Lesson 7 Reduction of Risk Potential

The nurse prepares to insert an indwelling urinary catheter in a female client. Arrange the following steps in the order the nurse should perform them. -Lubricate the tip of the catheter. -Wipe the client's urinary meatus with sterile solution in a downward motion. -Insert the catheter 2-3 inches into the urethra. -Inflate balloon. -Place the client in a supine position and bend her knees. -Put on sterile gloves.

-Place the client in a supine position and bend her knees. -Put on sterile gloves. -Lubricate the tip of the catheter. -Wipe the client's urinary meatus with sterile solution in a downward motion. -Insert the catheter 2-3 inches into the urethra. -Inflate balloon. The dominant hand needs to remain sterile and any step that requires both hands to complete should be done before the actual insertion of the catheter while maintaining a sterile field. Therefore, lubricating the tip of the catheter should occur before wiping the urinary meatus. Once the nurse has put on sterile gloves, they should open a lubricant package and squirt the lubricant on the tip of the catheter before touching the client with the nurse's non-dominant hand to clean the meatus.

Electrocardiogram (ECG)

A 12-lead ECG takes about 10 minutes to perform at the bedside. With each beat, an electrical impulse travels through the heart. The P-wave is the impulse of the atria, followed by a flat line when the electrical impulse goes to the bottom of the chambers. The QRS complex is the impulse of the ventricles and the T-wave represents the electrical recovery or return to a resting state for the ventricles.

Jackson-Pratt Surgical Drain

A Jackson-Pratt drain is a self-suction drain with a collection reservoir. The nurse will monitor the amount and character of the drainage and notify the health care provider if the drainage turns bright red.

T-tube Surgical Drain

A T-tube is commonly used after gallbladder surgery. It is placed in the common bile duct to allow the passage of bile. The nurse will keep the drain below the client's waist and fasten the drain to the dressing for safety. The nurse will monitor the drainage and teach their client how to care for the drain if they are being discharged with it. The drain must be clamped one hour before and after each meal.

Bone Marrow Transplant

A bone marrow transplant is used to replace or stimulate non-functioning bone marrow. It is done through an intravenous infusion from the donor to the recipient. Clients with leukemia, aplastic anemia and immunodeficiency disorders are common candidates for bone marrow transplants.

Radiographs (X-Rays)

A chest X-ray is used to detect detect malfunctions within heart and lung physiology. The client will remove jewelry from neck and chest and female clients will wear a lead apron.

Chest Tubes

A chest tube system is an intrapleural drainage system with one or more chest catheters in the pleural space attached to a drainage system.

Foam Dressing

A foam dressing is an absorptive dressing consisting of hydrophilic polyurethane or film-coated gel.Indications include stages II-IV pressure ulcers; partial- and full-thickness wounds with drainage or surgical wounds. Advantages: Comes in many sizes, shapes and forms Conformable Easy to apply and easy to remove (non-adherent) Disadvantages: Secondary dressing or tape may be needed to secure in place Not recommended for non-draining wounds or dry eschar May lead to macerating periwound skin if not changed appropriately

Hemovac Surgical Drain

A hemovac is a large, portable wound self-suction device with a reservoir. The hemovac is commonly used after a mastectomy. The nurse will monitor the amount and character of the drainage and notify the health care provider if the drainage turns bright red.

Hydrogel Dressing

A hydrogel dressing is impregnated with water or glycerin-based amorphous gel (high water content); non-adherent.Indications include partial or full thickness wounds, burns, deep or necrotic wounds or radiation-damaged skin. Advantages: Decreases pain Maintains humidity Debrides Does not stick to wound Can be used with infected wound Disadvantages: Must be covered with another dressing

NG Tube

A nasogastric tube may be placed to decompress the abdomen, administer medication or provide nutrition.

Pacemaker

A pacemaker is a battery-powered pulse generator that stimulates the heart via electrodes that transmit electricity to the heart. They are commonly used to correct dysrhythmias such as sinus bradycardia or ventricular tachycardia.Complications for pacemakers include infection, perforation of myocardium, pneumothorax, hemothroax, dysrhythmia, thrombosis, pacemaker failure, syncope, hypotension, pallor, hiccups and shortness of breath.Informed consent must be obtained prior to the procedure. The nurse will initiate preoperative care as ordered. The client's vital signs and ECG will be monitored as well as post-anesthesia care post-procedure. The client will be on bed rest as ordered.

