Content Area: Management of Care Topic: Findings following a total laryngectomy 1. Airway obstruction, swelling or spasm of the larynx or trachea, mucus in the airway, or relaxation of the tongue into the nasopharynx can cause airway obstruction often manifesting as stridor or snoring notify anesthesiologist 2. Provide humidifies oxygen, elevate HOB, perform head tilt/ chin lift maneuver to open airway 3. Plan for reintubation of endotracheal tube. Content Area: Safety & Infection Control Topic: Planning care to prevent infection for burns 1. Remove clothing or jewelry that might conduct heat 2. Apply cool water soaks or run cool water over injuries, do not use ice 3. Flush chemical burns with a large volume of water Topic: Interventions for a client who has neutropenia 1. Keep dedicated equipment in the clients room 2. Assign the client a private room 3. Avoid crowds and fresh fruits or veggies Topic: HIV/AIDS Teaching Home Care 1. Avoid crowded areas or traveling to countries with poor sanitation 2. Avoid raw foods (fruits, vegetables) and undercooked foods 3. Bathe daily using antimicrobial soap, keep home environment clean and avoid being exposed to family & friends who have colds or flu viruses Topic: Identifying allergic cross-reactivity 1. Allergies to banana or kiwi can indicate the client is at risk for a reaction to latex 2. Allergies to eggs or soybean oil is a contraindication to the use of propofol for anesthesia 3. Allergies to shellfish can result in a reaction to povidone-iodine Content Area: Health Promotion and Maintenance Topic: Heart failure and pulmonary edema instructions for home care 1. Instruct the client on effective breathing techniques 2. Instruct the client on a low-sodium diet and fluid restrictions 3. Instruct the client to report swelling of feet, ankles or any SOB or angina Topic: Recommended vaccinations for older adult clients 1. Pneumococcal: give PCV13 first and then PPSV23 6-12 months after to adults 65 and older who haven't been immunized with PCV12 or PPSV23. For adults who received a dose of PPSV23 at age 65 or older, an additional dose isn't indicated. 2. Meningitis: MPSV4 for adults 56 years or older, require a single dose, and haven't had MenACWY previously. 3. Zoster: 1 time dose for all adults older than 60. Topic: Risk factors for deep-vein thrombosis 1. Oral contraceptive use and estrogen therapy 2. Tobacco use, heart failure 3. Obesity, surgery, CVC, long-term immobility Content Area: Basic Care and Comfort Topic: Nonpharmacological interventions following total knee arthroscopy 1. Continuous passive motion machine, turn off during meals 2. Place 1 pillow under the lower calf and foot. Put pillow under ankle to keep heel off of bed 3. Apply ice to incisional area. Topic: Caring for a client receiving radiation 1. Place the client in a private room and keep door closed as much as possible 2. Limit visitors to 30 minutes 3. Linens and dressings are to remain in the room until the radiation source is removed Topic: Priority action for eye irrigation 1. Teach clients to wear sunglasses while outside 2. Educate clients to wear protective eyewear while playing sports and performing hazardous activities, such as welding and yard work 3. Encourage annual eye examinations and good eye health Topic: Preventing complications of musculoskeletal trauma 1. Assess neurovascular frequently at least every hour & report changes to HCP 2. Assess pain frequently and follow pain management protocol 3. Maintain body alignment and realign if the client seems uncomfortable or reports pain Topic: Low-potassium food resources for AKI & CKD 1. Rice, bread, cauliflower 2. Broccoli, noddle’s/pasta 3. Asparagus Content Area: Pharmacological and Parenteral Therapies Topic: Teaching about blood transfusions 1. Acute hemolytic transfusion reaction: Chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom 2. Initiate large-bore IV assess, an 18 or 20G needle 3. Prime the blood administration set with 0.9% sodium chloride only Topic: Treatment for circulatory overload 1. Admin O2 and monitor vital signs 2. Slow the infusion rate 3. Administer diuretics (furosemide) as prescribed and Notify provider Topic: Teaching about opioid use 