abdominal discomfort and shortness of breath are common complaints as a result of organ compression from the enlarged liver. Many clients mention nosebleeds, bleeding from the gums, or easy bruising. Skin may itch (pruritus) from accumulated bile salts. Compensated Intermittent mild fever Vascular spiders Palmar erythema (reddened palms) Unexplained epistaxis Ankle edema Vague morning indigestion Flatulent dyspepsia Abdominal pain Firm, enlarged liver Splenomegaly Decompensated Ascites Jaundice Weakness Muscle wasting Weight loss Continuous mild fever Clubbing of fingers Purpura (owing to decreased platelet count) Spontaneous bruising Epistaxis Hypotension Sparse body hair White nails Gonadal atrophy

stroke

Interventions for a stroke Elevate client's head for eating or drinking; position client on his or her side at other times. Sitting and facing food or liquids raises client's awareness and attention; a side-lying position prevents aspiration if vomiting occurs or saliva accumulates in the mouth. Keep a suction machine at the bedside. Mechanical suctioning facilitates clearing the airway of saliva, food, and fluids. Limit distractions (e.g., turn off the television when the client eats or drinks). The client can better concentrate and follow nursing instructions when distracting stimuli are reduced. Use a thickening agent for watery substances; request viscous or pureed food from nutrition services. The tongue can more easily manipulate thickened liquids against the palate and oral pharynx. Request small, frequent nourishment from nutrition services rather than three large meals. Eating small amounts is less tiring, and the client may consume more on a daily basis. Offer or remind client to load the fork or spoon with a small amount of food. A small amount is easier to manage in the mouth and less likely to cause a complete airway obstruction. Place thickened liquids or pureed food on the unaffected side of the mouth. The client can feel and use the unaffected side of the mouth for chewing and swallowing. Lower client's chin to his or her chest when swallowing. Lowering the chin helps close the laryngopharynx and reduces the potential for aspiration. Encourage client to swallow several times. Several efforts at swallowing may be necessary to move food to the esophagus. Check the mouth for pocketed food before offering more. The client may be unaware of food that remains unswallowed. Instruct client to use the tongue to relocate pocketed food or apply gentle pressure on the cheek to reposition food. Physical manipulation helps reposition trapped food. Collaborate with the physician concerning gastric or enteral tube feedings if oral intake is inadequate. These routes can provide sufficient nutrients when oral intake is compromised. Evaluation of Expected OutcomesThe airway remains patent, and lungs are clear to auscultation. There is an adequate intake of food and fluids. Nursing Diagnoses. Total Urinary Incontinence; Bowel Incontinence or Risk for Constipation related to diminished LOC, confusion, and immobility Expected Outcome. Urinary and bowel elimination will be controlled independently or with minimal assistance. InterventionsRationalesMaintain a record of bowel elimination. It provides data that can indicate if the client requires a stool softener, laxative, suppository, or enema. Place an elevated seat over the toilet. An elevated seat reduces the work of transferring to the toilet seat and back to a wheelchair. Assist client to the toilet every 2 hours while he or she is awake and after each meal. Positioning and environmental cues may help stimulate the client to eliminate. The gastrocolic reflex that promotes bowel evacuation is stronger soon after eating. Dress client in unrestricted clothing that facilitates elimination needs. Clothing that is easy to undo or lower reduces the potential for incontinence. Avoid negative comments if incontinence occurs; acknowledge client's success when he or she eliminates while on the toilet or commode. Criticism lowers self-confidence and self-esteem; praise encourages client to continue efforts at controlling elimination. Apply incontinence garments or place absorbent pads beneath client. Concealment of urine or stool preserves client's dignity. Collaborate with the physician concerning the insertion of an external or indwelling catheter. An external catheter is less likely to predispose to a urinary tract infection; a catheter helps keep the skin dry and reduces embarrassment of incontinence. Administer a prescribed suppository or low-volume enema when necessary. Chemical or mechanical stimulation increases intestinal contraction, which helps to evacuate the bowel. Evaluation of Expected OutcomeBowel and urinary elimination are managed at the highest level the client can achieve. Nursing Diagnoses. Self-Care Deficit related to hemiplegia; Unilateral Neglect related to hemianopia; Impaired Mobility: Physical related to hemiplegia Expected Outcomes. (1) Client will resume independent activities of daily living (ADLs). (2) Client will identify and care for paralyzed body parts. (3) Client will use assistive devices to achieve mobility. InterventionsRationalesApproach and place objects within client's field of vision. Client is likely to ignore objects and people that are located in areas where the visual field is impaired. Help reintegrate the weak side by reminding the client to look at it. Calling attention to the neglected side of the body helps the client recognize and accept that it exists. Set realistic goals for self-care. Unrealistic goals lead to frustration and discouragement. Consult with an occupational therapist (OT) or physical therapist (PT) regarding modifications in clothing, utensils, and assistive devices. Therapists have expertise in measures to accommodate for neurologic deficits. Attach a trapeze above the bed. Client can use a trapeze with one hand to independently facilitate position changes. Perform range-of-motion (ROM) exercises at least once each shift. ROM exercises maintain joint mobility and muscle tone. Support the affected arm in a sling when the client is upright. An arm sling improves posture and reduces musculoskeletal changes in the shoulder joint. Position client to avoid contractures (e.g., use a footboard, trochanter roll at the hip, rolled cloth in the paralyzed hand). Skeletal muscles tend to become permanently shortened unless efforts are made to maintain normal anatomic position. Consult the PT about devices to assist ambulation, such as a leg brace and walker. A brace promotes stability when standing and walking. A walker supports the client and facilitates ambulation. Evaluation of Expected OutcomesClient performs ADLs alone or with assistance; the client attends to bilateral body parts, and learns to use assistive devices. Nursing Diagnosis. Risk for Impaired Skin Integrity related to pressure over bony prominences secondary to immobility Expected Outcome. Skin will remain intact. InterventionsRationalesKeep skin clean and dry. Cleaning the skin removes transient bacteria. Drying the skin prevents maceration, a process in which skin is softened and easily eroded. Use a turning sheet and get assistance when changing client's position. A turning sheet prevents shearing, the movement of a layer of tissue in one direction as another moves in opposition. Massage skin areas that blanch when pressure is relieved. Massage improves blood flow to tissue, but it is contraindicated if tissue is already damaged as evidenced by a sustained redness when pressure is relieved. Use pressure-relieving devices or a therapeutic bed that alternately distributes the client's body weight. Tissue damage occurs unless intracapillary pressure is maintained at 32 mm Hg or more; relief of pressure at least every 2 hours reduces tissue hypoxia. Evaluation of Expected OutcomeSkin is intact; there is no evidence of pressure sores. Nursing Diagnosis. Impaired Verbal Communication related to expressive aphasia Expected Outcome. Client will make needs understood either verbally or nonverbally. InterventionsRationalesAsk questions requiring a "yes" or "no" and suggest the client respond by nodding the head. Nodding the head is a form of body language that communicates agreement or disagreement. Instruct client to speak slowly when attempting to communicate orally. If unpressured to quickly respond, the client may be able to formulate words and sentences more easily. Have client point to or write key words or phrases. Some clients retain the ability to read written language although they may not be able to express themselves orally. Support and practice techniques used in speech therapy. Practicing new techniques helps to promote mastery. Evaluation of Expected OutcomeClient can communicate orally, in writing, or with techniques that facilitate nonverbal communication. Nursing Diagnoses. Risk for Ineffective Coping and Risk for Compromised Family Coping related to diminished psychosocial resources to deal with multiple stressors Expected Outcome. Client and family will cope with illness and changes in lifestyle. InterventionsRationalesListen and try to identify clues to client's or family's future concerns. Identifying problems that require actions facilitates coping. Acknowledge personal strengths. Recognition of strengths promotes confidence in the ability to overcome current problems Encourage individuals in the client's social network to collaborate on problem solving. Successful outcomes are more likely when there is a team effort. Refer client and family to a discharge planner, social worker, or community social services for arranging extended care, home care, and respite care. The health team includes persons with expertise in assisting clients and their families with postdischarge issues. Evaluation of Expected OutcomesClient and family cope with the client's neurologic deficits; referrals are made to services or facilities that can assist with long-term recovery. The family pursues a plan for postdischarge management. Stroke Detailed nursing management for the client with a CVA is discussed in Nursing Care Plan 38-1. Client and family teaching also is essential and focuses on the following points:, Administer medications as directed and understand the potential side and adverse effects., Implement eating and swallowing techniques that reduce the potential for aspiration (Nutrition Notes).Perform the Heimlich maneuver to clear the airway if the client cannot speak or breathe after swallowing food (see Chap. 20).Continue follow-up care with the speech pathologist and dietitian. Contact community resources such as medical supply companies that rent or sell special care devices such as a hospital bed, bedside commode, walker, or tripod cane. Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Perform regular exercises, change the client's position frequently, and apply braces or splints designed to maintain extremities in proper anatomic position. Determine the following, Time symptoms began, Medical, drug, and allergy history from the family (or client if he or she can report), Vital signs and LOC, Size and response of pupils to light, Any musculoskeletal weakness or paralysis, Capacity to speak or understand spoken language, Changes in visual field, Ability to swallow, Any alteration in bladder or bowel control, Integrity of the skin; evidence of soft tissue injury as a consequence of falling