Penrose Surgical Drain

A penrose drain is a simple latex drain that is freely laid inside the wound/site without sutures to hold it in place. Drainage flows onto a gauze dressing.

Ventilator

A ventilator is used when the client needs assistance getting oxygen into the lungs and removing carbon dioxide from the body. The nurse must have the knowledge and skills to effectively and safely maintain a client that is on a ventilator.

Transparent Film Advantages & Disadvantages

Advantages: Doesn't have to be removed to examine wound Impermeable to external fluid and bacteria Available in many sizes Disadvantages: Fluid retention under dressing may lead to periwound maceration

Gauze Advantages & Disadvantages

Advantages: Wicks away wound exudate Does not interact with wound Comes in many sizes and lengths Disadvantages: Must be held in place by a secondary dressing Fibers may shed or adhere to wound

Alginates

Alginates are made from polysaccharide from seaweed.Indications include moderately or highly exudative wounds. Advantages: Forms gel on wounds and moist environments Reduces pain Can be used to pack cavities Low allergenic Disadvantages: Not recommended for dry wounds or hard eschar May require secondary dressing Not recommended in anaerobic infections

Radiation Safety

Always minimize the client's exposure to radioactivity, whether the therapy is intra-cavity, interstitial or metabolized.

Automatic Implantable Cardioverter-Defibrillator (AICD)

An AICD is a pulse generator implanted in a subcutaneous pocket. It delivers an electrical shock to the heart when a ventricular tachycardia or ventricular fibrillation is detected. It is used to treat life-threatening ventricular dysrhythmias.Complications include infection, malfunction and battery failure. Informed consent must be obtained prior to the procedure. The nurse will initiate preoperative care as ordered including medications and ECG.

Exercise Cardiac Stress Test (ECST)

An ECST is used to assess the cardiovascular response to increased workload. It measures how heart and blood vessels respond to exertion. The client may walk on a treadmill or pedal a stationary bicycle with continuous ECG monitoring.

Angiogram (Cardiac Catheterization)

An angiography is used to evaluate specific areas of the arterial system by injecting a dye through a catheter (via the groin or arm) that makes coronary arteries visible on an X-ray.An angiogram is performed with the use of local anesthesia and intravenous sedation and takes approximately 20-30 minutes. If a blockage is found during the procedure, the surgeon may perform a percutaneous coronary intervention (PCI) to open the blockage. The client will need to sign a consent form, and then empty their bladder prior to the test. The nurse will assess pulse rate and explain to the client that some people feel heat, palpitations or like they need to cough when the dye is injected.Clients who have the catheter inserted in their groin will have a compression bandage on the site and must lie flat on their back for several hours post-procedure. The nurse will assess for a hematoma, distal pulses and vital signs frequently post-test. The nurse will also compare the client's skin temperature, color and sensation in both extremities and notify the provider if bleeding or vital signs change. Check your organization's policy on post-cardiac catheterization orders.

Types of Bone Marrow Transplants

An autologous transplant is when a client receives their own bone marrow cells, harvested before high-dose chemotherapy or radiation. A syngeneic transplant is used when the donor and recipient are identical twins. An allogeneic transplant is used when the donor is not genetically identical to recipient but is a match.

Incentive Spirometer

An incentive spirometer is used to maximize respiration and mobilize secretions.

Coughing Techniques

Ask your client to lean forward and take deep breaths and cough several times during expiration. The cough must come from deep in the chest to help move secretions.

A client is receiving radiation therapy to the left axilla. The nurse should emphasize:

Avoid tight clothing around the area

Nuclear Scan

Before a nuclear scan, a radioactive material is injected. The scan charts the flow through the client's heart and lungs. The nurse will monitor the client for allergic reaction.

Types of Ostomies

Bowel ostomies include an ileostomy or colostomy. Urinary diversions include ileal conduit (ileal loop) and ureterostomies.

Abdominal & Pursed Lip Breathing

Breathing exercises include abdominal breathing and pursed lip breathing. The client is positioned on their back with their knees bent and hands placed on their abdomen during abdominal breathing. Pursed lip breathing is done by taking a deep breath in through the nose and pursing the lips while breathing out the mouth. The exhalation through the pursed lips should take twice as long as the inhale.