1. Avoid using opioids with antihypertensive agents 2. Avoid taking with other medications that have a CNS effect with opioid medication 3. Increase fluids and dietary fibers to prevent constipation Topic: Discharge teaching about a metered dose-inhaler 1. Shake the inhaler well before use three or four shakes and remove cap Breathe out away from the inhaler 2. Bring the inhaler to your mouth place it in your mouth between your teeth and close your mouth around it 3. Start to breathe in slowly press the top of your inhaler once and keep breathing in slowly until you have taken a full breath 3 to 5 seconds 4. Remove the inhaler from your mouth hold your breath for 10 seconds then breathe out Wait one minute between each puff Rinse mouth after each dose to prevent thrush Content Area: Reduction of Risk Potential Topic: Monitoring a client who has chronic lymphotic leukemia 1. The white blood cells are not functional, they invade and destroy bone marrow, and they can metastasize to the liver, spleen, lymph nodes, testes, and brain. 2. The goal of treatment is to eliminate all leukemic cells. 3. Lack of mature leukocytes leads to immunosuppression which can cause infection, which is the leading cause of death among patients who have leukemia. Topic: Teaching about water-seal drainage 1. Tidaling is expected with water-seal chamber with spontaneous respirations 2. Cessation of tidaling in the water seal chamber signals lung re-expansion or an obstruction within the system 3. Continuous bubbling in the water seal chamber indicates a water leak in the system Topic: Assessment findings for a client who has right-sided heart failure 1. JVD, ascending dependent edema 2. Abdominal distention, ascites, fatigue, weakness 3. Polyuria at rest, nausea & anorexia Topic: Teaching about left-sided cardiac catheterization 1. Monitor for sensation, color, capillary refill and peripheral pulses in the extremities distal to the insertion side 2. Assess insertion side for development of hematoma 3. Hold pressure for uncontrolled oozing/bleeding Content Area: Physiological Adaptation Topic: Manifestations of Anemia 1. Pallor, pain, hypoxia, dyspnea on exertion 2. Fatigue, somnolence and headache 3. Irritability, numbness and tingling of extremities Topic: Using a Peak flow meter 1. Stand up 2. Close lip tightly around the mouthpiece 3. Blow out as hard and quickly as possible 4. Read the number on the meter Topic: Caring for a client following an explosion 1. Assess and maintain airway 2. Initiate IV access using a large-bore needle for fluid replacement 3. Monitor for manifestations of shock ( increased cap refill, increase temp, decreased bowel sounds) Topic: Treatment for hypokalemia 1. Administer potassium replacement 2. Monitor and maintain adequate urine output 3. Observe for shallow ineffective respirations and diminished breath sounds Topic: Responding to changes in LOC 1. Close monitoring of vital signs and neurological status 2. Early reporting of changes in the GCS score 3. Increase in blood pressure and alteration in respiratory pattern and effort Topic: Indications of peritonitis 1. Fever 2. Abdominal pain or tenderness 3. Bloating for feeling of fullness in abdomen Topic: Hemodynamic shock client positioning 1. For hypotension, place the client flat with his legs elevated to increase venous return (Trendelenburg position) 2. During hypovolemic shock, replace volume first Be prepared to intubate the client. Have emergency resuscitation equipment ready Topic: Actions for hypertensive crisis 1. Administer IV antihypertensive therapies, such as nitroprusside, nicardipine, and labetalol 2. Before, during, and after administration of an IV antihypertensive, monitor blood pressure every 5 to 15 min. 3. Assess neurological status, such as pupils, level of consciousness, and muscle strength, to monitor for cerebrovascular change Topic: Monitoring clients permanent pacemaker rhythm Topic: Caring for a client who has venous insufficiency 1. Have client wear insulated socks 2. Elevate legs to reduce swelling, but not above the heart 3. Avoid stress, caffeine, and nicotine which can cause vasoconstriction Topic: Recommendations for low-purine diet 1. Nuts 2. Apricot
