CARE OF CLIENTS TAKING ORAL ANTICOAGULANTS
1. Medicate same time every day
2. Wear medical identification jewelry: wearer takes anticoagulants
3. Use a soft toothbrush
4. Do not use a straight razor; use an electric razor
5. Avoid alcohol
6. Report any signs of bleeding, red or black bowel movements, headaches, rashes, red or pink-tinged urine, sputum
7. Avoid trauma Monitor levels of the anticoagulant in the blood
Saturday, December 26, 2009
Friday, December 25, 2009
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC COMA (HHNKC)
- potentially fatal
- findings
- severe hyperglycemia usually > 600 mg/dL
- plasma hyperosmolarity
- dehydration
- altered LOC - decreased
- absence of ketoacidosis
- usually precipitated by physical stress such as an infection
- in non-diabetics can be due to tube feedings without supplemental water, or too rapid rate of infusion for parenteral nutrition
- occurs more often in the elderly, typically
- expected: to correct fluid depletion, insulin deficiency, and electrolyte imbalance
- potentially fatal
- findings
- severe hyperglycemia usually > 600 mg/dL
- plasma hyperosmolarity
- dehydration
- altered LOC - decreased
- absence of ketoacidosis
- usually precipitated by physical stress such as an infection
- in non-diabetics can be due to tube feedings without supplemental water, or too rapid rate of infusion for parenteral nutrition
- occurs more often in the elderly, typically
- expected: to correct fluid depletion, insulin deficiency, and electrolyte imbalance
Diabetic Ketoacidosis (DKA)
DIABETIC KETOACIDOSIS (DKA) –an acute complication
results from severe insulin deficiency
findings
- blood sugar levels > 350 mg/dL
- elevated ketone levels: sweet odor to breath may also have odor of someone drinking alcohol
- metabolic acidosis: Kussmaul's respirations, flushed appearance, dry skin
- thirst
- polyuria
- drowsiness
- anorexia, vomiting
- may lead to shock and coma
results from severe insulin deficiency
findings
- blood sugar levels > 350 mg/dL
- elevated ketone levels: sweet odor to breath may also have odor of someone drinking alcohol
- metabolic acidosis: Kussmaul's respirations, flushed appearance, dry skin
- thirst
- polyuria
- drowsiness
- anorexia, vomiting
- may lead to shock and coma
Hypoglycemia
HYPOGYCEMIA (Insulin Shock)
blood sugar falls below 50 mg/dL
- caused by too much insulin, too little food, or excessive physical activity
- may result from delayed meals, exercise, or vomiting
- rapid onset
- findings of insulin shock
- diaphoresis; cold, clammy skin
- anxiety, tremor, slurred speech
- weakness
- nausea
- mental confusion, personality changes, altered LOC
- headache
management of hypoglycemia
- if client is conscious, give oral simple sugar: hard candy, honey, Karo syrup, jelly, cola, juice
- if unconscious: give one mg glucagon IM, IV or subcutaneous (subQ); or 20 to 50 mL 50% dextrose IV push
SEIZURE PRECAUTIONS
Before seizure
Bed rest with padded side rails
Suction available at the bedside
Oxygen available at bedside
During seizures
Loosen any tight or restrictive clothing.
If clients are falling, gently help them to the ground and position clients on their side.
Do not place anything in the mouth.
Observe the seizure as it runs its course.
If it lasts longer than 5 minutes, notify health care provider immediately.
Note the activity and the time it begun and ended.
Daily life precautions
For children discourage climbing over 10 feet high.
Recommend for clients not to lock bathroom or shower doors.
If swimming, clients are to have someone with them who can rescue.
If old enough to drive, clients should be seizure free for six months. The time may vary in some states.
