ADVANCED CLINICAL CONCEPTS Trendelenburg because the weight of the lower organs
restricts breathing).
• ARDS is an unexpected, catastrophic pulmonary complication
occurring in a person with no previous pulmonary problems. • Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild
The mortality rate is high (50%)
• Epinephrine: 1:10,000, or 5ml IV for severe
• In ARDS, a common laboratory finding is lowered PO2.
However, these clients are not very responsive to high • Volume expanding fluids are usually given to clients in
concentrations of oxygen. shock. However, if the shock is cardiogenic, pulmonary
edema may result.
• Think about the physiology of the lungs by remembering
PEEP: Positive End Expiratory Pressure is the instillation and • Drugs of choice for shock
maintenance of small amounts of air into the alveolar sacs to - Digitalis preparations: Increase the contractility of the heart
prevent them from collapsing each time the client exhales. muscle
The amount of pressure can be set with the ventilator and is - Vasoconstrictors (Levophed, Dopamine): Generalized
usually around 5 to 10 cm of water. vasonconstriction to provide more available blood to the
heart to help maintain cardiac output.
• Suction only when secretions are present.
• A common volume-expanding substance is plasma and
• Before drawing arterial blood gases from the radial artery, possibly whole blood.
perform the Allen test to assess collateral circulation. Make
the client’s hand blanch by obliterating both the radial and • You are caring for a woman who was in severe automobile
ulnar pulses. Then release the pressure over the ulnar artery accident several days ago. She has several fractures and
only. If flow through the ulnar artery is good, flushing will be internal injuries. The exploratory laparotomy was successful
seen immediately. The Allen test is then positive, and the in controlling the bleeding. However, today you find that this
radial artery can be used for puncture. If the Allen test is client is bleeding from her incision, short of breath, has a
negative, repeat on the other arm. If this test is also negative, weak thready pulse, has cold and clammy skin, and
seek another site for arterial puncture. The Allen test ensures hematuria.
collateral circulation to the hand if thrombosis of the radial - What do you think is wrong with the client, and what would
artery should follow the puncture. you expect to do about it?
- These are typical signs and symptoms of DIC crisis. Expect
• If the client does not have O2 to his/her brain, the rest of the to administer IV heparin to block the formation of thrombin
injuries do not matter because death will occur. However, (Coumadin does not do this). However, the client described
they must be removed from any source of imminent danger, is already past the coagulation phase and into the
such as a fire. hemorrhagic phase. Her management would be
administration of clotting factors along with palliative
• PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. treatment of the symptoms as they arise. (Her prognosis is
poor).
• A child in severe distress should be on 100% O2.
• NCLEX-RN questions on CPR often deal with prioritization
• Early signs of shock are agitation and restlessness resulting of actions. Question: What actions are required for each of
from cerebral hypoxia. the following situations?
- A 24-year old motorcycle accident vistim with a ruptured
• If cardiogenic shock exists with the presence of pulmonary artery if the leg is pulseless and apneic.
edema, i.e., from pump failure, position client to REDUCE - A 36-year old first time pregnant woman who arrests during
venous return (HIGH FOWLER’s with legs down) in order to labor.
decrease venous return further to the left ventricle. - A 17-year old with no pulse or respirations who is trapped in
an overturned car, which is starting to catch fire.
• Severe shock leads to widespread cellular injury and impairs - A 40-year old businessman who arrests two days after a
the integrity of the capillary membranes. Fluid and osmotic cervical laminectomy.
proteins seep into the extra vascular spaces, further reducing
cardiac output. A vicious cycle of decreased perfusion to ALL
cellular level activities ensues. All organs are damaged, and if • WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS)
perfusion problems exist, the damage can be permanent.
- The American Heart Association recommends that those
with known angina pectoris seek emergency medical care if
• All vasopressors/vasodilator drugs are potent and dangerous chest pain is NOT relieved by three nitroglycerin tablets 5
and require weaning on and off. Do not change infusion rates minutes apart over a 150minute period.
simultaneously.
