GI Diagnostics Procedure: Plan of Care for a Client Who Has Gastroenteritis (Ch.46)
A positive finding for clostridium difficile is indicative of this opportunistic
infection, which usually becomes established secondary to use of broad-spectrum
antibiotics.
Medications: Some medications...
GI Diagnostics Procedure: Plan of Care for a Client Who Has Gastroenteritis (Ch.46)
A positive finding for clostridium difficile is indicative of this opportunistic
infection, which usually becomes established secondary to use of broad-spectrum
antibiotics.
Medications: Some medications ( NSAIDs, warfarin, aspirin) place the client at
risk for complications. Notify the provider if medication restrictions were not
followed.
Blood Test: Interpretations of Findings
o Aspartate aminotransferase/ Alanine Aminotransferase: Elevation
occurs with hepatitis or cirrhosis.
o Alkaline Phosphatase- Elevation indicates liver damage
o Amylase/ Lipase- Elevation occurs with pancreatitis
o Total Bilirubin- Elevation indicate altered liver function, bile duct
obstruction, or other hepatobiliary disorder.
o Albumin- Decrease can indicate hepatic disease.
o Alpha-fetoprotein- Elevated in liver cancer, cirrhosis and hepatitis.
o Ammonia- Elevated in liver disease.
Tuberculosis: Appropriate Interventions for a Client Who Has Tuberculosis(Ch.23)
TB diagnosis should be considered for any client who has a persistent cough,
chest pain, weakness, weight loss, anorexia, hemoptysis, dyspnea, fever, night
sweats, or chills.
Mantoux Test
o An intradermal injection of an extract of the tubercle bacillus is made.
o A positive Mantoux test indicates that the client has developed an
immune response to TB.
o Individuals who have latent TB can retain positive MT test and can
receive treatment.
Educate the client and family to continue medication therapy for its full
duration of 6 to 12 months, even up to 2 years for multi-drug resistant TB.
Airborne precautions are NOT needed in the home setting because family
members have already been exposed.
Medical and Surgical Asepsis: Maintaining a Sterile Field ( Ch. 10)
The outer wrapping and 1-inch edge of packaging that contains sterile items
are not sterile.
The inner surface of the sterile drape or kit, except for that 1-inch border
around the edge the sterile field to which other sterile items may be added.
Consider any object held below the waist or above the chest contaminated.
Grasp the tip of the top flap of the package, and with arm positioned away
from the sterile field, unfold the top flap away from the body.
o Next, open the side flaps, using the right hand for the right flap and
the left hand for the left flap.
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, o Grasp the last flap and turn it down toward the body.
Diagnostic and Therapeutic Procedures for Female Reproductive Disorders: Client
Teaching about Genital Herpes ( Ch. 62)
Diagnosis of genital herpes can be based on the client history and physical.
Laboratory test
o Herpes viral culture: fluid from a lesion is obtained using a swab and
placed in a cup for culture.
o Polymerase chain reaction: identifies genetic material of the virus.
Cells from a lesion, blood, or other body fluids can be tested.
o Antibody test: blood is tested for antibodies to the virus.
HerpeSelect Immunoblot, HerpeSelect ELISA, Western Blot
Postoperative Nursing Care : Preventing Complications (Ch.96)
Report a blood pressure difference of 25% from baseline, a drop to 15 to 20
mmH in diastolic or systolic pressures, or a trending decrease in diastolic or
systolic pressures by 5 mmHg at each 15 minute sign assessment.
Extubating of endotracheal tube is based on client’s response to commands,
ability to elevate head and use of thoracic breathing.
If the client responds to verbal stimuli, gradually elevate the head of the bed to
semi-fowlers position, if not contraindicated, to facilitate chest expansion.
Stroke: Caring for a Client Who has Left-sided Hemiplegia(Ch.15)
Left sided hemiplegia
o Right extremity hemiplegia (paralysis) or hemiparesis (weakness)
o Visual changes, such as hemianopsia (loss of visual field in one or
both eyes).
Right sided hemiplegia
o Unilateral neglect syndrome: ignore left side of the body: cannot see,
feel or move affected side, so client unaware of its existence). Can
occur when left hemispheric strokes, but is more common with right
hemispheric strokes.
o Left hemiplegia or hemiparesis
o Poor impulse control and judgement
Polycystic Kidney Disease, AKI and CKI: Dietary Recommendations for a Client who Has
Nephrotic Syndrome (Ch. 59)
Restrict dietary sodium, potassium, phosphorous and magnesium.
Provide a diet that is high in carbohydrates and moderate in fat.
Restrict intake of fluids (based on urinary output).
Instruct the client to monitor the daily intake of carbohydrates, proteins,
sodium, and potassium according to the providers prescription.
Instruct the client to avoid antacids containing magnesium.
Antibiotics Affecting the Bacterial Cell Wall: Manifestations to Report to the Provider
(Pharm Ch.44)
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