left sided heart faliure

Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea (effort at breathing when active) to be the first symptom. Inability to breathe unless sitting upright (orthopnea) or being awakened by breathlessness (paroxysmal nocturnal dyspnea) may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Pulse may be rapid or irregular. BP may be elevated from sympathetic nervous system stimulation. A cough, hemoptysis (blood-streaked sputum), and moist crackles on auscultation are typical respiratory findings. Urine output is diminished. If acute, left-sided heart failure with pulmonary edema develops, the client suddenly becomes hypoxic, restless, and confused. Fatigue, Paroxysmal nocturnal dyspnea, Orthopnea, Hypoxia, Crackles, Cyanosis, S3 heart sound, Cough with pink, frothy sputum, Elevated pulmonary capillary wedge pressure

macular degeneration signs and symptoms

Macular degeneration: In dry macular degeneration, blurred vision is the first symptom of disease, which becomes more noticeable when clients try to read or do close work. In wet macular degeneration, clients experience distortion of vision, such as straight lines appearing wavy or letters in words looking broken. A client's perception of color may also be diminished. When the macula becomes irreparably damaged, clients compare their vision to a target in which the bull's-eye area of the image is absent (Fig. 42-4). The peripheral field, or side vision, is unaffected, but the client cannot see images by looking at them directly. Fluorescein angiography shows pooling of the dye in the blister area. Optical coherence tomography uses fiberoptics to provide images of the ocular tissue structure. The Amsler grid (Fig. 42-5) is used to determine if the client has changes in central vision. AMD can cause lines on the grid to disappear or to appear wavy. BULLSEYE

nursing assessment for beta blockers

Monitor BP and pulse frequently during dosage adjustment and periodically throughout therapy. Monitor intake and output ratios and daily weight. Assess patient routinely for signs and symptoms of HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention). Angina: Assess frequency and severity of episodes of chest pain periodically throughout therapy. Migraine Prophylaxis: Assess frequency and severity of migraine headaches periodically throughout therapy.

