Nursing Blog

Nanda Ineffective Airway Clearance Definition: Inability to clear secretions or obstructions from the respiratory tract to maintaina clear airway RELATED FACTORS Environmental Smoking; secondhand smoke; smoke inhalation Obstructed airway Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial airway Physiological Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the bronchial walls Neuromuscular dysfunction Infection DEFINING CHARACTERISTICS Subjective Dyspnea Objective Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes] Cough, ineffective/absent; excessive sputum Changes in respiratory rate and rhythm Difficulty vocalizing Wide-eyed; restlessness Orthopnea Cyanosis Sample Clinical Applications: COPD, pneumonia, influenza, acute respiratory distress syndrome (ARDS), cancer of lung/head and neck, congestive heart failure (CHF), cystic f

Actions/Interventions NURSING PRIORITY NO. 1. To identify causative/contributing factors: Review daily dietary regimen. Note oral/dental health that can impact intake. Determine fluid intake, to note deficits. Evaluate medication/drug usage and note interactions or side effects (e.g., narcotics, antacids, chemotherapy, iron, contrast media such as barium, steroids). Note energy/activity level and exercise pattern. Identify areas of stress (e.g., personal relationships, occupational factors, financial problems). Determine access to bathroom, privacy, and ability to perform self-care activities. Investigate reports of pain with defecation. Inspect perianal area for hemorrhoids, fissures, skin breakdown, or other abnormal findings. Discuss laxative/enema use. Note signs/reports of laxative abuse. Review medical/surgical history (e.g., metabolic or endocrine disorders, pregnancy, prior surgery, megacolon). Palpate abdomen for presence of distention, masses. Check for presence of fecal impa

Standard Precautions - Infection Control Standard precautions were developed by the Centers for Disease Control and Prevention (CDC) to provide the widest possible protection against the transmission of infection. CDC officials recommend that health care workers handle all blood, body fluids (including secretions, excretions, and drainage), tissues, and contact with mucous membranes and broken skin as if they contain infectious agents, regardless of the patient's diagnosis. Standard precautions encompass much of the isolation precautions previously recommended by the CDC for patients with known or suspected blood-borne pathogens as well as the precautions previously known as body substance isolation. They are to be used in conjunction with other transmission-based precautions: airborne, droplet, and contact precautions. Standard precautions recommend wearing gloves for any known or anticipated contact with blood, body fluids, tissue, mucous membrane, and nonintact skin. (See Choosi

Nurses are assigned jobs that tackle any issues in patient care, ranging from surgery assistance to basic health care, to managing and maintaining charts and lab work. Despite all the responsibilities they are saddled with, they still must make time to develop their nursing care plans for many of their regular patients, especially in hospital settings. Nursing care plans serve a vital function in most hospitals and several clinics because they indicate to other nurses and doctors what type of diet patients are on, as well as any specific medical needs that the patient requires. Without such communication to night nurses or doctors, patients run the risk of being given medicine or food they are allergic to, or even missing a meal. Nursing care plans are relatively easy to create once you know the background of the patient. Spending some time with the patient additionally helps add to the nursing care plan; for example, if your patient is a particularly finicky eater, you can include thi

This phase of care begins when the patient arrives in the postanesthesia care unit (PACU) and continues as he moves on to the short procedure unit, medical-surgical unit, or intensive care unit. Postoperative care aims to minimize postoperative complications by early detection and prompt treatment. After anesthesia a patient may experience pain, inadequate oxygenation, or adverse physiologic effects of sudden movement. Recovery from general anesthesia takes longer than induction because the anesthetic is retained in fat and muscle. P.106 Fat has a meager blood supply; thus, it releases the anesthetic slowly, providing enough anesthesia to maintain adequate blood and brain levels during surgery. The patient's recovery time varies with his amount of body fat, his overall condition, his premedication regimen, and the type, dosage, and duration of anesthesia. Equipment Thermometer • watch with second hand • stethoscope • sphygmomanometer • postoperative flowchart or other docum

