Managing Client Care: Action Requiring Intervention During Tracheostomy Suctioning
- Suction 10-15 seconds maximum
- Wait one minute in-between
- When using suction catheter it shouldn’t exceed half of the internal diameter of the et
tube to prevent hypoxia
- Hyperoxygenation
- Have extra tach kit at bedside
- Don’t untie trach collar before tying new ones.
Coordinating Client Care: Planning Care for a Client Following a Stroke
- Immediately obtain a CT – to determine type of stroke
- NPO until Swallow test by ST
- Ischemic : most common, results from a clot blocking or impairing blood flow....deprives
the brain of o2 and nutrients. Alteplase
- Hemorrhagic : increased icp decreased loc , leakage of blood in brain.
Multiple Sclerosis: Priority Referral for a Client Who Has Amyotrophic Lateral Sclerosis
- ALS is a disease of the upper and lower motor neurons characterized by muscle
weakness progressing to muscle atrophy and eventually paralysis and death.
ALS does not involve autonomic changes, sensory alterations, or cognitive
changes.
- Death usually occurs due to respiratory failure within 3 to 5 years of the initial
manifestations. The cause of ALS is unknown, and there is no cure.
- Maintain a patent airway, and suction and/or intubate as needed.
- Monitor ABGs, and administer oxygen, intermittent positive pressure ventilation,
bilevel positive airway pressure, or mechanical ventilation as needed.
- Keep the head of the bed at 45°; turn, cough, and deep breathe every 2 hr; and
conduct incentive spirometry/chest physiotherapy.
- Facilitate effective communication (dysarthria) with the use of a communication
board or a speech language therapist referral.
- Assess coping and depression.
- Assess swallow reflex and ensure safety with oral intake. Thicken fluids as
needed.
- Meet nutritional needs for calories, fiber, and fluids. When no longer able to
swallow, provide enteral nutrition as prescribed.
- Use energy conservation measures.
- Address the client's interest in the establishment of advance directives/living
wills.
- PRIORITY RT,PT,OT
,Practice Settings and Nursing Roles in the Community: Identifying the Sequence of Steps
Required for a Home Visit
1. Pre planning – review referral, call pt, plan activities, bring forms, stock bags
2. Initiation- confirm visit, state name hospital that inhibit referral, establish rapport
3. Implementation- vitals, assessment, teaching, hazards, confront client problem
4. Termination – leave contact info, made contract, plan second visit, charting, plan next
5. Post home visit- leave, consult / collab with I team, make referral for family, stay
connected, document.
Legal and Ethical Issues: Caring for a Client Who Is Experiencing Acute Mania and Is in
Restraints
- explain reason/use to family and patient
- assess q2 and check vitals, offer food/fluid, toilet, ROM (offer q 15-30 min)
- pad bony prominences
- use quick-release knot
- must fit 1-2 fingers between body and restraint
- conduct eval and regularly determine if the restraint use needs to continue or if it
can be stopped
-provider must assess the patient within one hour of application
Mobility and Immobility: Evaluating Client Understanding of Crutch Safety
- Begin your step as if you were going to use the injured foot or leg, but shift your
weight to the crutches instead of the injured foot. Your body swings forward
between the crutches. Finish the step normally with your non-injured leg. When
the non-injured leg is on the ground, move your crutches ahead in preparation for
the next step.
- Up with the good, down with the bad food first.
Crutch Instructions
Do not alter crutch after fitting, Follow the Prescribes crutch gait.
Support bodyweight at the hand grips with elbows, Flexed at 20 degree to 30
degree.
Hold the crutches in one hand and grasp the arms of the chair with the hand
for balance while sitting and rising from a chair
The tripod position is the basic crutch stance, The client should place the
crutches 15 cm(6inches) in front of the 15 cm (6 in) to the side of each foot to
provided a wide base of support
Crutch gait: Client alternates weight from one leg to the other as well as on
the crutches
The clients should stand with a straight back, hips, head and neck and should
not place any weight on the axillae
Cane Instructions
, Maintain two points of support on the ground at all times
Keep the cane on the stronger side of the body
Support body weight on both legs
Move the cane forward 15 to 25 cm ( 6 to 10 inches)
Next, move the weaker leg forward toward the cane
Finally, advance the stronger leg past the cane
Musculoskeletal Trauma: Discharge Teaching Following Surgery for Carpal Tunnel Syndrome
- Cant remove wrist band, must have provider order
- warn the patient that it may take up to 4 weeks after surgery to regain full strength to
accomplish tasks.
- Refer to PT / OT
- Cover surgical incision when showering
- Don’t use ointments
- Don’t rub skin
- Ice therapy may be used
Nursing Care and Discharge Teaching: Teaching About Newborn Safety
- Car seat safety : -position newborn rear-facing until 2 years of age
-secure the car seat with the vehicle seat belt
-place the car seat at a 45 degree angle to prevent slumping and subsequent airway
obstruction in the newborn
-retainer clip should be at armpit level
- Crib slats should be no more than 2 and 1/4 in. apart
- Infants should be back to sleep , supine
- Sleep with pacifier to prevent sids.