assessment for digoxin

Monitor apical pulse for 1 full min before administering. Withhold dose and notify health care professional if pulse rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in an infant. Notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse. Pedi: Heart rate varies in children depending on age, ask health care professional to specify at what heart rates digoxin should be withheld. Monitor BP periodically in patients receiving IV digoxin. Monitor ECG during IV administration and 6 hr after each dose. Notify health care professional if bradycardia or new arrhythmias occur. Observe IV site for redness or infiltration; extravasation can lead to tissue irritation and sloughing. Monitor intake and output ratios and daily weights. Assess for peripheral edema, and auscultate lungs for rales/crackles throughout therapy. Before administering initial loading dose, determine whether patient has taken any digoxin in the preceding 2-3 wk. Lab Test Considerations: Evaluate serum electrolyte levels (especially potassium, magnesium, and calcium) and renal and hepatic function periodically during therapy. Notify health care professional before giving dose if patient is hypokalemic. Hypokalemia, hypomagnesemia, or hypercalcemia may make the patient more susceptible to digitalis toxicity. Pedi: Neonates may have falsely elevated serum digoxin concentrations due to a naturally occurring substance chemically similar to digoxin. Toxicity Overdose: Therapeutic serum digoxin levels range from 0.5-2 ng/mL. Serum levels may be drawn 6-8 hr after a dose is administered; usually drawn immediately before the next dose. Geri: Older adults are at increased risk for toxic effects of digoxin (on Beers list) due to age-related decreased renal clearance; may exist even when serum creatinine levels are normal. Digoxin requirements in older adult may change and a formerly therapeutic dose can become toxic. Observe for signs and symptoms of toxicity. In adults and older children, first symptoms of toxicity usually include abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias. In infants and small children, first signs of overdose are usually cardiac arrhythmias. If these appear, withhold drug and notify health care professional immediately. If signs of toxicity occur and are not severe, discontinuation of digoxin may be all that is required. Correct electrolyte abnormalities, thyroid dysfunction, and concomitant medications. Administer potassium to maintain serum potassium between 4.0 and 5.5 mmol/L. Monitor ECG for evidence of potassium toxicity (peaked T waves). Treatment of life-threatening arrhythmias may include administration of digoxin immune Fab (Digibind) , which binds to the digitalis glycoside molecule in the blood and is excreted by the kidneys.

ways to improve cardiac output

Monitor cardiac rhythm and rate, Measure urine output every 8 hours or more often if less than 500 mL/day, Maintain client on bed rest., Reduce anxiety by responding to requests for attention or assistance., Provide substitutes for dietary sources of caffeine and sodium, Promote ease in eliminating stool through such measures as increasing fiber and administering a prescribed stool softener, Reduce any fever by changing to lighter or fewer bed linens, assisting with tepid sponge baths, or administering prescribed antipyretics, Rapid heart rate and tachyarrhythmias compromise cardiac output, Renal output reflects the heart's ability to perfuse the renal arteries, Rest lowers heart rate, which increases diastolic filling volume, Relief of anxiety reduces tachycardia, Caffeine increases heart rate and promotes vasoconstriction; sodium contributes to fluid retention, Bearing down to eliminate stool interferes with cardiac filling; reduced cardiac filling decreases cardiac output, Increased heart rate accompanies fever and adds to the heart's workload, which may compromise cardiac output. Assess orientation. Confusion and disorientation are signs of compromised cerebral arterial blood flow secondary to decreased cardiac output. Maintain bed rest. Activity increases the demand for myocardial oxygenation, which depends on cardiac output. Administer supplemental oxygen as prescribed. Giving more than the 20% oxygen that is present in room air helps to reduce hypoxemia that results from inadequate cardiac output. Provide six small meals a day; avoid gas-forming foods. Abdominal distention crowds the thoracic cavity and compresses the space the heart needs to fill with blood and the lungs need to fill with air. Restrict caffeine and sodium. Caffeine increases heart rate and sodium increases circulating blood volume, both of which increase myocardial work and the need for cardiac output. Collaborate with the physician regarding a stool softener. Bearing down during bowel movements interferes with cardiac filling and output. Stool softeners promote ease of eliminating stool.

nursing interventions for pancreasitis

NPO, frequent blood sugar checks, fluids to sustain nutrition A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

discharge info for appendicitis

No heavy lifting, avoid Valsalva maneuver, avoid straining, keep stool soft , at risk for E.coli infection/sepsis, indicated by fever infection at sight, ridged abdomen, pain in the right side normal but new burning sensation in the gut, elevated whit blood cell count

nursing interventions for sodium imbalances

Nursing management includes early detection, especially in clients at risk for hyponatremia or hypernatremia. The nurse apportions oral fluids according to target volumes, maintains accurate intake and output measurements, assesses vital signs every 1 to 4 hours, and closely monitors the infusion of IV fluids. He or she implements prescribed dietary restrictions or supplements (Nutrition Notes). The nurse gathers data that indicate increased or decreased symptoms and notifies the physician if symptoms worsen or laboratory values show a significant change.

cerebral aneurysm

Perform a neurologic examination, taking care to avoid disturbing the client. Measure vital signs frequently. If the client is conscious, ask only essential questions while gathering the client's history, limiting it primarily to the current onset of symptoms. Obtain a more complete history from the family.

signs and symptoms of crushing's disease

Physical examination reveals muscle wasting and weakness resulting from extensive protein depletion. Carbohydrate tolerance is lowered, and signs and symptoms of diabetes mellitus develop (see Chap. 51). Fat is redistributed, leading to facial fullness and the characteristic moon face and buffalo hump. The skin is thin, and the face is ruddy. The client has increased susceptibility to wounds, and healing is prolonged; however, the immunosuppressive effects of the disorder usually mask symptoms of infection. Because the blood vessels are fragile, the client bruises easily, and striae often form over extensive skin areas. The bones become so demineralized that the client may have backache, kyphosis, and collapse of the vertebrae. He or she retains sodium and water, and peripheral edema and hypertension develop. The client reports mood changes and difficulty coping with stressors that were manageable in the past. The family may report serious mental changes. In women, Cushing's syndrome produces masculinization with hirsutism and amenorrhea. These sexual changes and alterations in appearance are reversible when adrenocortical hormone levels return to normal (Fig. 50-12).