Nurses value health promotion and well-being and assisting persons to achieve their optimum level of health in situations of normal health, illness, injury, disability or at the end of life. 1. Nurses must provide care directed first and foremost toward the health and well-being of the person, family or community in their care. 2. Nurses must recognize that health is more than the absence of disease or infirmity and must work in partnership with people to achieve their goals of maximum health and well-being. 3. Nurses should provide care addressing the well-being of the person in the context of that person’s relationships with their family and community. 4. Nurses must foster comfort and well-being when persons are terminally ill and dying to alleviate suffering and support a dignified and peaceful death. 5. Nurses should provide the best care that circumstances permit even when the need arises in an emergency outside an employment situation. 6. Nurses should respect and value the know

Used to move the patient's joints through as full a range of motion (ROM) as possible, passive ROM exercises improve or maintain joint mobility and help prevent contractures. Performed by a nurse, a physical therapist, or a caregiver of the patient's choosing, these exercises are indicated for the patient with temporary or permanent loss of mobility, sensation, or consciousness. Performed properly, passive ROM exercises require recognition of the patient's limits of motion and support of all joints during movement. Passive ROM exercises are contraindicated in patients with septic joints, acute thrombophlebitis, severe arthritic P.45 joint inflammation, or recent trauma with possible hidden fractures or internal injuries. Implementation Determine the joints that need ROM exercises, and consult the physician or physical therapist about limitations or precautions for specific exercises. The exercises below treat all joints, but they don't have to be performed in the order

Dangling legs To help the patient support himself in a dangling position, move an overbed table in front of him and place a pillow on it. Sitting Seat the patient in a chair with armrests and a straight back, with his lower back against the rear of the chair, feet flat on the floor, hips and knees at right angles, and upper body straight. Rest his forearms on the armrests. Walking Provide a path unimpeded by equipment and other objects, and avoid overexertion. If necessary, hold the patient so you can control his upper and lower body and any lateral movements.

A complete bed bath cleans the skin, stimulates circulation, provides mild exercise, and promotes comfort. Bathing also allows assessment of skin condition, joint mobility, and muscle strength. Depending on the patient's overall condition and duration of hospitalization, he may have a complete or partial bath daily. A partial bath—including hands, face, axillae, back, genitalia, and anal region—can replace the complete bath for the patient with dry, fragile skin or extreme weakness, and can supplement the complete bath for the diaphoretic or incontinent patient. Equipment Bath basin • bath blanket • soap • towel • washcloth • skin lotion • orangewood stick • gloves • deodorant • optional: bath oil, perineal pad, abdominal (ABD) pad, linen-saver pad. Preparation of equipment Adjust the temperature of the patient's room, and close any doors or windows to prevent drafts. Determine the patient's preference for soap or other hygiene aids because some patien

CCRN - Practice Questions - Self-assessment modules - Circulation 1. Blood flowing into the cardiac veins enters the _______ next. A. Coronary Sinus B. Left Ventricle C. Right Ventricle D. Left Atrium 2. The right coronary artery divides to form the posterior interventricular artery and the ___ artery. A. Marginal B. LVC C. RVC D. LAD 3. Prothrombin is a ____ globulin and is produced by the _____. A. Alpha, Kidney B. Alpha, Liver C. Beta, Kidney D. Beta, Liver 4. The innermost layer of a blood vessel is lined with _______ ______ cells A. Simple squamous B. Stratified squamous C. Simple cuboidal epithelium D. Stratified cuboidal epithelium 5. Which of the following occurs during ventricular systole? A. Increased aortic pressure B. Increased ventricular volume C. Dup heart sound D. P wave 6. Which of the following occurs during ventricular diastole? A. Increased aortic pressure B. Increased ventricular volume C. Lub heart sound D. T wave 7. If you are using a stethoscope and trying to de

Preparation of a surgical bed permits easy patient transfer from surgery and promotes cleanliness and comfort. To make such a bed, take the following steps: Assemble linens as you would for making an unoccupied bed, including two clean sheets (one fitted, if available), a drawsheet, a bath blanket, a spread or sheet, a pillowcase, facial tissues, a trash bag, and linen-saver pads. Raise the bed to a comfortable working height to prevent back strain. Slip the pillow into a clean pillowcase and place it on a nearby table or chair. Make the foundation of the bed using the bottom sheet and drawsheet. Place an open bath blanket about 15″ (38 cm) from the head of the bed, with its center fold positioned in the middle of the bed. The blanket warms the patient and counteracts the decreased body temperature caused by anesthesia. Place a top sheet or spread on the bath blanket, and position it as you did the blanket. Then fold the blanket and sheet back from the top so that the blanket shows o