Perfusion
I: Assess each area for signs of decreased tissue perfusion.
R: Early detection facilitates prompt, effective treatment.
Signs may be:
Peripheral: weak, absent pulses; edema; numbness, pain, aches; cool to touch; mottling; prolonged capillary refill
Cardiopulmonary: tachycardia, arrhythmias, hypotension, tachypnea, abnormal ABGs, angina
Renal: decreased output, hematuria, elevated BUN/creatine ratio
GI: decreased or absent bowel sounds; nausea; abdominal pain / distention
Cerebral: restless, change in mentation seizure activity, papillary changes and decrease reaction to light
I: Palpate pulses: carotid, brachial, radial, femoral, popliteal and pedal. Note quality and rate.
R: If carotid and femoral pulses are palpable, then the blood pressure is usually at least 60 – 80 mmHg systolic. If peripheral pulses are present, the blood pressure is usually higher than 80 mmHg systolic. Pulses may be weak and irregular.
I: Monitor vital signs. (T,P,R,B/P)
R: Adequate perfusion to vital organs is essential. A mean arterial blood pressure of at least 60 mmHg is essential to maintain perfusion.
Infection
I: Assess for presence of risk factors: open wounds, abrasions; indwelling catheters; drains; artificial airways; and venous access devices.
R: Represent a break in body’s first line of defense.
I: Monitor white blood count (WBC).
R: Normal WBC is 4-11 mm3. Rising WBC indicates the body’s attempt to combat pathogens.
I: Monitor temperature and the presence of sweating and chills.
R: In the first 24-48 hours fever up to 38 degrees C (100.4F) is related to the stress of surgery. After 48 hours fever above 37.7C (99.8F) suggests infection. High fever with sweating and chills suggests septicemia.
I: Monitor the appearance of urine.
R: Cloudy, foul-smelling urine, with sediments indicates a urinary tract or bladder infection.
Immunity
I: Administer MMR, Td, and meningococcal meningitis vaccines
prior to discharge from clinic.
R: To protect from the disease processes.
I: Observe closely for 30 minutes following immunization
R: There is a potential for an adverse response.
I: Provide instructions for comfort measures to relieve local and
systemic adverse effects of vaccines. Provide written instructions
on manifestations that should be reported to the physician.
R: Providing written information gives another source for patient understanding.
The other end of the Stethoscope
Delivering difficult news to a patient or family member will be hard for me. I believe establishing a good rapport with your patient will be the first step. As Marcus said, being honest is the best solution; so I will provide compassion, assistance and reassurance to my patient and family members. Nurses have many roles in patient care and being the bearer of bad news will not be an easy role to play. I personally will rely on my faith and pray for strength to give the patient and family what they need.
Three medication classifications that could potentially cause hyperglycemia, include one medication for each classification.
1.β2-adrenergic receptor agonist
Albuterol (Ventolin®, Proventil®)
2.Muscle Relaxer
Baclofen (Lioresal®)
3.Steroid
Betamethasone +clotrimazole (Lotrisone® (topical))
I: Assess each area for signs of decreased tissue perfusion.
R: Early detection facilitates prompt, effective treatment.
Signs may be:
Peripheral: weak, absent pulses; edema; numbness, pain, aches; cool to touch; mottling; prolonged capillary refill
Cardiopulmonary: tachycardia, arrhythmias, hypotension, tachypnea, abnormal ABGs, angina
Renal: decreased output, hematuria, elevated BUN/creatine ratio
GI: decreased or absent bowel sounds; nausea; abdominal pain / distention
Cerebral: restless, change in mentation seizure activity, papillary changes and decrease reaction to light
I: Palpate pulses: carotid, brachial, radial, femoral, popliteal and pedal. Note quality and rate.
R: If carotid and femoral pulses are palpable, then the blood pressure is usually at least 60 – 80 mmHg systolic. If peripheral pulses are present, the blood pressure is usually higher than 80 mmHg systolic. Pulses may be weak and irregular.
I: Monitor vital signs. (T,P,R,B/P)
R: Adequate perfusion to vital organs is essential. A mean arterial blood pressure of at least 60 mmHg is essential to maintain perfusion.
Infection
I: Assess for presence of risk factors: open wounds, abrasions; indwelling catheters; drains; artificial airways; and venous access devices.
R: Represent a break in body’s first line of defense.
I: Monitor white blood count (WBC).
R: Normal WBC is 4-11 mm3. Rising WBC indicates the body’s attempt to combat pathogens.
I: Monitor temperature and the presence of sweating and chills.
R: In the first 24-48 hours fever up to 38 degrees C (100.4F) is related to the stress of surgery. After 48 hours fever above 37.7C (99.8F) suggests infection. High fever with sweating and chills suggests septicemia.
I: Monitor the appearance of urine.
R: Cloudy, foul-smelling urine, with sediments indicates a urinary tract or bladder infection.
Immunity
I: Administer MMR, Td, and meningococcal meningitis vaccines
prior to discharge from clinic.
R: To protect from the disease processes.
I: Observe closely for 30 minutes following immunization
R: There is a potential for an adverse response.
I: Provide instructions for comfort measures to relieve local and
systemic adverse effects of vaccines. Provide written instructions
on manifestations that should be reported to the physician.
R: Providing written information gives another source for patient understanding.
The other end of the Stethoscope
Delivering difficult news to a patient or family member will be hard for me. I believe establishing a good rapport with your patient will be the first step. As Marcus said, being honest is the best solution; so I will provide compassion, assistance and reassurance to my patient and family members. Nurses have many roles in patient care and being the bearer of bad news will not be an easy role to play. I personally will rely on my faith and pray for strength to give the patient and family what they need.
Three medication classifications that could potentially cause hyperglycemia, include one medication for each classification.
1.β2-adrenergic receptor agonist
Albuterol (Ventolin®, Proventil®)
2.Muscle Relaxer
Baclofen (Lioresal®)
3.Steroid
Betamethasone +clotrimazole (Lotrisone® (topical))
