monitor for bleeding and nasal drainage for possible CSF leak (assess drainage for glucose or halo sign); assess neurological condition every hour for first 24h and every 4h after
NI for preventing delays in healing
encourage an intake of 2-3L of fluid/d, increase protein, keep serum albumin levels above 3.5
meds for sinus tachy
amiodarone, adenosine, and verapmil; synchronized cardioversion
chest pressure/pain, friction rub, SOB, pain releived when sitting and leaning foward
Fasting blood glucose
post pone admin of antidiabetic med until after elvels are drawn; ensure pt has fasted for 8hr prior to blood draw
Oral glucose tolerance test
fasting blood glucose level drawn at start then pt consumes a specified amount of glucose. Blood glucose levels drawn every 30m for 2hrs; instruct cleint to consume balanced diet for 3d prior then fast 10-12hr
Glycosylate hemoglobin
best indicator for average blood glucose level for the past 120d; normal range is 4-6%, diabetic range is 6.5-8%
Evaluating proper placement of NG tube
aspirate gnet to collect gastric contents and test pH (4 or less), x-ray; injecing air into tube to listen over abdomen is NOT an acceptable practice
IV urography
used to detect obstrction, assess for a parenchymall mass, and assess size of kidney
before an IV urography procedure the nurse should check if the pt is
allergic to iodine and check creatinine levels b/c dye can cause renal failure
Complications of chest tube insertion
air leaks - monitor the water seal chamber for continuous bubbling (air leak); tension pneumothorax - sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause this
gently wash skin over the irradiated area w/ mild soap and water, DON'T remove radiation tattoos, DON'T apply powders or lotions, wear soft clothing over irradiated area, avoid tight clothing, DON'T expose area to sun or heat
monitor fetal well-being, fetal consequences include miscarraige, preterm labor, and intrauterine growth restriction, obtain cultures, possible c section of lesions present during labor
4oz OF or 2 oz grape juice or 8 oz milk; recheck BG in 15m if still low (<70) give 15g more carbs, recheck BG in 15m, if w/n norm limits eat 1g protein (peanut butter, cheese)
NI for increased ICP
Keep HOP at 30 degrees, avoid extreme flexion, extension, or rotation of the head and maintain in midline neutral position; keep body aligned avoid hip flextion/extension; minimize endotracheal or oral suctioning; instruct pt to avoid coughing or blowing nose
S/S of bacterial vaginosis
vaginal oder, discharge, dysuria
NI for boggy uterus post partum
massage first then administer oxytocin
what acid-base imblances w/ a pt with chronic emphysema most likely have?
resp. acidosis and compensatory metabolic alkalosis
rename
hivacuwu's
version from
2015-06-24 16:38
