INTEGRATION OF NURSING FALL II Review notes by Ramona Friend
Topic Explanation
Needle inserted through abdominal wall into peritoneal cavity, withdrawing
fluid accumulation due to ascites.
Paracentesis: Findings
that need to be reported • Have pt void
• Obtain baseline v/s
ATI Pink Book pg. 99
• Position upright
• Administer mild sedation
• Administer prescribed IV fluids or albumin to restore fluid balance
(as much as 4-6L of fluid is slowly drained from the abdomen)
• Monitor v/s
• Record weight before and after
• Measure abdominal girth before and after
• Assess lab profile before and after: albumin, amylase, protein, BUN,
and creatinine.
Preventing foot drop Brace or splint
Physical therapy
Nerve stimulation
Surgery
Surgical perforation of the pleural space to obtain specimen, to remove
fluid or air, or to instill medication.
Findings following
• Obtain informed consent
thoracentesis
• Educate pt: remain still, feeling of pressure, positioning
ATI Pink Book pg. 87
• Position upright
• Monitor v/s and respiratory status
• Label specimens
• Document client response, amount, color and viscosity of fluid (max
amount of fluid to be removed at one time is 1L)
• Chest tube at bedside
• Obtain CXR before and after procedure.
Teaching after Teaching:
laryngectomy • Coughing and deep breathing to prevent pneumonia
• Ambulation to prevent pneumonia
• Speech therapy/swallowing maneuvers
• High fowlers/maintain patent airway
• Aspiration precautions
• Liquids (thickened) as tolerated/nutrition
, • Stoma care/pain management
Intrauterine infusion of an isotonic solution (0.9% sodium chloride or
lactated ringer) to reduce the severity of variable decelerations caused by
Amnioinfusion, when is it cord compression.
done and why?
Nursing Interventions:
ATI Pink Book pg. 209
• Explain the procedure to the client
• Assist with the amniotomy and insertion of IUPC if not already
present
• Warm fluid using a blood warm prior to infusion
• Maintain comfort and dryness of the pt
o Monitor pt continuously to prevent uterine overstimulation
and increased uterine tone
o Continually assess intensity and frequency of the pt’s
uterine contractions
o Continually monitor FHR.
Mastectomy restrictions Restrictions:
• Teach the client how to care for her incisions and drainage tubes
(drains are usually left for 1-3weeks)
• Advise the client to avoid placing her arm in a dependent position.
• Encourage early arm and hand exercises to prevent lymphedema
and to regain full range of motion.
, • Teach the client not to wear constrictive clothing and to avoid cuts
and injuries to the affected arm.
• Teach/reinforce about BSE
• Instruct the client to report numbness, pain, heaviness, or impaired
motor function of the affected arm to the surgeon.
• Have the client sit with the head of the bed elevated to 30 when
awake and to support her arm on a pillow. Lying on the unaffected
side can relieve pain.
• Have the client wear a sling while ambulating to support the arm
• Avoid administrating injections, taking blood pressure or obtaining
blood from the client’s affected arm
Surgical procedure performed to replace a joint with a prosthetic system.
Contributing Factors:
Total hip arthroplasty
teaching • Impaired mobility and uncontrolled pain related to osteoarthritis
• Congenital anomalies
ATI Pink Book pg. 117
• Trauma
• Osteonecrosis
Nursing interventions:
• Keep abductor pillow in place while in bed, do not flex hip more
than 90 (do not position on operative site)
• Assess for pain, rotation and extremity shortening
• Assess neurovascular status
• Use aseptic technique for wound care
• Monitor for indications of infection
• Ambulate day of surgery after stabilization and d/c from PACU
• Use toilet seat extender
• Teach exercise to reduce the risk of DVT: ankle dorsiflexion, circles
with feet, push feet into bed while tightening quads, and straight
leg raises
Pt Education:
• Instruct pt to participate in exercise regimen
• Instruct pt to use ambulatory device
• F/U with physical therapist and occupational therapist.
, Venous Thromboembolism: The collective condition of DVT and PE.
Contributing factors:
Which patients are at risk
• Immobility
for DVT?
• Surgery
ATI Pink Book pg. 136
• Trauma
• Obesity
• Age >65
• Spinal cord injury
• Disorders of coagulation
• Pregnancy
• Oral contraceptives
Manifestations:
• Edema of the affected limb
• Local swelling, bumpy, knotty
• Red tender, local induration
• Venous ulcers usually around the ankle, reddened and bluish;
edema often present
Diagnostic procedures:
• MRI, CT, Ultrasound
Nursing interventions:
• Heparin: monitor PTT
• Warfarin: monitor INR
• Thrombolytic therapy: alteplase
• Assess for bleeding and thrombocytopenia
• Elevate the affected extremity and apply warm, moist compact.
• Monitor for manifestations of PE: dyspnea, chest pain, tachycardia,
anxiety.