- A person with previously unrecognized coronary disease
experiencing chest pain persisting for 2 minutes or longer
• A client is brought into the hospital suffering shock symptoms should seek emergency medical treatment.
as a result of a bee sting. What is the first priority?
Maintaining an open airway (the allergic reaction damages the
• It is important for the nurse to stay current with the American
lining of the airways causing edema). Also, keep the client
Heart Association’s guidelines for Basic Life Support (BLS)
warm without constricting clothing; keep legs elevated (not
by being certified every two years as required.
1
, present, but the amount of solvent (fluid) is decreased.
• If one rescuer is performing CPR, 1 15:2 ratio of compression Therefore, the blood can be considered “more
to ventilations is performed for 4 cycles, then reassess for concentrated.”
breathing and pulse. If two rescuers are performing CPR, a - Urine osmolality and specific gravity increase.
15:2 ratio is now recommended for compressions to
ventilations. Perform for 15 cycles with a 100/min • Check the IV tubing container to determine the drip factor
compression rate. When trading off, start with compressions. because drip factors vary. The most common drip factors
are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60
• Initiate CPR with BLS guidelines immediately, then move on drops per milliliter.
to Advanced Cardiac Life Support (ACLS) guidelines.
• Flushing a saline lock requires approximately 1 ½ times the
• When significant arterial acidosis is noted, try to reduce PCO2 amount of fluid that the tubing will hold in order to efficiently
by increasing ventilation, which will correct arterial, venous, flush the tubing. REMEMBER to use sterile technique to
and tissue acidosis. Bicarbonate may exacerbate acidosis b prevent complications such as infiltration, emboli and
producing CO2. Thus, the ACLS guidelines have infection.
recommended bicarbonate NOT be used unless hyperkalemia
and/or preexisting acidosis is documented. • A pH of less than 6.8 or more than 7.8 is NOT
COMPATIBLE WITH LIFE.
• Infants/prematures may have problems with the following that
can predispose to arrest: Beware of the “H’s” – hypoxia, • The acronym ROME can help you remember: Respiratory,
hypoglycemia, hypothermia, increased H+ (metabolic and/or Opposite, Metabolic, Equal.
respiratory acidosis), hypercoagulability (if polycythemia
exists). • Review the order of blood flow to the heart:
- Unoxygenated blood flows from the superior and inferior
• Changes is osmolarity cause shifts in fluid. The osmolarity of vena cava into the right atrium, then to the right ventricle. It
the extracellular fluid (ECF) is almost entriely due to sodium. flows out of the heart through the pulmonary artery, to the
The osmolarity of intracellular fluid (ICF) is related to many lungs for oxygenation. The pulmonary vein delivers
particles, with potassium being the primary electrolyte. The oxygenated blood back to the left atrium, then to the left
pressures in the ECF and the ICF are almost identical. If ventricle (largest, strongest chamber) and out the aorta.
either ECF or ICF change in concentration, fluid shifts from - Review the three structures that control the one-way flow of
the area of lesser concentration to the area of greater blood through the heart:
concentration. 1. Valves Atrioventricular valves Tricuspid (right side)
Mitral (left side)
• Dextrose 10% is a hypertonic solution and should be Semilunar valves Pulmonary (in pulmonary
administered IV. artery) Aortic (in aorta)
2. Cordae Tendinae
• Normal saline is an isotonic solution and is used for irrigations, 3. Papillary muscles
such as bladder irrigations or IV flush lines with intermittent IV
medication. • Since the T waves represents repolarization of the ventricle,
this is a critical time in the heartbeat. This action represents
• Use only isotonic (neutral) solutions in irrigations, infusions, a resting and regrouping stage so that the next heartbeat
etc., unless the specific aim is to shift fluid into intracellular or can occur. If defibrillation occurs during this phase, the
extracellular spaces. heart can be thrust into a life-threatening dysrhythmia.
• Potassium imbalances are potentially life-threatening, must be • Observe the client for tolerance of the current rhythm. This
corrected immediately. A low magnesium often accompanies information is the most important data the nurse can collect
a low K+, especially with the use of diuretics. on the client with an arrythmia.