Increased Intracranial Pressure (ICP)
CARE OF CLIENT WITH INCREASED INTRACRANIAL PRESSURE
1. Institute seizure precautions
2. Administer oxygen as ordered
3. Monitor for changes in intracranial pressure
4. Monitor neuro vital signs as ordered
5. Maintain fluid restriction as ordered
6. Observe for herniation syndrome
7. Raise head of bed at 30-45 degrees; avoid 90 degrees since pressure in hip area increases ICP
8. Prevent any activities that increase ICP such as: laughing, straining at stool, coughing, vomiting, any restrictive clothing around neck, anxiety, pushing up in bed with heels, pulling on rails when turning, neck rotation, flexion or extension
9. Provide for the care of the unconscious clients if decreased LOC
1. Institute seizure precautions
2. Administer oxygen as ordered
3. Monitor for changes in intracranial pressure
4. Monitor neuro vital signs as ordered
5. Maintain fluid restriction as ordered
6. Observe for herniation syndrome
7. Raise head of bed at 30-45 degrees; avoid 90 degrees since pressure in hip area increases ICP
8. Prevent any activities that increase ICP such as: laughing, straining at stool, coughing, vomiting, any restrictive clothing around neck, anxiety, pushing up in bed with heels, pulling on rails when turning, neck rotation, flexion or extension
9. Provide for the care of the unconscious clients if decreased LOC
SUICIDE PRECAUTIONS
1. Remove all harmful objects from the environment
2. One to one monitoring of the client day and night, having the client in view at all times even during toileting, gradually progress to 15 minute and then hourly checks
3. Ask client exactly how she/he would commit suicide. Assess how lethal the attempt would be, and how quickly it could be carried out.
4. Keep client within one arm's length distance or less at all times
5. Use plastic utensils
6. Keep electrical cords to a minimum length
7. Take all potentially harmful gifts from visitors
8. Keep all windows locked and if possible keep client in room with unbreakable glass in windows
9. Do not assign a private room
1. Remove all harmful objects from the environment
2. One to one monitoring of the client day and night, having the client in view at all times even during toileting, gradually progress to 15 minute and then hourly checks
3. Ask client exactly how she/he would commit suicide. Assess how lethal the attempt would be, and how quickly it could be carried out.
4. Keep client within one arm's length distance or less at all times
5. Use plastic utensils
6. Keep electrical cords to a minimum length
7. Take all potentially harmful gifts from visitors
8. Keep all windows locked and if possible keep client in room with unbreakable glass in windows
9. Do not assign a private room
Therapeutic Communication Techniques
THERAPEUTIC COMMUNICATION TECHNIQUES
Not Necessarily Verbal
1. Acceptance - Recognizing the other person without inserting your own values or judgments. May be verbal or nonverbal; with or without understanding
2. Listening - Consciously receiving the client's message. Includes listening actively, responsibly, and seriously
3. Empathy - Experiencing another's feeling temporarily; truly being with and understanding another through active listening
4. Silence - Suspending talk for a therapeutic reason
5. Neutral response - Showing interest and involvement without saying anything else
6. Eye contact - As appropriate to the client's culture
Verbal
1. Self-disclosure - Sharing personal information at an opportune moment to convey understanding or to role model behavior
2. Clarification - Putting into words vague ideas or unclear thoughts of the client. Purpose is to help nurse understand, or invite the client to explain
3. Restating - Repeating to the client the main thought he has expressed to indicate the nurse is listening and interested. May encourage the client to elaborate
4. Refocusing - Picking up on central topics or "cues" given by the client
5. Open-ended questions - Asking questions that cannot be answered "yes" or "no." Used to broaden conversational opportunities and to enable the client to communicate.
6. Incomplete sentences - Encouraging the client to continue with phrases such as "Go on…"
Focusing - Helping the client to explore a specific topic
Not Necessarily Verbal
1. Acceptance - Recognizing the other person without inserting your own values or judgments. May be verbal or nonverbal; with or without understanding
2. Listening - Consciously receiving the client's message. Includes listening actively, responsibly, and seriously
3. Empathy - Experiencing another's feeling temporarily; truly being with and understanding another through active listening
4. Silence - Suspending talk for a therapeutic reason
5. Neutral response - Showing interest and involvement without saying anything else
6. Eye contact - As appropriate to the client's culture
Verbal
1. Self-disclosure - Sharing personal information at an opportune moment to convey understanding or to role model behavior
2. Clarification - Putting into words vague ideas or unclear thoughts of the client. Purpose is to help nurse understand, or invite the client to explain
3. Restating - Repeating to the client the main thought he has expressed to indicate the nurse is listening and interested. May encourage the client to elaborate
4. Refocusing - Picking up on central topics or "cues" given by the client
5. Open-ended questions - Asking questions that cannot be answered "yes" or "no." Used to broaden conversational opportunities and to enable the client to communicate.