Psoriasis treatment

Psoriasis has no cure. Symptomatic treatment to control the scaling and itching includes the use of topical agents such as coal tar extract, corticosteroids, or anthralin. Anthralin, a distillate of crude coal tar, is applied to thick plaques; it tends to irritate unaffected skin areas. Topical corticosteroids, topical retinoids, and analogs of vitamin D have proved beneficial. Methotrexate, an antimetabolite used in the treatment of cancer, is prescribed for clients with severe disease that does not respond to other forms of therapy. This drug inhibits the production of cells that divide rapidly (cancer cells, cells composing the skin and mucous membranes) and is capable of reducing plaque formation. Dosage is carefully individualized because the drug causes serious adverse effects. Etretinate (Tegison) is related to retinoic acid and retinol (vitamin A) and is used to treat psoriasis that does not respond to other therapies. Its use is recommended only for those clients who can reliably understand and carry out the treatment regimen, are capable of complying with mandatory contraceptive measures, and do not intend to become pregnant. Another method of treatment is the injection of triamcinolone acetonide (Kenacort), a corticosteroid, into isolated psoriatic plaques. This method of treatment is successful in some cases. Recently, healthcare providers have used biologic therapy techniques that alter immune system responses associated with plaque psoriasis with humanized monoclonal antibodies such as secukinumab (Cosentyx), apremilast (Otezla), and ixekizumab (Taltz). Similar drugs such as adalimumab (Humira), ustekinumab (Stelara), and etanercept (Enbrel), have been approved for the treatment of psoriatic arthritis and other autoimmune disorders (Mayo Clinic, 2015b). These drugs modify the activities of T cells (see Chap. 34) and reduce inflammation and hyperplasia of the epidermis in clients with psoriasis, resulting in rapid and significant improvement. Unfortunately, these drugs also are associated with anaphylaxis and serious infections. Consequently, they are reserved for moderate to severe cases. Photochemotherapy, a combination of UV light therapy and a photosensitizing psoralen drug such as methoxsalen (Oxsoralen-Ultra), also has been used for severe, disabling psoriasis that does not respond to other methods of treatment. The extent of exposure is based on the client's skin tolerance. Treatments are given once every other day or less because phototoxic reactions may appear 48 hours or more after light exposure. Once the psoriasis clears, the client is placed on a maintenance treatment program. Some clients respond well to treatment; others receive only minor relief. The condition tends to recur.

lupus signs and symptoms

SLE is known as the great imitator because the clinical signs resemble many other conditions (Box 63-2). SLE is also marked by remissions and exacerbations. Early signs and symptoms of SLE may include fever, weight loss, pain in the joints (arthralgia), malaise, muscle pain, and extreme fatigue. These symptoms are vague and may persist for several months to 2 years before more prominent symptoms develop and the client seeks medical advice. A prominent sign for about half of the clients with SLE is a red, butterfly-shaped rash known as malar rash, on the face over the bridge of the nose and the cheeks (Fig. 63-7). The word lupus means "wolf." The term may have been used as a description for the facial rash that, to some, resembled the mask of reddish-brown fur on a wolf. Two other types of skin manifestations may occur with SLE. The first is discoid lupus erythematosus (DLE), which involves a chronic rash with erythematous papules or plaques and scaling. Eventually, DLE can lead to scarring and pigmentation changes. The symptoms of DLE are related only to the skin, the most prominent symptom being the appearance of the facial rash. Skin manifestations of the disorder also may be found on the forehead, earlobes, and scalp. Scalp involvement usually results in patchy loss of hair (alopecia). These symptoms also may be seen in people with SLE. The second type is subacute cutaneous lupus erythematosus, which presents with papulosquamous lesions.

symptoms for emphysema

Shortness of breath with minimal activity is called exertional dyspnea and often is the first symptom of emphysema. As the disease progresses, breathlessness occurs even at rest. A chronic cough invariably is present and productive of mucopurulent sputum. Inspiration is difficult because of the rigid chest cage, and the chest is characteristically barrel-shaped The client uses the accessory muscles of respiration (muscles in the jaw and neck and intercostal muscles) to maintain normal ventilation. Expiration is prolonged, difficult, and often accompanied by wheezing. In advanced emphysema, respiratory function is markedly impaired. Clients with advanced emphysema characteristically appear drawn, anxious, and pale. They speak in short, jerky sentences. When sitting up, they often lean slightly forward and are markedly short of breath. The neck veins may distend during expiration. In advanced emphysema, memory loss, drowsiness, confusion, and loss of judgment may result from the markedly reduced oxygen that reaches the brain and the increased CO2 in the blood. If the disorder goes untreated, the CO2 content in the blood may reach toxic levels, resulting in lethargy, stupor, and, eventually, coma. This condition is called carbon dioxide narcosis. Lung auscultation reveals decreased breath sounds, wheezing, and crackles. Heart sounds are diminished or muffled. Visual inspection shows a barrel-chested person breathing through pursed lips and using the accessory muscles of respiration.

hypothyroidism signs and symptoms

Signs and symptoms are opposite those of hyperthyroidism in many respects (Fig. 50-8). Metabolic rate and physical and mental activity slow down. The client is lethargic, lacks energy, dozes frequently during the day, is forgetful, and has chronic headaches. The face takes on a masklike, unemotional expression, yet the client often is irritable. The tongue may be enlarged and the lips swollen, and there may be edema of the eyelids. Temperature and pulse rate are decreased; the client is intolerant to cold. Weight increases despite a low caloric intake. The skin is dry, and hair characteristically is coarse and sparse and tends to fall out. Menstrual disorders are common. Constipation may be severe. The voice is low pitched and hoarse, and speech is slow. Hearing may be impaired. The client may experience numbness or tingling in the arms or legs that is unrelieved by position change.