• Fluid Volume Deficit: Dehydration • REMEMBER to monitor the client as well as the machine! If
- Elevated BUN: The BUN measures the amount of urea the EKG monitor shows a severe dysrhythmia, but the client
nitrogen in the blood. Urea is formed in the liver as the end is sitting up quietly watching a TV without any sign of
product of protein metabolism. The BUN is directly related to distress, assess to determine if the leads are attached
the metabolic function of the liver and the excretory function of properly.
the kidneys.
- Creatinine, as with BUN, is excreted entirely by the kidneys • Marking the operative site is required for procedures
and is therefore directly proportional to renal excretory involving right/left distinctions, multiple structures (fingers,
function. However, unlike BUN, the creatinine level is affected toes), or levels (spinal procedures). Site marking should be
very little by dehydration, malnutrition, or hepatic function. done with the involvement of the client.
The daily production of creatinine depends on muscle mass,
which fluctuates very little. Therefore, it is a better test of • Wound dehiscence is separation of the wound edges and is
renal function than is the BUN. Creatinine is generally used in more likely to occur with vertical incisions. It usually occurs
conjunction with the BUN test and they normally are in a 1:20 after the early postoperative period, when the client’s own
ratio. granulation tissue is “taking over” the wound, after
- Serum osmolality measures the concentration of particles in a absorption of the sutures has begun. Evisceration of the
solution. It refers to the fact that the same amount of solute is
2
, wound is protrusion of intestinal contents (in an abdominal is often the preferred narcotic (REMEMBER: it causes
wound) and is more likely in clients who are older, diabetic, respiratory depression).
obese, or malnourished and have prolonged paralytic ileus.
• Other agonists are meperidine and methadone. Narcotic
• NCLEX-RN items will focus on the nurse’s role in terms of the antagonists block the attachment of narcotics to the
entire perioperative process. Sample: A 43-year old mother of receptors, such as Narcan (naloxone). Once Narcan has
2 teenage daughters enters the hospital to have her been given, additional narcotics cannot be given until the
gallbladder removed in a same-day surgery using a scope Narcan effects have passed.
instead of an incision. What nursing needs will dominate each
phase of her short hospital stay? • Do not take away the coping style used in a crisis state…
- Preparation phase: Education about postoperative care, NPO, DENIAL. It is a useful and needed tool at the initial stage for
assist with meeting family needs. some. Support, do not challenge, unless it hinders/blocks
- Operative phase: Assessment, management of the operative treatment – endangering the patient.
suite.
- Post-anesthesia phase: Pain management, post-anesthesia MEDICAL –SURGICAL NURSING
precautions.
- Post-operative phase: Prevent and assess for complications, RESPIRATORY SYSTEM
pain management, dietary restrictions, activity.
• Fever can cause dehydration from excessive fluid loss in
• HIV clients with tuberculosis require respiratory isolation. diaphoresis. Increased temperature also increases
Tuberculosis is the only real risk to non-pregnant caregivers metabolism and the demand for oxygen.
that is not related to a break in universal precautions (i.e.,
needle sticks, etc.). • High risk for pneumonia:
- Any person, who has altered level of consciousness, has
• STANDARD PRECAUTIONS: depressed or absent gag reflex and cough reflexes, is
- Wash hands, even if gloves have been worn to give care susceptible to aspirating oropharyngeal secretions.
- Wear gloves (latex) for touching blood or body fluids, or any (Alcoholics, anesthesized individuals, those with brain injury,
non-intact body surface. drug overdose, or stroke victims).
- Wear gowns during any procedure that might generate - When feeding, raise the head of the bed and position the
splashes (changing clients with diarrhea). client on side – not on back.
- Use masks and eye protection during activity which might
disperse droplets (suctioning). • Bronchial breath sounds are heard over areas of density or
- Do not recap needles, dispose of in puncture-resistant consolidation. Sound waves are easily transmitted over
containers. consolidated tissue.