Creatinine Clearance (CC)

CC is used to evaluate renal function. A 24-hour urine collection and a blood draw for a creatinine level at the end of the urine collection. Normal levels are between 1.42-2.08 mL/min.

C-Reactive Protein (CRP)

CRP is a protein produced by the liver; levels rise with inflammation throughout the body. CRP may help determine the risk of future cardiac events in clients who have had a heart attack. CRP is a simple blood draw and no client preparation is required.

Central Venous Pressure (CVP)

CVP measures blood volume and efficiency of the cardiac pump. A central line is threaded into the right atrium to measure the central venous pressure.

A 62-year-old client is admitted to the emergency department. The client has a history of anemia and peptic ulcer disease and is now experiencing chest pain, nausea and dizziness. The nurse anticipates which laboratory tests to be ordered right away? (Select all that apply.)

Cardiac enzymes Complete blood count (CBC) Chest pain with nausea and dizziness may be findings associated with angina or myocardial infarction. Cardiac enzymes, including creatinine kinase, myoglobin, and troponin, are indicated to determine if muscle damage has occurred (to help rule out a heart attack). Low hemoglobin (Hgb) can precipitate an angina attack if there is not enough Hgb to deliver oxygen to the myocardium; given the client's history, a CBC would be indicated. There are no findings of either overdose or poisoning, so a toxicology screen is not needed. A lipid panel is used to show one's risk for coronary heart disease and the presence of Helicobacter Pylori is associated with increased cardiovascular disease risk and lower HDL, but these tests are not used diagnostically for chest pain.

Casting

Casting immobilizes the affected body part. Casts may be plaster or fiberglass.With plaster casts, immediately after the cast is placed it should not be covered and allowed to dry. The client will avoid resting the cast on hard surfaces or edges. The affected limb should be elevated above the heart on a soft surface. Monitor for complications such as blueness/paleness, pain, numbness or tingling sensations on the affected area.Once the cast is dry, the client can be mobile. Encourage any prescribed exercises. The client will report any breaks or foul smells from the cast. Although difficult, the client should not scratch the skin under the cast or put anything underneath the cast. If the skin breaks under the cast, an infection is likely.Complications include impaired circulation, peripheral nerve damage and pressure necrosis.

Dressing Nursing Considerations

Change dressings per your health care organization's policy or orders. The nurse will maintain asepsis and make sure the dressing is secure. Document the type and amount of drainage, presence of drains and the condition of the wound. Observe for signs of infection and weigh the dressing if ordered.If necessary, the nurse will teach clients how to change their dressings when they return home.

Chest Physiotherapy

Chest physiotherapy is an airway clearance technique used by health care providers.

AICD Client Teaching

Client teaching will include: Findings of defibrillation discharge Importance of routine follow-up Findings of complications Limit activity as ordered Avoid strong magnetic fields Wear MedicAlert® identification Assure client that no household appliance will affect AICD Shock may be painful

Pacemaker Client Teaching

Client teaching will include: How to take their pulse and when to report a sudden increase or decrease in rate Carry an ID card and request hand scanning at security check points at airports Avoid situations involving electromagnetic fields Periodic battery replacement and medical follow-up Frequent rest periods at home or work Document information about your client's pacemaker including including the model of the pacemaker, date and time of insertion, location of the pulse generator, stimulation threshold and pacer rate.

Ventilator Nursing Considerations

Clients on a ventilator will have their vital signs assessed every four hours. Breath sounds will be evaluated for any abnormalities and continuous pulse oximetry is required. The nurse will assess for suctioning needs and provide good oral care at least twice a shift. Evaluate symptoms of hypoxia, neurologic status and ABG. Be sure to observe for skin breakdown around the tube site and for complications of aspiration.The nurse will ensure ventilator is working properly. If the high pressure alarm goes off - check for tube obstruction: Client biting the tube Increased secretions Tube slipping into right main stem bronchus Pneumothorax If the low pressure alarm goes off - check for disconnection of tubes.

Tracheostomy Care & Suctioning

Complications of tracheostomy care include airway obstruction, tracheal necrosis and infection. Complications of suctioning include hypoxia, bronchospasm, vagal stimulation, tissue trauma, cardiac dysrhythmia and infection.