sinus brady definition and treatment

Sinus Brady-Sinus bradycardia is an arrhythmia that proceeds normally through the conduction pathway but at a slower-than-usual rate (≤60 beats/minute; Fig. 26-2). Healthy athletes and others who are physically fit often have heart rates below 60 beats/minute; however, it reflects a well-toned heart conditioned through regular exercise. A heart rate slower than 60 beats/minute is pathologic in clients with heart disorders, increased intracranial pressure, hypothyroidism, or digitalis toxicity. The danger in sinus bradycardia is that the slow rate may be insufficient to maintain cardiac output. Atropine sulfate, a cholinergic blocking agent, is given intravenously to increase a dangerously slow heart rate.

sinus tachy definition and treatment

Sinus Tachy- Sinus tachycardia is an arrhythmia that proceeds normally through the conduction pathway but at a faster-than-usual rate (100 to 150 beats/minute; see Fig. 26-2). It occurs in clients with healthy hearts as a physiologic response to strenuous exercise, or anxiety and fear, pain, fever, hyperthyroidism, hemorrhage, shock, or hypoxemia.

hyperthyroidism signs and symptoms

Symptoms vary from mild to severe. Clients with hyperthyroidism characteristically are restless despite feeling fatigued and weak, highly excitable, and constantly agitated. Fine tremors of the hands occur, causing unusual clumsiness (Fig. 50-6). Clients cannot tolerate heat and have an increased appetite but lose weight. Diarrhea also occurs. Visual changes, such as blurred or double vision, can develop. Exophthalmos, seen in clients with severe hyperthyroidism, results from enlarged muscle and fatty tissue surrounding the rear and sides of the eyeball (see Fig. 49-8). Neck swelling caused by the enlarged thyroid gland often is visible. Table 50-1 compares the signs and symptoms of hyperthyroidism and hypothyroidism.

right heart failure

The client with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed by pressing into tissue over a bone for 5 seconds and then releasing the pressure. The pressure forces fluid into the underlying tissue causing an indentation that slowly disappears. (Fig. 28-2). This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. Fluid may distend the abdomen (ascites), and the liver may be enlarged (hepatomegaly). Jugular veins often are distended from increased central venous pressure (Nursing Guidelines 28-1). Enlarged abdominal organs often restrict ventilation, creating dyspnea. Clients may observe that rings, shoes, or clothing have become tight. Accumulation of blood in abdominal organs may cause anorexia, nausea, and flatulence. (Also see Evidence-Based Practice 28-1.) Weakness, Ascites, Weight gain, Nausea, vomiting, Arrhythmias, Elevated central venous pressure

hypervolemia treatment

The condition causing the fluid excess is treated. Oral and parenteral fluid intake is restricted. Diuretics, drugs that promote urinary excretion, are prescribed. Salt and sodium intake is limited.

nursing interventions for potassium imbalances

The nurse assesses clients for conditions with the potential to cause potassium imbalances, identifies signs and symptoms associated with potassium imbalances, monitors laboratory findings measuring serum potassium, administers medications that restore potassium balance, and evaluates the client's response to medical therapy. The nurse consults with the physician when a client is receiving prolonged IV fluid therapy without added potassium. If IV potassium is ordered, it must be diluted in an IV solution and administered at a rate below 10 mEq/hour. The nurse observes the infusion frequently to verify it is being administered at the appropriate rate. He or she also informs clients at risk for potassium imbalances and their families about Medications that cause urinary excretion of potassium, such as non-potassium-sparing diuretics Food sources of potassium: vegetables, dried peas and beans, wheat bran, bananas, oranges, orange juice, melon, prune juice, potatoes, and milk Taking oral potassium supplements shortly after meals or with food to avoid GI distress; effervescent tablets or liquids are taken with a full glass of water

nursing interventions for pneumonia

The nurse auscultates lung sounds and monitors the client for signs of respiratory difficulty. He or she checks oxygenation status with pulse oximetry and monitors arterial blood gases (ABGs). Assessments of cough and sputum production also are necessary. The nurse places the client in the semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes, administering antipyretics as indicated and ordered. Identifying clients at risk for pneumonia provides a means to practice preventive nursing care. In addition, nurses encourage at-risk and older adult clients to receive vaccination against pneumococcal and influenza infections. Because the nursing care of clients with infectious lung disorders is similar regardless of the etiology, refer to Nursing Process for the Client With Pulmonary Tuberculosis for additional interventions.

treatment for myocarditis

The nurse monitors the client's cardiopulmonary status to assess for possible complications such as heart failure or arrhythmias. Assessments include vital signs, daily weights, intake and output, heart and lung sounds, pulse oximetry measurements, and determining the presence of dependent edema. The nurse also maintains the client on bed rest to reduce cardiac workload and promote healing. If the client has a fever, the nurse administers a prescribed antipyretic along with independent nursing measures such as minimizing layers of bed linens, promoting air circulation and evaporation of perspiration, and offering oral fluids. Administering supplemental oxygen relieves tachycardia that may develop from hypoxemia. The nurse elevates the client's head to promote maximal breathing potential and uses a bedside cardiac monitor or telemetry unit to assess heart rhythm (see Chap. 26). The nurse uses cardiac rhythm analyses to determine if and when antiarrhythmic medications are necessary or the client's response to their use. Management aims at treating the underlying cause and preventing complications. Antibiotics are prescribed if the infecting microorganism is bacterial. Bed rest, a sodium-restricted diet, and cardiotonic drugs (digitalis and related drugs) are prescribed to prevent or treat heart failure. In severe cases of cardiomyopathy, a heart transplant is necessary.

nursing interventions for epistaxis

The nurse monitors vital signs and assesses for evidence of continued bleeding. The nurse may initiate measures to control bleeding, such as applying pressure and ice packs. Other treatments require a physician's order. The client experiencing epistaxis is usually anxious and requires reassurance. If underlying conditions are the cause, the nurse refers the client for medical follow-up. The nurse may also recommend humidification, use of a nasal lubricant to keep the mucous membranes moist, and avoidance of vigorous nose-blowing and nose-picking or other nose trauma. Client and Family Teaching 20-3 outlines teaching about the treatment of severe nosebleed.

