med Surg Remediation ati
1. wound dehiscence or evisceration (opening of incision)
-call for help
-cover with sterile towel or moisten with sterile saline
-DO NOT attempt to reinsert organ
-low fowlers position with hips and knees bent
-notify provider immediately: Interventions for wound disruption
2. control diabetes and hypertension, all antibiotics, provide skin cares, cough and
deep breathe if lethargic: Nursing interventions to prevent acute kidney dis- ease
3. Poor output and inadequate tissue perfusion:
-dyspnea
-orthopenea(SOB while laying down)
-fatigue
-displaced apical pulse(hypertrophy)
-S1 heart sound
-pulmonary congestion (cough, bibasilar crackles)
-frothy sputum
-altered mental status
-organ failure(decreased urine)
(Right is edema, vein and abdominal distention, ascites, polyuria, weight gain):
Recognizing Manifestations of Left-sided Heart Failure
4. -wash with mild soap and water
-no lotion in between toes
-mild food powder
-nail care only after baths/shower
-avoid open toe, plastic, barefeet,
-cotton socks
-NO hot water bottles or heating pads
-avoid long sitting, standing, crossing of legs: Teaching about foot care
5. fever, purulent drainage, redness, swelling, cloudy or discolored drained
dialysate: Manifestations of Peritonitis
6. loss of peripheral vision
halo around lights: Indications of glaucoma
7. tachycardia
bounding pulse
hypertension
, med Surg Remediation ati
tachypnea
weakness
headache/altered level of consciousness
ascites
crackles/cough/increased RR/dyspnea from fluids in lungs
peripheral edema
weight gain distended
neck vein
increased urine: Manifestations of Hypervolemia
8. No food until pain free
TPN if severe
provide insulin if needed Iv
fluids
antiemetic if needed
bland high protein diet small meals: Planning care for acute pancreatitis
9. same time each day
-marker is on zero
-close lips and blow out hard and quick
-repeat 3 times, 30 sec in between (record highest number): using a Peak flow meter
10. mask and aseptic technique
-topical anesthetic
-non coring Huber Needle
-check for blood return prior to giving meds
-flush 5ml heparine after every use.. at least once per month: Assisting with placement
of a central venous catheter
11. -antaacids
blood transfusions, TPN,sodium bicarb
-loss of gastric secretions... like prolonged vomiting or nasogastric suction
-potassium depletion from thiazide diuretic or over laxative use, or cushings
syndrome: Identifying client at risk for metabolic alkalosis
12. Ph- less than 7.35
PACO2- greater than 35-45
hCO2- 22-26: Respiratory/Metabolic Acidosis average number range...
13. ph- greater than 7.45
PACO2- less than 35 or 35-45
HCO2- 22-26 metabolic is greater than 26: Repiratory/Metabolic alkalosis average
number range
1. wound dehiscence or evisceration (opening of incision)
-call for help
-cover with sterile towel or moisten with sterile saline
-DO NOT attempt to reinsert organ
-low fowlers position with hips and knees bent
-notify provider immediately: Interventions for wound disruption
2. control diabetes and hypertension, all antibiotics, provide skin cares, cough and
deep breathe if lethargic: Nursing interventions to prevent acute kidney dis- ease
3. Poor output and inadequate tissue perfusion:
-dyspnea
-orthopenea(SOB while laying down)
-fatigue
-displaced apical pulse(hypertrophy)
-S1 heart sound
-pulmonary congestion (cough, bibasilar crackles)
-frothy sputum
-altered mental status
-organ failure(decreased urine)
(Right is edema, vein and abdominal distention, ascites, polyuria, weight gain):
Recognizing Manifestations of Left-sided Heart Failure
4. -wash with mild soap and water
-no lotion in between toes
-mild food powder
-nail care only after baths/shower
-avoid open toe, plastic, barefeet,
-cotton socks
-NO hot water bottles or heating pads
-avoid long sitting, standing, crossing of legs: Teaching about foot care
5. fever, purulent drainage, redness, swelling, cloudy or discolored drained
dialysate: Manifestations of Peritonitis
6. loss of peripheral vision
halo around lights: Indications of glaucoma
7. tachycardia
bounding pulse
hypertension
, med Surg Remediation ati
tachypnea
weakness
headache/altered level of consciousness
ascites
crackles/cough/increased RR/dyspnea from fluids in lungs
peripheral edema
weight gain distended
neck vein
increased urine: Manifestations of Hypervolemia
8. No food until pain free
TPN if severe
provide insulin if needed Iv
fluids
antiemetic if needed
bland high protein diet small meals: Planning care for acute pancreatitis
9. same time each day
-marker is on zero
-close lips and blow out hard and quick
-repeat 3 times, 30 sec in between (record highest number): using a Peak flow meter
10. mask and aseptic technique
-topical anesthetic
-non coring Huber Needle
-check for blood return prior to giving meds
-flush 5ml heparine after every use.. at least once per month: Assisting with placement
of a central venous catheter
11. -antaacids
blood transfusions, TPN,sodium bicarb
-loss of gastric secretions... like prolonged vomiting or nasogastric suction
-potassium depletion from thiazide diuretic or over laxative use, or cushings
syndrome: Identifying client at risk for metabolic alkalosis
12. Ph- less than 7.35
PACO2- greater than 35-45
hCO2- 22-26: Respiratory/Metabolic Acidosis average number range...
13. ph- greater than 7.45
PACO2- less than 35 or 35-45
HCO2- 22-26 metabolic is greater than 26: Repiratory/Metabolic alkalosis average
number range