Oxygen Therapy

Complications related to oxygen administration include infection, drying of mucosa, respiratory depression, oxygen toxicity and combustion. Be sure to change masks and tubing daily and attach humidification if needed. Monitor the respiratory rate frequently to watch for depression and toxicity.If the client is using oxygen in their home, the visiting nurse will assess the electrical plugs and equipment. Remind the client of the danger associated with smoking near oxygen. Place a sign on the front door that oxygen is in use.

Ostomy

Creating an ostomy is a surgical procedure that creates an opening into the abdominal wall for fecal or urinary elimination. A portion of intestinal mucosa or ureter is brought through the abdominal wall, creating a stoma through which feces or urine can drain.

(Serum) Enzymes/Cardiac Markers

Creatinine kinase lab results are used to diagnose an acute myocardial infarction (MI) and is detected in the blood within 3-5 hours post MI. Murakami (MM) bands present indicate skeletal muscle damage and the presence of Myocardial B and R (MB) bands indicate heart muscle damage.Troponin is a regulatory protein found in striated muscle; troponin levels are elevated 4-8 hours after a heart attack. This test is used to diagnose a heart attack and to assess the degree of damage to the heart muscle. There are two different cardiac-specific isoforms: troponin I and troponin T.

A client becomes short of breath and complains of chest pain during his hemodialysis. The nurse suspects an air embolism. What is the priority nursing action?

Discontinue dialysis and notify the health care provider.

Radionuclide Stress Testing (Nuclear Stress Test)

During this test, a radioactive isotope (typically thallium or cardiolite) is injected into the client and nuclear images of the client's heart are taken, first during rest and then following exercise. A blockage in a coronary artery results in diminished blood flow, which shows up as a "cold" spot on the scan.

Endotracheal Tube (ET tube)

Endotracheal tubes (ET) are placed when an artificial airway is needed.Check the tube placement by listening for bilateral breath sounds and looking for bilateral chest movement. The client will be monitored via pulse oximetry. Typically an X-ray is ordered for placement confirmation.The nurse will regularly assess tube placement and security, breath sounds, and bowel sounds. The ET tube should be marked where it touches the mouth or teeth and be secured with tape to stabilize.

Acute Radiation Side Effects

Fatigue Reddened, dry, itchy skin (possible sloughing and oozing) Alopecia (hair falls out) Altered taste Xerostomia (dry mouth) Esophagitis Anorexia Nausea and vomiting Diarrhea Cystitis Anemia; decreased white blood count; decreased platelets Pneumonitis Decreased sperm count; sterility

Gauze

Gauze is the oldest, most common dressing. It comes in woven and non-woven forms. Gauze may be impregnated with various products, e.g., antimicrobials.Indications include draining wounds, necrotic wounds, wounds with tunnels, tracts or dead space, surgical incisions, burns and pressure ulcers.

Hemodialysis

Hemodialysis removes accumulated waste products though the cleansing of the blood. It can be used short-term for acute illness or long-term with clients in renal failure.Complications include hemorrhage, hepatitis, nausea and vomiting, disequilibrium syndrome, muscle cramps, air embolism and sepsis.The nurse will check the "thrill" and bruit every eight hours. Blood pressure and lab draws are not to be conducted on the affected extremity.

Hemodynamic Monitoring

Hemodynamic monitoring uses an invasive balloon-tipped, flow-directed cardiac catheter to provide continuous monitoring. Readings reflect left ventricular end diastolic pressure.Complications include pneumothorax, dysrhythmias, infection, sepsis and thrombophlebitis. The nurse will monitor pressures, assess and change dressings and maintain patency with the fluids. Strict asepsis and standard precautions are required.

Hydrocolloid Dressing

Hydrocolloid dressing swells to accumulate exudate when it contacts the wound.Indications include shallow to moderate dermal wounds, e.g., venous or arterial ulcers and decubitus ulcers. Advantages: Debrides Maintains wound humidity Liquefies necrotic debris impermeable to contaminants May stay safely for days Disadvantages: Occlusive — does not allow air contact

Intra-aortic Balloon Pump Important Info

IMPORTANT: The client cannot bend the leg in which the balloon was inserted. This is an uncomfortable and difficult task for the client. Maintain emotional support to the client and family during the duration of the monitoring process.

Chest Tube Complications

If there is an air leak in the system indicated by a constant bubbling in the water-seal chamber, the health care provider must be contacted.If the chest tube becomes dislodged, the nurse will apply pressure over the site and let air escape. Contact the health care provider immediately.If the tube becomes disconnected from the drainage system, cut the contaminated tip off and insert a sterile connector. Then reattach it to the drainage system.