- Infants should consume 1 to 2 ounces ever 2 – 3 hrs. 8-12 times a day
- 6-8 wet diapers a day
- Bathe clean to dirty, cover body parts not being bathed
Burns: Priority Action to Reduce the Risk of Infection
- The client may need 5,000 calories per day.
- Increase caloric intake to meet increased metabolic demands and prevent hypoglycemia.
- Increase protein intake to prevent tissue breakdown and to promote healing
- Enteral therapy or total parenteral nutrition (TPN) may be necessary due to
decreased gastrointestinal motility and increased caloric needs.
, Postpartum Disorders: Assessing for Uterine Atony
- If the pt. abdomen is distended and grossly palpable it is suggestive of uterine atony.
Sources of Nutrition: Teaching About Food Sources of Calcium
- 1. Cheese 2. Yogurt 3. Milk 4. Sardines 5. Dark leafy greens like spinach, kale, turnips,
and collard greens 6. Fortified cereals such as Total, Raisin Bran, Corn Flakes (They have
a lot of calcium in one serving.) 7. Fortified orange juice 8. Soybeans
9. Enriched breads, grains, and waffles.
Substance Use and Addictive Disorders: Identifying Manifestations of Opioid Withdrawal –
- Agitation, insomnia, flulike symptoms, rhinorrhea, yawning, sweating, diarrhea .
Manifestations are non- life threatening however suicidal ideation may occur.
Postpartum Physiological Adaptations: Interventions to Promote Voiding
- Running water in room
- Warm cloth on lower abdomen
- Bladder training
- Offer fluids before voiding
Benign Prostatic Hyperplasia, Erectile Dysfunction, and Prostatitis: Identifying
Medication Interactions With Saw Palmetto
- Saw Palmetto medication interactions – Estrogen, birth control , anticoagulant.
(naproxen, NSAID, Heparin, Warfarin)
Medications for Depressive Disorders: Food and Medication Interaction
- MAOI (zines) & Tyramines (salami, aged cheese, sourcrout, beers) can not be mixed
together.
- SSRI – no st.johns wart, don’t take anything that boost serotonin
- Atypical , Tricyclic - no MAOI
- Suction 10-15 seconds maximum
- Wait one minute in-between
- When using suction catheter it shouldn’t exceed half of the internal diameter of the et
tube to prevent hypoxia
- Hyperoxygenation
- Have extra tach kit at bedside
- Don’t untie trach collar before tying new ones.
Coordinating Client Care: Planning Care for a Client Following a Stroke
- Immediately obtain a CT – to determine type of stroke
- NPO until Swallow test by ST
- Ischemic : most common, results from a clot blocking or impairing blood flow....deprives
the brain of o2 and nutrients. Alteplase
- Hemorrhagic : increased icp decreased loc , leakage of blood in brain.
Multiple Sclerosis: Priority Referral for a Client Who Has Amyotrophic Lateral Sclerosis
- ALS is a disease of the upper and lower motor neurons characterized by muscle
weakness progressing to muscle atrophy and eventually paralysis and death.
ALS does not involve autonomic changes, sensory alterations, or cognitive
changes.
- Death usually occurs due to respiratory failure within 3 to 5 years of the initial
manifestations. The cause of ALS is unknown, and there is no cure.
- Maintain a patent airway, and suction and/or intubate as needed.
- Monitor ABGs, and administer oxygen, intermittent positive pressure ventilation,
bilevel positive airway pressure, or mechanical ventilation as needed.
- Keep the head of the bed at 45°; turn, cough, and deep breathe every 2 hr; and
conduct incentive spirometry/chest physiotherapy.
- Facilitate effective communication (dysarthria) with the use of a communication
board or a speech language therapist referral.
- Assess coping and depression.
- Assess swallow reflex and ensure safety with oral intake. Thicken fluids as
needed.
- Meet nutritional needs for calories, fiber, and fluids. When no longer able to
swallow, provide enteral nutrition as prescribed.
- Use energy conservation measures.
- Address the client's interest in the establishment of advance directives/living
wills.
- PRIORITY RT,PT,OT
,Practice Settings and Nursing Roles in the Community: Identifying the Sequence of Steps
Required for a Home Visit
1. Pre planning – review referral, call pt, plan activities, bring forms, stock bags
2. Initiation- confirm visit, state name hospital that inhibit referral, establish rapport
3. Implementation- vitals, assessment, teaching, hazards, confront client problem
4. Termination – leave contact info, made contract, plan second visit, charting, plan next
5. Post home visit- leave, consult / collab with I team, make referral for family, stay
connected, document.