6. Incomplete sentences - Encouraging the client to continue with phrases such as "Go on…"
Focusing - Helping the client to explore a specific topic
Ineffective Communication Techniques
NINE INEFFECTIVE COMMUNICATION TECHNIQUES
1. Giving advice - Telling the client what to do. Giving an opinion or making decisions for the client. Implies the client cannot handle life decisions and that the nurse is accepting responsibility for client.
2. False reassurance - Using clichés, pat answers, cheery words and comforting statements as an attempt to reassure client.
3. Changing the Subject - Introducing new topics inappropriately. May result from poor listening skills
4. Social Response - Responding in a way that either focuses attention on the nurse instead of the client, or is not goal-directed on behalf of the client.
5. Invalidation - Ignoring or denying the client's thoughts or feelings.
6. Overloading - Talking rapidly, changing subjects or asking for more information than can be absorbed at one time; for example, asking two questions at once.
7. Underloading - Remaining silent and unresponsive, not picking up cues and failing to give feedback.
8. Incongruence - Sending verbal and nonverbal messages that contradict one another; often called a double message.
9. Value Judgments - Giving one's own opinion, evaluating , moralizing or implying one's own values by using words such as "should," "ought," "good," or "bad."
1. Giving advice - Telling the client what to do. Giving an opinion or making decisions for the client. Implies the client cannot handle life decisions and that the nurse is accepting responsibility for client.
2. False reassurance - Using clichés, pat answers, cheery words and comforting statements as an attempt to reassure client.
3. Changing the Subject - Introducing new topics inappropriately. May result from poor listening skills
4. Social Response - Responding in a way that either focuses attention on the nurse instead of the client, or is not goal-directed on behalf of the client.
5. Invalidation - Ignoring or denying the client's thoughts or feelings.
6. Overloading - Talking rapidly, changing subjects or asking for more information than can be absorbed at one time; for example, asking two questions at once.
7. Underloading - Remaining silent and unresponsive, not picking up cues and failing to give feedback.
8. Incongruence - Sending verbal and nonverbal messages that contradict one another; often called a double message.
9. Value Judgments - Giving one's own opinion, evaluating , moralizing or implying one's own values by using words such as "should," "ought," "good," or "bad."
Reflexes Test
TESTS FOR REFLEXES
- Deep tendon reflexes with selected site stimulus
- Biceps reflex (C5, C6): flexion of arm at elbow
- Triceps reflex (C6, C7): extension of arm at elbow and contraction of triceps muscles
- Brachioradialis (supinator) reflex (C5, C6): flexion at elbow and pronation of forearm
- Quadriceps (knee-jerk or patellar) reflex (L2, L3, L4): extension of leg at knee and contraction of quadriceps
- Achilles (ankle-jerk) reflex (S1, S2)
- Superficial reflexes
- Pharyngeal reflex (CN IX, CN X)
- Upper Abdominal reflex (T8, T9, T10): upward movement of umbilicus toward stimulus above umbilicus
- Lower Abdominal reflex (T10,T11,T12): downward movement of umbilicus toward stimulus below umbilicus
- Cremasteric reflex (T12, L1) Elevation of ipsilateral testicle (the side stimulated)
- Gluteal reflex (L4-S3): contraction of anal sphincter with gloved finger insertion
- Pathologic reflexes in adults - documented as "positive for ___"
- Babinski reflex (Plantar) (L4-S2): stroking lateral sole of foot causes dorsiflexion of great toe with fanning of other toes (normal expectation in children up to age 18 months on the average)
- Chaddock reflex (L4-S2): stroking below lateral malleolus causes dorsiflexion of great toe with fanning of other toes