Bone Marrow Transplant Complications

Infection: precautions to take to avoid infection Thrombocytopenia Anemia Micropulmonary emboli Bleeding Stomatitis Nutritional deficiencies Disease relapse Graft rejection Graft Versus Host Disease (GVHD): Occurs when donor T lymphocytes introduced into a host who is immunologically incompetent T lymphocytes proliferate and attack host cells, which they think are foreign GVHD risk peaks 30-50 days after BMT Graded according to degree of organ involvement Findings include dermatitis, hepatitis and enteritis with diarrhea

The client is admitted with anemia, suspected to be caused by slowly bleeding esophageal varices. Which physician order should the nurse question?

Insert nasogastric (NG) tube to gravity Esophageal varices are similar to varicose veins within the esophagus. A nurse would never insert an NG tube if this diagnosis is suspected because it might rupture the varices and cause an acute hemorrhage. The other orders make sense during a GI work-up for anemia. Checking CBC will provide hemoglobin and hematocrit values to quantify the degree of anemia. Ranitidine decreases stomach acid and may decrease loss of blood through a possible ulcer. Getting stool samples for occult blood can identify the presence of small amounts of blood in the stool that are not visible to the naked eye.

A nurse is assessing an 8-month-old infant with a malfunctioning ventriculoperitoneal shunt. Which of these findings should the nurse anticipate the infant might exhibit?

Irritability Irritability is an initial finding for cerebral hypoxia, which would occur from the retained fluid in the brain that results in increased intracranial pressure. Signs of increased intracranial pressure in infants include bulging fontanel, irritability, high-pitched cry, and continual crying when held. Changes in the pulse are variable, e.g., rapid to slow and bounding to feeble. Respirations are more often slow, deep and irregular.

The nurse cares for a client who was admitted in status epilepticus and whose last seizure was four hours ago. What is the most important nursing assessment for this client?

Level of consciousness Cerebral blood flow surges during seizure activity, depleting oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should monitor the client's level of consciousness very closely.

Central Venous Pressure (CVP) Procedure Nursing Care

Maintain a dry, sterile dressing and change dressing, IV bag, manometer and tubing every 24 hours. Instruct clients to hold their breath when the CVP is inserted, withdrawn or when a tube is changed to prevent an air embolism. Monitor clients for complications, which include pneumothorax from catheter insertion, air embolism or an infection at the insertion site.

An X-ray initially confirms the placement of a nasogastric (NG) feeding tube in the stomach. The nurse is now preparing to administer a medication through the tube. What action will the nurse take to verify tube placement?

Measure the pH of aspirated gastric contents Bubbling or coughing would indicate the possibility of the tube being in the airway, but neither are used to determine placement in the stomach. Forcing air through the NG tube and auscultating the abdomen for the sound of the air is an unreliable method to determine tube placement. Measuring the pH of aspirated stomach contents confirms gastric placement.

Arterial Blood Gases (ABGs)

Measures tissue oxygenation, carbon dioxide removal and acid-base balance.The nurse will perform an Allen test to check collateral circulation. Arterial blood will be collected in a heparinized syringe because the test requires blood without clots. Air bubbles cannot be present in the specimen.

Non-Adherent Gauze

Non-adherent gauze is made with a substance that hinders sticking (example: Telfa pad). Non-adherent gauze absorbs wound exudate but does not stick to the wound.

Ultrasound Echocardiogram

Non-invasive sound waves are used to diagnose and monitor heart failure, differentiating between systolic and diastolic heart failure.

Percussion and Vibration

Perform percussion and vibration during postural drainage. Percussion is a rhythmic striking of the chest with cupped hands and is alternated with vibrations. Vibrations are executed when the client exhales and pressure is applied to the chest.

The nurse recognizes that obtaining accurate post anesthesia vital signs is extremely important. Which of the following client conditions are not appropriate for electronic blood pressure measurement? (Select all that apply.)

Peripheral vascular obstruction Irregular heart rate Shivering Clients with irregular heart rates, peripheral vascular disease, seizures, tremors, and shivering are not candidates for using an electronic blood pressure machine.