Legal and Ethical Issues: Caring for a Client Who Is Experiencing Acute Mania and Is in
Restraints
- explain reason/use to family and patient
- assess q2 and check vitals, offer food/fluid, toilet, ROM (offer q 15-30 min)
- pad bony prominences
- use quick-release knot
- must fit 1-2 fingers between body and restraint
- conduct eval and regularly determine if the restraint use needs to continue or if it
can be stopped
-provider must assess the patient within one hour of application
Mobility and Immobility: Evaluating Client Understanding of Crutch Safety
- Begin your step as if you were going to use the injured foot or leg, but shift your
weight to the crutches instead of the injured foot. Your body swings forward
between the crutches. Finish the step normally with your non-injured leg. When
the non-injured leg is on the ground, move your crutches ahead in preparation for
the next step.
- Up with the good, down with the bad food first.
Crutch Instructions
Do not alter crutch after fitting, Follow the Prescribes crutch gait.
Support bodyweight at the hand grips with elbows, Flexed at 20 degree to 30
degree.
Hold the crutches in one hand and grasp the arms of the chair with the hand
for balance while sitting and rising from a chair
The tripod position is the basic crutch stance, The client should place the
crutches 15 cm(6inches) in front of the 15 cm (6 in) to the side of each foot to
provided a wide base of support
Crutch gait: Client alternates weight from one leg to the other as well as on
the crutches
The clients should stand with a straight back, hips, head and neck and should
not place any weight on the axillae
Cane Instructions
, Maintain two points of support on the ground at all times
Keep the cane on the stronger side of the body
Support body weight on both legs
Move the cane forward 15 to 25 cm ( 6 to 10 inches)
Next, move the weaker leg forward toward the cane
Finally, advance the stronger leg past the cane
Musculoskeletal Trauma: Discharge Teaching Following Surgery for Carpal Tunnel Syndrome
- Cant remove wrist band, must have provider order
- warn the patient that it may take up to 4 weeks after surgery to regain full strength to
accomplish tasks.
- Refer to PT / OT
- Cover surgical incision when showering
- Don’t use ointments
- Don’t rub skin
- Ice therapy may be used
Nursing Care and Discharge Teaching: Teaching About Newborn Safety
- Car seat safety : -position newborn rear-facing until 2 years of age
-secure the car seat with the vehicle seat belt
-place the car seat at a 45 degree angle to prevent slumping and subsequent airway
obstruction in the newborn
-retainer clip should be at armpit level
- Crib slats should be no more than 2 and 1/4 in. apart
- Infants should be back to sleep , supine
- Sleep with pacifier to prevent sids.
- Infants should consume 1 to 2 ounces ever 2 – 3 hrs. 8-12 times a day
- 6-8 wet diapers a day
- Bathe clean to dirty, cover body parts not being bathed
Burns: Priority Action to Reduce the Risk of Infection
- The client may need 5,000 calories per day.
- Increase caloric intake to meet increased metabolic demands and prevent hypoglycemia.
- Increase protein intake to prevent tissue breakdown and to promote healing
- Enteral therapy or total parenteral nutrition (TPN) may be necessary due to
decreased gastrointestinal motility and increased caloric needs.
, Postpartum Disorders: Assessing for Uterine Atony
- If the pt. abdomen is distended and grossly palpable it is suggestive of uterine atony.
Sources of Nutrition: Teaching About Food Sources of Calcium
- 1. Cheese 2. Yogurt 3. Milk 4. Sardines 5. Dark leafy greens like spinach, kale, turnips,
and collard greens 6. Fortified cereals such as Total, Raisin Bran, Corn Flakes (They have
a lot of calcium in one serving.) 7. Fortified orange juice 8. Soybeans
9. Enriched breads, grains, and waffles.
Substance Use and Addictive Disorders: Identifying Manifestations of Opioid Withdrawal –
- Agitation, insomnia, flulike symptoms, rhinorrhea, yawning, sweating, diarrhea .
Manifestations are non- life threatening however suicidal ideation may occur.
Postpartum Physiological Adaptations: Interventions to Promote Voiding
- Running water in room
- Warm cloth on lower abdomen
- Bladder training
- Offer fluids before voiding
Benign Prostatic Hyperplasia, Erectile Dysfunction, and Prostatitis: Identifying
Medication Interactions With Saw Palmetto
- Saw Palmetto medication interactions – Estrogen, birth control , anticoagulant.
(naproxen, NSAID, Heparin, Warfarin)
Medications for Depressive Disorders: Food and Medication Interaction
- MAOI (zines) & Tyramines (salami, aged cheese, sourcrout, beers) can not be mixed
together.
- SSRI – no st.johns wart, don’t take anything that boost serotonin
- Atypical , Tricyclic - no MAOI
