Management of Care ● A client who has an acute problem takes priority over a client who has a chronic problem. ● A client who has an urgent need takes priority over a client who has a non urgent need. ● A client who has unstable findings takes priority over a client who has stable findings. Safety and Infection Control ● Do not immerse the newborn when bathing until the newborn’s umbilical cord has fallen off and/or the circumcision has healed. Wash the area around the cord, taking care not to get the cord wet. Move from the cleanest to dirtiest part of the newborn’s body, beginning with the eyes, face, and head; proceed to the chest, arms and legs; and wash the groin area last. ● Make sure the hot water heater is set at 49 C (120.2 F) or less. The room should be warm, and the bath water should be 38 C or 100.4 F. Test water for comfort with your elbow prior to bathing the newborn. ● Avoid drafts or chilling of the newborn. Expose only the body part being bathed and dry the newborn thoroughly to prevent chilling and heat loss. Apply a fragrance-free, hypoallergenic, moisturizing emollient immediately after bathing to help prevent dry skin. Health Promotion and Maintenance ● Do not obtain rectal temperatures for clients who have diarrhea, are on bleeding precautions (those who have a low platelet count), or have rectal disorders. ● The difference between the apical rate and the radial rate. With dysrhythmias, the heart can contract ineffectively, resulting in a beat at the apical site with no pulsation at the radial pulse point. ● Ensure prescribed cultures are obtained before administering prescribed antibiotics, to promote test accuracy. Psychosocial Integrity ● The Joint Commission requires policies and procedures for medication reconciliation. Nurses compile a list of each client’s current medications, including all prescription medications, over-the-counter medications, vitamins, and supplements, with correct dosages and frequency. ● Question the provider if the prescription is unclear or seems inappropriate for the client’s condition. Refuse to administer a medication if it seems unsafe and notify the charge nurse or supervisor. ● Ensure that the prescription is complete and correct by reading it back to the provider: the client’s name, the name of the medication, the dosage, the time to give it, the frequency, and the route. Basic Care and Comfort ● For nursing care for a patient with multiple sclerosis, the nurse wants to encourage exercise and have the patient stretch the involved muscles, while avoiding fatigue and overheating. We want to promote energy conservation by grouping care and planning rest periods. Promote and maintain a safe home and hospital environment to reduce the risk of injury by teaching to walk with a wide base support, use assistive devices, and useskin precautions. ● The interprofessional care team will plan for disease progression and provide community resources and respite services for the client and family. Referring to a speech language therapist can help with dysarthria and dysphagia. There should be emphasis on the need to avoid overexertion, stress, extremes of temperatures, humidity, and people who have infections. ● When eating, thin fluids should be thickened with a commercial thickener to the prescribed consistency of thin, nectar-like, honey-like, or spoon-thick. Allow adequate time for assisting the patient who has dysphagia to eat and have the patient rest before meals. Teaching the patient who aspirates easily to tuck their chins when swallowing and arch the tongue in the back of the throat can help close off the trachea. Pharmacological and Parenteral Therapies ● When infusing TPN, check the capillary glucose every 4 to 6 hours for at least the first 24 hours. Patients who receive TPN frequently need supplemental regular insulin until the pancreas can increase its endogenous production of insulin. Older adult patients have an increased incidence of glucose intolerance. ● Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available. This will minimize the risk of hypoglycemia with abrupt changes in dextrose concentrations. If a bag is unavailable and administered late, do not attempt to catch up by increasing the infusion rate because the client can develop hyperglycemia. ● When administering the solution, monitor the flow rate carefully. Administering the solution too slowly will fail to meet the patient’s nutritional needs. Administering the infusion too rapidly can cause hyperosmolar diuresis, which can lead to dehydration, hypovolemic shock, seizures, coma, and death Reduction of Risk Potential ● A vital role the nurse must play during the acute phase of burn care is detection and prevention of infection through maintaining a clean environment and emphasizing the importance of implementing isolation procedures. ● The nurse must provide accurate assessments of wound condition, employ efficient wound dressing techniques, and provide emotional support to the patient during the emotionally draining and unpleasant experience of wound care. ● The nurse assists the patient and family by providing instruction, support, and encouragement to take an active part in dressing changes and wound care when appropriate. Physiological Adaptation ● Pericardial tamponade can result from fluid accumulation in the pericardial sac. Some expected findings are hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse. Diagnostic procedures include hemodynamic monitoring, which will reveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressures). ● Nursing actions include notifying the provider immediately. Administer IV fluids to combat hypotension while monitoring for fluid overload. Obtain a chest X-ray or echocardiogram to confirm diagnosis. Prepare the client for pericardiocentesis with informed consent, gather materials, and administer medications as appropriate. ● Nursing actions include monitoring hemodynamic pressures to ensure they normalize. Monitor the heart rhythm for changes that could indicate improper positioning of the needle. Monitor for recurrence of findings after the procedure Clinical Judgment ● Isolation guidelines are a group of actions that include hand hygiene and the use of barrier precautions, which intend to reduce the transmission of infectious organisms. ● Regularly check scheduled medication prescriptions. Some medications (antihypertensives, anticoagulants, antidepressants) can be withheld until after the procedure. Withhold anticoagulants at least 48 hrs before surgery. ● Perform skin preparation, which can include cleansing with antimicrobial soap. If absolutely necessary, use electric clippers or chemical depilatories to remove hair in areas that will be involved in the surgery.