- Ankle Clonus: Brisk dorsiflexion of foot with knee flexed causes up and down movement of foot; found in severe preeclampsia
- Oppenheim: stroking tibial surface causes great toe fans out
- Gordon: squeezing calf muscle; great toe fans out
- Hoffmann: flicking middle finger down; flexion of the thumb
- Common expected reflexes - normal for all ages
- Gag
- Corneal
Cerebellar Function
CEREBELLAR FUNCTION
Romberg test: tests position sense, note client's ability to stand upright when standing with feet together and eyes closed for 20-30 seconds
Hop in place: maintains balance while hopping on one foot
Knee bends: maintains balance while bending at knees
Tandem walking: walks heel to toe in straight line
Rapid skills:
Pronates and supinates hands rapidly with equal timing and purposeful movement
Touches alternate finger to nose rhythmically with eyes open and closed
Moves finger alternately from nose to examiner's finger in coordinated fashion
Runs contralateral heel down shin with bilateral coordination
One-foot balance
Maintains balance on one foot for at least five seconds
Bilateral response with eyes open and closed
Romberg test: tests position sense, note client's ability to stand upright when standing with feet together and eyes closed for 20-30 seconds
Hop in place: maintains balance while hopping on one foot
Knee bends: maintains balance while bending at knees
Tandem walking: walks heel to toe in straight line
Rapid skills:
Pronates and supinates hands rapidly with equal timing and purposeful movement
Touches alternate finger to nose rhythmically with eyes open and closed
Moves finger alternately from nose to examiner's finger in coordinated fashion
Runs contralateral heel down shin with bilateral coordination
One-foot balance
Maintains balance on one foot for at least five seconds
Bilateral response with eyes open and closed
Sensory Nerve Function Assessment
ASSESSMENT OF SENSORY NERVE FUNCTION(done with client's eyes closed)
Superficial pain
Prick with sterile needle
Have client identify whether sharp or dull
Temperature
Two test tubes: one filled with hot water, the other with cold water
Client identifies hot versus cold sensation and where it is felt
Light touch
Cotton ball; apply light wisp of cotton to different surface points;
Client identifies when touched
Vibration
Low pitched tuning fork
Apply to distal interphalangeal joint of finger then toe,
Client identifies when vibration stops
Position
Grasp client's finger or great toe, holding by its sides
Client identifies if moving up or down
Two-point discrimination
Two safety pins
Apply lightly and simultaneously to two different places on skin's surface.
Usually start with finger pads,
Find minimal distance at which client can discriminate one from two points, normally <5mm on finger pads;
Client identifies when can discriminate one from two points
Stereognosis
Use coin or paper clip or any familiar object with client's eyes closed
Client identifies object to identify by touch and manipulation
Graphesthesia (number identification)
Number is traced on the client's palm by a blunt object
Client identifies number
Extinction
Corresponding areas on both sides of body are simultaneously stimulated
Client identifies where touched
Superficial pain
Prick with sterile needle
Have client identify whether sharp or dull
Temperature
Two test tubes: one filled with hot water, the other with cold water
Client identifies hot versus cold sensation and where it is felt
Light touch
Cotton ball; apply light wisp of cotton to different surface points;
Client identifies when touched
Vibration
Low pitched tuning fork
Apply to distal interphalangeal joint of finger then toe,
Client identifies when vibration stops
Position
Grasp client's finger or great toe, holding by its sides
Client identifies if moving up or down
Two-point discrimination
Two safety pins
Apply lightly and simultaneously to two different places on skin's surface.