teaching for DJD

The nurse teaches about the purpose of drug therapy, administration times, and therapeutic and side effects. Because aspirin and NSAIDs can cause gastric bleeding, the nurse advises clients to take the medication with food. It is important that the client maintains moderate activity, with instructions about how to regulate the type, vigor, and frequency according to the symptoms experienced. If the client is overweight, he or she needs explanations about dietary changes that promote weight loss. The nurse may need to remind the client to assume good posture to avoid unusual stress on a joint. If the client needs ambulatory aids such as crutches, a cane, or a walker, he or she will need a referral to a PT for fitting and practice.When a client is taking NSAIDs for pain, ask about PPI self-treatment for heartburn. NSAIDs and salicylates can cause gastric distress. With proton pump inhibitors (PPI) available over the counter, client may self-treat GI problems. There is a correlation between bone density reduction and PPIs (Ozdil, 2013). Be aware of this risk as you care for your client

signs and symptoms of hypoglycemia

The pattern of symptoms varies somewhat depending on the degree of hypoglycemia, the individual reaction, and the type of insulin taken. Initial symptoms include tachycardia, weakness, headache, nausea, drowsiness, nervousness, hunger, tremors, malaise, and excessive perspiration. Some clients have characteristic personality or behavioral changes. Confusion and dizziness can occur. If hypoglycemia is not corrected, symptoms can progress to difficulty with coordination. The client may complain of double vision. If left untreated, unconsciousness and seizures can develop. Although symptoms vary, each client tends to have a uniquely repetitious pattern when hypoglycemia develops. The manifestation of hypoglycemic symptoms usually is quite rapid, with unconsciousness or seizures occurring shortly after onset. When a client with diabetes is found unconscious, DKA or hypoglycemia needs to be ruled out. These conditions are direct opposites: In ketoacidosis, the blood glucose level is high; in hypoglycemia, it is low. The nurse and client must be familiar with the symptoms of hypoglycemia and hyperglycemia to recognize and differentiate the complication as it is developing and treat it appropriately

signs and symptoms of BPH

The symptoms of BPH appear gradually. At first, the client notices that it takes more effort to void. Eventually, the urinary stream narrows and has decreased force. The bladder empties incompletely. Because residual urine accumulates, the client has an urge to void more often and nocturia occurs. Because residual urine is a good culture medium for bacteria, symptoms of cystitis (inflammation of the bladder) may develop

signs and symptoms of hyperglyscemia

The three classic symptoms of both types of diabetes mellitus are polyuria, polydipsia, and polyphagia. Additional symptoms include weight loss, weakness, thirst, fatigue, and dehydration. These signs and symptoms have an abrupt onset in clients with type 1 diabetes. Clients with type 2 diabetes have a gradual onset of symptoms. Some develop skin, urinary tract, and vaginal infections, possibly because the elevated level of blood glucose supports bacterial growth. There may be changes in visual acuity manifested by blurred vision because the hypertonicity of body fluid affects the cells in the lens and retina

HIV/AIDS Dietary Recommendations

There are no unanimously agreed-upon recommendations for calories or protein despite the universal goals of maintaining body weight and lean body mass in clients with HIV/AIDS. The registered dietitian should be consulted to create an individualized nutrition plan for each client (American Dietetic Association, 2010). A Mediterranean diet that is low in saturated fat and refined sugar and high in fruit, vegetables, and whole grains may help improve the common metabolic abnormalities of hypertriglyceridemia and impaired glucose tolerance, a consequence of some antiretrovirals. Low blood levels and inadequate intakes of some vitamins and minerals are associated with faster HIV disease progression and mortality. Nutrient deficiencies may occur from poor intake, malabsorption, infections, or diet-medication interactions. Although food is the preferred source for nutrients, multivitamin and mineral supplements are usually recommended at levels of 100% to 200% of the daily reference intakes. Some evidence suggests that supplements of vitamin A, zinc, and iron can produce adverse outcomes by negatively impacting immune system functioning. Nutritional intervention may help alleviate symptoms that interfere with intake or nutrient use: Clients with anorexia should be encouraged to eat small, frequent meals of easily digested food and liquids even when not hungry. Clients with nausea and vomiting may tolerate a low-fat, high-carbohydrate, soft, or liquid diet better than large, high-fat meals. Diarrhea and malabsorption may improve when clients avoid residue, lactose, fat, and caffeine. Liquids should be encouraged to replace fluid and electrolyte losses. Although eating may seem to trigger diarrhea, clients must understand that limiting food intake to control diarrhea only exacerbates wasting. Gravies, sauces, and broth added to soft, nonirritating foods may promote ease of swallowing in clients with oral or esophageal ulcerations. Some clients may require a blenderized or liquid diet. Because temperature extremes (very hot or very cold) can irritate the mucosa, room temperature foods and liquids are recommended for clients with a sore mouth. Clients unable to consume an adequate oral diet may require tube feeding for supplemental or complete nutrition. Because many formulas have the potential to cause diarrhea, closely monitoring the client's tolerance is essential. Advera and Impact are commercial formulas designed for clients with impaired immune function.