Chronic Radiation Side Effects

Permanent darkening of skin Permanent taste alteration Dental caries Fibrosis of gastrointestinal tract Malabsorption Radiation nephritis Cataracts Pulmonary and cardiovascular fibrosis

Bone Marrow Transplant Nursing Considerations

Pharmacological treatment includes Cyclosporin A (immunosuppressant drug), steroids and anti-thymocyte globulin (immunosuppressant drug). The nurse will explain the procedure to the client, answer any questions and obtain the client's informed consent. The nurse will also: Assess baseline hemodynamic status prior to the injection Assess vital signs every 15 minutes during infusion post-procedure Encourage intake of fluid and high protein, high calorie diet Provide frequent oral hygiene Weigh the client daily Measure I/O Monitor all mucous membranes, wounds and catheter sites daily Administer total parenteral nutrition (TPN) if ordered Maintain isolation as ordered (reverse isolation or laminar air flow room) Sterilize any non-sterile objects before bringing them into the room Administer medications as ordered Test urine, stool and emesis for occult blood Report any signs of bleeding immediately Avoid invasive procedures Maintain a safe environment Encourage progressive activity as ordered Provide emotional support Observe for findings of complications

Postural Drainage

Place clients in positions that facilitate drainage (head down, prone, right and left lateral, and upright). Secretions produced can be coughed or suctioned out.

The nurse is preparing to insert a NG tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?

Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.

The nurse is reviewing the lab results for a male client on a heparin infusion to treat a deep vein thrombosis (DVT) and cellulitis of the right lower leg. Which of the lab results would the nurse be most concerned about?

Platelet count Thrombocytopenia (abnormally low amount of platelets) and heparin-induced thrombocytopenia can occur in clients on heparin therapy. In an adult, a normal platelet count is about 150,000 to 450,000 platelets per microliter of blood (or 150-450 x 109/L). The PTT is within the therapeutic range. It is expected that the white blood cells would be slightly elevated in a client with an infection (cellulitis).

The nurse reviews the most recent lab results for a client on telemetry who is experiencing premature ventricular beats at 12 per minute. Which lab test would require immediate action by the nurse?

Potassium 2.5 mEq/L (2.5 mmol/L) The client low potassium levels is at high risk for ventricular dysrhythmias (normal lab values are 3.5 to 5.0 mEq/L [3.5 - 5 mmol/L]). Premature ventricular contractions may also be caused by low magnesium levels, digoxin and aminophylline toxicity, and hypoxia. Normal values for magnesium are about 1.5 to 2.4 mg/dL (0.75-1.2 mmol/L); normal values for calcium are about 8.5-10.3 mg/dL (2.12 - 2.57 mmol/L)

Ear Drops

Pull the outer ear up and back for an adult, or down and back for a child. Place the drops so they run down the wall of the ear canal. Have the client lie with the affected ear up to allow for absorption.

Radiation Therapy

Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells. X-rays, gamma rays and charged particles are types of radiation used for cancer treatment. The nurse must have knowledge on how to prepare and provide aftercare for clients having radiation therapy.

Radiation Methods of Delivery

Teletherapy is an external therapy treatment from a source outside the body. The tumor area is marked and other anatomical areas are protected. Radiation is administered in small doses over time. Brachytherapy is internal therapy radiation, which is placed in or directly on the body. Intra-cavity therapy is when radiation is inserted into a body cavity. This is often used with gynecological cancers. Interstitial therapy is the insertion of radioactive seeds, needles or capsules. This is used in head and neck lesions, intra-abdominal and intrathoracic lesions. Metabolized therapy is when radioactive material is ingested, installed or injected into the body; used for thyroid, leukemia, bone and intra-pleural lesions.

Brain Natriuretic Peptide (BNP) or N-terminal pro-BNP

The BNP is used to measure the production of a hormone found in the left ventricle and helps diagnose and evaluate the client's risk of future cardiac events, including heart failure. It is used for prognosis and to monitor therapy.Normal range is 0.5-30 pg/mL.

Blood Urea Nitrogen (BUN)

The BUN is also collected to evaluate renal function. Values are affected by the client's protein intake, tissue breakdown and fluid volume changes. Normal levels are between 10-20 mg/dL (3.6-7.1 mmol/L).

Computed Tomography (CT)

The CT test provides a three-dimensional assessment of the thorax (lungs, heart, bones and tissue). This test may also detect fractures not visible in an X-ray. It is non-invasive and painless and typically takes around 20 minutes. If contrast dye is used and a reaction occurs, the nurse will monitor the reaction.