- Use mouth piece for resuscitation efforts.
• Hydration – enables liquification of mucous trapped in the
- Refrain from giving care if you have open skin lesions.
bronchioles and alveoli, facilitating expectoration. Essential
for the client experiencing fever. Important because 300 to
• Caregivers who are pregnant may choose not to care for a 400 ml of fluid are lost daily by the lungs through
client with Cytomegalovirus (CMV). evaporation.
• Pediatric HIV is often evidenced by lymphoid interstitial • Irritability and restlessness are early signs of cerebral
pneumonitis. hypoxia – the client is not getting enough oxygen to the
brain.
• The focus of NCLEX-RN questions is likely to be assessment
of early signs of the disease and management of • Pneumonia preventatives:
complications associated with HIV.
- Elderly: flu shots; pneumonia immunizations; avoiding
sources of infection and indoor pollutants (dust, smoke, and
• For narcotic induced respiratory depression, administer aerosols); do not smoke.
Naloxone 0.1mg to 0.4mg IV every 2-3 minutes as needed,
- Immunosuppressed and debilitated persons: infection
until 1.0mg is achieved.
avoidance, sensible nutrition, adequate intake, balance of
rest and activity.
• Use non-invasive methods for pain management when
- Comatose and immobile persons: elevate head of bed to
possible:
feed; turn frequently.
- Relaxation techniques
- Distraction • Compensation occurs over time in clients with chronic lung
- Imagery disease, and arterial blood gases (ABGs) are altered. It is
- Biofeedback imperative that baseline data are obtained on the client.
- Interpersonal skills
- Physical care: altering positions, touch, hot and cold • Productive cough and comfort can be facilitated by Semi-
applications. Fowler’s or high Fowler’s positions, which lessen pressure
on the diaphragm from abdominal organs. Gastric distention
• Narcotic analgesics are prepared for pain relief because they becomes a priority in these clients because it elevates the
bind to the various opiate receptor sites in the CNS. Morphine diaphragm and inhibits lung expansion.
3
restricts breathing).
• ARDS is an unexpected, catastrophic pulmonary complication
occurring in a person with no previous pulmonary problems. • Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild
The mortality rate is high (50%)
• Epinephrine: 1:10,000, or 5ml IV for severe
• In ARDS, a common laboratory finding is lowered PO2.
However, these clients are not very responsive to high • Volume expanding fluids are usually given to clients in
concentrations of oxygen. shock. However, if the shock is cardiogenic, pulmonary
edema may result.
• Think about the physiology of the lungs by remembering
PEEP: Positive End Expiratory Pressure is the instillation and • Drugs of choice for shock
maintenance of small amounts of air into the alveolar sacs to - Digitalis preparations: Increase the contractility of the heart
prevent them from collapsing each time the client exhales. muscle
The amount of pressure can be set with the ventilator and is - Vasoconstrictors (Levophed, Dopamine): Generalized
usually around 5 to 10 cm of water. vasonconstriction to provide more available blood to the
heart to help maintain cardiac output.
• Suction only when secretions are present.
• A common volume-expanding substance is plasma and
• Before drawing arterial blood gases from the radial artery, possibly whole blood.
perform the Allen test to assess collateral circulation. Make
the client’s hand blanch by obliterating both the radial and • You are caring for a woman who was in severe automobile
ulnar pulses. Then release the pressure over the ulnar artery accident several days ago. She has several fractures and
only. If flow through the ulnar artery is good, flushing will be internal injuries. The exploratory laparotomy was successful
seen immediately. The Allen test is then positive, and the in controlling the bleeding. However, today you find that this
radial artery can be used for puncture. If the Allen test is client is bleeding from her incision, short of breath, has a
negative, repeat on the other arm. If this test is also negative, weak thready pulse, has cold and clammy skin, and
seek another site for arterial puncture. The Allen test ensures hematuria.
collateral circulation to the hand if thrombosis of the radial - What do you think is wrong with the client, and what would
artery should follow the puncture. you expect to do about it?