transient ischemia

Transient Ischemic attack: The nurse obtains a complete history of symptoms and medical, drug, and allergy histories. He or she weighs the client because obesity, hyperlipidemia, and atherosclerosis are related to cerebrovascular disease. The nurse checks the client's capillary blood sugar to help identify hyperglycemia associated with undiagnosed or uncontrolled diabetes mellitus. He or she measures vital signs and notes if the BP is at or greater than 140/90 mm Hg (refer to Chap. 27 for BP Classifications). The nurse asks the client about smoking habits. Although symptoms of a TIA usually are not permanent, the nurse performs a neurologic examination to identify the client's current status and establish a baseline for future comparisons. He or she documents and reports even subtle changes. If the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia and monitors the heart rhythm because arrhythmias (see Chap. 26) can alter blood flow to the brain as well. Because it is possible for the neck to swell after surgery, the nurse observes the client closely for difficulty breathing or swallowing and hoarseness. The nurse places an airway at the bedside and is prepared for endotracheal intubation if an airway obstruction occurs. The nurse teaches the client to Maintain hydration by drinking the equivalent of eight glasses of fluid a day unless contraindicated. Follow directions for drug therapy, including medications for controlling hypertension, hyperlipidemia, blood clotting, and diabetes. Monitor for signs of bruising or bleeding if antiplatelet or anticoagulant drugs are prescribed. Keep appointments for laboratory tests and medical follow-up to monitor the effectiveness of therapy. Report any future instances of sensory or motor impairment, or call 911 for emergency assistance.

metabolic acidosis signs and symptoms

deep and rapid breathing (Kussmaul's breathing), a compensatory mechanism to rid the body of CO2 and thus prevent carbonic acid from forming. The client may experience anorexia, nausea, vomiting, headache, confusion, flushing, lethargy, malaise, drowsiness, abdominal pain or discomfort, and weakness.

respiratory acidosis signs and symptoms

extreme respiratory insufficiency. The client may make frantic efforts to breathe, breathe slowly or irregularly, or stop breathing. Expiratory volumes are decreased. Lung sounds may be moist or absent in some lobes. Tachycardia usually is present, and cardiac arrhythmias can develop. In later stages, cyanosis, a dusky appearance to the skin, may be evident. The accumulation of CO2 leads to behavioral changes (mental cloudiness, confusion, disorientation, hallucinations), tremors, muscle twitching, flushed skin, headache, weakness, stupor, and coma. Responses to chronic respiratory acidosis are less prominent and can include an increased breathing effort, lack of energy, reduced activity, dull headache, and weakness. ABG values show a decreased pH and an increased PaCO2 above 45 mm Hg. As the kidney attempts to compensate, which may take 2 to 3 days, the HCO3 rises, followed by a return to normal pH if full compensation occurs

respiratory alkalosis signs and symptoms

increased respiratory rate. Accompanying symptoms include light-headedness, numbness and tingling of the fingers and toes, circumoral paresthesias, sweating, panic, dry mouth, and, in severe cases, convulsions. The ABG values indicate a pH above 7.45 and a PaCO2 below 35 mm Hg. If the kidney compensates by excreting bicarbonate ions, the HCO3 falls below 22 mEq to restore pH

SVT definition and treatment

is an arrhythmia in which the heart rate has a consistent rhythm but beats at a dangerously high rate (≥150 beats/minute). Diastole is shortened and the heart does not have sufficient time to fill. Cardiac output drops dangerously low and heart failure can occur, especially in clients with preexisting heart disease or damage. Clients with coronary artery disease (CAD) and SVT can develop chest pain because coronary blood flow cannot meet the increased need of the myocardium for oxygen imposed by the fast rate. Besides tachycardia and angina, hypotension, syncope, and reduced renal output are signs and symptoms of low cardiac output and impending heart failure. Digitalis, adrenergic blockers, and calcium channel blockers are used to slow the heart rate.

metabolic alkalosis signs and symptoms

manifest anorexia, nausea, vomiting, circumoral paresthesias, confusion, carpopedal spasm, hypertonic reflexes, and tetany. The respiratory rate and volume decrease in a compensatory effort to produce more carbonic acid to increase and restore the acidic level in the blood. Initially, ABGs show increased pH and HCO3 and normal PaCO2 levels (see Table 16-3). As compensatory respiratory mechanisms result in slower and shallower breathing, the PaCO2 level is elevated; eventually, pH may return to normal.

addisons disease signs and symptoms

ÙClients with primary adrenal insufficiency require daily corticosteroid replacement therapy for the rest of their lives. Fludrocortisone (Florinef), a synthetic corticosteroid preparation that possesses mineralocorticoid and some glucocorticoid properties, frequently is selected for replacement therapy. An additional glucocorticoid may be necessary depending on the client's response to therapy. Treatment for secondary adrenal insufficiency caused by bilateral adrenalectomy or pituitary failure is the same as treatment for primary adrenal insufficiency. Treatment of secondary adrenal insufficiency resulting from discontinuation of corticosteroid therapy or hemorrhagic infarction of the gland varies and depends on the ability of the adrenals to return to normal function. If the client is not given or does not take the medication, acute adrenal crisis can develop (see next section). This also applies to clients on long-term corticosteroid therapy for the treatment of disorders such as allergies, rheumatoid arthritis, and collagen diseases who abruptly discontinue taking their prescribed steroid. If the drug is to be discontinued, the dose must be tapered over time. Client and Family Teaching 50-3 discusses important information to teach clients receiving corticosteroid therapy. Corticosteroid therapy family teaching Addison's disease: Never omit, increase, or decrease a dose. Lifetime corticosteroid replacement therapy is necessary. If the prescribed drug is not taken, adrenal insufficiency, which is life threatening, will occur. Seek medical attention for dosage readjustment whenever there is stress. The body has limited ability to handle stress of any kind. Examples of stress include an infection, a motor vehicle accident (even if not noticeably hurt), a family crisis, and a heavy workload. Avoid exposure to infections and excessive fatigue. If an infection (e.g., sore throat, upper respiratory tract infection) or any other type of illness occurs, contact the physician immediately. An increased medication dose may be necessary. Seek immediate medical attention if vomiting, diarrhea, or any other condition prevents the medication from being taken orally or interferes with proper drug absorption. Parenteral administration will be necessary. (The physician instructs the client on the procedures to follow if the medication cannot be taken orally.) Wear identification, such as a Medic Alert tag or bracelet, stating that the wearer has adrenal insufficiency. If an accident or any other problem occurs, medical personnel must be made aware of the need for corticosteroids. Follow the diet recommended by the physician.