Usually start with finger pads,
Find minimal distance at which client can discriminate one from two points, normally <5mm on finger pads;
Client identifies when can discriminate one from two points
Stereognosis
Use coin or paper clip or any familiar object with client's eyes closed
Client identifies object to identify by touch and manipulation
Graphesthesia (number identification)
Number is traced on the client's palm by a blunt object
Client identifies number
Extinction
Corresponding areas on both sides of body are simultaneously stimulated
Client identifies where touched
Alteration in Level of Consciousness
ALTERATIONS IN LEVEL OF CONSCIOUSNESS
Alert
Awake and aware of person, place, time, and situation
Responds appropriately and to verbal stimuli
Lethargic
Sleeps but easily aroused
Speaks and responds slowly and appropriately
Obtunded
Difficult to arouse
Returns to sleep quickly; may respond inappropriately
Stuporous
Aroused only through pain
No verbal response
Semicomatose
Responds only to pain
Gag and blink reflexes intact
Comatose
No response to pain
No reflexes or muscle tone Note: dying clients will proceed through these levels in this above-listed sequence
Alert
Awake and aware of person, place, time, and situation
Responds appropriately and to verbal stimuli
Lethargic
Sleeps but easily aroused
Speaks and responds slowly and appropriately
Obtunded
Difficult to arouse
Returns to sleep quickly; may respond inappropriately
Stuporous
Aroused only through pain
No verbal response
Semicomatose
Responds only to pain
Gag and blink reflexes intact
Comatose
No response to pain
No reflexes or muscle tone Note: dying clients will proceed through these levels in this above-listed sequence
Lung Sounds - Adventitious
Adventitious Lung Sounds
• Crackles or Rales
1. Discontinuous crackling sounds created by air moving through fluid / mucous filled alveoli or bronchioles
2. Exaggerated with deep breath
3. Do not clear with coughing
4. Sign of inflammation with fluid / mucous
• Rhonchi
1. Low-pitched, coarse, rumbling sounds caused by air moving past secretions in larger airways, larger bronchioles
2. Sign of secretions
• Wheezes
1. Musical, continuous sounds; usually expected to be expiratory with COPD
2. Caused by air passing through narrowed airways, usually bronchioles
3. The higher the pitch, the narrower the airway
4. Inspiratory wheezes are more critical than expiratory
• Stridor
1. Primarily an inspiratory sound
2. Indicates partial obstruction of larynx or trachea, often from a spasm
3. Is a medical emergency
• Crackles or Rales
1. Discontinuous crackling sounds created by air moving through fluid / mucous filled alveoli or bronchioles
2. Exaggerated with deep breath
3. Do not clear with coughing
4. Sign of inflammation with fluid / mucous
• Rhonchi
1. Low-pitched, coarse, rumbling sounds caused by air moving past secretions in larger airways, larger bronchioles
2. Sign of secretions
• Wheezes
1. Musical, continuous sounds; usually expected to be expiratory with COPD
2. Caused by air passing through narrowed airways, usually bronchioles
3. The higher the pitch, the narrower the airway
4. Inspiratory wheezes are more critical than expiratory
• Stridor
1. Primarily an inspiratory sound
2. Indicates partial obstruction of larynx or trachea, often from a spasm
3. Is a medical emergency
Arterial and Venous Insufficiency
SIGNS OF ARTERIAL INSUFFICIENCY IN THE EXTREMITIES
1. Pale color on elevation, dusky red color when lowered
2. Cool to touch
3. Decreased or absent peripheral pulses
4. Little or no edema
5. Thin, shiny skin and decreased growth of hair
6. Thickened nails
7. Pain unrelieved by rest and/or activity
8. Chronic pain may be either steady or intermittent
9. Claudication pain as tight feeling, burning, fatigue, ache or cramping
SIGNS OF VENOUS INSUFFICIENCY IN THE EXTREMITIES
1. Skin color reddish brown or cyanotic if extremity lowered
2. Normal temperature
3. Normal pulse
4. Often marked edema, usually foot to calf
5. Brown pigmentation around ankles
1. Pale color on elevation, dusky red color when lowered
2. Cool to touch
3. Decreased or absent peripheral pulses
4. Little or no edema
5. Thin, shiny skin and decreased growth of hair
6. Thickened nails
7. Pain unrelieved by rest and/or activity
8. Chronic pain may be either steady or intermittent
9. Claudication pain as tight feeling, burning, fatigue, ache or cramping
SIGNS OF VENOUS INSUFFICIENCY IN THE EXTREMITIES
1. Skin color reddish brown or cyanotic if extremity lowered
2. Normal temperature
3. Normal pulse
4. Often marked edema, usually foot to calf
5. Brown pigmentation around ankles
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