Magnetic Resonance Imagine (MRI)

The MRI provides a detailed image of the body structures. It can be used to diagnose a heart issue but can also be used to diagnosis abnormalities in other systems. The nurse will explain the procedure and assess the client for claustrophobia and verify whether the client has any metal implants (e.g., pacemaker, screws). The client will remove all metal jewelry and objects.

Central Venous Pressure (CVP) Procedure

The client will have a catheter inserted in the jugular, subclavian or antecubital vein. The manometer will attach to a three-way stopcock that is also connected to the IV to the central catheter. The stopcock is opened to allow fluid in the manometer to flow to the client. The client must be in a flat bed. When the level stabilizes, the reading is taken at the highest level of fluctuation. Normal readings range between 2-6 mm. High levels indicate hypervolemia and low levels indicate hypovolemia.

Eye Irrigation

The client will tilt the head back and the nurse should direct fluid from the inner to the outer canthus using a small bulb syringe. Have a basin close by for fluid collection.

Ear Irrigation

The client will tilt their head and the nurse will direct a stream of fluid against the sides of the ear canal. The client will lie on the affected side to improve drainage. Do not irrigate if you observe swelling or tenderness.

The nurse is assessing the functioning of a chest tube drainage system. The nurse should expect which of the following assessment findings? (Select all that apply.)

The drainage system is maintained below the client's chest Drainage in the drainage collection chamber Occlusive dressing is over the insertion site Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. Gentle (not vigorous) bubbling should be noted in the suction control chamber.Drainage in the system is expected; however, drainage that is more than 70-100 mL/hour is considered excessive and the health care provider should be notified. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

Eye Drop Instillation

The dropper should be sterile and will not touch the eye during the procedure. Have the client tilt their head back and look up. The drops should be placed into the center of the lower conjunctival sac. Have the client blink several times between drops.

Intra-aortic Balloon Pump

The intra-aortic balloon pump is a device that helps blood circulate after myocardial failure.The device will not be used with clients who have aortic regurgitation, dissection or an abdominal aortic aneurysm. Complications include infection, bleeding, hematoma, diminished or absent pulse and/or thrombus at insertion site. The pump can cause an aortic dissection or perforation, thrombocytopenia, dysrhythmias and myocardial failure.An informed consent form must be obtained prior to the procedure. The nurse will take the client's baseline vital signs, hemodynamic parameters and ECG as ordered. The nurse will monitor the client's level of consciousness (LOC) and obtain arterial blood gases as ordered. It is important to maintain asepsis, monitor I/O and monitor for complications frequently.

Lipid Profile

The lipid profile evaluates the risk for atherosclerosis. The client should take nothing by mouth (NPO) 10-12 hours prior to the blood draw; water is permitted.

Radiation Therapy--Nursing Considerations

The nurse should be knowledgeable about the type of radiation used, the half-life of the isotope, the amount of isotope being used and the method of delivery.The nurse will provide skin care and encourage the client to avoid using soaps and lotions on the radiated site. Small, frequent, bland meals will initially be provided and antiemetic's and antidiarrheals will be administered as ordered. Monitor the client for signs of dehydration and skin breakdown. Provide good oral care, emotional support and a restful environment. The nurse will teach the client: Utilize nutritional support strategies During treatment, do not wash marked area If the area must be cleansed, use only tepid water, no soap Do not wear tight clothing in the area Do not expose the area to sunlight Do not shave or scratch the area Do not use creams, lotions or oils on the area Avoid persons with known infections Avoid injury to the area Utilize strategies to conserve personal energy

Urinary Catheters

The nurse will provide perineal hygiene, using soap and water or otherwise following the health care organization's procedure. Observe the client for signs of inflammation or infection and maintain patency of the catheter (irrigate if ordered). Document intake and output (I/O). Empty system every shift or when it is half to three-quarters full. Be sure to keep the collection system lower than the level of the bladder. Take measures to prevent catheter-associated urinary tract infections.