- These are typical signs and symptoms of DIC crisis. Expect
• If the client does not have O2 to his/her brain, the rest of the to administer IV heparin to block the formation of thrombin
injuries do not matter because death will occur. However, (Coumadin does not do this). However, the client described
they must be removed from any source of imminent danger, is already past the coagulation phase and into the
such as a fire. hemorrhagic phase. Her management would be
administration of clotting factors along with palliative
• PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. treatment of the symptoms as they arise. (Her prognosis is
poor).
• A child in severe distress should be on 100% O2.
• NCLEX-RN questions on CPR often deal with prioritization
• Early signs of shock are agitation and restlessness resulting of actions. Question: What actions are required for each of
from cerebral hypoxia. the following situations?
- A 24-year old motorcycle accident vistim with a ruptured
• If cardiogenic shock exists with the presence of pulmonary artery if the leg is pulseless and apneic.
edema, i.e., from pump failure, position client to REDUCE - A 36-year old first time pregnant woman who arrests during
venous return (HIGH FOWLER’s with legs down) in order to labor.
decrease venous return further to the left ventricle. - A 17-year old with no pulse or respirations who is trapped in
an overturned car, which is starting to catch fire.
• Severe shock leads to widespread cellular injury and impairs - A 40-year old businessman who arrests two days after a
the integrity of the capillary membranes. Fluid and osmotic cervical laminectomy.
proteins seep into the extra vascular spaces, further reducing
cardiac output. A vicious cycle of decreased perfusion to ALL
cellular level activities ensues. All organs are damaged, and if • WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS)
perfusion problems exist, the damage can be permanent.
- The American Heart Association recommends that those
with known angina pectoris seek emergency medical care if
• All vasopressors/vasodilator drugs are potent and dangerous chest pain is NOT relieved by three nitroglycerin tablets 5
and require weaning on and off. Do not change infusion rates minutes apart over a 150minute period.
simultaneously.
- A person with previously unrecognized coronary disease
experiencing chest pain persisting for 2 minutes or longer
• A client is brought into the hospital suffering shock symptoms should seek emergency medical treatment.
as a result of a bee sting. What is the first priority?
Maintaining an open airway (the allergic reaction damages the
• It is important for the nurse to stay current with the American
lining of the airways causing edema). Also, keep the client
Heart Association’s guidelines for Basic Life Support (BLS)
warm without constricting clothing; keep legs elevated (not
by being certified every two years as required.
1
, present, but the amount of solvent (fluid) is decreased.
• If one rescuer is performing CPR, 1 15:2 ratio of compression Therefore, the blood can be considered “more
to ventilations is performed for 4 cycles, then reassess for concentrated.”
breathing and pulse. If two rescuers are performing CPR, a - Urine osmolality and specific gravity increase.
15:2 ratio is now recommended for compressions to
ventilations. Perform for 15 cycles with a 100/min • Check the IV tubing container to determine the drip factor
compression rate. When trading off, start with compressions. because drip factors vary. The most common drip factors
are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60
• Initiate CPR with BLS guidelines immediately, then move on drops per milliliter.
to Advanced Cardiac Life Support (ACLS) guidelines.
• Flushing a saline lock requires approximately 1 ½ times the
• When significant arterial acidosis is noted, try to reduce PCO2 amount of fluid that the tubing will hold in order to efficiently
by increasing ventilation, which will correct arterial, venous, flush the tubing. REMEMBER to use sterile technique to
and tissue acidosis. Bicarbonate may exacerbate acidosis b prevent complications such as infiltration, emboli and
producing CO2. Thus, the ACLS guidelines have infection.
recommended bicarbonate NOT be used unless hyperkalemia
and/or preexisting acidosis is documented. • A pH of less than 6.8 or more than 7.8 is NOT
COMPATIBLE WITH LIFE.