Topic Explanation
Needle inserted through abdominal wall into peritoneal cavity, withdrawing
fluid accumulation due to ascites.
Paracentesis: Findings
that need to be reported • Have pt void
• Obtain baseline v/s
ATI Pink Book pg. 99
• Position upright
• Administer mild sedation
• Administer prescribed IV fluids or albumin to restore fluid balance
(as much as 4-6L of fluid is slowly drained from the abdomen)
• Monitor v/s
• Record weight before and after
• Measure abdominal girth before and after
• Assess lab profile before and after: albumin, amylase, protein, BUN,
and creatinine.
Preventing foot drop Brace or splint
Physical therapy
Nerve stimulation
Surgery
Surgical perforation of the pleural space to obtain specimen, to remove
fluid or air, or to instill medication.
Findings following
• Obtain informed consent
thoracentesis
• Educate pt: remain still, feeling of pressure, positioning
ATI Pink Book pg. 87
• Position upright
• Monitor v/s and respiratory status
• Label specimens
• Document client response, amount, color and viscosity of fluid (max
amount of fluid to be removed at one time is 1L)
• Chest tube at bedside
• Obtain CXR before and after procedure.
Teaching after Teaching:
laryngectomy • Coughing and deep breathing to prevent pneumonia
• Ambulation to prevent pneumonia
• Speech therapy/swallowing maneuvers
• High fowlers/maintain patent airway
• Aspiration precautions
• Liquids (thickened) as tolerated/nutrition
, • Stoma care/pain management
Intrauterine infusion of an isotonic solution (0.9% sodium chloride or
lactated ringer) to reduce the severity of variable decelerations caused by
Amnioinfusion, when is it cord compression.
done and why?
Nursing Interventions:
ATI Pink Book pg. 209
• Explain the procedure to the client
• Assist with the amniotomy and insertion of IUPC if not already
present
• Warm fluid using a blood warm prior to infusion
• Maintain comfort and dryness of the pt
o Monitor pt continuously to prevent uterine overstimulation
and increased uterine tone
o Continually assess intensity and frequency of the pt’s
uterine contractions
o Continually monitor FHR.
Mastectomy restrictions Restrictions:
• Teach the client how to care for her incisions and drainage tubes
(drains are usually left for 1-3weeks)
• Advise the client to avoid placing her arm in a dependent position.
• Encourage early arm and hand exercises to prevent lymphedema
and to regain full range of motion.
, • Teach the client not to wear constrictive clothing and to avoid cuts
and injuries to the affected arm.
• Teach/reinforce about BSE
• Instruct the client to report numbness, pain, heaviness, or impaired
motor function of the affected arm to the surgeon.
• Have the client sit with the head of the bed elevated to 30 when
awake and to support her arm on a pillow. Lying on the unaffected
side can relieve pain.
• Have the client wear a sling while ambulating to support the arm
• Avoid administrating injections, taking blood pressure or obtaining
blood from the client’s affected arm
Surgical procedure performed to replace a joint with a prosthetic system.
Contributing Factors:
Total hip arthroplasty
teaching • Impaired mobility and uncontrolled pain related to osteoarthritis
• Congenital anomalies
ATI Pink Book pg. 117
• Trauma
• Osteonecrosis
Nursing interventions:
• Keep abductor pillow in place while in bed, do not flex hip more
than 90 (do not position on operative site)
• Assess for pain, rotation and extremity shortening
• Assess neurovascular status
• Use aseptic technique for wound care
• Monitor for indications of infection
• Ambulate day of surgery after stabilization and d/c from PACU
• Use toilet seat extender
• Teach exercise to reduce the risk of DVT: ankle dorsiflexion, circles
with feet, push feet into bed while tightening quads, and straight
leg raises
Pt Education:
• Instruct pt to participate in exercise regimen
• Instruct pt to use ambulatory device
• F/U with physical therapist and occupational therapist.
, Venous Thromboembolism: The collective condition of DVT and PE.
Contributing factors:
Which patients are at risk
• Immobility
for DVT?
• Surgery
ATI Pink Book pg. 136
• Trauma
• Obesity
• Age >65
• Spinal cord injury
• Disorders of coagulation
• Pregnancy
• Oral contraceptives
Manifestations:
• Edema of the affected limb
• Local swelling, bumpy, knotty
• Red tender, local induration
• Venous ulcers usually around the ankle, reddened and bluish;
edema often present
Diagnostic procedures:
• MRI, CT, Ultrasound
Nursing interventions:
• Heparin: monitor PTT
• Warfarin: monitor INR
• Thrombolytic therapy: alteplase
• Assess for bleeding and thrombocytopenia
• Elevate the affected extremity and apply warm, moist compact.
• Monitor for manifestations of PE: dyspnea, chest pain, tachycardia,
anxiety.