Ostomy Nursing Interventions

The ostomy pouch should be emptied when it is about one half full using standard precautions and the skin will need to be protected around the stoma (see organizational policy). The nurse will monitor for and report immediately if the stoma oozes blood when touched, if there is blood in the pouch or any kind of bleeding from the stoma. Contact the health care provider if a urinary diversion output is less than 30mL/hour or if the urine has a foul smell, is cloudy or has blood in it. If the client is experiencing a burning sensation around the base of the urinary diversion stoma or they have back pain, chills or a fever, an infection may be present. The nurse will also address any issues with body image, fear of mutilation or shame which are common with new ostomy clients. The nurse will also provide teaching on the types of equipment used in ostomy care and maintenance, how to irrigate a colostomy, how to prevent complications and how to avoid constipation, diarrhea and excessive gas.

Radiation Side Effects

The severity of the side effects depends on the location of the radiation.

A bone marrow transplant is being considered for treatment of a client with acute leukemia who has not responded to chemotherapy. In discussing the treatment with the client, the nurse explains that:

The transplant procedure takes place in a sterile operating room to minimize the risk for infection

Your client patient has an endotracheal tube. You are assessing placement by listening to breath sounds and you notice that they are absent on the client's left side. What does this usually indicate to the nurse?

The tube may be displaced

Chest Tubes Nursing Considerations

The water-seal chamber should be filled with sterile water to the level that is specified by the manufacturer. If suction is to be used, the suction control chamber will need to be filled (per the health care provider's orders). Encourage clients to change positions as often as they can, cough and take deep breaths.The drainage system must be kept below the level of insertion. The system should be checked frequently for kinks in the tubing. Observe for fluctuations of fluid in the water-seal.To remove the chest tube, have clients forcibly bear down while holding their breath (Valsalva maneuver). The health care provider will remove the tube and the nurse will apply an occlusive dressing.

Enemas

There are three types of enemas: oil retention, soapsuds, and tap water. During the procedure, the solution is instilled into the rectum and sigmoid colon to promote defecation. The client will be in a Sims' position while the nurse inserts the tip of the tube no more than 3-4 inches into the rectum. The client should hold onto the solution for 5-10 minutes if possible. Do not administer an enema if the client complains of abdominal pain, nausea, vomiting or if you suspect appendicitis.

Composites

These are combinations of two or more different products, featuring a bacterial barrier, absorptive layer, foam, hydrocolloid or hydrogel. Advantages: Facilitate autolytic debridement Conformable and easy to apply and remove Come in many sizes and shapes Disadvantages: May be contraindicated for stage IV pressure ulcers Adhesive borders limit use on fragile skin

Ventilator Settings

Tidal volume: amount of air delivered with each machine breath Rate: number of breaths delivered by the machine in a minute FIO2: fraction of inspired oxygen (written as 0.6) % O2: percent of oxygen (for example: 60%) FIO2 of 0.6 = 60% oxygen Signs: deep breaths (higher volume) delivered periodically by ventilator Positive end expiratory pressure (PEEP): Normal physiologic PEEP is equal or less than 5 cm H2O Provides a baseline of positive pressure throughout exhalation Used to reduce airway collapse and intrapulmonary shunting

Transparent Film

Transparent film is made of polyurethane or copolymer. It has a porous adhesive layer that lets oxygen pass through and allows moisture vapor to escape from the wound.Indications include small, superficial wounds, e.g., over IV insertion sites, stage I or II pressure ulcers or partial-thickness wounds.

Urinary diagnostic tests

Urinary diagnostic tests are separated into the categories of: Normal Values Laboratory Tests Scans and X-Rays Diagnostic Procedures

A client is to receive three doses of potassium chloride 10 mEq in 100 mL of 0.9% normal saline to infuse over 30 minutes each. Which action is a priority assessment to perform before the nurse gives this medication?

Urine output Potassium chloride should only be administered after adequate urine output (greater than 20 mL/hour for two consecutive hours) has been established. For children the desired urine output is 1 mL/1 kg/1 hour. Impaired ability to excrete potassium via the kidneys can result in hyperkalemia.

Urine Culture & Sensitivity

Used to identify bacteria in the urine. The client will cleanse their external meatus and provide a midstream specimen. Normal levels are less than 100,000 colonies/mL.

A nurse is teaching a client with a diagnosis of metastatic bone disease about actions to prevent hypercalcemia. It would be important for the nurse to include which of these points?

Walking as much as possible keeps the calcium in the bone Mobility must be emphasized to prevent demineralization and breakdown of bones. Weight-bearing and resistance exercises will assist in this process.

Traction

pulling force and opposing force applied to an injured extremity.

Surgical Drains

used to collect excess fluid from a surgical wound.