Immunizations: Recommended Vaccinations for Older Adult Clients (Chp. 85)
- Pneumococcal: if 65 yrs.+ and not yet immunized, administer PCV13 first and then PPSV23 6-12 months later.
- Influenza vaccine should be given yearly
- MPSV4 for adults who are 56 yrs.+ and have not had MenACWY previously.
- Zoster: one time dose for al
Musculoskeletal Trauma: Maintaining Proper Traction (Chp. 71)
- maintain body alignment, avoid lifting and removing weights and ensure they hang freely
- ensure the pulley is free of knots, fraying and loosening every 8-12 hours.
- notify the provider if the. pt experiences severe pain from muscle spasms (unrelieved
Blood and Blood Product Transfusions: Indications of a Transfusion Reaction (Chp. 40)
Transfusion reactions can occur immediately or several hours after the transfusion.
--> can be acute hemolytic (immediate), febrile (within two hours), allergic (up to 24 hours), bacterial (several hours after), circulatory overload (can occur at any time
Blood and Blood Product Transfusions: Steps to Administer a Blood Transfusion (Chp. 40)
- Explain the procedure to the client and assess vital signs and the client's temperature prior to transfusion.
- Verify the prescription for a specific blood product and obtain consent for procedure if required.
- Initiate large?bore IV access; an 18? or
Cardiovascular Diagnostic and Therapeutic Procedures: Teaching About a Peripherally Inserted Central Catheter (Chp. 27)
- Instruct the client that he is awake and sedated during procedure and a local anesthetic is used.
- A small incision is made, often in the groin, to insert the catheter (the client can feel warmth and flushed when the dye is inserted)
- After the proced
Arthroplasty: Pain Control (Chp. 68)
- Analgesics: Opioids (epidural, PCA, IV, oral), NSAIDs
- Peripheral nerve blockade: Inject the femoral or sciatic nerve with a local anesthetic, or the client can receive a continuous infusion of local anesthetic directly into sciatic or femoral nerve. (
Gastrointestinal Therapeutic Procedures: Total Parental Nutrition (Chp. 47)
Ongoing Care
- The flow rate is gradually increased and gradually decreased to allow body adjustment (usually no more than a 10% hourly increase in rate)
- Never abruptly stop TPN - speeding up/slowing down the rate is contraindicated. an abrupt rate chan
Electrolyte Imbalances: Adequate Nutritional Status with Total Parenteral Nutrition (Chp. 44)
1. TPN is a hypertonic IV bolus solution used to correct nutritional deficiencies.
2. TPN is usually administered through a PICC line
3. Daily lab values including electrolytes will need to be pulled for each patient and TPN will be individualized based o
Electrocardiography and Dysrhythmia Monitoring: Analyzing ECG (Chp. 28)
Dysrhythmias are classified by the following: Site of origin (sinoatrial (SA) node, atria, atrioventricular (AV) node, or ventricle)
- Electrophysiological study is performed to determine the area of the heart causing the dysrhythmia (ablation of the area
Noninflammatory Bowel Disorders: Findings to Report (Chp. 51)
Hernia: Protrusion or lump at involved site (groin area, umbilicus, healed incision)
IBS: Cramping pain in abdomen, Abdominal pain (left lower quadrant) due to changes in bowel pattern and consistency, Nausea with meals or passing stool, Anorexia, Abdomin
Burns: Priority Action During Resuscitation Phase (Chp. 75)
Begins with the injury and continues for 24-48 hrs.
Priorities include securing the airway, supporting circulation and organ perfusion by fluid replacement, managing pain, preventing infection through wound care, maintaining body temperature, and providin
Stroke: Planning to Administer Thrombolytic Therapy (Chp. 15)
Thrombolytic medications reteplase recombinant: Give within 4.5 hr of initial symptoms.
Systemic or catheter?directed thrombolytic therapy restores cerebral blood flow - must be administered within 6 hr of the onset of symptoms. It is contraindicated for
Tuberculosis: Discharge Teaching About Tuberculosis (Chp. 23)
- Provide the client and family education because TB is often treated in the home setting.
- Airborne precautions are not needed in the home setting because family members have already been exposed.
- Exposed family members should be tested for TB.
- Educ
Electrocardiography and Dysrhythmia Monitoring: Identifying First-Degree Heart Block (Chp. 28)
On the ECG the PR wave is extended to greater than .20 seconds
Cancer Treatment Options: Prioritizing Client Care (Chp. 91)
-obtain signed informed consent form
-prepare the patient for procedure
-provide postoperative care as indicated by tumor location and procedure type
-prevent general postoperative complications
-prevent and treat pain as prescribed using pharmacological
Intravenous Therapy: Priority Action for Central Venous Access Device Complication
Infiltration/Extravasation: Stop the infusion and remove the catheter, elevate the extremity, encourage active range of motion, apply a warm or cold compress depending on the solution infusing, restart the infusion proximal to the site or in another extre
Parkinson's Disease: Teaching About Pathophysiology (Chp. 7)
Report of fatigue, report of decreased manual dexterity over time
PHYSICAL ASSESSMENT FINDINGS: stooped posture, slow, shuffling, and propulsive gait ,Slow, monotonous speech, tremors/pill?rolling tremor of the fingers, muscle rigidity (e.g., rhythmic int