• Infants/prematures may have problems with the following that
can predispose to arrest: Beware of the “H’s” – hypoxia, • The acronym ROME can help you remember: Respiratory,
hypoglycemia, hypothermia, increased H+ (metabolic and/or Opposite, Metabolic, Equal.
respiratory acidosis), hypercoagulability (if polycythemia
exists). • Review the order of blood flow to the heart:
- Unoxygenated blood flows from the superior and inferior
• Changes is osmolarity cause shifts in fluid. The osmolarity of vena cava into the right atrium, then to the right ventricle. It
the extracellular fluid (ECF) is almost entriely due to sodium. flows out of the heart through the pulmonary artery, to the
The osmolarity of intracellular fluid (ICF) is related to many lungs for oxygenation. The pulmonary vein delivers
particles, with potassium being the primary electrolyte. The oxygenated blood back to the left atrium, then to the left
pressures in the ECF and the ICF are almost identical. If ventricle (largest, strongest chamber) and out the aorta.
either ECF or ICF change in concentration, fluid shifts from - Review the three structures that control the one-way flow of
the area of lesser concentration to the area of greater blood through the heart:
concentration. 1. Valves Atrioventricular valves Tricuspid (right side)
Mitral (left side)
• Dextrose 10% is a hypertonic solution and should be Semilunar valves Pulmonary (in pulmonary
administered IV. artery) Aortic (in aorta)
2. Cordae Tendinae
• Normal saline is an isotonic solution and is used for irrigations, 3. Papillary muscles
such as bladder irrigations or IV flush lines with intermittent IV
medication. • Since the T waves represents repolarization of the ventricle,
this is a critical time in the heartbeat. This action represents
• Use only isotonic (neutral) solutions in irrigations, infusions, a resting and regrouping stage so that the next heartbeat
etc., unless the specific aim is to shift fluid into intracellular or can occur. If defibrillation occurs during this phase, the
extracellular spaces. heart can be thrust into a life-threatening dysrhythmia.
• Potassium imbalances are potentially life-threatening, must be • Observe the client for tolerance of the current rhythm. This
corrected immediately. A low magnesium often accompanies information is the most important data the nurse can collect
a low K+, especially with the use of diuretics. on the client with an arrythmia.
• Fluid Volume Deficit: Dehydration • REMEMBER to monitor the client as well as the machine! If
- Elevated BUN: The BUN measures the amount of urea the EKG monitor shows a severe dysrhythmia, but the client
nitrogen in the blood. Urea is formed in the liver as the end is sitting up quietly watching a TV without any sign of
product of protein metabolism. The BUN is directly related to distress, assess to determine if the leads are attached
the metabolic function of the liver and the excretory function of properly.
the kidneys.
- Creatinine, as with BUN, is excreted entirely by the kidneys • Marking the operative site is required for procedures
and is therefore directly proportional to renal excretory involving right/left distinctions, multiple structures (fingers,
function. However, unlike BUN, the creatinine level is affected toes), or levels (spinal procedures). Site marking should be
very little by dehydration, malnutrition, or hepatic function. done with the involvement of the client.
The daily production of creatinine depends on muscle mass,
which fluctuates very little. Therefore, it is a better test of • Wound dehiscence is separation of the wound edges and is
renal function than is the BUN. Creatinine is generally used in more likely to occur with vertical incisions. It usually occurs
conjunction with the BUN test and they normally are in a 1:20 after the early postoperative period, when the client’s own
ratio. granulation tissue is “taking over” the wound, after
- Serum osmolality measures the concentration of particles in a absorption of the sutures has begun. Evisceration of the
solution. It refers to the fact that the same amount of solute is
2
, wound is protrusion of intestinal contents (in an abdominal is often the preferred narcotic (REMEMBER: it causes
wound) and is more likely in clients who are older, diabetic, respiratory depression).
obese, or malnourished and have prolonged paralytic ileus.