diet for crohns disease

ÙHigh protein diet, fatty hard to digest food should be avoided, they have consistent chronic diarrhea so absorption is hindered, high calorie high electrolyte nutrisious meals The dietary approach varies. A high-fiber diet may be indicated when it is desirable to add bulk to loose stools. A low-fiber diet may be indicated in cases of severe inflammation or stricture. A high-calorie and high-protein diet helps replace nutritional losses from chronic diarrhea. The client may need nutritional supplements, depending on the area of the bowel affected. When the small intestine is inflamed, some clients experience lactose intolerance, requiring avoidance of lactose-rich foods. Some clients need an elemental diet formula, such as Tolerex, Vivonex, or Peptamen, that reduces proteins, fats, and carbohydrates to an easily absorbed form. Elemental diets effectively induce remission in Crohn's disease without medications. Unfortunately, clients are not allowed to eat or drink normally while on the elemental diet, making this treatment modality unacceptable for many. In addition, elemental formulas are not very palatable. Some may need to be administered through a nasogastric tube. Success with elemental diet therapy requires extensive education and client motivation. Newly introduced polymeric diets (Modulen) may provide the benefit of inducing remission and are more palatable. TPN may become necessary to provide intestinal rest. IV fluids, electrolytes, and whole blood are given to correct anemia and restore fluid and electrolyte balance.

skin assessment/ skin cancer prevention

ÙThe nurse examines and measures abnormal-appearing skin lesions, especially those in sun-exposed areas such as the face, nose, lips, and hands. The nurse determines facts about the lesion, including when the lesion first was noticed, whether the lesion has undergone any recent changes, and, if so, what kind being particularly mindful of the ABCDEs of melanoma: A refers to asymmetry, B represents border irregularity, C stands for color that is not uniform; D denotes diameter—especially one that is greater than the size of a pencil eraser, and E relates to the evolving change in any way (Skin Cancer Foundation, 2016). The client is taught how to perform a skin self-examination (Client and Family Teaching 65-2). Surgery for a malignant melanoma may involve structures of the head and neck, trunk, or extremities. The specific nursing management of those having radical surgery for this malignancy depends on the original site of the tumor and the extent of surgery. The nurse gives emotional support to those having disfiguring surgery. The nurse encourages all people with any type of skin change to seek medical attention. Those in high-risk groups for malignant skin lesions are advised to examine all areas of their body and scalp for new lesions or changes in moles, other growths, or pigmented lesions. If a client notes any change, an appointment should be made for a medical examination as soon as possible. The nurse educates clients about measures to prevent skin cancer, some of which include the following: Always use a sunscreen with an SPF of at least 15; higher SPFs are beneficial for clients who sunburn easily. Reapply sunscreen at least every 2 hours or more often if swimming or perspiring. Use a lip balm with sunscreen. Wear a hat with a wide brim and cover the back of the neck. Stay in the shade when outdoors. Wear tightly woven, but loose-fitting clothing. Avoid prolonged sun exposure between 10 AM and 4 PM. Avoid artificial tanning. The nurse also recommends that at-risk clients consult the UV forecast, a daily report that rates the UV conditions from 0 to 10+ in 30 metropolitan areas. The U.S. Environmental Protection Agency releases the forecast, which radio and television stations broadcast during weather reports as a public service. Depending on the numerical rating, called the UV index, sun-sensitive people are advised to take protective measures (Fig. 65-10). A sensometer, a credit card-sized device, also is available so that a person can determine the UV level in his or her immediate locale.

postoperative care following sinus surgery

ÙThe nurse informs the client receiving medical treatment that use of mouthwashes and humidification as well as increased fluid intake may loosen secretions and increase comfort. The nurse instructs the client to take nasal decongestants as recommended. If the client has had sinus surgery, the nurse institutes standards for postoperative care (see Chap. 14) and observes the client for repeated swallowing, a finding that suggests possible hemorrhage. One risk of sinus surgery is damage to the optic nerve. Thus, the nurse assesses postoperative visual acuity by asking the client to identify the number of fingers displayed. The nurse monitors the client's temperature at least every 4 hours, assessing for pain over the involved sinuses, a finding that may indicate postoperative infection or impaired drainage. The nurse administers analgesics as indicated and applies ice compresses to involved sinuses to reduce pain and edema.The postsurgical client will have nasal packing and a dressing under the nares ("moustache" dressing or "drip pad"). Because nasal packing forces the client to breathe through the mouth, the nurse encourages oral hygiene and gives ice chips or small sips of fluids frequently. Such measures alleviate the dryness caused by mouth breathing. The nurse instructs the client to change the drip pad as needed. In the first 24 hours, the client can expect to change this pad frequently. If bleeding is copious and/or continuous, the doctor must be notified. After 24 hours, the drainage normally decreases significantly. The client needs to report if excessive drainage persists. Postoperative client and family teaching includes telling the client not to blow the nose, lift objects more than 5 to 10 lb, or do the Valsalva maneuver for 10 to 14 days postoperatively. Airline travel must be avoided for 2 weeks. The nurse urges the client to remain in a warm environment and to avoid smoky or poorly ventilated areas. Nursing management is similar to that for nasal obstruction. The nurse instructs the client to keep the head elevated and to apply ice four times a day for 20 minutes to reduce the swelling and pain. He or she gives analgesics as ordered to alleviate pain. Postoperatively, the nurse assesses the client for airway obstruction, respiratory difficulty (i.e., tachypnea, dyspnea), dysphagia, signs of infection, pupillary responses, level of consciousness, and periorbital edema. In addition, the nurse helps reduce the client's anxiety by answering questions and offering reassurance that the bruising and swelling will subside and sense of smell will return.