1.Interventions for wound disruption
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
2.Nursing interventio...
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VATI RN MED-SURG COMPRIHENSIVE
1.Interventions for wound disruption
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
2.Nursing interventions to prevent acute kidney disease
control diabetes and hypertension, all antibiotics, provide skin cares, cough and deep breathe if
lethargic
3.Recognizing Manifestations of Left-sided Heart Failure
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)
4.Teaching about foot care
-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
5.Manifestations of Peritonitis
fever, purulent drainage, redness, swelling, cloudy or discolored drained dialysate
6.Indications of glaucoma
loss of peripheral vision
halo around lights
7.Manifestations of Hypervolemia
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, tachycardia
bounding pulse
hypertension
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
8.Planning care for acute pancreatitis
No food until pain free
TPN if severe
provide insulin if needed
Iv fluids
antiemetic if needed
bland high protein diet small meals
9.using a Peak flow meter
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)
10.Assisting with placement of a central venous catheter
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
11.Identifying client at risk for metabolic alkalosis
-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
12.Respiratory/Metabolic Acidosis average number range...
Ph- less than 7.35
PACO2- greater than 35-45
hCO2- 22-26
13.Repiratory/Metabolic alkalosis average number range
ph- greater than 7.45
PACO2- less than 35 or 35-45
HCO2- 22-26 metabolic is greater than 26
14.Hypoventilation... resp/meta acid/alka
respiratory acidosis...
(increase in CO2)
15.Hyperventilation... resp/meta acid/alka
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