• Other agonists are meperidine and methadone. Narcotic
• NCLEX-RN items will focus on the nurse’s role in terms of the antagonists block the attachment of narcotics to the
entire perioperative process. Sample: A 43-year old mother of receptors, such as Narcan (naloxone). Once Narcan has
2 teenage daughters enters the hospital to have her been given, additional narcotics cannot be given until the
gallbladder removed in a same-day surgery using a scope Narcan effects have passed.
instead of an incision. What nursing needs will dominate each
phase of her short hospital stay? • Do not take away the coping style used in a crisis state…
- Preparation phase: Education about postoperative care, NPO, DENIAL. It is a useful and needed tool at the initial stage for
assist with meeting family needs. some. Support, do not challenge, unless it hinders/blocks
- Operative phase: Assessment, management of the operative treatment – endangering the patient.
suite.
- Post-anesthesia phase: Pain management, post-anesthesia MEDICAL –SURGICAL NURSING
precautions.
- Post-operative phase: Prevent and assess for complications, RESPIRATORY SYSTEM
pain management, dietary restrictions, activity.
• Fever can cause dehydration from excessive fluid loss in
• HIV clients with tuberculosis require respiratory isolation. diaphoresis. Increased temperature also increases
Tuberculosis is the only real risk to non-pregnant caregivers metabolism and the demand for oxygen.
that is not related to a break in universal precautions (i.e.,
needle sticks, etc.). • High risk for pneumonia:
- Any person, who has altered level of consciousness, has
• STANDARD PRECAUTIONS: depressed or absent gag reflex and cough reflexes, is
- Wash hands, even if gloves have been worn to give care susceptible to aspirating oropharyngeal secretions.
- Wear gloves (latex) for touching blood or body fluids, or any (Alcoholics, anesthesized individuals, those with brain injury,
non-intact body surface. drug overdose, or stroke victims).
- Wear gowns during any procedure that might generate - When feeding, raise the head of the bed and position the
splashes (changing clients with diarrhea). client on side – not on back.
- Use masks and eye protection during activity which might
disperse droplets (suctioning). • Bronchial breath sounds are heard over areas of density or
- Do not recap needles, dispose of in puncture-resistant consolidation. Sound waves are easily transmitted over
containers. consolidated tissue.
- Use mouth piece for resuscitation efforts.
• Hydration – enables liquification of mucous trapped in the
- Refrain from giving care if you have open skin lesions.
bronchioles and alveoli, facilitating expectoration. Essential
for the client experiencing fever. Important because 300 to
• Caregivers who are pregnant may choose not to care for a 400 ml of fluid are lost daily by the lungs through
client with Cytomegalovirus (CMV). evaporation.
• Pediatric HIV is often evidenced by lymphoid interstitial • Irritability and restlessness are early signs of cerebral
pneumonitis. hypoxia – the client is not getting enough oxygen to the
brain.
• The focus of NCLEX-RN questions is likely to be assessment
of early signs of the disease and management of • Pneumonia preventatives:
complications associated with HIV.
- Elderly: flu shots; pneumonia immunizations; avoiding
sources of infection and indoor pollutants (dust, smoke, and
• For narcotic induced respiratory depression, administer aerosols); do not smoke.
Naloxone 0.1mg to 0.4mg IV every 2-3 minutes as needed,
- Immunosuppressed and debilitated persons: infection
until 1.0mg is achieved.
avoidance, sensible nutrition, adequate intake, balance of
rest and activity.
• Use non-invasive methods for pain management when
- Comatose and immobile persons: elevate head of bed to
possible:
feed; turn frequently.
- Relaxation techniques
- Distraction • Compensation occurs over time in clients with chronic lung
- Imagery disease, and arterial blood gases (ABGs) are altered. It is
- Biofeedback imperative that baseline data are obtained on the client.
- Interpersonal skills
- Physical care: altering positions, touch, hot and cold • Productive cough and comfort can be facilitated by Semi-
applications. Fowler’s or high Fowler’s positions, which lessen pressure
on the diaphragm from abdominal organs. Gastric distention
• Narcotic analgesics are prepared for pain relief because they becomes a priority in these clients because it elevates the
bind to the various opiate receptor sites in the CNS. Morphine diaphragm and inhibits lung expansion.
3
